REQUEST FOR PROPOSAL (RFP)

Quality Improvement Organization Services for Iowa Medicaid
MED-25-002

Pauline Rutherford
321 E 12th Street
Des Moines, IA 50319
Phone:  515-414-6613
RFPMED-25-002@dhs.state.ia.us

RFP Purpose.
The purpose of this Request for Proposal (RFP) is to solicit proposals that will enable the Iowa Department of Health and Human Services (Agency) to select the most qualified contractor to conduct Quality Improvement Organization functions and other related activities for the Iowa Medicaid program. 

In addition, through this procurement, the Agency seeks to achieve the following outcome and key objectives: 
Outcome: Implement quality improvement efforts and initiatives within the scope of work leading to improved health measures for Iowa Medicaid members. 
Key Objectives: 
1.	Provide medical and Long Term Services and Supports (LTSS).
2.	Provide quality oversight for Home and Community Based Services (HCBS), Money Follows the Person (MFP), and Habilitation programs. 
3.	Implement population health improvement special projects. 
4.	Provide project management and administrative support. 

In this effort, the Agency seeks vendors who will bring strategic solutions, processes, and business operations which can operate within the Agency's culture of continuous process improvement and proactive analysis. The goal of which is to support activities that lead to better health and performance outcomes for the program and effective oversight of the various delivery systems, including managed care. 

Duration of Contract.
The Agency anticipates executing a contract that will have an initial 2-year contract term with the ability to extend the contract for 4 additional 1-year terms. The Agency will have the sole discretion to extend the contract.  

Bidder Eligibility Requirements.
The Agency will accept proposals from bidders that are federally designated Quality Improvement Organization (QIO) or QIO-like entities. See Section 1.1, Background, for further information on this requirement. See Section 3.2.3.1.3 for documentation requirement. 

Procurement Timetable	
There are no exceptions to any deadlines for the Bidder; however, the Agency reserves the right to change the dates.  Times provided are in Central Time.

Event_Date_
Agency Issues RFP Notice to Targeted Small Business Website (48 hours):	November 2, 2023	
Agency Issues RFP to Bid Opportunities Website	November 4, 2023	
Bidder Letter of Intent to Bid Due By 	November 27, 2023	
Bidder Round One Written Questions Due By	November 27, 2023 by 3pm	
Agency Responses to Round One Questions Issued By	December 11, 2023	
Bidder Round Two Written Questions Due By	January 3, 2024 by 3pm	
Agency Responses to Round Two Questions Issued By	January 17, 2024	
Bidder Proposals and any Amendments to Proposals Due By	February 5, 2024 by 3pm 	
Agency Announces Apparent Successful Bidder/Notice of Intent to Award 	March 29, 2024	
Contract Negotiations and Execution of the Contract Completed 	May 1, 2024	
Anticipated Start Date for the Provision of Services	July 1, 2024	

Section 1  Background and Scope of Work	

1.1  Background.

Legal Authority
Section 1902(a)(30)(A) of the Social Security Act (the Act) requires that state Medicaid agencies provide methods and procedures to safeguard against unnecessary utilization of care and services and to assure “efficiency, economy and quality of care.” Under Section 1902(d), a state can contract with a QIO or QIO-like entity to perform medical and utilization review functions required by law. Section 1903(a)(3)(C) of the Act specifies that 75% Federal Financial Participation is available for state expenditures for the performance of medical and utilization reviews by a QIO, or by an entity, which meets the requirements of section 1152 of the Act (i.e., “QIO-like entity”).  

Also, pursuant to 42 C.F.R. § 456 and 42 C.F.R. § 456.2, a state plan may provide for the review of Medicaid services through a contract with a QIO. Pursuant to 42 CFR 433.15(b)(6)(i), 75% Federal Financial Participation is available for state expenditures for the performance of medical and utilization review activities. 

Overview
The Iowa Department of Health and Human Services (HHS) is the single state entity responsible for administering the Medicaid program in Iowa. The Iowa Medicaid Program reimburses providers for delivery of services to eligible Medicaid recipients under the authority of Title XIX of the Social Security Act through enrolled providers and health plans. The Agency operates this program through its Medicaid division. The Medicaid division also operates the Children’s Health Insurance Program (CHIP – the separate CHIP program is called Healthy and Well Kids in Iowa, or Hawki). 

On April 1, 2016, Iowa Medicaid transitioned to a managed care system.  As a result of this transition the model for service delivery and reimbursement changed from a primarily Fee-for-Service (FFS) model to a risk based Managed Care Organization (MCO) model. The majority of services are included in this statewide managed care structure, including long-term services and supports (LTSS), behavioral health, and pharmacy. Approximately 96% of all Iowa Medicaid Members are enrolled in an MCO with 4% remaining in FFS.  Iowa’s Hawki population is served by the same Medicaid MCOs and included in the total MCO population. 

There are four Iowa Medicaid coverage groups and corresponding programs: Managed Care, Medicaid Fee-for-Service (FFS), Program of All-Inclusive Care for the Elderly (PACE), and Hawki. Information regarding these programs is found at this link: https://hhs.iowa.gov/sites/default/files/Comm020.pdf. Please note, the data presented in the link focuses on Medicaid FFS programs. Most of the Agency’s FFS population either falls into a premium payment coverage group or into a historically exempt population.  The Agency provides dental benefits for all adult enrollees through the Dental Wellness program, delivered via prepaid ambulatory health plans (PAHPs). Beginning July 1, 2021, the Agency moved all Medicaid FFS children to PAHPs for dental coverage. 

Iowa Medicaid Coverage Groups and Corresponding Programs 
There are three Iowa Medicaid coverage groups and corresponding programs: IA Health Link; Medicaid Fee-for-Service (FFS); and Hawki. Information regarding these programs is found at: https://hhs.iowa.gov/sites/default/files/Comm020.pdf.  Please note, the data presented in the link focuses on Medicaid FFS programs. Most of the Agency’s FFS population either falls into a premium payment coverage group or into an historically exempt population. 

Table 1: Current Iowa Medicaid Population Structure 
Eligibility Group	March 2023 Enrollment	Average Monthly Claims Processed *	Delivery System	
IA Health Link
(including Hawki)	Medicaid   787,757	2,500,000 **	MCOs	
	Hawki         45,446			
FFS Medicaid	50,689	122,424	Agency	
FFS Dental	11,008	430	Agency	
Dental Wellness	796,134	52,350	PAHPs	
Hawki Dental (including dental-only)	52,762	6,890 	PAHP	

*Based on claims processed from July 2022 through March 2023 (9 months).
**MCO claim counts include all Medicaid and Hawki member counts combined.

On July 1, 2017, the Agency combined dental benefits for all adult Enrolled Members into 1 Dental Wellness Plan (DWP), delivered via prepaid ambulatory plans (PAHPs). In addition, the Agency provided children’s dental coverage through various packages. Medicaid children under the age of 19 received comprehensive dental coverage on an FFS basis and Hawki children received dental coverage through a PAHP. Hawki also included a dental-only program for children with third-party liability (TPL) coverage.  

Effective July 1, 2021, all Medicaid children under the age of 19 transitioned from the previous dental fee-for-service delivery system and began receiving dental benefits through the currently contracted PAHPs. The Agency worked to enroll children in PAHPs to better coordinate dental care for children and help promote oral health in an accessible and cost-effective manner. The Agency currently contracts with 2 PAHPs to deliver dental benefits. These current contracts can be found at this link: https://hhs.iowa.gov/ime/contracts/resource-library/dental. 

In May of 2023, HHS released a dental RFP seeking innovative strategies that would improve efficiencies, cost effectiveness, and establish greater network. This requires awardees to build stability for members and providers by coordinating and integrating care, improve the quality of services outcomes and efficiencies across the healthcare delivery system, and decrease costs through the reduction of unnecessary, inappropriate, and duplicative services.  The notice of intent to award is planned for November 1, 2023. 

The Agency is engaged in a community-based services redesign project that has the potential to significantly change the current LTSS landscape. The Hope and Opportunity in Many Environments (HOME) Project aims to improve Medicaid mental health and disability services. The goal is to ensure that everyone has fair access to high-quality behavioral health, disability, and aging services in their communities. To achieve this, the Agency collaborated with Mathematica and The Harkin Institute. They conducted an evaluation of community-based services and published a Final Evaluation Report (link: Recommendations for Strengthening Iowa’s Community-Based Services System. Final Evaluation Report) in early 2023. The report provides recommendations on how Iowa can improve these services. Based on the recommendations, the Agency created a Transformation Plan (link: Iowa Program Evaluation of Community-based Services) to guide the next steps and implement the suggested improvements. 

Table 2: Current Iowa Medicaid HCBS Program Enrollment 
HCBS Program	March 2023 Managed Care Enrollment	March 2023 FFS Enrollment	
AIDS-HIV Waiver	34	1	
Brain Injury Waiver	1284	148	
Children’s Mental Health Waiver	1185	45	
Elderly Waiver	7612	38	
Habilitation Program	6648	86	
Health and Disability Waiver	1946	316	
Hospice Program	857	1	
Intellectual Disability Waiver	11457	620	
MFP Program	156	2	
PACE Program	0	654	
Physical Disability Waiver	985	4	

Current Agency Environment 
Iowa Medicaid is a collaboration of third-party professional and system services contractors and Agency staff.  The Agency’s Medicaid staff consists of 96 employees. Agency staff provide program and policy guidance, oversight, and contract monitoring to ensure access, cost effectiveness, and quality. To support the Iowa Medicaid structure, the Agency’s contractors execute the majority of the Medicaid program business functions under a performance-based structure. 

Iowa Medicaid currently has Core MMIS, Pharmacy Point of Sale (POS) and Program Integrity (SURS) vendors who provide what CMS would consider a system or sub-system of Iowa Medicaid. At the core of the Iowa Medicaid is its MMIS, a mainframe application hosted within the state’s data center, used primarily for batch processing claims and processing various file updates. The Iowa Medicaid MMIS is built around subsystems that organize and control the data files used to process claims and provide reports. The MMIS contains standard subsystems such as:  Recipient, Provider, Claims, Reference, Management and Administrative Reporting (MAR), Managed Care and Third-Party Liability (TPL), as well as the supporting Medically Needy and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) subsystems. The Core MMIS contractor provides, per contractual requirements, an Electronic Data Interchange (EDI) system and support services, and imaging/scanning solutions.  
Additionally, the Agency leverages systems and applications to provide automated access to and/or support for information within the MMIS and Agency business processes.  These systems are internally developed and hosted within the State’s data center by the Agency’s Division of Information Technology (DoIT).  They include:
•	Data Warehouse/Decision Support (DW/DS) system provides data analysis and decision -making capabilities and access to information, including online access to flexible, user-friendly reporting, analysis, and modeling functions.  Agency staff and contractors use the DW/DS system while DoIT provides technical support and assistance in developing queries and reports to fulfill the analytical needs for Iowa Medicaid.  The DW/DS system provides Iowa Medicaid users with the flexibility to produce reporting without MMIS reprogramming in acceptable formats that do not require manual intervention or data manipulation.  The DW/DS system also maintains the most recent 10 years of claims data from the MMIS.  The DW/DS system’s relational database includes the full claim record for adjudicated claims and other Member, provider, reference, prior authorization, and encounter data from the MMIS.

•	Eligibility Verification Information System (ELVS) performs three primary request and response functions for providers and other authorized users:  
o	Recipient eligibility request and response; 
o	Claims status request and response; and 
o	Provider summary request and response.
The system contains a telephone voice and touch-tone response component and a web portal.

•	Institutional and Waiver Authorization and Narrative System (IoWANS) is the Agency home and Community Based Services (HCBS) workflow and slot management system.  It assists workers in the facility, HCBS waiver, and targeted case management programs in both processing and tracking applications and authorizations through approval or denial.The IoWANS application is currently used by Income Maintenance Workers (IMWs), case managers, Quality Improvement Oversight (QIO) contractor staff, child health specialty clinics, transition specialists, financial management service authorization staff, Member and provider customer service representatives, and Agency policy staff.  It provides authorized users workflows and access to information about a Member.  IoWANS also retains data on provider types and the services they are allowed.

•	Iowa Medicaid Electronic Records Systems (I-MERS) is a web-based tool that allows treating providers electronic access to up-to-date information about all claims submitted to Iowa Medicaid for all current eligible Medicaid Members.  It is used by treating providers to access critical claim information for medical procedures, and other medical care that eligible Medicaid Members have received.  I-MERS also assists providers in caring for Members, coordinating their care, reducing costly duplicated services, and assisting in maintaining high quality care for Medical Members.

•	Iowa Medicaid Portal Access System (IMPA) provides access to a wide range of business functions from viewing and downloading remittance advices to uploading documents for provider reenrollment and critical incident reporting.  Managed Care Organizations and Iowa Medicaid Member Services use IMPA to view eligibility, enrollment, and LTSS information that is specific to a Member.  The source of this data originates from OnBase, Iowa Automated Benefits Calculation (IABC), DW/DS, and Worker Information System Exchange (WISE).

•	Medicare buy-in (Buy-In) system displays Medicare Parts A and B buy-in information and history.

•	Premium Payment System (PPS) creates invoices for billing and processes payments received from Members.  Member Services uses the system to assist Members who inquire about payments and apply for hardships as needed.

•	Title XIX system is primarily a translator for the MMIS, transforming data from other medical systems into a consumable format for the MMIS.  Moreover, TXIX acts as a part of the eligibility enrollment process by choosing the most advantageous plan for new Members.  TXIX captures eligibility data from the Eligibility Integrated Application Solution (ELIAS), Medicaid Presumptive Eligibility Portal (MPEP), Family Planning Program (FPP), and IABC systems, runs through a hierarchy, and then sends it to MMIS.

A summary of professional and system services contracts and their primary business functions is below: 
Table 3: Iowa Medicaid Primary Business Functions  
Contract	Business Functions	
Member Management, Consumer Assistance, and Eligibility Help Desk Services 
(including Member Services and HHS Contact Center)	•	Member Enrollment/ Enrollment Broker 
•	Member, DHS Contact, and Hawki Call Centers
•	Member Outreach and Communications
•	Escalated MCO Issues	•	Application and Renewal Assistance 
•	Support ELIAS Level 1 Help Desk/Ticketing
•	Consumer Assistance for Program Eligibility Requirements	
Program Integrity 	•	PI System and Database
•	Data Analytics and Program Analysis 
•	Surveillance and Utilization Review
•	Encounter Data Quality
•	MCO Oversight
•	PERM Project	•	Medical Necessity Reviews, Audits, and Payment Recovery 
•	Referrals to Department of Inspections, Appeals, and Labor (DIAL) 
•	CHIPRA and Adult Medicaid Quality Measure Reporting
•	Ad Hoc Reports 	
Provider Cost Audit and Rate Setting Services	•	Provider Cost Audits
•	Provider, Nursing Facility, and LTC Rate Setting	•	Provider Cost Settlements 
•	Drug Pricing and Pharmacy Reimbursement Methodologies	
Provider Services	•	Provider Cost Audits
•	Provider, Nursing Facility, and LTC Rate Setting	•	Provider Cost Settlements 
•	Drug Pricing and Pharmacy Reimbursement Methodologies	
Quality Improvement Organization Services 
(including Medical Services and HCBS QA)	•	Medical Support
•	Utilization Management
•	Claims Pre-Payment Review	•	HCBS Quality Oversight
•	Project management and administrative support 	
Revenue Collections and Estate Recovery Services	•	Third Party Liability Recovery
•	Pay and Chase
•	Yield Management
•	Provider Overpayment and Credit Balance Recovery
•	Hawki Data Match	•	Estate Recovery Services
•	Provider Withholds and Tax Offsets
•	Stale Dated Checks
•	Bank Deposits
•	MCO Come-Behind Recoveries	
Core MMIS Services	•	FFS Claims Processing
•	MMIS Support
•	EDI Services
•	Capitation Payment Processing for MCO, Dental Wellness, Hawki and NEMT  	•	Imaging 
•	Workflow and Document Management
•	Mailroom and Courier Services
•	Spend-down	
Pharmacy Point-of-Sale System & Pharmacy Medical Services 	•	Pharmacy Claims Adjudication (FFS & MCO)
•	Retro Drug Utilization Review (FFS administrates & MCOs participate)
•	Pharmacy Prior Authorization (FFS & MCO)	•	Preferred Drug List (PDL) and Supplemental Rebate Program (FFS)
•	Rebate Services: Invoice rebates for all claims (Pharmacy, Medical, FFS, & MCO)	
Ancillary DDM Systems 
(these are State, not contracted, systems, but including here to show the Medicaid business functions) 	•	Historical MCO Data Retention
•	Historical FFS & Hawki Data Retention
•	Historical Provider Data Retention
•	Maintenance and Assistance Status/Basis of Eligibility
•	Data Marts 	•	Historical Member Data Retention 
•	Agency Data Quality Measures
•	Agency Data Quality Standards
•	Other Federal Reporting 
•	Premium Payments (including Hawki)	

Agency Mission and Vision 
Iowa Medicaid’s mission is: Iowa Medicaid is committed to ensuring that all members have equitable access to high quality services that promote dignity, barriers are removed to increase health engagement, and whole person health is improved across populations. Iowa Medicaid’s vision is: Iowa Medicaid works diligently to operate a fiscally responsible and sustainable program that improves the lives of its members through effective internal and external collaboration, innovative solutions to identified challenges, and data driven program improvement. 

Department of Justice (DOJ) Consent Decree and Children’s Mental Health (CMH) Class Action Lawsuit 

In 2019, the Department of Justice began an investigation at Glenwood Resource Center in Glenwood, Iowa. The investigation resulted in findings that the State of Iowa has relied too heavily on institutions to meet the needs of persons with intellectual disabilities. The Agency is currently involved in negotiations to finalize a Consent Decree outlining specific actions the Agency must take to increase home and community-based supports and services.  

In 2022, a class action lawsuit was filed alleging that the Agency has not met the needs of Iowa children with mental health needs. In 2023, a settlement was reached outlining systematic changes that the Agency will engage in to improve access to children’s mental health services. 

Planning for systemic and policy changes that address the needs of people with disabilities are in development through the HOME Project and other Agency efforts. Resulting from these efforts, the Agency reserves the right to amend the Scope of Work and/or the resulting contract to support the requirements of the DOJ Consent Decree and the CMH settlement. The resulting changes would be handled through negotiation and potential amendments that may include both a revised Scope of Work and budget. 

1.2  RFP General Definitions.  
When appearing as capitalized terms in this RFP, including attachments, the following quoted terms (and the plural thereof, when appropriate) have the meanings set forth in this section.

“Agency” means the Iowa Department of Health and Human Services.  

“Bid Proposal” or “Proposal” means the Bidder’s proposal submitted in response to the RFP.  

“Bidder” means the entity that submits a Bid Proposal in response to this RFP.

“Contractor” means the Bidder who enters into a Contract as a result of this Solicitation.

“Deliverables” means all of the services, goods, products, work, work product, data (including data collected on behalf of the Agency), items, materials and property to be created, developed, produced, delivered, performed, or provided by or on behalf of, or made available through, the Contractor (or any agent, contractor or subcontractor of the Contractor) in connection with any contract resulting from this RFP.

“Invoice” means a Contractor’s claim for payment.  At the Agency’s discretion, claims may be submitted on an original invoice from the Contractor or may be submitted on a claim form accepted by the Agency, such as a General Accounting Expenditure (GAX) form.

Definitions Specific to this RFP. 
When appearing as capitalized terms in this RFP, including attachments, the following quoted terms (and the plural thereof, when appropriate) have the meanings set forth in this section.

“Business Hours” means 8:00 AM thru 5:00 PM Central Time, Monday through Friday, excluding state holidays.
 
“Centers for Medicare and Medicaid Services” or “CMS” is part of the U.S. Department of Health and Human Services. CMS oversees Medicare and Medicaid, as well as many other federal healthcare programs, including those that involve Health Information Technology such as the meaningful use incentive program for electronic health records (EHR). In addition to Medicare and Medicaid, CMS administers the Children's Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and key portions of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) law. 

“Consumer Choices Option” or “CCO” is an option available under the Home and Community Based Services waivers that gives Members control over a targeted amount of Medicaid dollars so that they may develop a plan to meet their needs by directly hiring employees and/or purchasing other goods and services.

“Health Home” is a team of professionals working together to provide whole-person, patient-centered, coordinated care for certain Medicaid populations. Programs that currently fall under Health Home are:

“Chronic Condition Health Home” is for individuals who have two chronic conditions or one chronic condition and are at risk for a second chronic condition from the following list:
o	High Blood Pressure
o	Obesity
o	Heart Disease
o	Diabetes	o	Substance Abuse
o	Asthma
o	Mental Health Needs	

“Integrated Health Home” or “IHH” is for adults with a serious mental illness (SMI) and children with a serious emotional disturbance (SED). The Integrated Health Home is administered by the Medicaid Managed Care Organizations and provided by community-based Integrated Health Homes. 

“Home and Community-based Services (HCBS) Programs are for people with disabilities and older Iowans who need services to allow them to stay in their home and community instead of going to an institution. LTSS are delivered through seven 1915(c) waiver programs and five non-waiver programs. More information can be found at this link: http://dhs.iowa.gov/ime/members/medicaid-a-to-z/hcbs. 

HCBS Waiver Programs. Under HCBS waiver programs, Iowa can waive certain Medicaid program requirements, allowing the state to provide care for people who might not otherwise be eligible under Medicaid. Through the following 1915(c) waivers, Iowa targets services to people who need LTSS: 
o	AIDS/HIV
o	Brain Injury
o	Children’s Mental Health
o	Elderly	o	Health and Disability
o	Intellectual Disability
o	Physical Disability	
 
HCBS Non-waiver Programs include:
•	Habilitation Services – State Plan 1915(i) program
•	Home Health program (including EPSDT private duty nursing/personal cares)
•	Hospice program
•	Money Follows the Person (MFP) program
•	Program of All-inclusive Care for the Elderly (PACE) program

“ICF/ID” means Intermediate Care Facility for persons with Intellectual Disability. 

“Iowa Medicaid Bureaus” means the operating units withing the Iowa Medicaid that serve as the policy subject matter experts for Iowa Medicaid program business functions.

“Iowa Medicaid Units” are the professional and system services contractors within the Iowa Medicaid that perform the majority of Iowa Medicaid program business functions under performance-based contracts.

“IoWANS” is Institutional and Waiver Authorization and Narrative System

“Level of Care” or “LOC” is the medically necessary care needed for a Member, based on criteria established in Iowa Administrative Code.

“Long Term Services and Supports” or “LTSS” are services and supports used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals, and administering medications.

“Managed care organization” or “MCO” means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” in Iowa Code section 514B.1. 

“Managed care plan” or “MCP” refers to managed care organizations (MCOs) and prepaid ambulatory health plans (PAHPs).

“Member” means an individual enrolled in Iowa’s Medicaid, or CHIP (Hawki) Programs. 

“Minimum Data Set” or “MDS” is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS information is transmitted electronically by nursing homes to the national MDS database at CMS. 

