REQUEST FOR PROPOSAL

CIHA 2019-001

CHEROKEE INDIAN HOSPITAL AUTHORITY

(CIHA)

CIHA Tribal OptionBusiness Functions

Opening Date: April 10, 2018

BID RESPONSE INSTRUCTIONS

  • READ ALL TERMS, CONDITIONS AND SPECIFICATIONS
  • Label your bid response envelope with the Bid Number and Opening Date. Bids not identified may be rejected.
  • ALL PROPOSALS MUST BE RECEIVED BY THE OPENING DATE. The Cherokee Indian Hospital Authority assumes no responsibility for bid responses that are late due to delay or failure of delivery by the U. S. Postal Service, private courier or any other reason.
  • Responses to the RFP must be signed. Signatures must be original, and hand written.
  • Bid pricing should be submitted on a pricing sheet in a format consistent with the requested information.
  • Vendors are to submit one original copy of proposal marked “Original” and four (4) copies marked “Copy.” Each copy must be individually bound.
  • Any errors or corrections in a bid response should be initialed.
  • Any questions or clarifications concerning this bid should be directed to Lori Lambert, CFO at (828) 497-9163 ext. 6462 or .The deadline for submitting questions is April 24, 2018.
  • This RFP and any contract(s) awarded hereunder will be governed by the laws of the Eastern Band of Cherokee Indians (EBCI), including its Tribal Employment RightsOrdinance (TERO), pursuant to which tribal members and members of other federally-recognized tribes are given preference in employment and contract opportunities. A contract awarded hereunder shall be subject to the jurisdiction of the courts of the EBCI.
  • The Cherokee Indian Hospital Authority is exempt from State Tax. Prices should not reflect a State Tax.
  • All Bid responses must be submitted to:

Cherokee Indian Hospital Authority

Attention: Lacy Kilby, Contracting Assistant

Caller Box C-268 (U.S. Postal Service delivery)

1 Hospital Road (physical address)

Cherokee, NC 28719

REQUEST FOR PROPOSAL

TRIBAL OPTION MANAGED CARE BUSINESS FUNCTIONS SERVICES

Introduction

The North Carolina Medicaid 1115 waiver demonstration for Medicaid managed care will be implemented statewide. S.L. 2015-245 requires the 1115 waiver demonstration toinclude statewide and regional contracts (“Prepaid Health Plans,” or PHPs) with both Provider Led Entities (PLEs) and Commercial Plans. The Eastern Band of Cherokee Indians (EBCI) Cherokee Indian Hospital Authority (CIHA) will be a PLE Tribal Optionwith a regional PHP contractthat considers and addresses the unique cultural, behavioral health, and medical needs that are often the root causes of health issues among federally recognized tribal members.The Cherokee Indian Hospital Authority is a political sub-unit and legal entity of the Eastern Band of Cherokee Indians. It serves as a primary health system for the EBCI and has the delegated authority to manage the Programs, Functions, Services and Activities formally provided by the United States through the Indian Health Services Agency, consistent with the authority established in the Indian Self Determination Education and Assistance Act and the Indian Health Care Improvement Act and all subsequent amendments.

To achieve its desired outcomes, this Tribal Optiondemonstration must involve the whole community and be founded on the strengths, values and beliefs of the Cherokee People. TheCIHAstrives to improve the health of the Cherokee population through itsefforts to reflect the Cherokee values of spirituality, group harmony, strong individual character, strong connection to the land, honoring the past, and educating the children. Health care services and facilities should incorporate cultural elements that reflect a ‘sacred healing environment’ and the Cherokee connection to the earth below the trees. It is essential that these programs operate as fully integrated elements of the Tribe’s overall service array. These services must offer gender-specific treatment, address chronic medical conditions, treat co-occurring psychiatric and substance use disorders, and have the capacity to address the needs of pregnant women and women with children. The services must emphasize the delivery of evidence-based treatment that is founded in traditional Cherokee beliefs and healing practices. The 1115 waiver will authorize the contracted PHPs to offer “in lieu of” or “value added” services specific to their networks. The State and CIHA will work together to identify culturally competent “in lieu of” services including acupuncture, biofeedback, therapeutic massage, healing touch, and chiropractic services.

This Request for Proposal (RFP) is for the solicitation of bids for integral business functions that will beneeded to plan, implement, and sustain the CIHA PLETribal Optionwithin the North Carolina Medicaid managed care environment. The Tribal Optionwill provide the full array of medical, behavioral health, and pharmacy services covered by the Medicaid and Children’s Health Insurance Plan (NC Health Choice) programs to all persons eligible for EBCI health services (enrolled members of the Eastern Band of Cherokee Indians, as defined in Cherokee Tribal Code, Sec. 49-2; direct lineal descendants; members of other federally recognized Native American Tribes and Alaskan Natives; and a small number of others eligible for EBCI health services under Indian Health Service guidelines)who live within the defined CIHA Tribal Option geographical area. The Tribal Option area comprises the fivecounty Contract Health Service Delivery Area (CHSDA) which includes Cherokee, Graham, Haywood, Jackson, and Swain Counties (counties that comprise Tribal Trust lands).

