Invitation to Negotiate Comprehensive Surgical and Medical Procedures Entity DMS -17/18-031 ADDENDUM # 1 FAILURE TO FILE A PROTEST WITHIN THE TIME PRESCRIBED IN SECTION 120.57(3), FLORIDA STATUTES, OR FAILURE TO POST THE BOND OR OTHER SECURITY REQUIRED BY LAW WITHIN THE TIME ALLOWED FOR FILING A BOND SHALL CONSTITUTE A WAIVER OF PROCEEDINGS UNDER CHAPTER 120, FLORIDA STATUTES. The Department s responses to timely submitted questions are below. 1 1.2 5 2 1.2 (2)(a) 5 Can you provide a complete breakdown of the number of enrollees and members by plan type? Could you also identify the TPA by name for each plan? What is the scope of the term " services for surgery and other medical procedures which may be accessed a the option of the enrollee." See Attachment 1 included below. 110.12303(2)(a), Florida Statutes, references services for surgery and other medical procedures which may be accessed at the option of the enrollee." The scope of services and length of time of a Bundled Services arrangement may vary depending on the service. For example, some Bundled Services arrangements include all services from pre-operative to post-operative or all services provided from hospital 1 of 10
3 1.2 (2)(a) 5 4 1.2 5 5 9. 9 and 18 43 6 5 27 When reference is made to "other medical procedures", what other medical procedures are contemplated by the department? Is travel, meals and incidentals a covered benefit for the member and companion? Is it contemplated that the successful vendor offer, complete utilization management, as part of the services offered under this program? Or can we success partner with the current UM provider? Is the Department looking for one vendor to perform all items in the Minimum Service Requirements or can the full scope of services be provided by an integrated partnership amongst multiple entities? admission to discharge. Enrollees will have the option to choose a Bundled Services arrangement that best meets their needs. 110.12303(2)(a), Florida Statutes, references "other medical procedures." Other medical procedures that could be needed when services for surgery are provided include but are not limited to x-ray, intubation, or catheterization. Vendors may propose services to be provided as part of a Bundled Services arrangement, including travel, meals, and incidentals. Refer to Attachment C, Minimum Service Requirement #38. The Department contemplates that utilization management for Bundled Services arrangements is included in proposals submitted by vendors. The Department requires each of its third party administrators to provide utilization management. See ITN, section 3.3.8. Each Respondent must certify that it can and will provide, at a minimum, all Minimum Service 2 of 10
7 1.2 5 8 ITN, Attachment C, Statement of Work, 30 Attachment C, page 12 Under the Program, what covered benefits are there for Enrollees and Members for travel? Are the benefits for travel the same for the various PPO and HMO plans.? Please specify what is the scope of "Contractor shall coordinate with Medicare's third-party administrators " Requirements as described in 5 and Attachment C Statement of Work. Vendors may propose an alternate approach for any MSR and provide an explanation in their proposals and during negotiations. The Department, in its sole discretion, may consider any proposed alternate approach. During negotiations, the Department may, at its sole discretion, modify, reduce, eliminate MSRs when it determines it is in its best interest to do so. Vendors may subcontract to provide services subject to provisions in 2.14 of the ITN and 3 of Attachment A. Under the current PPO and HMO plans, travel is not a covered benefit for Enrollees. However, the vendor may propose services to be provided as part of a Bundled Services arrangement, including travel, meals, and incidentals. The Contractor will have to coordinate benefits with Medicare's third-party administrators for enrollees who are Medicare-eligible. The State Group Health Insurance 3 of 10