“National Correct Coding Initiative” or “NCCI” is a CMS program that consists of coding policies and edits. Providers report procedures/services performed on beneficiaries utilizing Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes. These codes are submitted on claim forms. NCCI policies and edits address procedures / services performed by the same provider for the same beneficiary on the same date of service. The coding policies of NCCI are based on coding conventions defined in the American Medical Association’s Current Procedural Terminology Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice.

“PACE” or “Program of All-inclusive Care for the Elderly” is a program that provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits. An interdisciplinary team of health professionals provides PACE participants with coordinated care. 

“Payment Error Rate Measurement” or “PERM” is a CMS program that measures improper payments in Medicaid and CHIP and produces error rates for each program.  The error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the federal fiscal year (FFY) under review. CMS audits Iowa every three years.

“Resource Utilization Group” or “RUG” means any of a number of classifications into which a nursing facility resident is categorized, based on functional status and anticipated use of services and resources. RUGs are assigned to individuals based on data elements derived from the Minimum Data Set (MDS) that in turn generate a case mix score used in the calculation of facility payment.

1.3 Scope of Work. 
1.3.1 Deliverables.
The Contractor shall provide the following:  

1.3.1.1 General Obligations
A.	Staffing.  
1.	The Contractor shall designate individuals as “key personnel” and as appropriate and when required, these positions shall interface with the state leadership, program staff, providers, and other stakeholders. Personnel obtained for the key positions below are subject to Agency’s review and approval. Special requirements for key personnel are as follows:
a.	Account Manager.  Responsible for the overall service delivery of the team, complying with contractual requirements and meeting the Agency’s expectations. The Account Manager shall be responsible for Contract compliance and general project oversight. The Account Manager must adopt an exemplary behavior; and collaborate, cultivate, and promote the spirit of trust and professionalism with the Agency, other Iowa Medicaid Units, and stakeholders. The Account Manager shall represent the Contractor and be the primary liaison with the Agency. Minimum qualifications include:
i.	Three years of experience in account management or major supervisory role for government or in the private sector as a healthcare payer or provider.
ii.	Bachelor’s Degree or at least 4 years relevant experience to the position. 
iii.	Previous management experience with Medicaid, specifically Medicaid managed care, LTSS, medical services, behavioral health, utilization management, coding and billing, and knowledge of HIPAA rules and requirements, is desired. 
b.	Transition Manager. Responsible for facilitating all planning and operational readiness activities necessary to ensure a successful transition. This position will no longer be required once the Contractor has successfully transitioned to operations. The Transition Manager may also serve as the Account or Operations Manager. Minimum qualifications include:
i.	Three years of experience in account management or major supervisory role for government or in the private sector as a healthcare payer or provider.
ii.	Bachelor’s Degree or equivalent relevant experience to the position.
c.	LTSS Operations Manager. Responsible for day-to-day project management and supervision. Minimum qualifications include:
i.	Four years of experience managing a major component of a healthcare operation in an environment similar in scope and volume to the Iowa Medicaid Program. The experience shall include LTSS, utilization management, behavioral health, Medicaid managed care, Medicare dual eligibles, Indian Health Services, and quality management. 
ii.	Bachelor’s Degree or equivalent relevant experience to the position.
d.	HCBS Quality Oversight Operations Manager. Responsible for day-to-day project management and supervision. Minimum qualifications include:
i.	Four years of experience managing a major component of a healthcare operation in an environment similar in scope and volume to the Iowa Medicaid Program. The experience shall include HCBS quality control and outcomes, federal requirements for HCBS waiver programs, and provider relations. 
ii.	Bachelor’s Degree or equivalent relevant experience to the position.
e.	Clinical Manager. Responsible for day-to-day project management and supervision. Minimum qualifications include: 
i.	Four years of experience managing a major component of healthcare operation in an environment similar in scope and volume to the Iowa Medicaid Program. 
ii.	Registered Nurse licensed in the State of Iowa preferred. 
f.	Medicaid Medical Director (MMD). Responsible for ensuring medical oversight of QIO professional staff, overall leadership related to all medical facets that may affect the Medicaid Program, and helping the Iowa Medicaid program deliver value-driven, high-quality, cost-effective health care in an efficient manner. The MMD shall participate in the Medicaid Medical Directors Learning Network (MMDLN), the Iowa Medicaid quality committee, the Pharmacy and Therapeutics (P&T) and Drug Utilization Review (DUR) committees, and other state and national committees as requested by the Agency, chair the Clinical Advisory Committees, and provide input in the review of Medicaid policies and procedures. The Medical Director plays an important role in continuous quality improvement and the implementation of policy for an efficient Medicaid Program. The MMD shall collaborate with the Medicaid Director, MCO chief medical officers, and policy staff to ensure clinical policies and procedures are implemented consistently throughout the entire delivery system. The Agency may hire a state MMD in the future. Should that occur, the role of the QIO position will be revised. Minimum qualifications include:
i.	Four years of experience as a managing physician in a managed care environment as either an MD or DO. 
g.	Key Project Personnel for Population Health Improvement Special Projects, as identified within Contract Section 1.3.1.5.
2.	Named key personnel shall:
a.	Be committed to the project full time and co-located with Agency staff at the Iowa Medicaid permanent facility in Des Moines, Iowa. The Agency will allow flexibility with staff working from home and on-site, subject to the Agency-approved remote work policy.  
b.	Be available during normal Business Hours to respond to questions and concerns related to the Contract, except for routine absences or participation in required off-site meetings. Account Manager and Operations Manager positions are required to communicate absences with the Agency contract manager and provide suitable coverage during extended absences;
c.	Must comply with the remote work policy as defined by the Agency; 
d.	Provide policy advice and support to the Agency and participate in meetings with the Agency as subject matter experts;
e.	Prepare and present status updates to the Agency and other stakeholders, as requested by the Agency;
f.	Comply with all timelines in the Agency-approved project work plans; and
g.	Develop and maintain a plan for job rotation and knowledge transfer to ensure that all functions can be adequately performed during the absence of key personnel for vacation and other reasons.  Any planned absences of key personnel shall be immediately communicated to the Agency per established communication process. The Contractor shall ensure staff are trained and able to perform the functions of sensitive positions when the primary staff member is absent.
3.	The Agency reserves the right of prior approval for any replacement of the key personnel:
a.	The Contractor must commit named key personnel to the project on or before the conclusion of the transition period of the Contract and for at least six months, and must not replace key personnel during this period except in cases of termination, death, or the key person’s resignation. 
b.	The Contractor shall provide the Agency with a minimum of 15 days’ notice prior to any proposed transfer or replacement of named key personnel. At the time of providing notice, the Contractor shall also provide the Agency with the resumes and references of the proposed replacement of named key personnel; 
c.	Replacement personnel must be in place performing their new functions before the departure of the personnel they are replacing; 
d.	Replacement personnel shall have knowledge transfer, experience, and ability comparable to the person originally in the position; and
e.	When it is not possible to have replacement personnel in place prior to the departure of the personnel they are replacing, the Contractor commits to replacing key personnel within thirty days (30) of the departure of a key person and to providing temporary personnel in the interim that are capable of maintaining operational performance at acceptable levels.
4.	The Contractor shall retain, on staff or in a consulting capacity, medical and social service professionals and other fields as deemed necessary by the Agency in order to perform Contractor duties identified within the Contract. Contractor staff and/or consultants shall be knowledgeable about the Iowa Medicaid Program's policies and procedures regarding coverage and limitations. These professionals shall provide consultation to the Agency in the following areas at a minimum:
a.	Anesthesiology
b.	Audiology
c.	Brain injury
d.	Behavioral health
e.	Cardiovascular, vascular, and thoracic surgery
f.	Child psychiatry
g.	Chiropractic services
h.	Dentistry
i.	Developmental disability services (such as autism spectrum, cerebral palsy, intellectual disability, and similar conditions)
j.	Disability services
k.	Durable medical equipment
l.	Geriatrics
m.	Family practice
n.	Hematology
o.	Medical supplies and equipment
p.	Neurology
q.	Obstetrics/gynecology
r.	Occupational therapy
s.	Oncology
t.	Ophthalmology
u.	Optical
v.	Optometry
w.	Organ transplant services
x.	Orthodontics
y.	Pathology
z.	Pediatrics
aa.	Pharmacy
bb.	Physical medicine
cc.	Plastic surgery
dd.	Podiatry
ee.	Psychiatry
ff.	Psychology
gg.	Radiology and nuclear medicine
hh.	Rehabilitation (physical therapy, occupational therapy and speech therapy)
ii.	Speech pathology
jj.	Substance use
5.	The Contractor shall also provide the following non-managerial positions:
a.	Claims and coding staff qualified to provide technical assistance and support to the Agency, providers, and MCOs; and 
b.	Quality assurance/quality control staff with experience developing, executing and reporting formal quality assurance plans.
6.	The Contractor shall ensure that all staff, whether they are employees, agents, subcontractors or anyone acting for or on behalf of Contractor, are properly licensed, certified or accredited as required under applicable state law and/or Iowa Administrative Code. Contractor shall establish standards, subject to Agency approval, for service providers who are not otherwise required to be licensed, certified or accredited under State law and/or Iowa Administrative Code.
The Contractor shall ensure that staff directly associated with the provision of Contract services are available to collaborate with Agency staff, as needed. As part of the Contract agreement the Agency will not require all Contractor non-managerial staff be housed at the Iowa Medicaid facility. The Agency will allow flexibility with staff working remotely, hybrid, and on-site, subject to Agency approval. See Special Contract Attachment H. 
B.	System and Software Requirements 
1.	The Contractor shall utilize and maintain systems and software listed in Attachment H, as necessary, to support all QIO functions.
2.	The Contractor shall provide sufficient staff to maintain and update code as necessary for current MQUIDS and QPS applications hosted by the Agency. The applications are deployed in a 3-tier configuration:
a.	Client components are installed on the user system, along with the executable application and its associated libraries;
b.	Application server components are hosted in Internet Information Services (IIS) running on Windows 2008 server and .NET Framework; and
c.	SQL end database.
3.	The Contractor shall maintain all current program information within the Agency's computer network.

C.	Receipt of Checks
1.	In the event that the Contractor receive checks or money orders related to the work that it performs, the Contractor shall deliver them to the Agency’s mailroom secure area for Revenue Collections contractor to collect and deposit.
 
D.	Appeals and Hearings   
1.	The Contractor shall provide administrative assistance to the Agency in tracking and assigning all Iowa Medicaid appeals related to the FFS population, as well as any appeals the Iowa Medicaid may receive of MCO decisions, utilizing protocols and timeframes determined by the Agency. 
2.	The Contractor shall submit a report of all Iowa Medicaid appeal hearings to the Agency on a quarterly basis. This includes but is not limited to:
a.	Status;
b.	Disposition of case; 
c.	Analysis of appeal trends and recommendations for policy changes identified from appeals; 
d.	Breakout analysis of appeal hearings for Level of Care and needs based assessment determinations and PAs, with fiscal year-to-date totals, analysis of trends, recommendations for improvements (including internal quality improvements); and
e.	The Contractor shall complete an Agency provided appeals and grievance template to document FFS population appeals hearings for the Iowa Medicaid dashboard. 
3.	The Contractor shall provide medical expertise and necessary assistance in any stage of the appeal process concerning Contractor’s findings that result in an appeal, including but not limited to:  
a.	Research issues as necessary;
b.	Provide administrative support in preparing for and representing the Agency in appeals;
c.	Provide written statements; 
d.	Provide expert testimony where appropriate to defend Agency decisions; and
e.	Review ALJ decisions to determine if a Director’s review of reversed decision is warranted. If warranted, prepare documentation for Director’s review and submit within 10 days of receipt of the ALJ decision.
 
E.	Quality Improvement and MCO Quality Oversight
1.	The Contractor shall implement quality improvement procedures that are based on proactive improvements rather than retroactive responses. The Contractor must understand the nature of and participate in quality improvement procedures that may occur in response to critical situations and shall assist in the planning and implementation of quality improvement procedures based on proactive improvement. Duties include but are not limited to:
a.	Monitor the quality and accuracy of the Contractor’s own work.
b.	Perform continuous workflow analysis to improve performance of Contractor functions and submit quarterly reports of the quality assurance activities, findings and corrective actions (if any) to the Agency electronically.
c.	Provide the Agency with a description of any changes to the workflow for approval prior to implementation.
2.	The Contractor shall provide data to inform current or future internal and external Iowa Medicaid dashboards. 
a.	Validate current lists of diagnosis and CPT codes being used in templates that support dashboards. 
b.	Create documentation that simplifies and streamlines requests for diagnosis and CPT codes.
3.	MCO Quality Oversight. In accordance with CMS Special Terms and Conditions for Iowa's 1915(b) Waiver, the Contractor shall: 
a.	LTSS Care Plan Review. Duties include but are not limited to:
i.	Review a representative sample of LTSS plans of care that includes a reduction, suspension, or termination in services for the first year. 
ii.	Receive a monthly service plan reduction report from each of the MCOs documenting any reductions they have made in the past month; 
iii.	Request additional information from a representative sample of these service plan reductions; 
iv.	Review the information provided for these service plan reductions to see if the rationale for reduction provided by the MCOs is consistent with the MCOs documentation and permissible under federal and state laws as well as the terms of the contract; and
v.	Report findings to the Agency on a monthly basis.
b.	MCO Interdisciplinary Team (IDT) Ride Alongs. To ensure that MCO IDTs follow a person-centered process, are individualized to address Member-specific needs, and result in person-centered service plans based on historical information and future desires and outcomes. Ride Alongs shall be conducted at a rate that is statistically valid and agreed upon by the Agency. If the number or percentage of Ride Alongs is anticipated to increase, the Agency will provide the Contractor 60 calendar days notice. Contractor duties include but are not limited to:
i.	Ensure a representative sample of Waiver and Habilitation Case Managers from each MCO is interviewed each quarter at a 95% confidence level;
ii.	Observe the service planning process during the IDT meetings;
iii.	Record observations on Agency-approved forms; 
iv.	Provide training and support to the IDT in the moment; 
v.	Provide recommendations to the Agency for quality improvement and/or corrective actions addressing areas of noncompliance; and
vi.	Report findings to the Agency on a monthly basis.

F.	Performance Reporting and Corrective Actions 
1.	The Contractor shall submit monthly performance reports using an Agency-approved format, similar to the sample in Attachment J, detailing all deliverables and performance measures that have been met or unmet during the month. This report shall be submitted with the monthly invoice.
2.	The Contractor shall provide written notification to the Agency within two business days of discovery of any problems, concerns, or issues of non-compliance. 
3.	The Contractor shall maintain records of such reports and other related communications issued in writing during the course of Contract performance.  
4.	The Agency has final authority to approve problem-resolution activities.
5.	The Agency’s acceptance of a problem report shall not relieve the Contractor of any obligation under this Contract or waive any other remedy.  The Agency’s inability to identify the extent of a problem or the extent of damages incurred because of a problem shall not act as a waiver of performance or damages under this Contract.  
6.	To the extent that deficiencies are identified in the Contractor’s performance and notwithstanding other remedies available under this Contract, the Agency may require the Contractor to develop and comply with a corrective action plan to resolve the Deficiencies, subject to Agency approval.

G.	Requests for Information 
1.	The Contractor shall respond to Agency requests for information and other requests for assistance within the timeframe that the Agency specifies. The Contractor shall provide information in response to:
a.	Freedom of Information Act (FOIA) requests;
b.	Requests for Information (RFIs) from Iowa Legislators, Ombudsman’s Office, and other state or federal governmental offices.
c.	Open Records Act requests, as required in Iowa Code Chapter 22; and
d.	Miscellaneous requests.
2.	The Contractor shall comply with information protocols and response timeframes as determined by the Agency.

H.	Centralized Email Mailboxes and Toll-free Telephone Lines. 
1.	The Contractor shall manage assigned Agency centralized email mailboxes and toll-free telephone lines for communication with Members, authorized representatives, providers, and facilities necessary to support QIO functions.
2.	The Contractor shall track and log communications within Iowa Medicaid systems.
3.	The Contractor shall monitor the quality and accuracy of the Contractor’s communications in accordance with the Agency-approved quality assurance plan.
4.	The Contractor shall submit a report to the Agency on management of communications, to include timeliness and accuracy of responses, on a quarterly and annual basis.

I.	Branding 
1.	The Contractor shall not reference the Contractor's corporate name in any Deliverables associated with this Contract and shall not mark Deliverables as confidential or proprietary.  

1.3.1.2 Transition 
A.	Planning. The Contractor shall develop, maintain, and comply at all times with the following, subject to Agency approval:
1.	Project work plans to include, but not be limited to: 
a.	A transition plan detailing Contractor’s strategy to implement staff, systems, applications, software, and services contemplated by this Contract; 
b.	An operations plan detailing the daily performance of all required activities by the Contractor, including required coordination and safeguards;
c.	A communications plan specifying expectations for all parties involved. This plan shall be developed in consultation with the Agency;
d.	A quality assurance plan detailing requirements and timeframes for monitoring the quality and accuracy, as well as continuous workflow analysis, of the Contractor’s QIO and MCO oversight functions;
e.	A reporting plan detailing requirements for submitting reports to the Agency. This plan shall be developed in consultation with the Agency. Reporting plan requirements include but are not limited to:
i.	Use of standard naming conventions; 
ii.	Templates for standardized reports that may be necessary to implement the project. The Contractor shall revise report content as needed and upon Agency request;
iii.	Use of the Agency-designated SharePoint site to upload reports, with links sent to relevant Agency staff via email; 
iv.	Detail of whom the reports should be delivered to for review and approval, as necessary;
v.	Any posting requirements for external stakeholders; 
vi.	Frequency and due dates for reports; 
vii.	An Agency report monitoring tool similar to the sample in Attachment I; and
viii.	A monthly performance reporting tool similar to the sample in Attachment J.  
f.	A training plan detailing, at minimum:
i.	Training of Contractor staff in all systems, applications, and software that they will use. 
ii.	Training of Contractor staff on privacy and security policies and procedures to include but not limited to:
a)	Orienting new employees on privacy and security policies and procedures;
b)	Conducting periodic review sessions on privacy and security policies and procedures; and
c)	Developing lists of personnel to be contacted in the event of a potential or suspected security breach;
iii.	Training of Contractor staff in operational procedures required to perform the Contractor’s functions under the Contract.
iv.	Continuous standard operating procedures training process for Contractor staff. At minimum, the Contractor shall train staff when:
a)	New staff or replacement staff are hired;
b)	New policies or procedures are implemented; and
c)	Changes are made to any existing policies or procedures prior to the change’s implementation if possible, and if not, concurrent with the change’s implementation.
v.	Training of Agency employees and other Agency contractors, as requested. Such training shall be at no additional cost to the Agency. Each plan shall generally adhere to the approximate timing and requirements set forth in Section 1.3.1.3 and 1.3.2, to include, at minimum:
a)	Definition of each project activity; 
b)	Sequence of activities; 
c)	Identification of who is responsible for each project activity;
d)	Defined deliverables and outcomes;
e)	Timeframe in which each activity will be completed;
f)	A plan update schedule, which shall include updates no less frequently than quarterly; and
g)	Identification of Agency responsibilities and expectations.
2.	Standard operating procedures (SOPs). 
a.	SOPs shall be maintained in the Agency-prescribed format using standard naming conventions in the documentation. 
b.	SOPs shall document the processes and procedures used by the Contractor in the performance of its obligations under this Contract, including but not limited to:
i.	Notification and issue escalation procedures and timelines; and
ii.	Policy manuals required.
c.	SOPs shall be updated with any changes to the methods and procedures used by the Contractor in the performance of its duties under this Contract. The Contractor shall document all changes within 30 calendar days of the change, subject to Agency approval. 
d.	The Contractor shall use version control to identify the most current documentation and any previous versions, including their effective dates. 
e.	The Contractor shall provide all documentation in electronic form and store all documentation within the Agency-designated repository.
f.	Collaborate with other Iowa Medicaid Units to incorporate information relevant to provider operations on all levels.
g.	Develop and distribute informational letters, emails, and Agency website postings for Iowa Medicaid providers that provide a brief description of changes, as appropriate.
h.	SOPs shall be reviewed with the Agency no less than annually.
3.	The Contractor shall collaborate with the Agency and other Iowa Medicaid Units to maintain and update provider manuals as necessary.    

B.	 Operational Readiness
1.	The incoming Contractor shall prepare for the onset of operations in the existing Agency environment. This includes but is not limited to the following:
a.	Review the turnover plan from the outgoing contractor; 
b.	Utilize the Agency’s comprehensive operational readiness checklist of its start-up activities;
c.	Develop and implement a corrective action plan for all outstanding activities for review and approval by the Agency;
d.	Conduct training for its staff;
e.	Gather and document all Agency technical and operational requirements pertaining to work performed under this Contract;
f.	Produce and update all operations documentation, to include SOPs, and obtain Agency approval of each iteration;
g.	Establish Agency-approved interfaces, as necessary;
h.	Provide the Agency assurance that all checklist activities have been satisfactorily completed and signed-off by the Agency; and
i.	Obtain written approval from the Agency to start operations.
2.	The incoming Contractor shall work proactively with the Agency and the outgoing Contractor to take over the management of any work that remains open when the outgoing contract ends on June 30, 2024, such as Utilization Management activities identified in Contract Section 1.3.1.3 and HCBS Reviews identified in Contract Section 1.3.1.4.