The federal definition of an Indian Managed Care Entity (IMCE) is, “a managed care organization. . . that is controlled (within the meaning of the last sentence of section 1903(m)(1)(C) of the Social Security Act) by the Indian Health Service, a Tribe, Tribal Organization, or Urban Indian Organization, or a consortium, which may be composed of one or more Tribes, Tribal Organizations, or Urban Indian Organizations, and which also may include the Indian Health Service.” The Eastern Band of Cherokee Indians is the only federally recognized Tribe in North Carolina, and its Cherokee Indian Hospital Authority will control the Provider Led Entity (Tribal Option) that operates under a regional PHP contract with the State.

As the single State agency for North Carolina’s Medicaid program, DHHS may obtain federal authority to operate a Medicaid managed care program through its proposed Section 1115 Demonstration waiver that was last amended in November of 2017. The waiver is currently pending approval with the Centers for Medicare and Medicaid Services (CMS). In its waiver application, DHHS included the possible establishment of an IMCEPHP contract referenced as a “Tribal Option.” The waiver application language reads: “The State and EBCI will continue to collaborate in the development of a Tribal Option that considers and addresses the unique cultural, behavioral health and medical needs of federally recognized tribal members.” The tribal demonstrationwill be a shared risk health plan.

The complete NC DHHS 1115 waiver application is available for review at:

Controlling Authorities

This RFP has been structured and published in compliance with the federal Office of Management and Budget’s procurement standards at 2 C.F.R. § 200.320 and § 200.321. Solicitation of proposals under these regulations includes solicitation from an adequate number of qualified sources. Qualified sources include small, minority, and women’s businesses and labor surplus area firms. Any vendor awarded a contract under this Request for Proposal will be subject to all applicable federal and State laws, including but not limited to:

  • Title XIX of the Social Security Act
  • Title XXI of the Social Security Act
  • Indian Health Care Improvement Act at 25 U.S.C. 1601 et seq.
  • Section 5006 of the American Recovery and Reinvestment Act
  • The Americans with Disabilities Act
  • Section 1557 of the Patient Protection and Affordable Care Act
  • Title VI of the Civil Rights Act of 1964
  • The Age Discrimination Act of 1975
  • The Rehabilitation Act of 1973
  • Title IX of the Education Amendments of 1972
  • Applicable North Carolina statutes and administrative rules
  • Medicaid and NC Health Choice State Plans
  • Medicaid and NC Health Choice program clinical coverage policies

RFP BUSINESS REQUIREMENT FUNCTIONS

for CIHATribal Option

For the implementation of applicable business requirements, the contractor will be subject to compliance with the Centers for Medicare and Medicaid Services (CMS) managed care Final Rule at 42 C.F.R. Part 438 and all other applicable federal and State authorities. The contractor will also comply with the terms and conditions set forth in the PHP contract between the Cherokee Indian Hospital Authority and the North Carolina Department of Health and Human Services.

This RFP provides the 1115 waiver application and federal and State regulatory context for each of 11broad business functions. Those functions are listed below in the order in which they appear on the pages that follow.

  • Member Services
  • Quality Management
  • Care Coordination
  • Beneficiary Appeals
  • Provider Network – Adequacy Standards
  • Provider Network – Credentialing
  • Provider Network – Appeals
  • Program Integrity
  • Information Technology – Claims Processing
  • Information Technology – Reporting
  • Information Technology – CIHA Resource and Patient Management System
  • Information Technology - Data Privacy and Security

MEMBER SERVICES

The waiver application states: “The Department envisions that the enrollment broker, PHP member services, and the ombudsman program will jointly serve as the beneficiary support system.”

Telephone Assistance

The contractor will manage a call center with a member service line that must be adequately staffed to answer member calls within 30 seconds during standard business hours. Federal regulations require the service line to be available24 hours a day, seven days a week. Call agents will be provided with job aids and will be expected to address most member inquiries,assist with understanding covered benefits policies, and escalate issues as needed. All inbound calls and related metrics must be logged.

The contractor will also manage a nurse line that allows members to connect with a Registered Nurse to ask health questions and obtain health advice, education, assistance with understanding covered benefits policies, and referrals if needed.The contractor must staff the nurse line with an adequate number of Registered Nurses 24 hours a day, seven days a week. Specific nurse line responsibilities will include, but not be limited to: answering basic health care and urgent care questions; giving health care advice; helping plan members find a provider; scheduling next-day appointments for the members; evaluating symptoms and determining an appropriate method of treatment, which may include home-based remedies or referring members to an urgent care facility or the emergency room; explaining the emergency prescription process; and answering questions about Service Management.

Grievances

As the typical point of contact for members when they have grievance inquiries, Member Services advises members of their rights to file a grievance and assists with the filing process. 42 C.F.R. 438.400 defines a grievance as “an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee's rights regardless of whether remedial action is requested. Grievance includes an enrollee's right to dispute an extension of time proposed by the MCO, PIHP or PAHP to make an authorization decision.” Members may file a grievance at any time, orally or in writing. The contractor will be required to give any “reasonable assistance” needed for members to complete grievance and appeal paperwork, including translation services (see: Information Requirements below).