9 ITN Attachment A: Draft Contract Attachment A, page 10 10 ITN 1.2 5 11 ITN 1.2 5 12 ITN 1.3 (clause l) 7 Who is covered by the clause "Bills for Travel expenses are not permitted under this Contract." (1) Is it the intent of the Department to require the incumbent TPA's to administer Bundled provider fee invoices? (2) Will the Department expect the bundled payment vendor to remit payments to the bundled providers? (1) If the TPA's will be responsible, to what standards will the Department's TPA's be held so as to ensure they make timely payments to the Bundled Service Vendor? (2) Will the Department establish a separate pool of funds for the sole purpose of bundled payment administration? Please list services for which the Department requires preauthorization. Program serves as secondary payer for enrollees on Medicare. The Department anticipates limited engagement from enrollees who are Medicare-eligible as Bundled Services arrangements are currently available to this population through Medicare. The Contractor is subject to the clause, "Bills for Travel expenses are not permitted under this Contract." (1) No, the Department will not require incumbent TPAs to administer Bundled Services Vendor fee invoices. (2) Yes, the Department expects the Bundled Services Vendor(s) awarded in this procurement to remit payments to providers that render services as part of a Bundled Services arrangement. (1) Not applicable. Refer to answer to #10. (2) The Department will make payments to vendor from its Health Insurance Trust Fund. For the PPO plan, refer to pages 38-39 in the Plan Booklet: https://www.mybenefits.myflorid a.com/content/download/13020 4 of 10
13 14 15 ITN 1.3 (clause l) ITN 1.3 (clause l) ITN 1.3 (clause l) 7 7 7 Will the frequency of preauthorization file transfers sent to the Bundled Service Vendor be hourly or another frequency, and if so, what will be the frequency? What data elements in the preauthorization transfer file will the Department require its TPA s utilization management vendors to provide to the Bundled Service Vendor? Please confirm if member eligibility files will be transmitted to the Bundled Service Vendor weekly or at another frequency and if the eligibility files will be received from the Department s TPAs or another source? 0/808814/2017_PPO_Plan_Gro up_health_insurnace_plan_bo oklet_and_benefits_doc.pdf. For the HMO plan, refer to page 31 in the Plan Booklet: https://www.mybenefits.myflorid a.com/content/download/14055 5/906753/Aetna_2018_SPD_no _markup_and_toc.pdf. The Department will not be providing preauthorization file transfers to the Bundled Services Vendor. Prior authorizations will be the responsibility of the Bundled Services Vendor and will need to be obtained by the Bundled Services Vendor. Enrollees will be responsible for contacting the Bundled Services Vendor to obtain information on available bundled services arrangements, and schedule and receive bundled services arrangements through the Bundled Services Vendor. See answer to #13. Member eligibility files will be transmitted to the Bundled Service Vendor on a weekly basis and will be received from 5 of 10