1.3.1.3 Medical and LTSS Operations
A.	Medical Support 
1.	Clinical Support, Technical Assistance, and Consulting. 
The Contractor shall provide consultation on policy development for specific service areas on behalf of the Agency. The Contractor shall have available the requisite medical and professional staff to meet Agency requests for professional advice on individual service requests for all areas of the program as well as recommendations on potential additions or changes to the existing coverage array for Medicaid. 
a.	Provide clinical support to ensure that Iowa Medicaid policy reflects current medical practice in the State. 
b.	Provide the Agency with appropriate medical and professional expertise to evaluation any requests for new or unusual services or treatment modalities. 
c.	Provide clinical expertise to support administrative or court challenges, including coverage decisions. 
d.	Provide technical support to the Agency in responding to program reviews and audits. 
2.	Claims Pre-pay Reviews.
The Contractor shall review FFS claims assigned by the Agency and make decisions on individual service claims that reflect current Iowa Medicaid policy. This includes but is not limited to:
a.	Manually review claims that have been suspended within the MMIS for review to determine medical necessity or appropriateness and take appropriate action to adjudicate the claims; 
b.	Approve payment for all reasonable and necessary medical services and supplies;
c.	Manually price claims when no current fee or payment exists for the service; and
d.	Update Iowa Medicaid data systems to reflect review outcomes. 
3.	Post Pay Medical Necessity Reviews. 
The Contractor shall: 
a.	Conduct post pay medical necessity reviews and other analyses of utilization and appropriateness of care to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine; 
b.	Follow the Agency’s process for initiating and conducting desk, onsite, and self-audit(s); 
c.	Ensure that audit samples are statistically valid based on data informed priorities based upon industry standard algorithm and federal and state trends; 
d.	Track and report its Medical Necessity Review findings to the Agency. Such report shall include, but not be limited to: 
i.	Total number of claims reviewed; 
ii.	Percentage and count of claims validated; 
iii.	Percentage and count of claims denied; 
iv.	Count and dollar amount of identified overpayments with accompanying details for recovery; and 
v.	Initiate overpayment recoveries identified in accordance with SOPs; and  
e.	Ensure documentations support Agency action in the event of an appeal or litigation.  
4.	Inquiries Related to Payable Codes for Provider Claims. 
Upon receipt of provider FFS claims inquiries, the Contractor shall
a.	Review claims information and documentation, requesting additional information if needed; 
b.	Determine whether the service/code is payable; 
c.	Notify the provider of the outcome of the review; and 
d.	If the service/code is payable, the Contractor shall update the appropriate Iowa Medicaid data systems. 
5.	Exceptions to policy (ETP). 
The Contractor shall provide necessary assistance in the FFS ETP process, including but not limited to:
a.	Log, track, and review ETP requests for Iowa Medicaid;
b.	When necessary, request additional information from the requestor;
c.	Consult with Iowa Medicaid policy staff and other Iowa Medicaid units as necessary;
d.	Make recommendations for approval or denial of the request based on Agency policies and procedures, cost-effectiveness, medical necessity, and the availability of lower cost alternatives;
e.	Prepare response letters for approval by policy staff and the Medicaid Director and signature by the HHS Director; 
f.	Submit a report of all Iowa Medicaid ETPs to the Agency on a quarterly basis. This includes but is not limited to:
i.	Requestor; 
ii.	Subject: Medicaid member SID or provider NPI; 
iii.	Status; 
iv.	Rule impacted;
v.	Cost of the exception as applicable;
vi.	Disposition of request; and 
vii.	Analysis of ETP trends and recommendations for policy changes identified from ETP requests.
g.	Review MCO ETP determinations based on Agency policies and procedures, cost-effectiveness, medical necessity, and the availability of lower cost alternatives and provide monthly summary report to the Agency. 
6.	Procedure and Diagnosis Codes.
The Contractor shall provide professional and technical support to the Agency related to procedure and diagnosis codes. This includes but is not limited to:
a.	Quarterly and annual review ICD-10 diagnosis and surgical code and HCPCS updates including review of codes sets needed for MMIS processing; 
b.	Review quarterly Medicaid National Correct Coding (NCCI) files and maintain accurate tracking of changes to NCCI guidelines;
c.	Determine MMIS and policy impacts; 
d.	Recommend code updates to Iowa Medicaid policy for approval; 
e.	Update Iowa Medicaid systems, as appropriate; 
f.	Answer MCP questions and review MCP documents related to billings, claims, and codes, as requested by the Agency; 
g.	Participate as subject matter expert in meetings related to code updates and issues, as requested; and
h.	Any software and/or tools needed to complete this work shall be provided by the Contractor. Software and/or tool solutions and costs will be agreed upon with the Agency and costs reimbursed by the Agency. 
7.	Clinical Advisory Committees (CAC).
a.	Medical Assistance CAC
The Medical Assistance CAC provides a process for physician/provider intervention to promote quality care, member safety, cost effectiveness and positive physician/provider relations through discussion about Medicaid benefits and healthcare services.
In order to meet this requirement, the Contractor shall:
i.	Provide medical support, coordination and facilitation for the Medical Assistance CAC. The committee members will represent all medical services providers. The committee will meet at a minimum quarterly and consist of seven to nine medical services providers. The Contractor’s MMD will chair the Medical Assistance CAC. Payment for attendee pass-through costs shall be made as expenses are incurred as requested by the Agency, which include but are not limited to quarterly meeting costs and ad hoc committee meetings for clinical advisory committee member attendance.
ii.	Submit a report summarizing activities of the Medical Assistance CAC to the Agency on an annual basis, within 90 days of the end of each state fiscal year.
b.	Hawki CAC
Iowa Code § 514I.5(7)(j) requires the Hawki Board to “Establish and consult with a clinical advisory committee to make recommendations to the Board regarding the clinical aspects of the Hawki program.”  This committee is made up of a variety of health care professionals.  
In order to meet this requirement, the Contractor’s MMD shall chair the Hawki CAC and the Contractor shall:
i.	Maintain a schedule of meetings.  This includes identifying a location for the meeting and/or arranging for a conference call.  Meetings shall be scheduled at least on a quarterly basis;
ii.	Plan the agenda for the meetings;
iii.	Record minutes of the meetings;
iv.	Recruit committee members as needed; and
v.	Be available to present recommendations from the committee to the Hawki Board.
8.	Minimum Data Set Support and Nursing Facility Case Mix Index.  
a.	The Contractor shall provide support and technical assistance to the Agency related to any CMS updates to the Minimum Data Set (MDS), Resource Utilization Group (RUG), and Patient Driven Payment Model (PDPM) scores, including participating in CMS calls on MDS and RUG development. 
b.	The Contractor shall develop and maintain RUG-based methodologies, subject to Agency approval.
c.	The Contractor shall extract and maintain data from the national MDS database at CMS, to include maintaining appropriate data use agreements with CMS.
d.	The Contractor shall calculate a nursing facility case mix index (CMI) and resident roster on a quarterly basis, ensuring roster rules are applied consistently from quarter to quarter.
e.	The Contractor shall submit the CMI and resident roster to the Iowa Medicaid Provider Cost Audit and Rate Setting (PCA) unit for quality assurance review, and incorporate any feedback prior to submitting the resident rosters to Iowa nursing facilities.
f.	The Contractor shall communicate as necessary with nursing facility staff, to include providing help desk support services to Iowa nursing facilities, related to case mix index and RUG scores developed by the Contractor.
9.	MDS Section “Q” Intake Process. 
a.	The Contractor shall receive notification from nursing facilities reporting a resident (regardless of pay source) has expressed interest about returning to the community. 
b.	Following the intake referral, Contractor shall refer residents to an MCP or, for FFS member, to the MFP Coordinator for options counseling and possible transition planning. 
10.	Payment Error Rate Measurement (PERM). 
The Contractor shall provide support to the Agency during the CMS PERM project on a tri-annual basis, as requested. This includes but is not limited to:
a.	Monitor the PERM website as requested for new claims to be added to the list of reviews. 
b.	Providing timely medical review on all cases that were identified by the auditors and assigned to the Contractor, to include:
i.	Research claims information on MMIS; and 
ii.	Medical record review including coding verification, billing and unit validation, appropriate setting of services, medical necessity of procedures and hospital stays.
c.	Provide findings from each of the medical reviews along with detailed explanation of agreement or disagreement with the PERM auditor’s findings to the Agency.
d.	Explain in detail any disputes with CMS findings to the Agency liaison with supporting rationale from the Iowa Administrative Code (IAC) and provider manuals.
11.	The Contractor shall ensure that Iowa Medicaid policies align with current and/or changing medical practices. This includes but is not limited to:
a.	Advising the Agency on changes to evidence-based best practices, national and state trends, and federal policy changes; 
b.	Consulting the Agency on requested changes to Medicaid services, whether from the Agency, providers, or other stakeholders. This responsibility includes drafting proposed policy clarifications, informational letters, or new policy regarding services covered under the Medicaid program; and
c.	Providing the Agency with appropriate medical and professional expertise to evaluate any requests for new or unusual services or treatment modalities and their impact on current coverage policy.
12.	The Contractor shall answer MCP questions and review MCP documents related to HEDIS measures, case management, clinical, medical, and general health policies and procedures, as requested by the Agency.
13.	The Contractor shall provide professional support to Medicaid providers regarding policy, prior authorization, or billing requirements. This support may be in the form of oral instruction or written communication and must be documented in Agency data systems.
14.	The Contractor shall provide professional and technical support to the Agency in responding to program reviews and audits.
15.	Contractor staff and/or consultants shall attend meetings with providers, MCPs, or other stakeholder groups in support of the Medicaid program, as requested by the Agency.
16.	The Contractor shall certify new outpatient hospital programs for appropriateness of Medicaid coverage and make recommendations to the Agency regarding appropriateness of new and/or existing programs and determine criteria to be used regarding coverage for new and/or existing programs.
17.	The Contractor shall prepare and submit to the Agency for approval, the CMS 64.9 Quarterly Report of Abortions, Hysterectomies and Sterilization, including supplemental worksheets relating to abortions and qualifications for federal funding.  
18.	The Contractor shall assist the Agency in its efforts to secure grants as requested and perform functions that are within the scope of work of this Contract that fall under the grant.
19.	The Contractor shall be responsible for ongoing efforts to ensure the Agency and its managed care partners are in compliance with the Mental Health parity and Addiction Equity Act (2008). The Contractor shall update, complete, and submit the Mental Health Parity report on an annual basis. 

B.	Utilization Management
1.	Prior Authorizations (PA). This section applies only to the FFS population. 
a.	Routine PAs. 
The Contractor shall process PA requests for routine services to include but not limited to:
i.	Audiology;
ii.	Certain dental services, including orthodontia; 
iii.	Certain HCBS services, including CCO;
iv.	Certain medical services; 
v.	Durable medical equipment (DME); 
vi.	Enteral;
vii.	Home health;
viii.	Surgical, including physician administered drugs and genetic testing; and
ix.	Organ transplant services/related; and
x.	Vision. 
b.	Special PAs. 
The Contractor shall process PA requests for the following special types of PAs: 
i.	Swing bed admissions and continued stays. Contractor duties include but are not limited to: 
a)	Determination of nursing facility or skilled nursing facility Level of Care;
b)	Determination of appropriate number of days for authorization based on medical needs of the member;
c)	Verification of swing-bed hospital provider efforts to locate appropriate alternative care within a 30-mile radius; 
d)	Necessary monitoring of swing bed providers to ensure active discharge planning is taking place; and
e)	Special consideration for Iowa Wellness Plan Members, as they have different skilled nursing care benefits.
ii.	Behavioral health services. The Contractor shall review criteria approved by the Agency to determine medical necessity and appropriateness for and duration of hospital or other facility stays (if applicable) for persons to receive services addressing behavioral health concerns. These services include but are not limited to:
a)	Inpatient psychiatric hospitalization; 
b)	Residential behavioral health treatment; 
c)	Psychiatric Medical Institute for Children (PMIC); and
d)	Psychiatric Intensive Care (PIC). 
iii.	Community-based neurobehavioral rehabilitation services. The Contractor shall follow criteria set forth in Iowa Admin. Code r. 441- 78.56 to determine medical necessity for initial and subsequent community-based neurobehavioral rehabilitation services. This includes but is not limited to:
a)	Review the provider’s treatment plan and supporting documentation, and approve if the following conditions are met:
1)	The plan conforms to the medical necessity requirements;
2)	The plan is consistent with the written diagnosis and treatment recommendations;
3)	The plan is sufficient in amount, duration, and scope to reasonably achieve its purpose;
4)	The provider can demonstrate that the provider possesses the skills and resources necessary to implement the plan; and
5)	The plan does not exceed 180 days in duration.
iv.	Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).  The Contractor shall review criteria approved by the Agency to determine medical necessity for EPSDT private duty nursing and personal care services. In addition to processing PAs, the Contractor shall conduct care promotion activities to include but not limited to:
a)	Collaborate with an interdisciplinary team, as requested, for care conferences when a decrease in the approved number of hours occurs. The interdisciplinary team reviews the options available to assist the family in maintaining their special needs member in the home.  
b)	Provide a monthly electronic PA summary, including PAs on file for the next 6 months of authorized services, to the University of Iowa Child Health Specialty Clinic (CHSC) for their clients. 
v.	Facility short-stays. Contractor duties include but are not limited to: 
a)	Conduct reviews to identify short-stay approvals for members seeking admission to a Nursing Facility (NF), Skilled Nursing Facility (SNF), ICF/ID, Nursing Facility for the Mentally Ill (NF/MI), Inpatient Psychiatric Hospital, PIC, or PMIC when the prior living arrangement was a community setting. 
b)	Conduct reviews for continued stay for FFS members to ensure that facility placement is for the shortest duration possible, allowing members who choose to return to the community to do so at the earliest possible opportunity. 
vi.	High-tech imaging (such as MRI, MRA, CT, and PET) for radiology services, except in hospital and emergency room settings. The Contractor shall perform the medical review process for high-tech imaging that target variation in practice, promote cost-effective clinical decision making and increase the safety of Iowa Medicaid members.
c.	The Contractor shall provide timely review of all PA requests in accordance with Iowa Admin. Code r. 441-79.9 and the conditions for payment as established in Iowa Admin. Code Ch. 441-78 to determine whether the service to be provided is medically necessary and appropriate, determine whether the service should be approved, denied, or modified, and (if approved) determine an approved duration, as required. Extensions may apply when the Member or Provider requests an extension or the Contractor justified the need for additional information and how the extension is in the Members interest.  
i.	The Contractor shall request additional PA documentation, as necessary.  If additional documentation is not received within 45 days of initial request, the Contractor shall issue a technical denial no earlier than day 45 but no later than 60 days of initial request.
ii.	For any PA requests for which a decision has not been reached within 60 days of request, the Contractor shall:
a)	Automatically approve the PA request, per Iowa Admin. Code r. 441-79.8(7); and
b)	Report immediately to the Agency in writing the reason for inaction.
iii.	The Contractor may approve, but cannot deny, a PA request without first referring it to a peer consultant.
iv.	When a PA request is denied or modified, the Contractor shall send a copy of the Request for Prior Authorization form(s) to the provider and produce and send notice of decision (NOD) to the Member and provider, on Agency-approved forms, to include but not limited to the following information:
a)	The reason and the circumstances for the adverse action; 
b)	The appropriate section of the Iowa Administrative Code; 
c)	Information as to the specific reason for the denial that Members would understand as the basis for denial; and
d)	Member appeal rights. 
i.	When a PA request is approved, the Contractor shall send a copy of the Request for Prior Authorization form(s) to the provider with the PA decision. 
ii.	The Contractor shall maintain PA files, to include but not limited to:
a)	Maintain detailed audit trail reports of all changes to PA records, indicating date of last change, ID of the person making the change, and information changed for each PA record;
b)	Maintain PA requests and supporting documentation in the Agency workflow management system. Hardcopy requests and documentation will be imaged by the Agency-approved system contractor and be made available to the Contractor electronically; and
c)	Update Agency data systems with outcomes of PA decisions.
iii.	The Contractor shall track, trend and analyze services requiring prior authorization and report recommendations for policy changes to the Agency as requested. 
iv.	The Contractor shall submit a report of HCBS PA activities that occurred the previous month, with fiscal year-to-date totals, analysis of trends, and recommendations for improvements (including internal quality improvements) to the Agency on a monthly basis.
2.	Level of Care and Needs Based Eligibility Assessment Reviews for LTSS.
a.	The Contractor shall perform the following types of Level of Care (LOC) and Needs Based Eligibility assessment (NBA) reviews for the LTSS programs and populations identified:
i.	Initial LOC Review, for all applicants or Members (FFS and MCO) upon admission or when accessing HCBS waiver program, facility (NF, SNF, ICF/ID, PIC, and PMIC), and PACE (regardless of funding source) services for the first time; 
ii.	Continued Stay Review (LOC-CSR), for HCBS waiver program, facility, and PACE services, annually or when there is a significant change in the Member’s needs for the following populations:
a)	All FFS Members; 
b)	Any MCO Member where the MCO determines the LOC has changed; and
c)	All PACE members, regardless of funding source (i.e., FFS, MCO, Medicare, and private payer).
iii.	Initial NBA Review for all applicants or Members (FFS and MCO) requesting Medicaid funding for Habilitation services for the first time;
iv.	Continued Stay Review (NBA-CSR) for Habilitation services, annually or when there is a significant change in the Member’s needs for the following populations:
a)	All FFS Members; and
b)	Any MCO Member where the MCO determines the NBA has changed.
b.	The Contractor shall begin LOC and NBA reviews once request is received viaIoWANS workflow milestone, certification form, or core standardized assessment submittal. 
c.	The Contractor shall accept documentation for LOC and NBA review from the Member’s physician, provider, case manager, MCO, and/or core standardized assessment (CSA) vendor. The Contractor shall request additional information, as necessary.  
d.	The Contractor shall ensure LOC and NBA reviews are based on an objective and accurate evaluation of the individuals’ needs. Based on these reviews, the Contractor shall:
i.	Determine whether LOC and NBA criteria are met in accordance with all state and federal requirements based on information provided;
ii.	Approve or deny LOC or NBA requests, in accordance with criteria and within timeframes established by the Agency;
iii.	Ensure member service plan encompasses needs as identified in approved LOC or NBA. If changes to the service plan are necessary, notify the case manager, as required;
iv.	Document LOC and NBA decisions within Agency data systems; and 
v.	Produce and send notice of decision (NOD) to the Member, physician, provider, case manager, and/or facility, per Agency requirements.
e.	The Contractor shall submit a quarterly report to the Agency on applicants and Members approved and denied for LTSS based on LOC and NBA determinations, using Agency-approved criteria.
3.	Tiered Rates.
The Contractor shall assist the Agency in determining payment tiers for supported community living services, residential-based supported community living services, day habilitation services, and adult day care services provided under the Intellectual Disabilities (ID) waiver. Duties include but are not limited to:
a.	Determine acuity tiers based on the results of the SIS assessment tool;
b.	Assign acuity tiers based on mathematically valid processes;
c.	Assign tiers to all new applicants or Members (FFS and MCO) requesting Medicaid funding for ID waiver services for the first time; and 
d.	Assign tiers annually or when there is a significant change in the Member’s needs for the following populations:
i.	All FFS Members; and
ii.	Any MCO Member where the MCO determines the Level of Care has changed.
4.	Quality Reviews.
The Contractor shall conduct quality reviews in accordance with all state and federal requirements, as approved by the Agency. Duties include but are not limited to:
a.	HCBS Waiver and Habilitation Program Performance Measure Data Reviews
i.	Coordinate the collection of data for FFS and MCO. 
ii.	Aggregate the FFS and MCO data. 
iii.	Coordinate data reviews with other Iowa Medicaid Units and Agency staff. 
iv.	Review the performance data and develop the HCBS performance data report for the Agency. 
v.	Develop an Agency approved HCBS performance measure data reporting dashboard for the Agency and update the dashboard on a monthly basis. 
vi.	Report activities to the Agency on a quarterly and annual basis. 
b.	Review service plans for assessed needs, medical necessity, person-centered care planning, effective services delivered timely, and discharge plans. The review shall determine whether:
i.	Services are individualized and reflect member's preferences and needs.
ii.	Services are implemented as planned and produce the desired results.
iii.	Members are safe and secure.
iv.	Members are free to exercise their rights.
v.	Services strive to improve quality outcomes for members. 
vi.	Providers reimbursement rates are consistent with Administrative Rule and Iowa Code. 
vii.	Provide results of these reviews to the Agency for approval, prepared in accordance with the Agency’s HCBS evidentiary materials guidelines, as approved by CMS. 
viii.	Provide a written review findings report to the Agency, to include recommendations for enhancements, corrective actions, or both, within 30 business days of completion of the quality reviews, subject to Agency approval.  
c.	Community-based Neurobehavioral Rehabilitation Services (CNRS) Quality Reviews. 
i.	All CNRS providers shall be reviewed over a randomized three-year cycle.
ii.	Review risk-based service needs, medical necessity, person-centered care planning, effective services delivered timely, and discharge plans to determine whether:
a)	Members have a need for assistance. 
b)	Members have a qualifying brain injury diagnosis co-occurring with a DSM-V diagnosis.
c)	Members have a standardized comprehensive neurobehavioral assessment  documenting the member’s need for services.
d)	Members treatment plans are individualized and reflect the members needs.
e)	Services are implemented as planned and produce the desired results.
f)	CNRS staff delivering or supervising direct service to the members meet the training criteria in rule. 
iii.	Coordinate the reviews with other Iowa Medicaid Units and Agency staff. 
iv.	Provide a written review findings report of the quality review to the Agency, to include recommendations for enhancements, corrective actions, or both, within 30 business days of completion of the quality reviews, subject to Agency approval. 
v.	Forward a copy of the report to the provider once approved.
5.	Minimum Data Set Validation Reviews.  
The Contractor shall conduct annual MDS validation reviews of a minimum of 25 percent or approximately 110 of the current Iowa certified nursing facilities, to include but not limited to:
a.	Ensure every facility has been reviewed at least once within each four year period.
b.	Ensure facilities currently identified as being at-risk and those with the highest MDS error rates from the previous state fiscal year are given priority for reviews. 
c.	For each facility reviewed, conduct MDS validation on 25 percent, or a minimum of five, whichever is higher, of the Medicaid residents. 
d.	MDS validation reviews may be conducted remotely as desk reviews or on-site, if deemed necessary based on the complexity and professional opinion of the reviewer. 
e.	Ensure a minimum inter-rater reliability of 95 percent. 
f.	The validation review will utilize all pertinent information, including the MDS, the member’s medical record, and interviews with facility staff.
g.	Conduct exit conference with the nursing facility administrative staff to identify inconsistencies found in the MDS fields utilized for RUGs III classifications. The exit conference shall include MDS assessment with patterns of errors, areas that need improvement, staff education and training needs, and notice of when the final report will be sent to the facility.
h.	Confirm Pre-Admission Screening and Resident Review (PASRR) was complete and appropriate documentation is included in the member’s medical record.
i.	Provide formal written report of the MDS validation process to the facility.
j.	Notify the Agency if a nursing facility’s error rate is greater than the established threshold or questionable patterns of coding or transmission are noticed.
k.	Submit reports of MDS validation review activity and findings to the Agency on a quarterly basis.
6.	Utilization Reviews (URs).
For the entire Medicaid population, the Contractor shall conduct UR activity in accordance with 42 CFR Part 456. Contractor duties include but are not limited to:
a.	For facilities, ICF/ID, PMIC, and Mental Health Institute (MHI) facilities, evaluate the appropriateness of placement and that services are meeting the treatment needs of the member, to include but not limited to:  
i.	Conduct an annual on-site review of current medical records and observe members in the facility at the time of the onsite visit.
ii.	Provide a written review findings report of the UR results to the included facility, to include recommendations for enhancements, corrective actions, or both, within 30 business days of completion of the review. 
iii.	Report aggregate findings to the Agency on a quarterly basis.

b.	For hospitals, evaluate utilization control processes to assess their comprehensiveness and verify their completion. Duties include but are not limited to:
i.	Conduct a triennial desk review of hospital utilization control process documentation. 
ii.	Notify the provider of the review results, including any identified deficiencies. This letter will be sent to each CAH within three business days following review completion.
iii.	Provide a written review findings report of the UR results to the Agency, to include recommendations for enhancements, corrective actions, or both, within 30 business days of completion of the review. 
iv.	Report aggregate findings to the Agency on a quarterly basis.