The contractor will be required to log and track grievances in accordance with contract specifications, provide written acknowledgment to members of receipt of grievances, and provide written notice to members regarding the resolution of grievances. The contractor must also have adequate information technologyand database software for tracking and reportingcall center and nurse line calls, all referrals to services generated through member calls, andgrievance inquiries and resolutions.

Information Requirements

This RFP requires the development and dissemination of information to beneficiaries.

42 C.F.R. 438.10(d)(3) states, “written materials that are critical to obtaining services, including, at a minimum, provider directories, enrollee handbooks, appeal and grievance notices, and denial and termination notices, available in the prevalent non-English languages in its particular service area. Written materials must also be made available in alternative formats upon request of the potential enrollee or enrollee at no cost. Auxiliary aids and services must also be made available upon request of the potential enrollee or enrollee at no cost. Written materials must include taglines in the prevalent non-English languages in the state, as well as large print, explaining the availability of written translation or oral interpretation to understand the information provided and the toll-free and TTY/TDY telephone number of the MCO's, PIHP's, PAHP's or PCCM entity's member/customer service unit. Large print means printed in a font size no smaller than 18 point.” The NC DHHS Office of Civil Rights monitors compliance with numerous federal laws, including Section 1557 of the Affordable Care Act, which also includes notice requirements to ensure access to federally funded information, services, and programs for individuals with Limited English Proficiency. 42 C.F.R. 438.10(a) defines a “prevalent” non-English language as one that is “spoken by a significant number or percentage of potential enrollees and enrollees” who are Limited English Proficient. NC DHHS has identified nine prevalent languages across North Carolina: Arabic, Cambodian, Chinese, Creole, Hmong, Korean, Russian, Spanish, and Vietnamese. The State will have the responsibility of identifying prevalent non-English languages within each PHP region (when contracts are regional versus statewide) and informing the PHPs. The CIHA has identified Cherokee and Spanish as the two languages specific to the Tribal Option region.

42 C.F.R. 438.10also stipulates:

  • Limited English Proficient individuals may be eligible to receive language assistance for a particular type of service, benefit, or encounter. The contractor will be responsible for assisting the CIHA with the procurement of mandatory interpreter services for both non-English languages and American Sign Language.
  • Each MCO (CIHA Tribal Option) must make its pharmacy formulary available electronically on its Web site and also available in hard copy. Information shall include which generic and name brand medications are covered, and which tier each medication is on.
  • Each MCO (CIHA Tribal Option) must provide a handbook that includes: a summary of benefits and coverage, including prior approval or referral requirements and cost sharing; how and where to access services, including information about non-emergency medical transportation; how to access and use emergency services; choice of provider; enrollee rights and responsibilities; how to report fraud or abuse; how to exercise an advance directive; how to access Member Services and auxiliary aids and services; and grievance and appeal rights, timeframes, and processes. The contractor will develop and distribute the member handbook for the CIHA Tribal Option.

RFP Response Prompt

In your response to this section of the RFP, please describe:

  1. your organization’s experience with staffing, managing, and reporting on nurse line and member call center activities;
  2. how your organization will report call center performance statistics to CIHA at a frequency to be established in the contract;
  3. how your organization will share the data with CIHA to review at any time outside of required reporting intervals;
  4. your organization’s experience with triaging, researching, and resolving member grievances;
  5. your organization’s experience with developing, maintaining, and distributing a member handbook for a private or public assistance health plan;
  6. your organization’s experience with procuring and using translation services to comply with requirements for federally funded programs or health plans; and
  7. your organization’s experience with database software and what it would use to fulfill the terms, conditions, and specifications for this business function.

QUALITY MANAGEMENT

The waiver application states: “The Department is committed to supporting providers in quality improvement and finding the most effective ways to reward providers for delivering high quality care.” Quality is multi-faceted, as noted in the CMS regulations:

“Quality, as it pertains to external quality review, means the degree to which an MCO. . . increases the likelihood of desired outcomes of its enrollees through: (1) Its structural and operational characteristics. (2) The provision of services that are consistent with current professional, evidenced-based-knowledge. (3) Interventions for performance improvement.” [42 C.F.R. 438.330]

CMS requires States to conduct annual, external independent reviews of the quality, timeliness, and accessibilityof services covered under MCO contracts. There are mandatory and optional external quality review organization (EQRO) activities. The three mandatory ones are:

1.Review, within the previous three-year period, to determine MCO compliance with state standards for access to care, structure and operations, and quality measurement and improvement;

2.Validation of performance measures; and

3.Validation of performance improvement projects (PIPs).

The contractor will help the CIHA Tribal Optioncollect and maintain data that can be used by the external quality review organization, with a focus on metrics and ensuring that data are reliable and valid.

CMS requires States to develop standardized performance measures for MCOs related to enrollee quality of life, rebalancing, and community integration activities for individuals receiving long-term services and supports. CMS subsequentlyrequires MCOs to generate annual performance reports based on the State’s standardized measures; therefore, the contractor will need to have the information technology capacity to manage this administrative function.