16 17 18 ITN 1.3 (clause n) ITN 1.3 (clause w) ITN 4.3.6 (clause m) 7 7 25 With respect to offering bundled services to retirees, please confirm how the Department defines retirees and how this program is intended to service retirees. Are there any special considerations needed to plan for when offering a retiree solution? Will the Department support a co-branded enrollment process in order to maximize member awareness and adoption of the Bundled Service Vendor program? At what point during the Negotiations Phase may Bundled Service Vendor responders expect to receive historical claims data in order to generate a detailed savings proposal? Northgate Arinso, the Department's third party administrator for human resources support. See section 110.123(2)(h), F.S. The State Group Health Insurance Program serves early retirees (defined as those who are retired but are not Medicare-eligible) and Medicare-eligible retirees. Retirees are eligible for the same services as active employees. The Department recommends vendors outline special considerations in their proposals and discuss these considerations in the negotiations process. Yes, the Department will support a co-branded enrollment process in order to maximize member awareness and adoption of the Bundled Service Vendor program. The extent to which the Department co-brands will be determined during the negotiations process. The Department will determine if and when it will provide historical claims data to Bundled Service Vendors during the Negotiations Phase. 6 of 10
19 ITN 4.3.6 (clause m) 25 20 ITN 8.3 39 Will a de-identified member census by plan type and TPA be made available to the Bundled Service Vendor with a count of covered lives by zip code? (1) Will the bundled payment vendor receive and/or gain access to a post adjudicated paid claims report to perform ongoing savings analysis for the Department? (2) What frequency will said reports be generated? Yes, See Attachment 1. (1) Yes, the Bundled Service Vendor will receive a paid claims report to perform a savings analysis for the Department. (2) Paid claims reports will be provided on a monthly basis. 21 ITN 4.3.6 (clause m) 25 What time period will the historical claims data cover? At least 2-3 calendar years of data, including full year 2017, is recommended, if available, to analyze medical cost trend as well as recent claims costs. See answer to #18. Which of the following claim line data fields will not be included in the historical claims data?: 22 ITN 4.3.6 (clause m) 25 1. Group ID 2. Group Name 3. Plan ID 4. Referring Provider NPI 5. Rendering Provider Tax ID 6. Rendering Provider NPI 7. Rendering Provider Name 8. Rendering Provider Address 1 9. Rendering Provider Address 2 10. Rendering Provider City 11. Rendering Provider State 12. Rendering Provider Zip Code 13. Rendering Provider Specialty See Attachment 2 included below. 7 of 10
14. Rendering Provider Type 15. Billing Provider Name 16. Billing Provider Address 1 17. Billing Provider Address 2 18. Billing Provider State 19. Billing Provider Zip Code 20. Network Code 21. Network Description 22. Claim No 23. Claim Line No 24. Units 25. Billed Charges 26. Excluded Charges 27. Eligible Charges 28. Allowed Amount 29. Discount Amount 30. Paid Amount 31. Patient Share Coinsurance Amount 32. Patient Share Copay Amount 33. Patient Share COB Amount 34. Patient Share Deductible Amount 35. UB/HCFA Status 36. IP/OP Status 37. Date of Service Start Date 38. Date of Service End Date 39. Days Visits 40. Paid Date 41. Admission Date 42. Discharge Date 43. Place of Service (claims to include place of service 11 and 22 distinction) 44. Procedure Type 45. Procedure Code 46. Modifier 1 8 of 10