1.3.1.4 Quality Oversight Operations for HCBS Waiver, MFP, and Habilitation Programs
A.	General Requirements
For requirements listed in Section 1.3.1.4, the Contractor shall:
1.	HCBS Quality Assurance and Quality Improvement Recommendations. Duties include but are not limited to:
a.	Identify improvements to the technical and functional requirements of the HCBS waiver and habilitation continuous quality improvement (CQI) process.
b.	Make recommendations to the Agency that identify system improvements and best practices in quality assurance and quality improvement within the HCBS waiver, Habilitation and MFP programs.
c.	Recommendations shall be based upon trending and analysis of data collected from Contractor functions. 
d.	Collaborate with other Iowa Medicaid Units to make recommendations to the Agency that recommend policy revisions based on identified quality indicators.
e.	Report findings to the Agency on a quarterly and annual basis.
2.	HCBS Website. Duties include but are not limited to:
a.	Provide rule hyperlinks that explain processes related to provider quality oversight.
b.	Provide an updated list of provider training schedules.
c.	Provide updated list of staff to include the Program Supervisors and all Specialists with county assignments, a telephone number, and email address.
d.	Establish, develop, and maintain a continuous FAQ link containing information approved by the Agency SMEs.
e.	Provide all other information, to be determined by the Agency, on a timely basis. 
f.	Contractor shall provide relevant data to update the HCBS dashboard on a monthly basis. 
g.	Review the HCBS website content no less than quarterly for accuracy and recommend changes to the Agency. 
h.	Report activities to the Agency on a monthly, quarterly, and annual basis.
3.	Administrative Support. Duties include but are not limited to:
a.	Complete any clerical and administrative functions associated with program administration of services, as assigned by the Agency.
b.	Prepare for and assist the Agency with audits/renewals and reviews related to the provider quality assurance oversight data.
c.	Discover and remediate provider payment issues, including but not limited to issues with covered benefits, billing codes, provider types, National Correct Coding Initiative (NCCI) edits, and provider improper billing.    
d.	Assist with the development and review of Agency Standard Operating Procedures (SOPs) and provider manual updates.
e.	Maintain a resource guide.
f.	Provide assistance to providers and field staff on specified program issues as approved by the Agency.
g.	Work with the Agency and other Iowa Medicaid Units on identified issues.
h.	Report activities to the Agency on a quarterly and annual basis.
4.	Provider Training. Duties include but are not limited to:
a.	Develop and conduct training in collaboration with the Agency’s Competency Based Training (CBT) contract vendor and the MCOs;
b.	Various methods of training dissemination including web-enabled training for providers as approved by the Agency.
c.	Interpretation, clarification, guidance, and training providers on procedural expectations of state and Federal regulations and administrative code, as well as industry accepted standards for best practice.
d.	Focus areas based on HCBS quality assurance processes and supported by Contractor data analysis, subject to Agency approval.
e.	Coordinate with other Iowa Medicaid Units to develop and deliver provider training tools and reference materials.
f.	Identify system improvements and best practices in provider training related to the delivery of HCBS and participation in the Medicaid program.
g.	Report activities to the Agency on a quarterly and annual basis.
5.	Log all provider reviews, complaints, incidents, and surveys into the current Agency electronic tracking database, to include discovery, remediation, and improvement activities. Duties include but are not limited to:
a.	Associated data shall be stored for no less than ten (10) years.
b.	Data shall undergo internal quality checks by the Contractor to mitigate data entry errors.
c.	Present an internal quality assurance analysis to the Agency on a quarterly and annual basis.
6.	Provide statistically valid and reliable processes to include but not limited to:
a.	Samples, reviews, tools, and techniques shall be evaluated for statistical validation and reliability.
b.	100% of processes should be included in all relevant SOPs and maintained at an annual basis to ensure accuracy.

B.	HCBS Provider Reviews 
1.	The Contractor shall conduct the following types of reviews for HCBS waiver and Habilitation programs as determined by the Agency:
a.	Periodic Reviews. Duties include but are not limited to:
i.	100% of targeted providers are reviewed over a randomized five-year cycle. Periodic reviews may be completed in a combination of desk review or onsite visits, depending on the level of provider intervention required. 
ii.	Reviews shall always include, but are not limited to, review of member documentation, policies and procedures, employee records, and financial statements.
iii.	Verify the accuracy of the provider’s self-assessment by reviewing evidence of the implementation of required policies and procedures.
iv.	Periodic review tool(s) shall be approved by the Agency on an annual basis.
v.	Communicate the findings of the review to the Providers in a format approved by the Agency. 
vi.	Periodic review data will be stored in an accessible database enabling reporting as determined by the Agency. 
b.	Focused Desk Reviews. Duties include but are not limited to:
i.	100% of targeted providers are reviewed over a randomized five-year cycle. Focused reviews may be completed in a combination of desk review or onsite visits, depending on the level of provider intervention required.
ii.	Areas of focus are determined by the Agency, based on CMS quality framework, HCBS settings requirements, and other trends.
iii.	Reviews may include, but are not limited to, review of member documentation, policies and procedures, employee records, and financial statements.
iv.	Verify the accuracy of the provider’s self-assessment by reviewing evidence of the implementation of required policies and procedures.
v.	Focused review tool(s) shall be approved by the Agency on an annual basis.
vi.	Communicate the findings of the review to the Providers in a format approved by the Agency. 
vii.	Present an internal quality assurance analysis to the Agency on a monthly, quarterly, and annual basis.
viii.	Focused desk review data will be stored in an accessible database enabling reporting as determined by the Agency. 
c.	Targeted Reviews. Duties include but are not limited to:
i.	Review shall be initiated as a result of concerns arising from a desk review, complaint, incident, or Agency referral.
ii.	Reviews shall include investigation of the targeted issue or concern.  Areas of reviews may include, but are not limited to, review of member documentation, policies and procedures, employee records, incident reports, member survey and financial statements.
iii.	Verify the accuracy of the provider’s self-assessment by reviewing evidence of the implementation of required policies and procedures.
iv.	Conduct provider targeted reviews as desk reviews unless circumstances rise to level that requires an onsite review.
v.	The Contractor shall provide technical assistance and training to providers to demonstrate increased provider compliance of targeted review areas, to include but not limited to:
a)	Analyze and trend areas of deficiency in MCO and FFS each quarter and provide appropriate aggregate outreach to providers on a quarterly or annual basis.
b)	Document activities performed to enhance provider understanding of State and Federal rules, laws, and regulations as well as industry accepted standards for best practice.
c)	Report findings to the Agency on a quarterly and annual basis.
vi.	Communicate the findings of the review to the Providers in a format approved by the Agency. 
vii.	Present an internal quality assurance analysis to the Agency on a monthly, quarterly, and annual basis.
viii.	Targeted review data will be stored in an accessible database enabling reporting as determined by the Agency. 
d.	Certification Reviews of Enrolled Providers. Duties include but are not limited to:
i.	Certification reviews shall be conducted within the program mandated timeframe found in Iowa Admin. Code Ch. 441-77.
a)	Review and determine approval for assigned applications for new HCBS providers as determined by the Agency, to include but not limited to:
a.	Review to ensure applications are complete;
b.	Send notification to providers of the requirements and documents needed for becoming a Medicaid HCBS waiver provider;
c.	Conduct a desk review of provider application and documentation to determine if application can be approved; and
d.	Notify Iowa Medicaid Provider Services unit, as applicable.
ii.	Reviews include, but are not limited to: 
a)	Verifying the accuracy of the provider’s self-assessment by reviewing evidence of the implementation of required policies and procedures.
b)	Reviewing for compliance with state and federal HCBS codes and regulations, provider operating policies and procedures, staff training records, member service records, and employee records.
iii.	Develop certification tool(s) for use by the HCBS Specialist.
a)	Review the certification tool annually to ensure compliance with HCBS codes and regulations. 
b)	Prior to implementation, submit certification tool(s) updates to the Agency for approval.
iv.	The Contractor shall provide technical assistance and training to providers to demonstrate increased provider compliance on certification onsite reviews to include but not limited to:
a)	Analyze and trend areas of deficiency each quarter and provide appropriate aggregate outreach to providers on a quarterly or annual basis;
b)	Document activities performed to enhance provider understanding of State and Federal rules, laws, and regulations as well as industry accepted standards for best practice; 
c)	Communication the findings of the review to the Providers in a format approved by the Agency. 
d)	Report findings to the Agency on a quarterly and annual basis; and
e)	Present an internal quality assurance analysis to the Agency on a monthly, quarterly, and annual basis. 
e.	Chapter 24/HCBS Waiver Provider Onsite Reviews.  The Contractor shall collaborate with the Agency’s Division of Behavioral Health and Disability Services (BHDS) to provide quality oversight of providers of Iowa Admin. Code ch. 441-24 services, also known as Chapter 24 providers, and HCBS waiver services. The Contractor shall manage, monitor, and follow-up on collaborative on-site reviews to include but not limited to:
i.	Reviews include, but are not limited to: 
a)	Verifying the accuracy of the provider’s self-assessment by reviewing evidence of the implementation of required policies and procedures.
b)	Reviewing for compliance with state and federal HCBS codes and regulations, provider operating policies and procedures, staff training records, member service records, and employee records.
ii.	Develop certification tool(s) for use by the HCBS Specialist.
a)	Review the certification tool annually to ensure compliance with HCBS codes and regulations. 
b)	Prior to implementation, submit certification tool(s) updates to the Agency for approval.
iii.	The Contractor shall provide technical assistance and training to providers to demonstrate increased provider compliance on certification onsite reviews to include but not limited to:
a)	Analyze and trend areas of deficiency each quarter and provide appropriate aggregate outreach to providers on a quarterly or annual basis.
b)	Document activities performed to enhance provider understanding of State and Federal rules, laws, and regulations as well as industry accepted standards for best practice. 
c)	Report findings to the Agency on a quarterly and annual basis; and
d)	Present an internal quality assurance analysis to the Agency on a monthly, quarterly, and annual basis.  
iv.	Collaborate with the BHDS to include but not limited to:
a)	Attend meetings to discuss progress on reviews.
b)	Coordinate scheduled reviews.
c)	Communicate the findings of the review to the Providers in a format approved by the Agency. 
d)	Discuss and collaborate on all rule revisions and implementation that are necessary.
e)	Report activities to the Agency on a quarterly and annual basis.
f.	Provider Self-Assessment Reviews. The Contractor shall review completed provider annual self-assessments to ensure full completion and compliance to include but not limited to:
i.	Ensure that providers are complying with quality self-assessment requirements defined in State and Federal laws, rules, and regulations as well as industry accepted standards for best practice.
a)	Ensure that 100% of providers required to submit an annual self-assessment submit an annual self-assessment by the communicated deadline. 
b)	Annually remind providers of the self-assessment requirement in writing. 
c)	Within five business days, initiate a referral to the Bureau of Program Integrity and Compliance for administrative review of providers that are found non-compliant with program requirements.  
ii.	Review and revise self-assessment tool(s) on an annual basis and attain approval by the Agency.
iii.	Annually provide training to HCBS providers required to complete the self-assessment on completion of the provider self-assessment. 
iv.	Publish the self-assessment tool, as approved by the Agency, and a publicly communicate a deadline for submission on the HCBS website.
v.	Report findings to the Agency on a monthly, quarterly, and annual basis.
g.	Reviews of Self-directed Services. The Contractor shall assign key positions(s) to develop standard operating procedures, review tools and workplans to perform periodic reviews of self-directed services to assess compliance with the following quality assurances:      
i.	Verify that provider(s) initially met the specific qualification and continuously meet these qualifications.
ii.	Verify that provider(s) initially have a clear background check or record evaluation and are not excluded from receiving federal/state funding prior to submission of claims for payment. 
iii.	Verify existence of a backup plan to the primary caregiver or in the event of an emergency. 
iv.	Assess member’s access to care and documentation of freedom of choice including:  
a)	Choice of home and community-based services; 
b)	Choice of services; and 
c)	Choice of providers. 
v.	Assess for conflict-free needs assessment and service plan development and adequacy. 
vi.	Assure the service plans address all participants’ assessed needs including: 
a)	Service plan is developed in accordance with the Agency’s policies and procedures; 
b)	Service plans are updated/revised at least annually or when needs changes; and
c)	Services are delivered in accordance with the service plan, including in the type, scope, amount, duration, and frequency specified in the service plan. 
vii.	Assess and monitor the length of time between the signed service plan and start of direct service delivery. 
viii.	Assess member’s understanding of their roles and responsibilities as an employer of self-directed services. 
ix.	Assess member’s understanding of their roles and responsibilities as an employer of self-directed services. 
x.	Assess member’s understanding of the required use of EVV to review and verify service delivery. 
xi.	Assess member’s understanding of how to request EVV access and training. 
xii.	Assess member's understanding of how to manage manual entries of missed visit such as a provider failing to clock in/out. 
xiii.	Assess provider’s understanding of their roles and responsibilities in the required use of EVV, including and not limited to:
a)	Accessing the EVV solution to report time worked and task performed; and 
b)	Reporting missed visits to member (employer). 
xiv.	Assess member and provider’s knowledge of how to report fraud, waste, abuse, neglect, and exploitation. 
xv.	Assess for provider practices during service delivery that may cause potential harm or restrict the rights of a member. 
xvi.	Conduct provider reviews using Agency approved methods unless trends indicated a need to target certain areas of vulnerabilities.
xvii.	Provide technical assistance and training to assist members and providers to understand program expectations and gain compliance with program requirements. 
xviii.	Track review data, analyze, and trend areas of deficiencies and present findings to the Agency on a quarterly and annual basis. 
xix.	Review and revise standard operating procedures, review tools and workplans as necessary to ensure information in these documents are current and up to date. 
xx.	Ensure that review data is stored in an accessible database enabling reporting as determined by the Agency. 
2.	Unless otherwise specified in the section above, the Contractor shall collaborate with the Agency’s Managed Care Organizations (MCOs) to provide technical assistance and training to providers to demonstrate increased provider compliance on reviews to include but not limited to:
a.	Analyze and trend areas of deficiencies and provide appropriate aggregate outreach to providers on a quarterly basis.
b.	Document activities performed in collaboration with MCOs to address provider compliance. 
c.	Document activities performed to enhance provider understanding of State and Federal rules, laws, and regulations as well as industry accepted standards for best practice.
d.	Report findings to the Agency on a monthly, quarterly, and annual basis.
3.	The Contractor shall submit all reports of provider reviews to include but not limited to:
a.	Findings report shall articulate the findings and outcomes of the review and when deficiencies are found, the relevant correlations to State and Federal rule, law, and regulation as well as industry accepted standards for best practice. 
b.	Report findings and outcomes to the Agency on a monthly, quarterly, and annual basis, in an Agency-approved format.
4.	The Contractor shall initiate development of corrective action plans (CAPs) with providers who have policy, procedure, and outcome deficiencies based off reviews, to include but not limited to:
a.	CAP initiation shall occur simultaneously with review findings report.
b.	Provide education and assistance when areas of compliance are not clearly established such that the provider can attain a plan for achievable success within the timeframe preceding the follow-up compliance review.
i.	Provide the specific action required to correct the deficiency to achieve compliance when the provider is unable to submit an acceptable CAP following education and assistance. 
c.	Review and approve CAPs to come into compliance with IAC standards at a 100% level.
d.	The review and approval process shall be based on established protocols approved by the Agency.
e.	Subsequent correspondence with providers shall be in a format approved by the Agency.
f.	Report findings to the Agency on a monthly, quarterly, and annual basis.
5.	The Contractor shall conduct a follow up compliance review to ensure that the provider has implemented policies and procedures agreed upon in the approved CAP, and report findings to the Agency on a monthly, quarterly, and annual basis.

C.	HCBS Waiver, Habilitation, and MFP Provider Complaints
When there is a complaint filed against a provider, the Contractor shall request more information from the complainant if known and follow-up as described below. 
1.	The Contractor shall handle complaints in a manner consistent with the Agency to include but not limited to:
a.	Develop a standardized operating procedure for conducting complaint investigations for approval by the Agency. 
b.	Ensure complaints have an initial assessment completed within three (3) business days unless members involved are in immediate jeopardy. 
i.	When the potential for immediate jeopardy exists, the Contractor shall complete the initial assessment within one (1) business day of receiving the complaint. 
c.	The resulting action(s) will be in accordance with HCBS waiver, Habilitation, and MFP program policies, procedures and State and Federal rules, laws, and regulations. 
i.	Resulting action (e.g. investigation, closure, or referral) shall be logged and reported to the Agency.
d.	Initiate fact-finding correspondence with relevant parties within two (2) business days of initial assessment.  
e.	Correspondence with all parties shall be in a format approved by the Agency.
f.	Communicate the findings of the review to the Providers in a format approved by the Agency. 
g.	Report findings to the Agency on a monthly, quarterly, and annual basis.
2.	The Contractor shall conduct investigations of complaints with the Agency approved SOP when determined necessary during the initial assessment to include but not limited to: 
a.	Notify the Agency and the applicable provider if it is determined during the initial assessment that an investigation is necessary.
b.	Correspondence with the provider shall be in a format approved by the Agency.
c.	Correspondence and associated data shall be logged within an electronic database.
d.	Conduct the complaint review in accordance with 1.3.1.4.B.1.c. 
e.	Report findings to the Agency on a monthly, quarterly, and annual basis.
3.	The Contractor shall make written recommendations to the Agency related to complaint management to include but not limited to:
a.	Recommendations identify system improvements and best practices in complaint management.
b.	Recommendations identify systemic solutions to the root cause of the complaints received. 
c.	Collaborate with other Iowa Medicaid Units and MCOs to recommend policy revisions based on identified quality indicators.
d.	Report recommendations to the Agency on a quarterly and annual basis.

D.	HCBS Waiver, Habilitation, and MFP Provider Incident Reporting Management 
The Contractor shall be responsible for operating and overseeing the Agency incident management system for HCBS Waiver, Habilitation, and MFP providers. 
1.	The Contractor shall develop a standard operating procedure for the management and oversight of the Agency incident management system for Agency approval. 
2.	The Contractor shall utilize Agency identified ICD-10 diagnosis codes matching the State identified definition of major incident to complete a monthly comparison of the emergency room visits and hospitalizations for HCBS Waiver, Habilitation, and MFP enrolled members.  
a.	For emergency room visits and hospitalizations meeting the definition of major incident for enrolled members, follow up with the case manager for FFS members or the member’s MCO to request completion of a major incident report.    
b.	The Contractor shall ensure that the case manager or member’s MCO has completed the major incident report in Iowa Medicaid Portal Access (IMPA) by monitoring for incident report submission in IMPA.  
c.	The Contractor shall report findings to the Agency on a quarterly and annual basis.  
d.	The Contractor shall provide monthly reporting tracking and trending of emergency room visits with ICD-10 diagnosis codes that do not substantiate the need for emergency room visits.  
3.	The Contractor shall ensure that HCBS waiver, Habilitation and MFP providers are complying with incident reporting requirements to include but not limited to:
a.	Provide guidance and education to providers on the development of incident management and reporting policies and procedures which are compliant with State and Federal requirements. 
b.	Provide education and assistance when it is discovered that providers are not adhering or are misinterpreting requirements or industry accepted standards for best practice.
c.	Identify trend areas of deficiency each quarter and provide training or outreach to clarify requirements.
d.	Document activities performed to enhance provider understanding of State and Federal rules, laws, and regulations as well as industry accepted standards for best practice.
e.	Report findings to the Agency on a quarterly and annual basis.
4.	The Contractor shall manage the Agency incident management system and ensure that providers are submitting incident reports into the IMPA system on a timely basis to include but not limited to:
a.	For critical (major) incidents that are faxed/mailed to the Agency, the Contractor shall follow up with provider to remind them of the IMPA requirement and monitor IMPA for submission.
b.	Provide training or outreach to providers and case managers who are not submitting incident reports within the mandated timeframe or who are not submitting reports for incidents meeting the definition of major incident.
c.	Initiate contact with the provider, case manager, and MCO to remediate any deficiencies identified. 
d.	Report findings to the Agency on a quarterly and annual basis.
5.	The Contractor shall complete targeted reviews of providers that have established a trend or pattern of major incidents to include but not limited to:  
a.	Health and welfare of an individual or individuals appears to be at risk, either presently or in the future.
b.	Immediately notify the Agency, the member’s case manager, and MCO.
c.	Notify the provider in advance of the onsite targeted review unless it is not in the best interest of the Agency or individual(s) served .
d.	Notify the Agency in advance of the intent to conduct an unannounced site visit to obtain prior agency approval.
e.	Associated correspondence shall be in a format approved by the Agency.
f.	Report findings to the Agency on a timeline approved by the Agency, which could be weekly, monthly, quarterly, and annual basis.
6.	The Contractor shall meet with the Agency staff to review the previous quarter’s major incidents, to include but not limited to:
a.	Report the identified systemic, provider, and member trends and patterns for the previous quarter’s major incidents.
b.	Report the discovery, remediation, and improvement activities for flagged incident reports.
c.	Provide monthly, quarterly and annual reports with statistical analysis and trending of aggregate incident data as well as detailed information on the discovery and remediation associated with flagged incident reports in a format approved by the Agency.
d.	Perform an evaluation of a statistically valid sample at a 95% confidence level to identify an error rate of data entry for provider submitted reports. 
e.	Report findings to the Agency on a monthly, quarterly, and annual basis, in an Agency-approved format.
7.	The Contractor shall make written recommendations to the Agency related to incident reporting, to include but not limited to:
a.	Recommendations identify improvements and best practices in incident report management, tracking, and reporting. 
b.	Collaborate with Iowa Medicaid Bureaus, other Iowa Medicaid Units, and MCOs to recommend policy revisions based on identified quality indicators.
c.	Report recommendations to the Agency on a quarterly and annual basis.

E.	HCBS Waiver and Habilitation Member Surveys 
This section applies only to the FFS population.
1.	The Contractor shall manage, monitor, and maintain the Agency designated Participant Experience Survey (PES) tool, to include but not limited to:
a.	Provide initial and ongoing training to contract staff on reliable interviewing techniques for the member survey tool being used; 
b.	Revisions or newly developed components of the survey tool must be approved by the Agency and statistically validated; 
c.	Work with other units within the Agency to identify the representative sample to be surveyed; 
d.	Provide each MCO with the representative sample of their enrolled populations to interview each quarter; 
e.	Ensure a representative sample of members from each HCBS waiver and Habilitation are interviewed each quarter at a 95% confidence level; and
f.	Report interview findings to the Agency on a monthly, quarterly, and annual basis. 
g.	Complete an Agency provided template to document FFS population IPES data for the Iowa Medicaid dashboard.
2.	The Contractor shall develop appropriate and universal follow up for responses that are flagged, to include but not limited to:
a.	The follow up questions mirror the language from the member survey tool, and as approved by the Agency.
b.	100% of flagged responses shall be remediated with a case manager or care coordinator within 15 business days.
c.	Documentation of the discovery, remediation, and improvement associated with flagged responses in an electronic database or equivalent.
d.	Development of communication strategies with case managers and care coordinators to facilitate improvement of the members’ experience, quality of life, and services. 
e.	Report findings to the Agency on a quarterly and annual basis.
3.	The Contractor shall make written recommendations to the Agency related to member surveys to include but not limited to:
a.	Recommendations identify system improvements and best practices in member surveys.
b.	Collaborate with other Iowa Medicaid Units and MCOs to recommend policy revisions based on identified quality indicators.
c.	Identify trends in member survey responses that could be used to drive systemic policy changes and improvements
d.	Data shall be derived from a centralized database, or equivalent, such that it can undergo replication for future reports.
e.	Report recommendations to the Agency on a quarterly and annual basis.

