The Georgia Cares Program for Medical Assistance

1
The Georgia Cares Program for

Medical Assistance PeachCare for Kids
Presentation to the Georgia Department of
Community Health Board of Directors
Kathy Driggers, Chief Division of Managed Care
Quality Georgia Department of Community
Health January 13, 2005
2
Georgia Cares Update

• A Request for Proposals (RFP) was posted to the
  state procurement registry on Thursday, January
  6th (www.procurement.state.ga.us)
• A Model contract (Appendix E) and Data Book
  (Appendix K) were posted on Tuesday, January 11th
  
• Our DOAS procurement officer has begun receiving
  questions related to components of the RFP

3
Georgia Cares Timeline

• RFP posted to Georgia Procurement
  Registry January 6, 2005
• Technical Proposal Assistance Session January
  25, 2005
• Cost Proposal Assistance Session January 26,
  2005
• Deadline for written questions by 500
  p.m. February 2, 2005
• Post Answers to Written Questions on
  Registry February 23, 2005
• Offerors Conference February 28, 2005
• Proposals Due by 400 p.m. April 4, 2004
• Issuance of Apparent Successful Offeror
  Letter May 31, 2005
• Contract Negotiations June 1-16, 2005
• Operations begin in the Atlanta and Central
  Service Regions January 1, 2006
• Operations begin in the East and North Service
  Regions July 1, 2006
• Operations begin in the Southeast and Southwest
  Service Regions December 1, 2006

4
Georgia Cares RFP Structure

• Project Summary
• Proposal Submission Requirements
• Contract Term
• Project Scope of Work
• Instructions Information
• Process Preparation
• Questions that will elicit bidder responses and
  enable DCH to ascertain their ability to carry
  out the required scope of work
• Evaluation
• RFP Appendices

5
Georgia Cares The Details
High Points

• One-year term with 6 renewal options
• Technical mandatory requirements include
• Department of Insurance Certificate of Authority
• Minimum 3 years experience operating a full-risk
  Medicaid program in another state(s)
• Able to provide all covered services to all
  members on first day of operation
• NCQA or URAC accreditation in at least one state
  by submission date
• No offshore programming or call center services

6
Georgia Cares Member
Enrollment

• Outreach by Enrollment Broker
• Choice of an in-network Primary Care Provider
  (PCP)
• If no PCP choice made, auto-assignment based on
  an algorithm of previous PCP relationship with
  Member or family member, then geographic
  proximity
• Emphasis placed on timely newborn enrollment in
  plan and PCP selection
• Member-requested disenrollment without cause in
  first 90 days, then once every 12 months
  thereafter

7
Georgia Cares Member Services

• Stringent requirements for written materials
  including
• Alternative formats
• Prevalent non-English languages
• Cultural competency
• Understandable reading level
• Member handbook with all Member Rights,
  Responsibilities, Benefits, Grievance and Appeal
  Procedures
• Provider Directory
• ID Card
• Telephone Hotline
• Translation Services

8
Georgia Cares Covered
Benefits Services

• All Medically Necessary services and benefits
  pursuant in State Medicaid Plan and Medicaid
  Policies Procedures
• Enhanced Services including
• Programs to enhance health and well-being
• Health promotion materials
• Annual wellness clinics
• Community-sponsored health fairs
• Education regarding early intervention and
  management strategies for specific diseases and
  conditions

9
Georgia Cares Provider Network

• Adequate to provide access to all covered
  services
• Appropriately and currently licensed and
  credentialed providers
• Significant Traditional Providers (STPs) must be
  included in-network for 2 years, which include
• PCPs (Internal Medicine, Family Practice,
  Pediatrics)
• OB/GYNs
• Behavioral Health Providers
• Dental Providers
• Pharmacies
• Hospitals
• Critical Access Hospitals must be included
• FQHCs and RHCs must be included

10
Georgia Cares Access
Requirements

• Provider Type Urban Rural
• PCPs 2 within 8 miles 2 within 15 miles
• Specialists 1 within 30 minutes/miles 1 within
  45 minutes/miles
• Dental Providers 1 within 30 minutes/miles 1
  within 45 minutes/miles
• Hospitals 1 within 30 minutes/miles 1 within 45
  minutes/miles
• Mental Health Providers 1 within 30
  minutes/miles 1 within 45 minutes/miles
• Pharmacies 1 24-hour/seven days per 1
  24-hour/seven days per
• week within 15 minutes/ week within 30
  minutes/
• miles miles

11
Georgia Cares Provider Network

• Reports to DCH within 7 days of significant
  network changes
• 5 or greater decrease in PCPs
• Loss of all specialty providers where another is
  not available within 60 miles
• Loss of a hospital where another is not available
  within 25 miles
• Other changes that impair or deny Member access
  to network providers, including culturally
  diverse access
• Significant network changes may be grounds for
  contract sanctions or termination

12
Georgia Cares Disease
Management

• Required for Diabetes and Asthma
• In addition, at least 2 more from
• Perinatal case management
• Obesity
• Hypertension
• Sickle cell disease
• HIV/AIDS

13
Georgia Cares Quality
Improvement

• Multi-disciplinary Quality oversight committee
• Ongoing Quality Improvement Program
• Clinical Performance Improvement Projects
  mandatorily required for
• Health Check screens
• Immunizations
• Blood lead screens
• Chronic kidney disease
• With one additional project in
• Coordination/continuity of care
• Chronic care management
• High-volume conditions
• High-risk conditions

14
Georgia Cares Quality
Improvement- contd

• Non-clinical Performance Improvement Projects
  mandatorialy required for
• Member satisfaction
• Provider satisfaction
• With one additional project in
• Cultural competence
• Appeals/Grievance/Provider Complaints
• Access/service capacity
• Appointment availability

15
Georgia Cares Other Quality
Measures

• At least 3 evidence-based clinical practice
  guidelines
• At least 2 focused studies each year
• Patient Safety Plan
• External Quality Review

16
Georgia Cares Other
Requirements

• Limitation on market share by each plan, by
  region
• 40-50 in Atlanta region, depending on final
  number of plans
• 65 in other regions
• Stringent information systems requirement
• Financial solvency requirements in addition to
  the Department of Insurance required cash
  reserves
• Re-insurance
• Payment Bond
• Irrevocable Letter of Credit

17
Georgia Cares Stakeholder
Concerns

• DCH has been responsive to the needs and concerns
  as shared by our key stakeholders

18
Georgia Cares

• Questions Comments