23 ITN 4.3.6 (clause m) 25 24 N/A N/A 25 ITN 9.9 43 47. Modifier 2 48. Revenue Code 49. DRG Code 50. Diagnosis Code 1 51. Diagnosis Code 2 52. Tertiary Diagnosis Code 53. Admitting Diagnosis 54. Remark Code 55. Remark Code Description 56. Member ID 57. Member City 58. Member State 59. Member Zip Code 60. Patient ID 61. Patient City 62. Patient State 63. Patient Zip 64. Patient Date of Birth 65. Patient Sex 66. Patient Relationship Once data is transmitted, what time period will the Department grant for the Bundled Service Vendor to generate a detailed savings analysis? Adequate time is recommended to serve the Department s interests and goals. Per FL Senate bill 7022. Line 469 Departments that in 2020, the start of year two of the Bundled Service Vendor contract, the Department will be restructuring benefit levels into four (4) actuarial value levels. Please elaborate on the details of this new structure if available since it could necessitate potential program changes in 2020 and how value is demonstrated. (1) Is it the intent of the Department to require the bundled service vendor to provider Utilization Management (medical necessity determinations) for bundled services? (2) Is it the intent of the See answer to #18. There are no details available at this time. (1) Yes, the Department expects the Bundled Services Vendor to provide utilization 9 of 10
Department to require the incumbent TPA s to coordinate prior authorizations with the bundled payment vendor? management for Bundled Services arrangements. Refer to Attachment C, Minimum Service Requirement #38. (2) No, prior authorizations will be the responsibility of the Bundled Service Vendor and will need to be obtained by the Bundled Service Vendor. Enrollees will be responsible for contacting the Bundled Service Vendor to obtain information on available bundled services arrangements, and schedule and receive bundled services arrangements through the Bundled Service Vendor. 10 of 10
ATTACHMENT 1 'STATE EMPLOYEES' GROUP HEALTH INSURANCE PROGRAM PPO & HMO ENROLLMENT BY COUNTY BY PLAN FEBRUARY 2018 PPO (EE & DEP) HMO (EE & DEP) TOTAL (EE + DEP) County STDP HDHP STDP HDHP STDP HDHP Alachua 17,557 784 11,211 182 28,768 966 Baker 482 15 2,046 15 2,528 30 Bay 3,085 51 399 8 3,484 59 Bradford 947 10 1,881 17 2,828 27 Brevard 2,090 47 2,222 17 4,312 64 Broward 6,225 186 10,068 93 16,293 279 Calhoun 729 15 743 5 1,472 20 Charlotte 1,037 25 670 16 1,707 41 Citrus 937 23 567 7 1,504 30 Clay 1,355 54 2,053 21 3,408 75 Collier 1,218 16 506 6 1,724 22 Columbia 1,909 16 2,613 36 4,522 52 Desoto 772 7 162 5 934 12 Dixie 224 4 943 3 1,167 7 Duval 4,949 204 6,733 63 11,682 267 Escambia 2,886 84 2,572 22 5,458 106 Flagler 565 10 558 7 1,123 17 Franklin 392 6 394 4 786 10 Gadsden 975 24 6,563 46 7,538 70 Gilchrist 439 3 772 11 1,211 14 Glades 85 4 12 0 97 4 Gulf 831 9 70 0 901 9 Hamilton 406 10 428 6 834 16 Hardee 470 18 198 2 668 20 Hendry 365 13 88 1 453 14 Hernando 856 22 1,392 3 2,248 25 Highlands 1,253 21 747 3 2,000 24 Hillsborough 9,519 598 10,322 145 19,841 743 Holmes 1,275 6 37 1 1,312 7 Indian River 1,201 22 240 3 1,441 25 Jackson 5,846 45 715 3 6,561 48 Jefferson 319 5 1,739 3 2,058 8 Lafayette 471 2 227 2 698 4 Lake 1,932 35 1,404 32 3,336 67 Lee 4,001 159 3,340 62 7,341 221 Leon 10,134 376 48,499 303 58,633 679 Levy 730 24 1,110 9 1,840 33 Liberty 207 2 876 5 1,083 7 Madison 550 21 626 10 1,176 31 Manatee 1,621 48 1,176 30 2,797 78 Marion 3,098 108 3,587 29 6,685 137 Martin 967 44 217 1 1,184 45 Miami-Dade 6,735 220 18,334 173 25,069 393 Monroe 926 47 68 2 994 49 Nassau 330 29 654 3 984 32 Okaloosa 1,549 31 582 9 2,131 40 Okeechobee 592 21 150 5 742 26 Orange 6,049 357 8,972 103 15,021 460 Osceola 835 39 1,640 20 2,475 59 Palm Beach 7,617 209 4,996 47 12,613 256 Pasco 2,339 128 3,731 35 6,070 163 Pinellas 3,576 192 4,860 77 8,436 269 Polk 3,168 80 5,236 36 8,404 116 Putnam 1,133 14 533 0 1,666 14 Santa Rosa 1,890 89 2,336 15 4,226 104 