F.	MFP Surveys. This scope of work shall extend through the duration of the MFP Program and will cease when the MFP Program ends. 
1.	The Contractor shall manage, monitor and maintain the Agency designated MFP participant survey to include but not limited to:
a.	Provide initial and ongoing training to contract staff on reliable interviewing techniques for the member survey tool being used.
b.	Revisions or newly developed components of the survey tool must be approved by the Agency and statistically validated.  Work with other units within the Agency to identify the representative sample to be surveyed.
c.	Ensure a representative sample of members from each HCBS waiver and Habilitation are interviewed each quarter at a 95% confidence level.
d.	Report interview findings to the Agency on a monthly, quarterly, and annual basis.
2.	The Contractor shall develop appropriate and universal follow up for MFP survey responses that are flagged to include but not limited to:
a.	The follow up questions mirror the language from the member survey tool, and as approved by the Agency.
b.	100% of flagged responses shall be remediated with a case manager or care coordinator within 15 business days.
c.	Documentation of the discovery, remediation, and improvement associated with flagged responses in an electronic database or equivalent.
d.	Development of communication strategies with case managers and care coordinators to facilitate improvement of the members’ experience, quality of life, and services. 
e.	Report findings to the Agency on a quarterly and annual basis.
3.	The Contractor shall make written recommendations to the Agency related to MFP surveys to include but not limited to:
a.	Recommendations identify system improvements and best practices in MFP surveys.
b.	Collaborate with other Iowa Medicaid Units to recommend policy revisions based on identified quality indicators.
c.	Identify trends in member survey responses that could be used to drive systemic policy changes and improvements.
d.	Data shall be derived from a centralized database, or equivalent, such that it can undergo replication for future reports.
e.	Report recommendations to the Agency on a quarterly and annual basis.

G.	HCBS Waiver Slot Management
1.	The Contractor shall at a minimum assign one full-time HCBS Slot Manager and one fully trained backup to manage HCBS Waiver allocations to include but not limited to:
a.	Process HCBS Waiver slot requests as received following the agency approved policy and procedure.
b.	Allocate slots based on waiver funding allocation and wait list characteristics including: 
i.	Waiver priority needs assessments (WPNA), and 
ii.	Reserved capacity slots (RCS)
c.	Meet with Agency staff as necessary to determine distribution strategy and discuss status.
d.	Publish funding allocations on the website within 10 business days of the end of the reporting period.
e.	Published status format must be accessible to the public and formatted as approved by the Agency.
f.	Report waiver slot and wait list data to the Agency on a monthly, quarterly, and annual basis.
g.	Ad hoc reporting, upon Agency request.

1.3.1.5 Population Health Improvement Special Projects
A.	Program of All Inclusive Care for the Elderly (PACE)
The Contractor shall support Agency PACE activities based on requirements set forth in 42 CFR Part 460, to include but not limited to: 
1.	PACE on-boarding and implementation
a.	Point of contact and responsible for onboarding all new or expanding PACE organizations. 
b.	Develop a tool to track, monitor, and review all onboarding documents, and three-way agreement between CMS, PACE, and the Agency. 
c.	Provide recommendations to the Agency on viability and the preparedness of the organization. 
d.	The contractor shall conduct all new or expanding PACE organizations readiness reviews, including review of documents and onsite visit to ensure the location meets all CRF and state requirements. The contractor shall identify deliverables and develop a data collection tool to document the review. The review shall include, but not limited to the following areas: 
i.	Licensure and accreditation
ii.	Subcontractors
iii.	Maintenance of records
iv.	Organizational structure
v.	Operational protocol
vi.	Written policies
vii.	Implementation plan
viii.	Marketing
ix.	Member communication
x.	Iowa Medicaid website updates
e.	In cooperation with CMS and the Agency for newly established or expanding PACE organizations, provide adequate staff to complete the initial technical assistance review. 
f.	The Contractor shall work with the newly established or expanding PACE organization to meet their timeline for their go live date. 
2.	PACE quality assurance and compliance
The Contractor shall operate a quality assurance and compliance monitoring plan for the PACE providers in accordance with 42 CFR Part 460, to include but not limited to: 
a.	Operate a quality assurance and compliance monitoring plan for PACE providers.
b.	Conduct at least one quality review on site annually utilizing the quality review process approved by the Agency, unless otherwise authorized by the Agency to conduct desk reviews, or a hybrid model of onsite and desk review. 
c.	In cooperation with CMS and the Agency, participate with adequate staff in the annual reviews of the PACE organization. 
d.	Conduct an initial exit conference with the PACE organization for the preliminary outcomes of the review. 
e.	Utilizing the Agency approved format, submit a written report on the findings of the quality assurance and compliance monitoring of PACE providers, as well as recommendations and any corrective actions, to the Agency within 30 business days of completion of the review. 
f.	Monitor and follow up to ensure corrective actions are implemented. 
g.	Clinical review of medical documentation by a licensed medical physician as requested. 
h.	Targeted reviews on specific participants when identified by the contractor, the Agency, or when the participant files a grievance with the Department. 
B.	Health Homes
The Contractor shall support Agency Health Home initiatives based on provisions within the Affordable Care Act of 2010 and Iowa Medicaid State plan, to include but not limited to:
1.	Health Home Coordinator
a.	Provide quality oversight of Health Home programs and remain flexible with program design.
b.	Keep current and advise the Agency regarding any innovative best practices to Health Home models including but not limited to, medical, dental, behavioral and LTSS, or related issues.
c.	Maintain and facilitate ongoing primary stakeholder understanding and buy-in on Health Home programs.
d.	Provide guidance and education necessary to engage potential Health Home clinics.
e.	Maintain the interface for reimbursement and incentive methodology to ensure care coordination and quality of care are part of the Health Home programs.
f.	Develop performance indicators to identify effective Health Homes for incentive payments.
g.	Develop a plan to monitor new Health Home programs screening and assessment outcomes.
h.	Facilitate evaluation of Health Home programs and CMS quality measure reporting.
i.	Answer MCO questions and review MCO documents related to Health Home programs, as requested by the Agency.
j.	Provide reports to the Agency monthly on Health Home activities and annually on Health Home savings. 
k.	Conduct Health Home provider record reviews for the FFS population enrolled in the Health Home Program completing a statistically valid sample on a monthly basis. 
l.	Make appropriate referrals to Program Integrity for any identified overpayments identified in the record reviews. 

C.	Quality Improvement
The contractor shall support Agency’s quality activities based on the requirements outlines in CFR 457.1240, 438.340, 438.6, to include but not limited to:
1.	The contractor shall facilitate a Quality Committee  
a.	Provide Quality Oversight of the Medicaid Quality Strategy;
b.	Support Policy staff to identify performance measures for their programs;
c.	Keep current and advise the Agency regarding innovative best practices; including the CMS national quality strategy goals found at this link:  CMS National Quality Strategy | CMS;
d.	Oversee performance indicators to identify areas of improvement; and
e.	Provide support to the MCO Bureau around Managed Care and PCCM performance measures.
2.	Facilitate pre-print evaluations for MCP directed payments in accordance with 42 CFR 438.6(c) 
a.	Ensure Provider’s evaluation aligns with the Quality Strategy;
b.	Monitor provider deadlines for compliance; and
c.	Provide technical assistance as needed to ensure provider success.
3.	Administrative management of Quality Incentive Payment Programs including:  
a.	Sending letters to NSGO facilities;
b.	Data collection and scoring of performance measures;
c.	Producing and maintaining scorecards; and
d.	Determine eligibility of a facilities quality of care rankings and coordinate with Iowa Medicaid policy and other Iowa Medicaid units to determine eligibility for the quality add-on payment.
4.	Prepare legislative reports for the Agency. 

1.3.1.6 Project Management and Administrative Support
A.	The Contractor shall provide administrative support for special projects as assigned by the Agency. 
1.	Ensure understanding of the special project needs and administrative support needs parameters; and
2.	Designate a staff member(s) to provide the administrative support based on project needs.
B.	The Contractor shall conduct project management as assigned by the Agency for special projects. 
C.	The Contractor shall: 
1.	Ensure understanding of the special project needs and project management parameters; 
2.	Conduct research necessary to understand the project need and make recommendations to the Agency; 
3.	Analyze information and data researched; 
4.	Determine the fiscal impact of potential recommendations to the Agency; 
5.	Recommend implementation concepts and approaches to the Agency; and
6.	Report research, analysis, fiscal impact, and recommendations to the Agency. 

1.3.1.7	DOJ Consent Decree and CMH Settlement
A.	The Contractor shall negotiate in good faith with the Agency on any amendments in response to the DOJ Consent Decree and/or the CMH settlement and the resulting budget. 

1.3.1.8  Turnover Phase
Within this final phase of the Contract, the Contractor turns over operations to a new contractor near the end of the Contract term. This phase is activated when the Agency enters into a contract with a new entity (such as a newly awarded contractor) and begins the process of transferring responsibility for operations to that entity. 
Once the turnover phase begins, the Contractor shall:
A.	Fully cooperate with the Agency and new entity. 
B.	Develop and comply with a turnover plan detailing the activities necessary to transfer responsibility for operations to the new entity.

1.3.2 Performance Measures.  
A.	General Requirements
1.	The Contractor shall respond to email or telephone inquiries from Members, authorized representatives, providers, or facilities within two business days of receipt. 
2.	The Contractor shall participate in 100% of assigned appeal hearings.
B.	Transition
1.	The Contractor shall submit transition and operations plans to the Agency for approval within 15 business days after execution of this Contract, unless specified otherwise. The Contractor shall receive final approval no later than 10 business days after first submission.
2.	The Contractor shall submit the communications, quality assurance, reporting, and training plans to the Agency for approval within 20 business days after execution of this Contract. The Contractor shall receive final approval no later than 10 business days after first submission.
3.	The Contractor shall submit SOPs to the Agency for approval within 25 business days after the execution of this Contract. The Contractor shall receive final approval no later than 10 business days after first submission. The Contractor shall document all SOP changes within 30 calendar days of the change.
C.	Medical Support
1.	Inquiries Related to Payable Codes for Provider Claims.
a.	The Contractor shall notify providers within five business days of receipt of a claims inquiry with missing or incomplete information. 
b.	The Contractor shall send the final determination letter on a claims inquiry to the provider within 10 business days of receipt of complete documentation. 
c.	The Contractor shall review CMS quarterly/annual code updates including verification of MMIS logic for claims processing within 30 days of release and present to the Agency for approval. 
2.	The Contractor shall open a minimum of 20 cases for provider reviews during each month. These include audits and investigations for post payment reviews for medical necessity. 
a.	All tips and notices received by the Contractor must be vetted within 2 business days of receipt. 
b.	All vetted tips must be opened for audits/investigation or referred to MCPs or MFCU within 10 business days. The Contractor shall close all tips and notices that are not opened or referred. 
c.	The Contractor shall provide a summary report of active audits and investigations bi-monthly per Agency direction. 
3.	ETPs.
a.	The Contractor shall provide ETP recommendations to Bureau staff within eight business days of receipt unless additional information is requested. 
b.	The Contractor shall request additional information, if needed, within two business days of ETP receipt. 
c.	The Contractor shall complete 95 percent of ETP determinations within 10 business days of receipt of complete information, and 100 percent within 20 business days. 
4.	PERM.
a.	The Contractor shall complete medical record reviews for the PERM project within 10 business days of receipt of records, to include physician review if required. 
D.	Utilization Management 
1.	HCBS PAs:
a.	The Contractor shall review and communicate decisions on 100 percent of HCBS PAs within two business days of requests of initial service plans once all required materials are received. 
b.	The Contractor shall review and communicate decisions within five business days of requests for reassessments of service plans once all required materials are received. 
c.	The Contractor shall arrange for peer-to-peer conversations, as requested, within one business day of request. 
2.	Medical PAs:
a.	The Contractor shall review and communicate decisions on 100 percent of Medical PA requests within 14 calendar days of initial receipt.
b.	The Contractor shall review and communicate decisions on expedited PA requests within 72 hours from receipt of the request. 
c.	The Contractor shall review and communicate decisions on 100 percent of PA requests that require an extension within 28 business days of initial receipt.  
3.	LOC and NBA Reviews:
a.	The Contractor shall complete 95 percent of Initial LOC and NBA determinations within two business days of receipt of complete information, and 100 percent within five business days. 
b.	The Contractor shall complete 95 percent of LOC-CSR and NBA-CSR determinations within five business days of receipt of complete information, and 100 percent within ten business days. 
4.	Utilization Reviews:
a.	The Contractor shall conduct annual onsite UR facility visits between months 10 and 12 months following the prior year visit. 
b.	The Contractor shall conduct UR hospital desk review every three years for each hospital. 
c.	The Contractor shall complete desk review of hospital utilization control process within 25 business days following receipt of submitted documentation. 
d.	The Contractor shall submit written UR findings report to the Agency within 30 business days of completion of each review. 
5.	Quality Reviews: 
a.	The Contractor shall complete quality reviews within 30 calendar days of receipt of all the information needed to complete the review. 
b.	The Contractor shall submit the quality review report within 30 calendar days after completion of the review for approval. 
E.	HCBS Quality Oversight Operations
1.	The Contractor shall submit provider review findings reports to the Agency within 15 business days of the review and approval. 
2.	The Contractor shall articulate the findings of the provider review to the provider within 15 business days of Agency approval. 
3.	HCBS Waiver and Habilitation Program Performance Measure Data Review:  
a.	Data aggregation should be completed within 10 business days of the receipt of the MCO HCBS performance data.
b.	The review findings shall be reported to the Agency within 15 days of completed data aggregation. 
4.	HCBS Incidents and Complaints:
a.	The Contractor shall complete initial assessments within 3 business days.
b.	The Contractor shall initiate fact-finding correspondence with relevant parties within 2 days of initial assessment.
5.	The Contractor shall submit to the Agency the provider self-assessment completion data within 15 business days of the self-assessment due date.
6.	The Contractor shall initiate referrals to Program Integrity for any delinquent self-assessments within 45 business days of the self-assessment due date. 
F.	HCBS Provider Reviews
1.	HCBS Certification Reviews of Enrolled Providers:
a.	Complete certification reviews of enrolled providers within 60 days prior to the expiration of the Provider’s certification.
b.	Issue the certification review report within 30 days of completion of the certification review.  
c.	Issue the response to the Provider’s submitted CAP within 30 days of receipt of the CAP. 
d.	Report certification review findings to the Agency by the 15th day following the close of the quarter. 
e.	
2.	HCBS Provider Reviews (Targeted, Focused, and Periodic)
a.	Complete certification reviews of enrolled providers within 60 days prior to the expiration of the Provider’s certification.
b.	Issue the certification review report within 30 days of completion of the certification review.  
c.	Issue the response to the Provider’s submitted CAP within 30 days of receipt of the CAP. 
d.	Report certification review findings to the Agency by the 15th day following the close of the quarter. 
3.	CNRS Quality Reviews:
a.	CNRS quality reviews must be completed within 60 days prior to the expiration of the Provider’s certification.
b.	Issue the certification review report within 30 days of completion of the certification review.  
c.	Issue the response to the Provider’s submitted CAP within 30 days of receipt of the CAP. 
d.	Report CNRS quality review to the Agency by the 15th day following the close of the quarter. 
4.	Complaints: 
a.	The Contractor shall log data within 24 hours of receipt of the complaint. 
b.	The Contractor shall initiate the complaint assessment within 3 business days of receipt of the complaint that does not include immediate jeopardy for the Member. 
c.	The Contractor shall initiate the complaint assessment where immediate jeopardy has been identified within 24 hours of the receipt of the complaint. 
G.	FFS and MCO critical incidents data 
a.	The Contractor shall aggregate and analyze critical incident data monthly, and report the findings to the Agency by the 15th business day of the following month in a format approved by the Agency. 
H.	PACE
1.	The Contractor shall submit the written PACE findings report to the Agency within 30 business days of completion of the review.
I.	Reporting 
1.	The Contractor shall deliver accurate and timely reports to the Agency. All submitted reports shall be clear, concise, objective, free from typographical and grammatical errors, and come to logical conclusions. 
2.	Unless otherwise specified, the Contractor shall provide all identified reports in an Agency-approved format and in accordance with timeframes established in the Agency-approved reporting plan. 
3.	The Contractor shall submit reports within the timeframes established in the Agency-approved reporting plan and according to the following schedule, unless otherwise specified within the Agency-approved reporting plan:  
a.	Weekly reports: within two business days of end of reporting period;
b.	Monthly reports: within ten business days of end of reporting period;  
c.	Quarterly reports: within fifteen business days of end of reporting period;
d.	Annual reports: within twenty business days of end of reporting period; and
e.	Ad hoc reports: within two business days of request, unless otherwise specified. The Contractor will track ad hoc requests with due date and delivery date, reporting with monthly reporting.  
f.	Reporting log: The Contractor will include with the monthly report a list of regularly occurring and ad hoc reports including data on reports requested, reports completed, reports submitted, who reports were submitted to, and relevant dates. 
4.	For those reports that will be released to external stakeholders, and other special reports as identified within the reporting plan, the Contractor shall:  
a.	Submit a draft to the Agency for review 30 calendar days prior to the release date. 
b.	Revised reports shall be submitted within 5 business days of request unless otherwise indicated by the Agency. 

1.3.3 Contract Payment Methodology.
a.	The Contractor will be paid a fixed amount for services rendered, in accordance with the pricing set forth in Special Contract Attachment F (i.e., the Cost Proposal).
b.	The Contractor will be paid volume-based pricing for MCO Ride Alongs.  
c.	Withhold of First Payment. The Agency will withhold the first monthly payment until such time as the final work plans and SOPs are accepted by the Agency.
d.	Deliverables and Performance Measure Withholding Payment. The Contractor may invoice 92% of the fixed amount each month. The Agency will withhold 8% of the monthly amount to assure the Contractor meets required Deliverables and Performance Measures as follows: 
i.	Section 1.3.2.D Utilization Management - 3% of the monthly amount
ii.	Section 1.3.2.E HCBS Quality Oversight Operations - 2% of the monthly amount
iii.	Section 1.3.2.I Reporting - 3% of the monthly amount 
In order to claim the withhold amount, the Contractor must show in the monthly performance report that each performance measure has been met. Determination of whether performance measures have been met is strictly and solely at the discretion of the Agency.
e.	Withholding of Final Payment.  The Agency may withhold the last full monthly payment due at the end of the Contract until such time as the Contractor has fully completed all Turnover activities and completely closed out the Contract.

Section 2  Basic Information About the RFP Process	

2.1  Issuing Officer.
The Issuing Officer is the sole point of contact regarding the RFP from the date of issuance until selection of the successful Bidder.  The Issuing Officer for this RFP is:
Pauline Rutherford
321 E 12th Street
Des Moines, IA 50319
Phone:  515-414-6613
RFPMED-25-002@dhs.state.ia.us

2.2  Restriction on Bidder Communication. 
From the issue date of this RFP until announcement of the successful Bidder, the Issuing Officer is the point of contact regarding the RFP.  There may be no communication regarding this RFP with any State employee other than the Issuing Officer, except at the direction of the Issuing Officer or as otherwise noted in the RFP.  This section shall not be construed as restricting communications related to the administration of any contract currently in effect between a Contractor and the Agency.

The Issuing Officer will respond only to questions regarding the procurement process.  Questions pertaining to the interpretation of this RFP may be submitted in accordance with the Questions, Requests for Clarification, and Suggested Changes section of this RFP.  

2.3  Downloading the RFP from the Internet.
The RFP and any related documents such as amendments or attachments (collectively the “RFP”), and responses to questions will be posted at the State of Iowa’s website for bid opportunities:  http://bidopportunities.iowa.gov/.  Check this website periodically for any amendments to this RFP.  The posted version of the RFP is the official version.  The Agency will only be bound by the official version of the RFP document(s).  Bidders should ensure that any downloaded documents are in fact the most up to date and are unchanged from the official version.  

2.4  Online Resources
Resourced related to this RFP are available at the following website: Bidder’s Library. 
Materials available electronically include: 
	Medicaid Program Information
	Iowa Medicaid Organization Chart
	QIO Contract
	Operational Procedures
	Report Examples
	Vendor Security Questionnaire
	Telework Policy
	Medicaid Dashboard
	HCBS Program Information
A notice will be posted in Bid Opportunities if additional resources are added. 

2.5  Intent to Bid.
The Agency requests that Bidders provide their intent to bid by email to the Issuing Officer by the date and time in the Procurement Timetable.  The Bidder may wish to request confirmation of receipt of the email from the Issuing Officer to ensure delivery.  Do not submit letters of intent by mail, shipping service, or hand delivery.  The intent to bid should include the Bidder's name, contact person, mailing address, email address, telephone number, and a statement of intent to submit a bid in response to this RFP.  Though it is not mandatory that the Agency receive an intent to bid, the Agency will only respond to questions about the RFP that have been submitted by Bidders who have expressed their intent to bid.  The Agency may cancel an RFP for lack of interest based on the number of letters of intent to bid received.    

2.6  Reserved.  (Bidders’ Conference)

2.7  Questions, Requests for Clarification, and Suggested Changes. 
Bidders who have provided their intent to bid on the RFP are invited to submit written questions, requests for clarifications, and/or suggestions for changes to the specifications of this RFP (hereafter “Questions”) by the due date and time provided in the Procurement Timetable.  Bidders are not permitted to include assumptions in their Bid Proposals.  Instead, Bidders shall address any perceived ambiguity regarding this RFP through the question and answer process.  If the Questions pertain to a specific section of the RFP, the page and section number(s) must be referenced.  Bidders shall submit questions to the Issuing Officer by email.  The Bidder may wish to request confirmation of receipt from the Issuing Officer to ensure delivery.  Do not submit questions by mail, shipping service, or hand delivery.

The Agency will post responses to questions received on the State’s website at: http://bidopportunities.iowa.gov/ by the dates provided in the Procurement Timetable.  Follow-up questions to initial responses are permissible as long as all questions are received by the final due date and time for Bidder Questions as provided in the Procurement Timetable.  

The Agency assumes no responsibility for verbal representations made by its officers or employees unless such representations are confirmed in writing and incorporated into the RFP.  In addition, the Agency’s written responses to Questions will not be considered part of the RFP.  If the Agency decides to change the RFP, the Agency will issue an amendment.    

2.8  Submission of Bid Proposal.
Each Bidder is responsible for ensuring that the Issuing Officer receives the Bid Proposal by the time and date specified in the Procurement Timetable at the address provided in the RFP for the Issuing Officer.  The Agency will not waive this mandatory requirement.  Any Bid Proposal received after this deadline will be rejected and will not be evaluated.  

Bid Proposals are to be submitted in accordance with the Bid Proposal Formatting section of this RFP.  Bid Proposals may not be hand-delivered to the Issuing Officer.  Rather, Bid Proposals are to be mailed through the postal service or shipping service.   

2.9  Amendment to the RFP and Bid Proposal.    
Each Bidder is responsible for ensuring that the Issuing Officer receives the Bid Proposal and any permitted amendments by the established deadlines at the address provided in the RFP for the Issuing Officer.  Amendments must be received utilizing the same delivery method as set forth in the RFP for the submission of the original Bid Proposal.

Bidders may amend a previously submitted Bid Proposal at any time before the bid submission date and time.  Any such amendment must be in writing and signed by the Bidder.  The Bidder shall provide the same number of copies of the amended Bid Proposal as is required for the original Bid Proposal, for both hardcopy and electronic copies, in accordance with the Bid Proposal Formatting Section.  

The Agency reserves the right to amend or provide clarifications to the RFP at any time.  RFP amendments will be posted to the State’s website at http://bidopportunities.iowa.gov/.  If an RFP amendment occurs after the closing date for receipt of Bid Proposals, the Agency may, in its sole discretion, allow Bidders to amend their Bid Proposals.    

2.10  Withdrawal of Bid Proposal.
The Bidder may withdraw its Bid Proposal prior to the closing date for receipt of Bid Proposals by submitting a written request to withdraw signed by the Bidder, scanned, then emailed to the Issuing Officer.  The Bidder should request confirmation of receipt of the email from the Issuing Officer to ensure delivery.

2.11  Costs of Preparing the Bid Proposal.
The costs of preparation and delivery of the Bid Proposal are solely the responsibility of the Bidder.      

2.12  Rejection of Bid Proposals.
The Agency reserves the right to reject any or all Bid Proposals, in whole and in part, and to cancel this RFP at any time prior to the execution of a written contract.  Issuance of this RFP in no way constitutes a commitment by the Agency to award or enter into a contract.    

2.13  Review of Bid Proposals.
Only Bidders that meet the mandatory requirements and are not subject to disqualification will be considered for award of a contract.    

2.13.1  Mandatory Requirements.
Bidders must meet these mandatory requirements or will be disqualified and not considered for award of a contract: 

•	The Issuing Officer must receive the Bid Proposal, and any amendments thereof, prior to or on the due date and time (See RFP Sections 2.8 and 2.9).
•	The Bidder is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from receiving federal funding by any federal department or agency (See RFP Additional Certifications Attachment).
•	The Bidder is eligible to submit a bid in accordance with the Bidder Eligibility Requirements of this RFP (See RFP Bidder Eligibility Requirements Section).  
•	The Bidder’s Cost Proposal adheres to any pricing restrictions regarding the project budget or administrative costs (See RFP Section 3.3). 

2.13.2  Reasons Proposals May be Disqualified.
Bidders are expected to follow the specifications set forth in this RFP.  However, it is not the Agency’s intent to disqualify Bid Proposals that suffer from correctible flaws.  At the same time, it is important to maintain fairness to all Bidders in the procurement process.  Therefore, the Agency reserves the discretion to permit cure of variances, waive variances, or disqualify Bid Proposals for reasons that include, but may not be limited to, the following: 

•	Bidder initiates unauthorized contact regarding this RFP with employees other than the Issuing Officer (See RFP Section 2.2);
•	Bidder fails to comply with the RFP’s formatting specifications so that the Bid Proposal cannot be fairly compared to other bids (See RFP Section 3.1);
•	Bidder fails, in the Agency’s opinion, to include the content required for the RFP;
•	Bidder fails to be fully responsive in the Bidder’s Approach to Meeting Deliverables Section, states an element of the Scope of Work cannot or will not be met, or does not include information necessary to substantiate that it will be able to meet the Scope of Work specifications (See RFP Section 3.2.3); 
•	Bidder’s response materially changes Scope of Work specifications;
•	Bidder fails to submit the RFP attachments containing all signatures (See RFP Section 3.2.6);
•	Bidder marks entire Bid Proposal confidential, makes excessive claims for confidential treatment, or identifies pricing information in the Cost Proposal as confidential (See RFP Section 3.1);
•	Bidder includes assumptions in its Bid Proposal (See RFP Section 2.7); or
•	Bidder fails to respond to the Agency’s request for clarifications, information, documents, or references that the Agency may make at any point in the RFP process.
•	Bidder is a “scrutinized company” included on a “scrutinized company list” created by a public fund pursuant to Iowa Code §12J. This list is maintained by the Iowa Public Employees’ Retirement System. The list is currently found here: https://ipers.org/investments/restrictions.  

The determination of whether or not to disqualify a proposal and not consider it for award of a contract for any of these reasons, or to waive or permit cure of variances in Bid Proposals, is at the sole discretion of the Agency.  No Bidder shall obtain any right by virtue of the Agency’s election to not exercise that discretion.  In the event the Agency waives or permits cure of variances, such waiver or cure will not modify the RFP specifications or excuse the Bidder from full compliance with RFP specifications or other contract requirements if the Bidder enters into a contract.  

2.14  Bid Proposal Clarification Process.    	
The Agency may request clarifications from Bidders for the purpose of resolving ambiguities or questioning information presented in the Bid Proposals.  Clarifications may occur throughout the Bid Proposal evaluation process.  Clarification responses shall be in writing and shall address only the information requested.  Responses shall be submitted to the Agency within the time stipulated at the occasion of the request.    

2.15  Verification of Bid Proposal Contents.    
The contents of a Bid Proposal submitted by a Bidder are subject to verification.  

2.16  Reference Checks.
The Agency reserves the right to contact any reference to assist in the evaluation of the Bid Proposal, to verify information contained in the Bid Proposal, to discuss the Bidder’s qualifications, and/or to discuss the qualifications of any subcontractor identified in the Bid Proposal.    

2.17  Information from Other Sources.
The Agency reserves the right to obtain and consider information from other sources concerning a Bidder, such as the Bidder’s capability and performance under other contracts, and the Bidder’s authority and ability to conduct business in the State of Iowa.  Such other sources may include subject matter experts.      

2.18  Criminal History and Background Investigation.
The Agency reserves the right to conduct criminal history and other background investigations of the Bidder, its officers, directors, shareholders, or partners and managerial and supervisory personnel retained by the Bidder for the performance of the resulting contract.  The Agency reserves the right to conduct criminal history and other background investigations of the Bidder’s staff and subcontractors providing services under the resulting contract.    

2.19  Disposition of Bid Proposals.    
Opened Bid Proposals become the property of the Agency and will not be returned to the Bidder.  Upon issuance of the Notice of Intent to Award, the contents of all Bid Proposals will be in the public domain and be open to inspection by interested parties subject to exceptions provided in Iowa Code chapter 22 or other applicable law.    

2.20  Public Records and Request for Confidential Treatment.
Original information submitted by a Bidder may be treated as public information by the Agency following the conclusion of the selection process unless the Bidder properly requests that information be treated as confidential at the time of submitting the Bid Proposal.  See the Bid Proposal Formatting Section for the proper method for making such requests.  The Agency’s release of information is governed by Iowa Code chapter 22.  Bidders are encouraged to familiarize themselves with Chapter 22 before submitting a Bid Proposal.  The Agency will copy public records as required to comply with public records laws.    

The Agency will treat the information marked confidential as confidential information to the extent such information is determined confidential under Iowa Code chapter 22 or other applicable law by a court of competent jurisdiction.  However, the Bidder shall certify by signing and returning RFP Attachment B its understanding that any Agency references to Bid Proposal information marked confidential made during the evaluation process may become part of the public domain  

In the event the Agency receives a request for information marked confidential, written notice shall be given to the Bidder seventy-two (72) hours prior to the release of the information to allow the Bidder to seek injunctive relief pursuant to Iowa Code § 22.5 or 22.8.    

The Bidder’s failure to request confidential treatment of material pursuant to this section and the relevant law will be deemed, by the Agency and State personnel, as a waiver of any right to confidentiality that the Bidder may have had.    

2.21  Copyrights.
By submitting a Bid Proposal, the Bidder agrees that the Agency may copy the Bid Proposal for purposes of facilitating the evaluation of the Bid Proposal or to respond to requests for public records.  By submitting a Bid Proposal, the Bidder acknowledges that additional copies may be produced and distributed, and represents and warrants that such copying does not violate the rights of any third party.  The Agency shall have the right to use ideas or adaptations of ideas that are presented in the Bid Proposals.    

2.22  Release of Claims.
By submitting a Bid Proposal, the Bidder agrees that it shall not bring any claim or cause of action against the Agency based on any misunderstanding concerning the information provided herein or concerning the Agency's failure, negligent or otherwise, to provide the Bidder with pertinent information as intended by this RFP.    

2.23  Reserved.  (Presentations)  

2.24  Notice of Intent to Award.
Notice of Intent to Award will be sent to all Bidders that submitted a Bid Proposal by the due date and time.  The Notice of Intent to Award does not constitute the formation of a contract between the Agency and the apparent successful Bidder.    

2.25  Acceptance Period.
The Agency shall make a good faith effort to negotiate and execute the contract.  If the apparent successful Bidder fails to negotiate and execute a contract, the Agency may, in its sole discretion, revoke the Notice of Intent to Award and negotiate a contract with another Bidder or withdraw the RFP.  The Agency further reserves the right to cancel the Notice of Intent to Award at any time prior to the execution of a written contract.    

2.26  Review of Notice of Disqualification or Notice of Intent to Award Decision.
Bidders may request reconsideration of either a notice of disqualification or notice of intent to award decision by submitting a written request to the Agency:    

Bureau Chief
c/o Bureau of Service Contract Support
Department of Health and Human Services 
	Lucas State Office Building
321 E 12th Street
Des Moines, Iowa 50319-0075
email:  reconsiderationrequest@dhs.state.ia.us

The Agency must receive the written request for reconsideration within five days from the date of the notice of disqualification.  The written request may be emailed or delivered by postal service or other shipping service.  Do not deliver any requests for reconsideration to the office in person.  It is the Bidder’s responsibility to ensure that the request for reconsideration is received prior to the deadline.  Postmarking or submission to a shipping service by the due date shall not substitute for actual receipt of a request for reconsideration by the Agency. 

The request for reconsideration shall clearly and fully identify all issues being contested by reference to the page and section number of the RFP.  If a Bidder submitted multiple Bid Proposals and requests that the Agency reconsider a notice of disqualification or notice of intent to award decision for more than one Bid Proposal, a separate written request shall be submitted for each.  At the Agency’s discretion, requests for reconsideration from the same Bidder may be reviewed separately or combined into one response.  The Agency will expeditiously address the request for reconsideration and issue a decision.  The Bidder may choose to file an appeal with the Agency within five days of the date of the decision on reconsideration in accordance with 441 IAC 7.41 et seq.  
 
2.27  Definition of Contract.
The full execution of a written contract shall constitute the making of a contract for services and no Bidder shall acquire any legal or equitable rights relative to the contract services until the contract has been fully executed by the apparent successful Bidder and the Agency.    

2.28  Choice of Law and Forum.
This RFP and the resulting contract are governed by the laws of the State of Iowa without giving effect to the conflicts of law provisions thereof.  Changes in applicable laws and rules may affect the negotiation and contracting process and the resulting contract.  Bidders are responsible for ascertaining pertinent legal requirements and restrictions.  Any and all litigation or actions commenced in connection with this RFP shall be brought and maintained in the appropriate Iowa forum.    

2.29  Restrictions on Gifts and Activities.    	
Iowa Code chapter 68B restricts gifts that may be given or received by state employees and requires certain individuals to disclose information concerning their activities with state government.  Bidders must determine the applicability of this Chapter to their activities and comply with the requirements.  In addition, pursuant to Iowa Code § 722.1, it is a felony offense to bribe or attempt to bribe a public official.    

2.30  Exclusivity.
Any contract resulting from this RFP shall not be an exclusive contract.

2.31  No Minimum Guaranteed.
The Agency anticipates that the selected Bidder will provide services as requested by the Agency.  The Agency does not guarantee that any minimum compensation will be paid to the Bidder or any minimum usage of the Bidder’s services. 

2.32  Use of Subcontractors.
The Agency acknowledges that the selected Bidder may contract with third parties for the performance of any of the Contractor’s obligations.  The Agency reserves the right to provide prior approval for any subcontractor used to perform services under any contract that may result from this RFP.

2.33 Bidder Continuing Disclosure Requirement.
To the extent that Bidders are required to report incidents when responding to this RFP related to damages, penalties, disincentives, administrative or regulatory proceedings, founded child or dependent adult abuse, or felony convictions, these matters are subject to continuing disclosure to the Agency.  Incidents occurring after submission of a Bid Proposal, and with respect to the successful Bidder after the execution of a contract, shall be disclosed in a timely manner in a written statement to the Agency.  For purposes of this subsection, timely means within thirty (30) days from the date of conviction, regardless of appeal rights.  

Section 3 How to Submit A Bid Proposal: Format and Content Specifications
These instructions provide the format and technical specifications of the Bid Proposal and are designed to facilitate the submission of a Bid Proposal that is easy to understand and evaluate.  

3.1  Bid Proposal Formatting.
Subject		Specifications	
Paper Size	8.5" x 11" paper (one side only).  Charts or graphs may be provided on legal-sized paper.	
Font	Bid Proposals must be typewritten.  The font must be 11 point or larger (excluding charts, graphs, or diagrams).  Acceptable fonts include Times New Roman, Calibri and Arial. 	
«IF Page Limitations» Page Limit	Pages included in Proposal Tab 3 and any attachments the Bidder creates in a “Tab 3 Attachments” section is limited to 250 pages. See Section 3.2 for further information about Tab 3 Attachments.  	
Pagination	All pages in Proposal Tabs 1-5 are to be sequentially numbered from beginning to end (do not number these Proposal sections independently of each other).  The contents in Proposal Tab 6 may be numbered independently of other sections.	
Bid Proposal General Composition
	•	Bid Proposals shall be divided into two parts: Technical Proposal and Cost Proposal. 
•	Technical Proposals submitted in multiple volumes shall be numbered in the following fashion: 1 of 4, 2 of 4, etc.
•	Bid Proposals must be bound and use tabs to label sections.	

Envelope Contents and Labeling 	•	Envelopes shall be addressed to the Issuing Officer.
•	The envelope containing the original Bid Proposal shall be labeled “original.” The Technical and Cost Proposal must be packaged separately. 	

Number of Hard Copies	Submit one (1) original hard copy of the Proposal (separate Technical and Cost proposals).  The original hard copy must contain original signatures.  	
USB Flash Drive	•	The Technical Proposal and Cost Proposal must be provided on separate USB flash drives.  Bidders shall submit two flash drives, each with a copy identical to the content of the original hard copy of the Technical Proposal and two flash drives of the Cost Proposal, each with a copy identical to the content of the original hard copy of the Cost Proposal.  
•	The Technical Proposal must be saved in less than three files, with a preference for the entire Technical Proposal in one file.  Proposals shall be provided in either PDF or Microsoft Word format.  Files shall be text-based and not scanned image(s) and shall be searchable and not password protected or contain restrictions that prevent copying, saving, highlighting, or printing of the contents.   	
Request for Confidential Treatment	Requests for confidential treatment of any information in a Bid Proposal must meet these specifications:
•	The Bidder will complete the appropriate section of the Primary Bidder Detail Form & Certification which requires the specific statutory citation supporting the request for confidential treatment and an explanation of why disclosure of the information is not in the best interest of the public. 
•	The Bidder shall submit one complete paper copy of the Bid Proposal from which confidential information has been redacted.  This copy shall be clearly labeled on the cover as a “public copy” and each page upon which confidential information appears shall be conspicuously marked as containing confidential information.  The confidential material shall be redacted in such a way as to allow the public to determine the general nature of the material removed.  To the extent possible, pages should be redacted sentence by sentence unless all material on a page is clearly confidential under the law.  The Bidder shall not identify the entire Bid Proposal as confidential.    
•	The Cost Proposal will be part of the ultimate contract entered into with the successful Bidder.  Pricing information may not be designated as confidential material.  However, Cost Proposal supporting materials may be marked confidential if consistent with applicable law.   
•	The transmittal letter may not be marked confidential.   
•	The Bidder shall submit a USB flash drive containing an electronic copy of the Bid Proposal from which confidential information has been redacted.  This USB flash drive shall be clearly marked as a “public copy”.  
•	The Technical Proposal must be saved in less than three files, with a preference for the entire Technical Proposal in one file.  Proposals shall be provided in either PDF or Microsoft Word format.  Files shall be text-based and not scanned image(s) and shall be searchable and not password protected or contain restrictions that prevent copying, saving, highlighting, or printing of the contents.  	
Exceptions to RFP/Contract Language
	If the Bidder objects to any term or condition of the RFP or attached Sample Contract, specific reference to the RFP page and section number shall be made in the Primary Bidder Detail & Certification Form.  In addition, the Bidder shall set forth in its Bid Proposal the specific language it proposes to include in place of the RFP or contract provision and cost savings to the Agency should the Agency accept the proposed language.
The Agency reserves the right to either execute a contract without further negotiation with the successful Bidder or to negotiate contract terms with the selected Bidder if the best interests of the Agency would be served. 	

3.2  Contents and Organization of Technical Proposal.
This section describes the information that must be in the Technical Proposal.  Bid Proposals should be organized into sections in the same order provided here.  Hard copies of Bid Proposals should use tabs to separate each section.  If a Bidder chooses to provide information in attachments to respond to any section below, please create a new tabbed attachment section immediately behind the applicable section.  For example, to add attachments related to information asked for in Section 3.2.3 Information to Include Behind Tab 3: Bidder’s Approach to Meeting Deliverables, the Bidder would create a new tab in the Technical Proposal that is called Tab 3 Attachments and place the attachment(s) there.  The Bidder would follow suit by creating new tabbed sections for attachments created to respond to any other section below in their bid proposal

3.2.1  Information to Include Behind Tab 1:
Transmittal Letter.
The transmittal letter serves as a cover letter for the Technical Proposal.  It must consist of an executive summary that briefly reviews the strengths of the Bidder and key features of its proposed approach to meet the specifications of this RFP.  

3.2.2  Information to Include Behind Tab 2: Proposal Table of Contents.
The Bid Proposal must contain a table of contents.

3.2.3  Information to Include Behind Tab 3: Bidder’s Approach to Meeting Deliverables.
The Bidder shall address each Deliverable that the successful contractor will perform as listed in Section 1.3, Scope of Work, by first restating the Deliverable from the RFP and then detailing the Bidder’s planned approach to meeting each contractor Deliverable immediately after the restated text.  Bid responses should provide sufficient detail so that the Agency can understand and evaluate the Bidder’s approach, and should not merely repeat the Deliverable.    

Bidders are given wide latitude in the degree of detail they offer or the extent to which they reveal plans, designs, examples, processes, and procedures.  Bidders do not need to address any responsibilities that are specifically designated as Agency responsibilities.

Note:
•	Responses to Deliverables shall be in the same sequence as presented in the RFP.  
•	Bid Proposals shall identify any deviations from the specifications the Bidder cannot satisfy.  
•	Bid Proposals shall not contain promotional or display materials unless specifically required.

If a Bidder proposes more than one method of meeting the RFP requirements, each method must be drafted and submitted as separate Bid Proposals.  Each will be evaluated separately.  

3.2.3.1  Special Submissions.
The Agency is requesting the following information in addition to the contents immediately above.  

3.2.3.1.1 Draft project work plans detailing activities and timelines, to include:
1.	Transition Plan
2.	Operations Plan

3.2.3.1.2 Proof of licensure for the following key staff: 
1.	Medicaid Medical Director (MMD) – MD or DO

3.2.3.1.3 Proof of CMS QIO or QIO-like entity designation. 

3.2.4  Information to Include Behind Tab 4: Bidder’s Experience.  

3.2.4.1  Level of technical experience in providing the types of services sought by the RFP.

3.2.4.2  Description of all services similar to those sought by this RFP that the Bidder has provided to the Agency and other businesses or governmental entities within the last twenty-four (24) months. 
For each similar service, provide a matrix detailing:    

A.	Project title; 
B.	Project role (primary contractor or subcontractor); 
C.	Name of client agency or business; 
D.	General description of the scope of work;
E.	Start and end dates of contract as originally entered into between the parties; 
F.	If there were any alteration(s) to the contract timeframe(s) or the contract was terminated for any other reason before completion of all obligations under the contract provisions, fully explain the reason(s) for the alteration or termination;
G.	Total value of the contract at the time it was executed and any alteration(s) to that amount.  Provide reason(s) for the alteration(s) to the contract value; 
H.	Whether the services were provided timely and within budget;
I.	Any damages, penalties, disincentives assessed, or payments withheld, or anything of value traded or given up by the Bidder that are valued at or above $500,000.  Include the estimated cost assessed against the Bidder for the incident with the details of the occurrence;
J.	List administrative or regulatory proceedings or adjudicated matters related to this service to which the Bidder has been a party; and
K.	Contact information for the client’s project manager including address, telephone number, and email address. 

3.2.4.3  Letters of reference from three (3) of the Bidder’s previous clients knowledgeable of the Bidder’s performance in providing services similar to those sought in this RFP, including a contact person, telephone number, and email address for each reference.  It is preferred that letters of reference are provided for services that were procured in a competitive environment.  Form letters of reference that do not elaborate on the Bidder’s performance under the specific relationships addressed in the reference letter may negatively impact the Bidder’s evaluation/score.  Persons who are currently employed by the Agency are not eligible to be references.  

3.2.4.4  Description of experience managing subcontractors, if the Bidder proposes to use subcontractors.

3.2.5  Information to Include Behind Tab 5:  Personnel.  
The Bidder shall provide the following information regarding personnel:  

3.2.5.1  Tables of Organization.
Illustrate the lines of authority in two tables:
•	One showing overall operations
•	One showing staff who will provide services under the RFP  

3.2.5.2 Names and Credentials of Key Corporate Personnel. 
•	Include the names and credentials of the owners and executives of your organization and, if applicable, their roles on this project.  
•	Include names of the current board of directors, or names of all partners, as applicable.  
•	Include resumes for all key corporate, administrative, and supervisory personnel who will be involved in providing the services sought by this RFP.  The resumes should include: name, education, years of experience, and employment history, particularly as it relates to the scope of services specified herein.  Resumes shall not include social security numbers.

3.2.5.3  Information About Project Manager and Key Project Personnel.
•	Include names and credentials for the project manager and any additional key project personnel who will be involved in providing services sought by this RFP.  Include resumes for these personnel. The resumes shall include: name, education, and years of experience and employment history, particularly as it relates to the scope of services specified herein.  Resumes shall also include the percentage of time the person would be specifically dedicated to this project on a monthly basis, if the Bidder is selected as the successful Bidder.  Resumes should not include social security numbers.
•	Include the project manager’s experience managing subcontractor staff if the Bidder proposes to use subcontractors.

3.2.5.4  Disclosures.
List any details of whether the Bidder or any owners, officers, primary partners, staff providing services or any owners, officers, primary partners, or staff providing services of any subcontractor who may be involved with providing the services sought in this RFP, have ever had a founded child or dependent adult abuse report, or been convicted of a felony.  

3.2.6 Information to Include Behind Tab 6: RFP Forms.
The forms listed below are attachments to this RFP.  Fully complete and return these forms behind Tab 6:
•	Release of Information Form
•	Primary Bidder Detail & Certification Form
•	Subcontractor Disclosure Form (one for each proposed subcontractor)
•	Certification and Disclosure Regarding Lobbying

3.2.7  Reserved.  (Financial Statements)

3.3  Cost Proposal. 
Content and Format.
The Cost Proposal shall be submitted using the pricing worksheet set forth in Attachment F of this RFP. Bidders should submit both an Excel and a PDF version of Attachment F. 