Sarasota 1,818 50 1,349 23 3,167 73 Seminole 3,141 221 4,149 19 7,290 240 St Johns 2,656 72 1,446 14 4,102 86 St Lucie 2,704 44 677 5 3,381 49 Sumter 671 10 266 3 937 13 Suwannee 1,011 20 1,585 9 2,596 29 Taylor 836 5 539 10 1,375 15 Union 794 5 1,560 15 2,354 20 Volusia 2,678 70 3,591 31 6,269 101 Wakulla 625 9 5,979 21 6,604 30 Walton 1,017 15 158 5 1,175 20 Washington 1,753 11 114 0 1,867 11 Out Of State 6,040 129 1,121 25 7,161 154 Total 157,393 5,293 205,352 1,942 362,745 7,235 Source: NGA Monthly Enrollment Files Bureau of Financial & Fiscal Management
Attachment 2 Which of the following claim line data fields will not be included in the historical claims data? Vendor 1 Vendor 2 Vendor 3 Vendor 4 Vendor 5 Vendor 6 1. Group ID Yes Yes Yes Yes Yes No 2. Group Name No No No No No No 3. Plan ID No No No No No No 4. Referring Provider NPI No No No No No No 5. Rendering Provider Tax ID Yes Yes Yes Yes Yes Yes 6. Rendering Provider NPI Yes Yes Yes Yes Yes Yes 7. Rendering Provider Name Yes Yes Yes Yes Yes Yes 8. Rendering Provider Address 1 Yes Yes Yes Yes No Yes 9. Rendering Provider Address 2 Yes Yes Yes Yes No Yes 10. Rendering Provider City Yes Yes Yes Yes No Yes 11. Rendering Provider State Yes Yes Yes Yes Yes Yes 12. Rendering Provider Zip Code Yes Yes Yes Yes Yes Yes 13. Rendering Provider Specialty Yes Yes Yes Yes Yes Yes 14. Rendering Provider Type Yes Yes Yes Yes Yes Yes 15. Billing Provider Name No No No No No No 16. Billing Provider Address 1 No No No No No No 17. Billing Provider Address 2 No No No No No No 18. Billing Provider State No No No No No No 19. Billing Provider Zip Code No No No No No No 20. Network Code Yes Yes Yes Yes Yes No 21. Network Description No No No No No No 22. Claim No Yes Yes Yes Yes Yes Yes 23. Claim Line No All services lines are provided, but line numbers aren t necessairly 24. Units Yes Yes No Yes Yes No 25. Billed Charges Yes Yes Yes Yes Yes Yes 26. Excluded Charges No No Yes Yes Yes Yes 27. Eligible Charges No No No No No No 28. Allowed Amount Yes Yes Yes Yes Yes Yes 29. Discount Amount No Yes No No Yes No 30. Paid Amount Yes Yes Yes Yes Yes Yes 31. Patient Share Coinsurance Amount Yes Yes Yes Yes Yes Yes 32. Patient Share Copay Amount Yes Yes Yes Yes Yes Yes 33. Patient Share COB Amount Yes Yes Yes Yes No Yes 34. Patient Share Deductible Amount Yes Yes Yes Yes Yes Yes 35. UB/HCFA Status Unknown 36. IP/OP Status Yes Yes Yes Yes Yes Yes 37. Date of Service Start Date Yes Yes Yes Yes Yes Yes 38. Date of Service End Date Yes Yes Yes Yes Yes Yes 39. Days Visits No No No No No No 40. Paid Date Yes Yes Yes Yes Yes Yes 41. Admission Date No Yes Yes Yes No Yes 42. Discharge Date No Yes Yes Yes No Yes 43. Place of Service (claims to include place of serv Yes Yes Yes Yes Yes Yes 44. Procedure Type Yes Yes Yes Yes Yes Yes 45. Procedure Code Yes Yes Yes Yes Yes Yes 46. Modifier 1 Yes Yes Yes Yes Yes Yes 47. Modifier 2 Yes Yes Yes Yes Yes Yes 48. Revenue Code Yes Yes Yes Yes Yes No 49. DRG Code Yes Yes Yes Yes Yes Yes 50. Diagnosis Code 1 Yes Yes Yes Yes Yes Yes 51. Diagnosis Code 2 Yes Yes Yes Yes Yes Yes 52. Tertiary Diagnosis Code Yes Yes Yes Yes Yes Yes 53. Admitting Diagnosis Yes Yes Yes Yes Yes Yes 54. Remark Code Yes Yes Yes Yes Yes Yes 55. Remark Code Description No No No No No No 56. Member ID Yes Yes Yes No No No 57. Member City No No No No No No
Attachment 2 58. Member State No No No No No No 59. Member Zip Code No No No No No No 60. Patient ID Yes Yes Yes Yes Yes Yes 61. Patient City No No No No No No 62. Patient State No No No No No No 63. Patient Zip No No No No No No 64. Patient Date of Birth Yes Yes No Yes Yes Yes 65. Patient Sex Yes Yes No Yes Yes Yes 66. Patient Relationship No Yes No No No No