The Bidder’s Cost Proposal shall include all charges of any kind associated with the goods and services offered by the bidder in order to meet all RFP requirements. Bidders are instructed to not bid a cost for the transition period prior to start of operations. Any charges associated with the Contract transition period shall be reflected in operations costs beginning July 1, 2024. The Agency will not be liable for any fees or charges for the goods and services offered by the bidder that are not set forth in the Cost Proposal. 

Bidders shall submit a pricing sheet for MCO Ride Along volume based pricing. 

Section 4 Evaluation Of Bid Proposals

4.1  Introduction.
This section describes the evaluation process that will be used to determine which Bid Proposal provides the greatest benefit to the Agency.  When making this determination, the Agency will not necessarily award a contract to the Bidder offering the lowest cost to the Agency or to the Bidder with the highest point total.  Rather, a contract will be awarded to the Bidder that offers the greatest benefit to the Agency. 

4.2  Evaluation Committee.
The Agency intends to conduct a comprehensive, fair, and impartial evaluation of Bid Proposals received in response to this RFP.  In making this determination, the Agency will be represented by an evaluation committee.  

4.3  Proposal Scoring and Evaluation Criteria.  
The evaluation committee will use the method described in this section to assist with initially determining the relative merits of each Bid Proposal.

Scoring Guide.
Points will be assigned to each evaluation component as follows, unless otherwise designated:
4 	Bidder has agreed to comply with the requirements and provided a clear and compelling description of how each requirement would be met, with relevant supporting materials.  Bidder’s proposed approach frequently goes above and beyond the minimum requirements and indicates superior ability to serve the needs of the Agency.	
3	Bidder has agreed to comply with the requirements and provided a good and complete description of how the requirements would be met.  Response clearly demonstrates a high degree of ability to serve the needs of the Agency.	
2	Bidder has agreed to comply with the requirements and provided an adequate description of how the requirements would be met.  Response indicates adequate ability to serve the needs of the Agency.	
1	Bidder has agreed to comply with the requirements and provided some details on how the requirements would be met.  Response does not clearly indicate if all the needs of the Agency will be met.	
0	Bidder has not addressed any of the requirements or has provided a response that is limited in scope, vague, or incomplete.  Response did not provide a description of how the Agency’s needs would be met.	

Technical Proposal Components.
When Bid Proposals are evaluated, the total points for each component are comprised of the component’s assigned weight multiplied by the score the Bid Proposal earns.  Points for all components will be added together.  The evaluation components, including maximum points that may be awarded, are as follows:
Technical Proposal Components	Weight	Score (0-4)	Potential Maximum Points	
General Obligations (Section 1.3.1.1)	40		160	
Transition (Section 1.3.1.2)	20		80	
Medical and LTSS Operations (Section 1.3.1.3) 				
Medical Support (Section 1.3.1.3.A)	45		180	
Utilization Management- PA (Section 1.3.1.3.B.1)	40		160	
Utilization Management- LOC and NBA     Reviews (Section 1.3.1.3.B.2)	50		200	
Utilization Management- Other (Section 1.3.1.3.B.3-6)	30		120	
Quality Oversight Operations for HCBS and Habilitation Programs (Section 1.3.1.4)				
General Requirements (Section 1.3.1.4.A)	10		40	
HCBS Provider Reviews (Section 1.3.1.4.B)	60		240	
HCBS Waiver, Habilitation, and MFP Program Complaints and Incident Reporting Management (Section 1.3.1.4.C-D)	50		200	
HCBS Waiver and Habilitation Member Surveys, MFP Surveys, and Slot Management (Section 1.3.1.4.E-G)	30		120	
Population Health Improvement Special Projects (Section 1.3.1.5)				
Program of All-Inclusive Care for the Elderly (PACE) (Section 1.3.1.5.A)	15		60	
Health Homes (Section 1.3.1.5.B)	10		40	
Quality Improvement (Section 1.3.1.5.C)	20		80	
Turnover (Section 1.3.1.6)	10		40	
Bidders Experience (Section 3.2.4)	150		600	
Personnel (Section 3.2.5) 	120		480	
Total Potential Score	700		2,800	

Scoring of Cost Proposal Pricing.
Cost Proposal pricing will be scored based on a ratio of the lowest Cost Proposal versus the cost of each higher priced Bid Proposal.  Under this formula, the lowest Cost Proposal receives all of the points assigned to pricing.  A Cost Proposal twice as expensive as the lowest Cost Proposal would earn half of the available points.  The formula is:

Weighted Cost Score = (price of lowest Cost Proposal/price of each higher priced Cost Proposal) X (points assigned to pricing)

Total Points Assigned to Pricing: 1200

Total Points Possible for Technical and Cost Proposals:  4000  

4.4  Recommendation of the Evaluation Committee.  
The evaluation committee shall present a final ranking and recommendation(s) to the Medicaid Deputy Director for consideration.  In making this recommendation, the committee is not bound by any scores or scoring system used to assist with initially determining the relative merits of each Bid Proposal.  This recommendation may include, but is not limited to, the name of one or more Bidders recommended for selection or a recommendation that no Bidder be selected.  The Medicaid Deputy Director shall consider the committee’s recommendation when making the final decision, but is not bound by the recommendation.  

Attachment A: Release of Information
(Return this completed form behind Tab 6 of the Bid Proposal.)

	_________________________________ (name of Bidder) hereby authorizes any person or entity, public or private, having any information concerning the Bidder’s background, including but not limited to its performance history regarding its prior rendering of services similar to those detailed in this RFP, to release such information to the Agency.    

	The Bidder acknowledges that it may not agree with the information and opinions given by such person or entity in response to a reference request.  The Bidder acknowledges that the information and opinions given by such person or entity may hurt its chances to receive contract awards from the Agency or may otherwise hurt its reputation or operations.  The Bidder is willing to take that risk.  The Bidder agrees to release all persons, entities, the Agency, and the State of Iowa from any liability whatsoever that may be incurred in releasing this information or using this information.    

_______________________________
Printed Name of Bidder Organization

_______________________________		___________________________
Signature of Authorized Representative 		Date

_______________________________		
Printed Name		

Attachment B: Primary Bidder Detail & Certification Form
(Return this completed form behind Tab 6 of the Proposal.  If a section does not apply, label it “not applicable”.)

Primary Contact Information (individual who can address issues re: this Bid Proposal)	
Name:		
Address:		
Tel:		
Fax:		
E-mail:		
Primary Bidder Detail	
Business Legal Name (“Bidder”):		
“Doing Business As” names, assumed names, or other operating names:		
Parent Corporation Name and Address of Headquarters, if any:		
Form of Business Entity (i.e., corp., partnership, LLC, etc.):		
State of Incorporation/organization:		
Primary Address:		
Tel:		
Local Address (if any):		
Addresses of Major Offices and other facilities that may contribute to performance under this RFP/Contract:		
Number of Employees:		
Number of Years in Business:		
Primary Focus of Business:		
Federal Tax ID:		
DUNS #:  		

Bidder’s Accounting Firm:		
If Bidder is currently registered to do business in Iowa, provide the Date of Registration:  		
Do you plan on using subcontractors if awarded this Contract?  {If “YES,” submit a Subcontractor Disclosure Form for each proposed subcontractor.}		
	(YES/NO)	

Request for Confidential Treatment (See Section 3.1)	
Check Appropriate Box:                  
  Bidder Does Not Request Confidential Treatment of Bid Proposal 
  Bidder Requests Confidential Treatment of Bid Proposal	
Location in Bid Proposal (Tab/Page)	Specific Grounds in Iowa Code Chapter 22 or Other Applicable Law Which Supports Treatment of the Information as Confidential	Justification of Why Information Should Be Kept in Confidence and Explanation of Why Disclosure Would Not Be in The Best Interest of the Public	

	

Exceptions to RFP/Contract Language (See Section 3.1)	
RFP Section and Page	Language to Which Bidder Takes Exception	Explanation and Proposed Replacement Language:	Cost Savings to the Agency if the Proposed Replacement Language is Accepted	

PRIMARY BIDDER CERTIFICATIONS 

1.	BID PROPOSAL CERTIFICATIONS.  By signing below, Bidder certifies that:  

1.1	Bidder specifically stipulates that the Bid Proposal is predicated upon the acceptance of all terms and conditions stated in the RFP and the Sample Contract without change except as otherwise expressly stated in the Primary Bidder Detail & Certification Form.  Objections or responses shall not materially alter the RFP.  All changes to proposed contract language, including deletions, additions, and substitutions of language, must be addressed in the Bid Proposal.  The Bidder accepts and shall comply with all Contract Terms and Conditions contained in the Sample Contract without change except as set forth in the Contract;
1.2	Bidder has reviewed the Additional Certifications, which are incorporated herein by reference, and by signing below represents that Bidder agrees to be bound by the obligations included therein;
1.3	Bidder has received any amendments to this RFP issued by the Agency; 
1.4	No cost or pricing information has been included in the Bidder’s Technical Proposal; 
1.5	If Bidder requests confidential treatment of any information submitted in its Proposal, the Bidder expressly acknowledges and agrees that the Agency’s evaluation document(s) may reference information of which the Bidder requested confidential treatment in the Bid Proposal.  These Agency evaluation documents may then be in the public domain and be open to inspection by interested parties upon the Agency’s issuance of a Notice of Intent to Award.  The Agency will not redact information or references to information in evaluation documents even in instances which a Bidder requested confidential treatment in the Bid Proposal; and,
1.6	The person signing this Bid Proposal certifies that he/she is the person in the Bidder’s organization responsible for, or authorized to make decisions regarding the prices quoted and, Bidder guarantees the availability of the services offered and that all Bid Proposal terms, including price, will remain firm until a contract has been executed for the services contemplated by this RFP or one year from the issuance of this RFP, whichever is earlier.

2.	SERVICE AND REGISTRATION CERTIFICATIONS.  By signing below, Bidder certifies that:  

2.1	Bidder certifies that the Bidder’s organization has sufficient personnel and resources available to provide all services proposed by the Bid Proposal, and such resources will be available on the date the RFP states services are to begin.  Bidder guarantees personnel proposed to provide services will be the personnel providing the services unless prior approval is received from the Agency to substitute staff;
2.2	Bidder certifies that if the Bidder is awarded the contract and plans to utilize subcontractors at any point to perform any obligations under the contract, the Bidder will (1) notify the Agency in writing prior to use of the subcontractor, and (2) apply all restrictions, obligations, and responsibilities of the resulting contract between the Agency and contractor to the subcontractors through a subcontract.  The contractor will remain responsible for all Deliverables provided under this contract;
2.3	Bidder either is currently registered to do business in Iowa or agrees to register if Bidder is awarded a Contract pursuant to this RFP; 
2.4	Bidder certifies it is either: 1) registered or will become registered with the Iowa Department of Revenue to collect and remit Iowa sales and use taxes as required by Iowa Code chapter 423; or 2) not a “retailer” of a “retailer maintaining a place of business in this state” as those terms are defined in Iowa Code subsections 423.1(42) & (43).  The Bidder also acknowledges that the Agency may declare the Bid Proposal void if the above certification is false.  Bidders may register with the Department of Revenue online at:  http://www.state.ia.us/tax/business/business.html; and,
2.5  Bidder certifies it will comply with Davis-Bacon requirements if applicable to the resulting contract.

3.	EXECUTION.

By signing below, I certify that I have the authority to bind the Bidder to the specific terms, conditions and technical specifications required in the Agency’s Request for Proposals (RFP) and offered in the Bidder’s Proposal.  I understand that by submitting this Bid Proposal, the Bidder agrees to provide services described herein which meet or exceed the specifications of the Agency’s RFP unless noted in the Bid Proposal and at the prices quoted by the Bidder. The Bidder has not participated, and will not participate, in any action contrary to the anti-competitive obligations outlined in the Additional Certifications.  I certify that the contents of the Bid Proposal are true and accurate and that the Bidder has not made any knowingly false statements in the Bid Proposal.  

Signature:	
	
Printed Name/Title:	
	
Date:	

Attachment C: Subcontractor Disclosure Form
(Return this completed form behind Tab 6 of the Bid Proposal.  Fully complete a form for each proposed subcontractor.  If a section does not apply, label it “not applicable.” If the Bidder does not intend to use subcontractor(s), this form does not need to be returned.)

Primary Bidder (“Primary Bidder”):		
Subcontractor Contact Information (individual who can address issues re: this RFP)	
Name:		
Address:		
Tel:		
Fax:		
E-mail:		

Subcontractor Detail	
Subcontractor Legal Name (“Subcontractor”):		
“Doing Business As” names, assumed names, or other operating names:		
Form of Business Entity (i.e., corp., partnership, LLC, etc.)		
State of Incorporation/organization:		
Primary Address:		
Tel:		
Fax:		
Local Address (if any):		
Addresses of Major Offices and other facilities that may contribute to performance under this RFP/Contract:		
Number of Employees:		
Number of Years in Business:		
Primary Focus of Business:		
Federal Tax ID:		
Subcontractor’s Accounting Firm:		
If Subcontractor is currently registered to do business in Iowa, provide the Date of Registration:  		
Percentage of Total Work to be performed by this Subcontractor pursuant to this RFP/Contract.		
General Scope of Work to be performed by this Subcontractor	

Detail the Subcontractor’s qualifications for performing this scope of work	

By signing below, Subcontractor agrees to the following:

1.	Subcontractor has reviewed the RFP, and Subcontractor agrees to perform the work indicated in this Bid Proposal if the Primary Bidder is selected as the winning Bidder in this procurement;
2.	Subcontractor has reviewed the Additional Certifications and by signing below confirms that the Certifications are true and accurate and Subcontractor will comply with all such Certifications;
3.	Subcontractor recognizes and agrees that if the Primary Bidder enters into a contract with the Agency as a result of this RFP, all restrictions, obligations, and responsibilities of the contractor under the contract shall also apply to the subcontractor; 
4.	Subcontractor agrees that it will register to do business in Iowa before performing any services pursuant to this contract, if required to do so by Iowa law; and,
5.	Subcontractor certifies that it will comply with Davis-Bacon requirements if applicable to the resulting contract.  

The person signing this Subcontractor Disclosure Form certifies that he/she is the person in the Subcontractor’s organization responsible for or authorized to make decisions regarding the prices quoted and the Subcontractor has not participated, and will not participate, in any action contrary to the anti-competitive obligations outlined in the Additional Certifications.

I hereby certify that the contents of the Subcontractor Disclosure Form are true and accurate and that the Subcontractor has not made any knowingly false statements in the Form.

Signature for Subcontractor:	
	
Printed Name/Title:	
	
Date:	

Attachment D: Additional Certifications
(Do not return this page with the Bid Proposal.)

1.	 CERTIFICATION OF INDEPENDENCE AND NO CONFLICT OF INTEREST
By submission of a Bid Proposal, the Bidder certifies (and in the case of a joint proposal, each party thereto certifies) that:

1.	The Bid Proposal has been developed independently, without consultation, communication or agreement with any employee or consultant of the Agency who has worked on the development of this RFP, or with any person serving as a member of the evaluation committee;
2.	The Bid Proposal has been developed independently, without consultation, communication or agreement with any other Bidder or parties for the purpose of restricting competition;
3.	Unless otherwise required by law, the information in the Bid Proposal has not been knowingly disclosed by the Bidder and will not knowingly be disclosed prior to the award of the contract, directly or indirectly, to any other Bidder;
4.	No attempt has been made or will be made by the Bidder to induce any other Bidder to submit or not to submit a Bid Proposal for the purpose of restricting competition;
5.	No relationship exists or will exist during the contract period between the Bidder and the Agency that interferes with fair competition or is a conflict of interest.
6.	The Bidder and any of the Bidder’s proposed subcontractors have no other contractual relationships which would create an actual or perceived conflict of interest.

2.	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION -- LOWER TIER COVERED TRANSACTIONS
By signing and submitting this Bid Proposal, the Bidder is providing the certification set out below:

1.	The certification in this clause is a material representation of fact upon which reliance was placed when this transaction was entered into.  If it is later determined that the Bidder knowingly rendered an erroneous certification, in addition to other remedies available to the federal government the Agency or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.
2.	The Bidder shall provide immediate written notice to the person to whom this Bid Proposal is submitted if at any time the Bidder learns that its certification was erroneous when submitted or had become erroneous by reason of changed circumstances.
3.	The terms covered transaction, debarred, suspended, ineligible, lower tier covered transaction, participant, person, primary covered transaction, principle, proposal, and voluntarily excluded, as used in this clause, have the meaning set out in the Definitions and Coverage sections of rules implementing Executive Order 12549.  You may contact the person to which this Proposal is submitted for assistance in obtaining a copy of those regulations.
4.	The Bidder agrees by submitting this Proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by the Agency or agency with which this transaction originated.
5.	The Bidder further agrees by submitting this Proposal that it will include this clause titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion--Lower Tier Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
6.	A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered transaction that it is not proposed for debarment under 48 CFR part 9, subpart 9.4, debarred, suspended, ineligible, or voluntarily excluded from covered transactions, unless it knows that the certification is erroneous.  A participant may decide the method and frequency by which it determines the eligibility of its principals.  A participant may, but is not required to, check the List of Parties Excluded from Federal Procurement and Nonprocurement Programs.
7.	Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause.  The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
8.	Except for transactions authorized under paragraph 4 of these instructions, if a participant in a covered transaction knowingly enters into a lower tier covered transaction with a person who is proposed for debarment under 48 CFR part 9, subpart 9.4, suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the federal government, the Agency or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3.	CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND/OR VOLUNTARY EXCLUSION--LOWER TIER COVERED TRANSACTIONS
1.	The Bidder certifies, by submission of this Proposal, that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.
2.	Where the Bidder is unable to certify to any of the statements in this certification, such Bidder shall attach an explanation to this Proposal.

4.	CERTIFICATION OF COMPLIANCE WITH PRO-CHILDREN ACT OF 1994
By signing and submitting this Bid Proposal, the Bidder is providing the certification set out below:

The Bidder must comply with Public Law 103-227, Part C Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act).  This Act requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted by an entity and used routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if the services are funded by federal programs either directly or through State or local governments.  Federal programs include grants, cooperative agreements, loans or loan guarantees, and contracts. The law also applies to children’s services that are provided in indoor facilities that are constructed, operated, or maintained with such federal funds.  The law does not apply to children’s services provided in private residences; portions of facilities used for inpatient drug or alcohol treatment; service providers whose sole source of applicable federal funds is Medicare or Medicaid; or facilities (other than clinics) where WIC coupons are redeemed.

The Bidder further agrees that the above language will be included in any subawards that contain provisions for children’s services and that all subgrantees shall certify compliance accordingly.  Failure to comply with the provisions of this law may result in the imposition of a civil monetary penalty of up to $1000 per day.

5.	CERTIFICATION REGARDING DRUG FREE WORKPLACE
1.	Requirements for Contractors Who are Not Individuals.  If the Bidder is not an individual, by signing and submitting this Bid Proposal the Bidder agrees to provide a drug-free workplace by:
a.	publishing a statement notifying employees that the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance is prohibited in the person’s workplace and specifying the actions that will be taken against employees for violations of such prohibition;  
b.	establishing a drug-free awareness program to inform employees about:
(1)  the dangers of drug abuse in the workplace;  
(2)  the person’s policy of maintaining a drug- free workplace;  
(3)  any available drug counseling, rehabilitation, and employee assistance programs; and  
(4)  the penalties that may be imposed upon employees for drug abuse violations;  
c.	making it a requirement that each employee to be engaged in the performance of such contract be given a copy of the statement required by subparagraph (a);    
d.	notifying the employee in the statement required by subparagraph (a), that as a condition of employment on such contract, the employee will:
(1)  abide by the terms of the statement; and 
(2)  notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later than 5 days after such conviction;  
e.	notifying the contracting agency within 10 days after receiving notice under subparagraph (d)(2) from an employee or otherwise receiving actual notice of such conviction;  
f.	imposing a sanction on, or requiring the satisfactory participation in a drug abuse assistance or rehabilitation program by, any employee who is so convicted, as required by 41 U.S.C. § 703; and  
g.	making a good faith effort to continue to maintain a drug-free workplace through implementation of subparagraphs (a), (b), (c), (d), (e), and (f).  
2.	Requirement for Individuals.  If the Bidder is an individual, by signing and submitting this Bid Proposal the Bidder agrees to not engage in the unlawful manufacture, distribution, dispensation, possession, or use of a controlled substance in the performance of the contract.  
3.	Notification Requirement. The Bidder shall, within 30 days after receiving notice from an employee of a conviction pursuant to 41 U.S.C. § 701(a)(1)(D)(ii) or 41 U.S.C. § 702(a)(1)(D)(ii):
a.	take appropriate personnel action against such employee up to and including termination; or  
b.	require such employee to satisfactorily participate in a drug abuse assistance or rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency.  

6.	NON-DISCRIMINATION
The Bidder does not discriminate in its employment practices with regard to race, color, religion, age (except as provided by law), sex, marital status, political affiliation, national origin, or handicap.

Attachment E: Certification and Disclosure Regarding Lobbying Attachment
(Return this executed form behind Tab 6 of the Bid Proposal.)

Instructions: 
Title 45 of the Code of Federal Regulations, Part 93 requires the bidder to include a certification form, and a disclosure form, if required, as part of the bidder’s proposal.  Award of the federally funded contract from this RFP is a Covered Federal action.  

1)	The bidder shall file with the Agency this certification form, as set forth in Appendix A of 45 CFR Part 93, certifying the bidder, including any subcontractor(s) at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) have not made, and will not make, any payment prohibited under 45 CFR § 93.100.  
2)	The bidder shall file with the Agency a disclosure form, set forth in Appendix B of 45 CFR Part 93, in the event the bidder or subcontractor(s) at any tier (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) has made or has agreed to make any payment using non-appropriated funds, including profits from any covered Federal action, which would be prohibited under 45 CFR § 93.100 if paid for with appropriated funds.  All disclosure forms shall be forwarded from tier to tier until received by the bidder and shall be treated as a material representation of fact upon which all receiving tiers shall rely.

Certification for Contracts, Grants, Loans, and Cooperative Agreements
The undersigned certifies, to the best of his or her knowledge and belief, that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of  any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to  influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the  undersigned shall complete and submit Standard Form-LLL, ‘‘Disclosure Form  to Report  Lobbying,’’ in accordance with its instructions.
(3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into.  Submission of this certification is a prerequisite for making or entering into this transaction  imposed by section 1352, title 31, U.S. Code.  Any person who fails to file the required certification shall be   subject to a civil penalty of  not less than $10,000 and not more than $100,000 for each such failure.

Statement for Loan Guarantees and Loan Insurance
The undersigned states, to the best of his or her knowledge and belief, that:
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, ‘‘Disclosure Form to Report Lobbying,’’ in accordance with its instructions.
Submission of this statement is a pre-requisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code.  Any person who fails to file the required statement shall be subject to a civil penalty of not less than $10,000 for each such failure.

I certify that the contents of this certification are true and accurate and that the bidder has not made any knowingly false statements in the Bid Proposal.  I am checking the appropriate box below regarding disclosures required in Title 45 of the Code of Federal Regulations, Part 93.

  The bidder is NOT including a disclosure form as referenced in this form’s instructions because the bidder is NOT required by law to do so. 
  The bidder IS filing a disclosure form with the Agency as referenced in this form’s instructions because the bidder IS required by law to do so.  If the bidder is filing a disclosure form, place the form immediately behind this in the Proposal. 

Signature:	
	
Printed Name/Title:	
	
Date:	

Attachments Specific To This RFP

Attachment F: Cost Proposal 

Quality Improvement Organization Services for Iowa Medicaid	
ATTACHMENT F - COST PROPOSAL	
NOT CONFIDENTIAL – this form may not be designated as confidential in whole or in part.
INSTRUCTIONS TO BIDDERS:  Bidders are instructed to enter a monthly firm, fixed-price value for each of the Categories of Services within each time period listed.  Bidders are instructed to not bid a cost for the transition period prior to start of operations. Any charges associated with the Contract transition period shall be reflected in operations costs beginning July 1, 2024. The bid price needs to include all costs for meeting all RFP requirements including general requirements. The Cost Proposal Form will automatically calculate a Grand Total. The Agency will use the figure in the Grand Total to score cost proposal pricing. 	
The Bidder Only Enters Information Into Cells With This Background Color ------->	 				
Company Name -------------------------------->	 	
 	Initial Contract Years - Monthly Prices	Optional Contract Years - Monthly Prices	
Categories of Services	Year 1
 7/1/2024 - 6/30/2025	Year 2
 7/1/2025 - 6/30/2026	Year 3
 7/1/2026 - 6/30/2027	Option Year 1 7/1/2027 - 6/30/2028	Option Year 2 7/1/2028 - 6/30/2029	Option Year 3 7/1/2029 - 6/30/2030	
Fixed Fee Monthly Pricing	 	 	 	 	 	 	
Medical Support (Section 1.3.1.3.A)	 	 	 	 	 	 	
Prior Authorizations (Section 1.3.1.3.B.1)	 	 	 	 	 	 	
LOC and NBA Reviews for LTSS (Section 1.3.1.3.B.2)	 	 	 	 	 	 	
Utilization Management- Other (Sections 1.3.1.3.B.3-6)	 	 	 	 	 	 	
HCBS Provider Reviews (Section 1.3.1.4.B) 	 	 	 	 	 	 	
HCBS Waiver, Habilitation, and MFP Provider Complaints and Incident Reporting Management (Sections 1.3.1.4.C-D) 	 	 	 	 	 	 	
HCBS Waiver and Habilitation Member Surveys, MFP Surveys, and Slot Management (Sections 1.3.1.4.E-G) 	 	 	 	 	 	 	
Program of All-Inclusive Care for the Elderly (Section 1.3.1.5.A)	 	 	 	 	 	 	
Health Homes (Section 1.3.1.5.B)	 	 	 	 	 	 	
Quality Improvement (Section 1.3.1.5.C)	 	 	 	 	 	 	
Project Management and Administration Support (Section 1.3.1.6) 	 	 	 	 	 	 	
Volume Based Pricing (Section 1.3.3)	 	 	 	 	 	 	
MCO Ride Alongs (Section 1.3.1.1.E.3.b) 
(Bidders shall submit a pricing sheet for MCO Ride Along volume based pricing)	 	 	 	 	 	 	
Sub Totals - Auto Filled; Do Not Enter Amounts below	
 Annual Fixed Fee Costs Subtotal	 $                -   	 $               -   	 $               -   	 $                -   	 $                 -   	 $                 -   	
 Annual Volume Based Costs Subtotal	 $                -   	 $               -   	 $               -   	 $                -   	 $                 -   	 $                 -   	

Total Annual Cost	 $                -   	 $               -   	 $               -   	 $                -   	 $                 -   	 $                 -   	
Grand Total For The Entire Project   	 $                                           -   	

Attachment G:
Agency-provided Facilities, Equipment, and Software 

As part of the Contract agreement the Agency will not require all Contractor staff be housed at the Iowa Medicaid facility. The Agency will allow flexibility with staff working from home and on-site, subject to Agency approval. Regardless of whether staff are working from home or on-site, the Agency will provide the following to Contractor staff, unless otherwise noted below:

•	Shared office work space* (on-site only)	•	HHS Standard Forms	
•	Telephones and telephone service	•	Access to storage (on-site only)	
•	Standard Agency Desktop PC or Laptop with docking station	•	Access to break rooms, restrooms, and conference rooms (on-site only)	
•	Keyboard and mouse	•	Internet Access (on-site only)	
•	DHS Network Access	•	Access to shredding (on-site only)	
•	Access to HHS laptops for occasional use	•	Access to copiers including copy supplies, network printers, and Fax (on-site only)	
•	Printing, envelopes, and postage for correspondence directly related to the Iowa Medicaid Program	•	Access to Agency training equipment (on-site only)	
•	Software List (see table below)		

Note:
* Work surfaces throughout the building have been installed at the “standard” height.  If a Contractor employee is tall or short the work surface can be adjusted for that employee up or down.  If an employee has pain due to equipment they are using, an ergonomic evaluation can be completed at the Contractor’s expense.  If special equipment is needed based on the ergonomic evaluation, purchase of equipment is at the Contractor’s expense.  If any change is needed due to a medical necessity, a note from the employee’s doctor is required. This includes lights out or on, work surfaces raised for standing purposes (more than an inch or two), etc.

Systems and Software List
Below is a list of Agency-licensed systems and software available for use on Agency computers. 

Name of System/Software	Business Purpose	
Adobe Acrobat	Reports	
Appeals Information System (AIS)	DHS System for appeal tracking	
Cisco CallRex	Call center recording software	
Cisco VPN	Field staff use to connect to the DHS network	
First Data Bank (previously known as MEDISPAN)	Clinical drug information to help inform medication-related decisions	
Microsoft Windows 10 Enterprise Operating System	Operating system	
Microsoft Outlook	Email and Calendar	
Microsoft Teams	Video conferencing 	
Iowa Health Information Network (IHIN)	Iowa’s Health Information Exchange system, access EHR information, alerts, and notifications for Members	
Iowa Medicaid Portal Access (IMPA)	Secure DHS system for document uploads.	
Institutional and Waiver Authorization and Narrative System (IoWANS)	HCBS services coordination and workflow system.	
Microsoft 365 (Access, Excel, Powerpoint, Project, Publisher, Sharepoint, Visio, Word)		
Microsoft Windows 7 Enterprise Operating System	Operating system	
MMIS	Medicaid information system (enrollment, PA entry, claims)	
Medicaid Quality Utilization Information Data System (MQUIDS)	Data entry and retrieval application for documenting review data and outcomes related to HCBS Programs 	
OnBase Client	Workflow and document management system	
PowerBI	Data visualization software	
QualAssure Performance System (QPS)	Data entry and retrieval application for documenting data and outcomes related to provider reviews	
RightFax Utility Software	Fax utility software	
Roxio CD/DVD Creator Basic	CD/DVD Creator	
Worker Information System Exchange (WISE) 	Slot database, number of slots filled, released, member info for each slot assigned, etc)  	
WinZip	Send/receive compress/ encrypted files 	

Attachment H: Sample Report Monitoring Tool

Note: this sample is for illustrative purposes only. 

Report	Contract Section 	Frequency 	Due Date 	Copy Provided to	
1.3.1.1 General Obligations	
Appeals and Hearings		Quarterly			
ALJ Decision Report		As Needed			
Bi-Annual Appeals Report 		Bi-Annual			
Quality Assurance and Corrective Actions Report		Quarterly			
MCO Quality Oversight Reports		Monthly			
Performance Report		Monthly			
1.3.1.2 Transition	
Project Work Plans		TBD			
Operational Readiness Checklist		One-time			
1.3.1.3.A Medical Support	
Report of Abortions, Hysterectomies, and Sterilization CMS 64.96		Quarterly			
Trend Report		Quarterly 			
Appeal Hearings Summary Report		Quarterly			
Exception to Policy Summary Report		Monthly			
Clinical Advisory Committees Activities Report		Annual			
A-15 Report		Monthly			
PIC Report		Monthly			
CSR Overdue Report		Weekly			
LT Pending Report		Bi-Weekly			
MDS Section Q Report		Quarterly 			
QIPP Project Report		Semi-Annual			
MCO Critical Incidents Report		Monthly & Quarterly			
FFS Critical Incidents Report		Monthly & Quarterly			
MCO Claims and Benefits Update Report		Monthly			
Abortion Report		Quarterly			
RBSCL Providers Report		As Needed			
Habilitation Providers Report		As Needed			
1.3.1.3.B Utilization Management	
Monthly Activity Report for HCBS PA 		Monthly			
LOC and NBA Reviews Report		Monthly			
No Units of Service Report		Monthly			
ETP Service Request Report		As Needed			
ETP Pharmacy Report		Quarterly			
ETP Trends		As Needed			
1.3.1.4 HCBS Quality Oversight Operations	
QA Quarterly Report		Quarterly			
FFS AccQual E-17 HCBS Habilitation Report					
Bi-Weekly Quality Report		Bi-Weekly			
BI, HAB, ID, ICF/ID Denial Reasons Report		Monthly			
A-16 CBCM Ride Along Report		Monthly & Quarterly			
FFS AccQual E-14 HCBS Habilitation Report		Quarterly 			
FFS IPES Results Report		Quarterly & As Needed			
MFP Survey Results Report		Quarterly 			
Residential Assessment Results Report		Monthly & Quarterly			
Waiver Slots Report		Weekly			
Emergency Room Claims to CIR Comparison Report		Monthly & Quarterly			
Five Person Homes Report		Monthly			
372/Evidentiary Report		As Needed			
Technical Assistance Report		Monthly & Quarterly			
MFP Critical Incidents Report		Quarterly			
Self Assessments Report		Annually			
Quality Oversight Review Outcomes Report		Quarterly			
HCBS Locations/Settings Report		As Needed			
1.3.1.5 Population Health Improvement Special Projects	
Health Home Monitoring Report		Monthly			
Health Home Enrollment Report		Monthly			
Health Home Claims Report		Monthly			
Bi-Weekly Health Home Report		Bi-Weekly			
Health Home Yearly Savings Report		Annually			

Attachment I: Sample Monthly Performance Reporting Tool

Note: this sample is for illustrative purposes only. Bidders may propose a Monthly Performance Reporting template for Agency review and approval. 

Business Area	Contract Section	Performance Standard	Frequency	Total Completed within timeframes	Standard Met (Y/N)	
Appeals and Hearings		Participate in 100% of assigned appeal hearings.				
Transition		Submit transition and operations plans to the Agency for approval within 15 business days after Contract execution.				
Claims Inquiries		Send the final determination letter on a claims inquiry to the provider within 10 business days of receipt of complete documentation.				
Exceptions to Policy		Complete 95 percent of Exception to Policy Determinations within 10 business days of receipt of complete information. Complete 100 percent within 20 business days.				
Prior Authorizations		Complete 95 percent of PA requests not requiring physician review, enter into system, and send appropriate notice within 10 business days of initial receipt.
Complete 100 percent within 15 business days of initial receipt.				
 Prior Authorizations		Complete 95 percent of PA requests requiring physician review, enter into system and send appropriate notice within 15 business days of initial receipt. 
Complete 100 percent within 20 business days of initial receipt.				
LOC and NBA Reviews		Complete 95 percent of initial LOC and NBA determinations within two business days of receipt of complete information. 
Complete 100 percent within five business days.				
Utilization Reviews		Conduct annual on-site UR visits between months 10 and 12 following the prior year visit to ICF/ID, NF/MI, PMIC and MHI facilities.				

Attachment J: Sample Contract

(These contract terms contained in the Special Terms, General Terms, and Contingent Terms for Services Contracts are not intended to be a complete listing of all contract terms but are provided only to enable Bidders to better evaluate the costs associated with the RFP and the potential resulting contract.  Bidders should plan on such terms being included in any contract entered into as a result of this RFP.  All costs associated with complying with these terms should be included in the Cost Proposal or any pricing quoted by the Bidder.  See RFP Section 3.1 regarding Bidder exceptions to contract language.)

This is a sample form.  DO NOT complete and return this attachment.

CONTRACT DECLARATIONS AND EXECUTION

RFP #	Contract #	
MED-25-002	{To be completed when contract is drafted.}	

Title of Contract	
{To be completed when contract is drafted.}	

This Contract must be signed by all parties before the Contractor provides any Deliverables.  The Agency is not obligated to make payment for any Deliverables provided by or on behalf of the Contractor before the Contract is signed by all parties.  This Contract is entered into by the following parties:

Agency of the State (hereafter “Agency”)	
Name/Principal Address of Agency:   
Iowa Department of Health and Human Services
1305 E. Walnut
Des Moines, IA 50319-0114

	Agency Billing Contact Name / Address:
{To be completed when contract is drafted.}
	
Agency Contract Manager (hereafter “Contract Manager” ) /Address (“Notice Address”): 
{To be completed when contract is drafted.}
 
	Agency Contract Owner (hereafter “Contract Owner”) / Address:  
{To be completed when contract is drafted.}

Contractor:  (hereafter “Contractor”)	
Legal Name:  {To be completed when contract is drafted.}	Contractor’s Principal Address:
{To be completed when contract is drafted.}	
Tax ID #:  {To be completed when contract is drafted.}	Organized under the laws of:  {To be completed when contract is drafted.}	
Contractor’s Contract Manager Name/Address (“Notice Address”):  
{To be completed when contract is drafted.}	Contractor’s Billing Contact Name/Address:  
{To be completed when contract is drafted.}	

Contract Information	
Start Date:  {To be completed when contract is drafted.}	End Date of Base Term of Contract:  
End Date of Contract:  {To be completed when contract is drafted.}	
Possible Extension(s):  {To be completed when contract is drafted.}	
Contract Contingent on Approval of Another Agency:  
Yes
Which Agency?  CMS	ISPO Number:  ***	
Contract Include Sharing SSA Data?  No
	DoIT Number:  N/A

Contract Execution	
This Contract consists of this Contract Declarations and Execution Section, the Special Terms, any Special Contract Attachments, the General Terms for Services Contracts, and the Contingent Terms for Service Contracts.

In consideration of the mutual covenants in this Contract and for other good and valuable consideration, the receipt, adequacy and legal sufficiency of which are hereby acknowledged, the parties have entered into this Contract and have caused their duly authorized representatives to execute this Contract.

SECTION 1: SPECIAL TERMS

1.1 Special Terms Definitions.
{To be completed when contract is drafted.}
1.2 Contract Purpose. 
{To be completed when contract is drafted.}

1.3 Scope of Work. 
1.3.1 Deliverables.
The Contractor shall provide the following:  
{To be completed when contract is drafted.}

1.3.2 Performance Measures.  
{To be completed when contract is drafted.}

1.3.3 Monitoring, Review, and Problem Reporting.   

1.3.3.1 Agency Monitoring Clause.  The Contract Manager or designee will:
•	Verify Invoices and supporting documentation itemizing work performed prior to payment;
•	Determine compliance with general contract terms, conditions, and requirements; and 
•	Assess compliance with Deliverables, performance measures, or other associated requirements based on the following:

1.3.3.2 Agency Review Clause.  The Contract Manager or designee will use the results of monitoring activities and other relevant data to assess the Contractor’s overall performance and compliance with the Contract.  At a minimum, the Agency will conduct a review annually; however, reviews may occur more frequently at the Agency’s discretion.  As part of the review(s), the Agency may require the Contractor to provide additional data, may perform on-site reviews, and may consider information from other sources. 

The Agency may require one or more meetings to discuss the outcome of a review.  Meetings may be held in person.  During the review meetings, the parties will discuss the Deliverables that have been provided or are in process under this Contract, achievement of the performance measures, and any concerns identified through the Agency’s contract monitoring activities.  

1.3.3.3 Problem Reporting.  As stipulated by the Agency, the Contractor and/or Agency shall provide a report listing any problem or concern encountered.  Records of such reports and other related communications issued in writing during the course of Contract performance shall be maintained by the parties.  At the next scheduled meeting after a problem has been identified in writing, the party responsible for resolving the problem shall provide a report setting forth activities taken or to be taken to resolve the problem together with the anticipated completion dates of such activities.  Any party may recommend alternative courses of action or changes that will facilitate problem resolution.  The Contract Owner has final authority to approve problem-resolution activities.

The Agency’s acceptance of a problem report shall not relieve the Contractor of any obligation under this Contract or waive any other remedy.  The Agency’s inability to identify the extent of a problem or the extent of damages incurred because of a problem shall not act as a waiver of performance or damages under this Contract.  

1.3.3.4 Addressing Deficiencies.  To the extent that Deficiencies are identified in the Contractor’s performance and notwithstanding other remedies available under this Contract, the Agency may require the Contractor to develop and comply with a plan acceptable to the Agency to resolve the Deficiencies.

1.3.4 Contract Payment Clause.
1.3.4.1 Pricing.  In accordance with the payment terms outlined in this section and the Contractor’s completion of the Scope of Work as set forth in this Contract, the Contractor will be compensated as follows:  
{To be determined.}

1.3.4.2 Payment Methodology.
{To be completed when contract is drafted.}

1.3.4.3 Timeframes for Regular Submission of Initial and Adjusted Invoices.  The Contractor shall submit an Invoice for services rendered in accordance with this Contract.  Invoice(s) shall be submitted monthly.  Unless a longer timeframe is provided by federal law, and in the absence of the express written consent of the Agency, all Invoices shall be submitted within six months from the last day of the month in which the services were rendered.  All adjustments made to Invoices shall be submitted to the Agency within ninety (90) days from the date of the Invoice being adjusted.  Invoices shall comply with all applicable rules concerning payment of such claims.  

1.3.4.4 Submission of Invoices at the End of State Fiscal Year.  Notwithstanding the timeframes above, and absent (1) longer timeframes established in federal law or (2) the express written consent of the Agency, the Contractor shall submit all Invoices to the Agency for payment by August 1st for all services performed in the preceding state fiscal year (the State fiscal year ends June 30).  

1.3.4.5 Payment of Invoices.  The Agency shall verify the Contractor’s performance of the Deliverables before making payment. The Agency will not automatically pay end of state fiscal year claims that are considered untimely. If the Contractor seeks payment for end of state fiscal year claim(s) submitted after August 1st, the Contractor may submit the late claim(s), The Agency may require a justification from the Contractor for the untimely submission. The Agency may reimburse the claim if funding is available after the end of the state fiscal year. If funding is not available after the end of the state fiscal year, the Agency may submit the claim to the Iowa State Appeal Board for a final decision regarding reimbursement of the claim. 

The Agency shall pay all approved Invoices in arrears and in conformance with Iowa Code 8A.514.  The Agency may pay in less than sixty (60) days, but an election to pay in less than sixty (60) days shall not act as an implied waiver of Iowa law.

1.3.4.6 Reimbursable Expenses.  Unless otherwise agreed to by the parties in an amendment to the Contract that is executed by the parties, the Contractor shall not be entitled to receive any other payment or compensation from the State for any Deliverables provided by or on behalf of the Contractor pursuant to this Contract.  The Contractor shall be solely responsible for paying all costs, expenses, and charges it incurs in connection with its performance under this Contract. 

1.4 Insurance Coverage.  
The Contractor and any subcontractor shall obtain the following types of insurance for at least the minimum amounts listed below: 

Type of Insurance	Limit	Amount	
General Liability (including contractual liability) written on occurrence basis	General Aggregate

Product/Completed
Operations Aggregate

Personal Injury

Each Occurrence	$2 Million

$1 Million

$1 Million

$1 Million	
Automobile Liability (including any auto, hired autos, and non-owned autos)
	Combined Single Limit
	$1 Million	
Excess Liability, Umbrella Form	Each Occurrence

Aggregate	$1 Million

$1 Million	
Workers’ Compensation and Employer Liability	As required by Iowa law	As Required by Iowa law	
Property Damage
	Each Occurrence

Aggregate	$1 Million

$1 Million	
Professional Liability	Each Occurrence

Aggregate	$2 Million

$2 Million	

1.5 Data and Security.  If this Contract involves Confidential Information, the following terms apply:
1.5.1 Security Framework. The Contractor shall comply with either of the following: 
•	Provide certification of compliance with a minimum of one of the following security frameworks: NIST SP 800-53, HITRUST version 9, COBIT 5, CSA STAR Level 2 or greater, ISO 27001 or PCI-DSS version 3.2 prior to implementation of the system and when the certification(s) expire, or
•	Provide attestation of a passed information security risk assessment, passed network penetration scans, and passed web application scans (when applicable) prior to implementation of the system and annually thereafter. Passed means no unresolved high or critical findings. 

1.5.2	Vendor Security Questionnaire. If not previously provided to the Agency through a procurement process, the Contractor shall provide a fully completed copy of the Agency’s Vendor Security Questionnaire (VSQ). 

1.5.3	Cloud Services. The Contractor shall comply with either of the following:
•	Provide written designation of FedRAMP authorization with impact level moderate prior to implementation of the system, or
•	Provide certification of compliance with a minimum of one of the following security frameworks: HITRUST version 9, COBIT 5, CSA STAR Level 2 or greater or PCI-DSS version 3.2 prior to implementation of the system and when the certification(s) expire.

1.5.4    Addressing Concerns. The Contractor shall timely resolve any outstanding concerns identified by the Agency regarding the Contractor’s submissions required in this section.

1.6  Reserved.  (Labor Standards Provisions.)  

1.8 Incorporation of General and Contingent Terms.  
1.8.1 General Terms for Service Contracts (“Section 2”).  The version of the General Terms for Services Contracts Section posted to the Agency’s website at https://hhs.iowa.gov/contract-terms
 that is in effect as of the date of last signature in the Contract Declarations and Execution section, or a more current version if agreed to by amendment, is incorporated into the Contract by reference.  The General Terms for Service Contracts may be referred to as Section 2.  

The contract warranty period (hereafter "Warranty Period") referenced within the General Terms for Services Contracts is as follows:  The term of this Contract, including any extensions. 

1.8.2 Contingent Terms for Service Contracts (“Section 3”). The version of the Contingent Terms for Services Contracts posted to the Agency’s website at https://hhs.iowa.gov/contract-terms that is in effect as of the date of last signature in the Contract Declarations and Execution section, or a more current version if agreed to by amendment, is incorporated into the Contract by reference.  The Contingent Terms for Service Contracts may be referred to as Section 3.  

All of the terms set forth in the Contingent Terms for Service Contracts apply to this Contract unless indicated otherwise in the table below:

Contract Payments include Federal Funds?  Yes
{The items below will be completed if the Contract includes Federal Funds}  
The Contractor for federal reporting purposes under this Contract is a:  {To be completed when contract is drafted.} 
Office of Child Support Enforcement (“OCSE”) Funded Percentage:  {To be completed when contract is drafted.}
Federal Funds Include Food and Nutrition Service (FNS) funds?  {To be completed when contract is drafted.}
DUNS #:  {To be completed when contract is drafted.}
The Name of the Pass-Through Entity:  {To be completed when contract is drafted.}
CFDA #:  {To be completed when contract is drafted.}
Grant Name:  {To be completed when contract is drafted.}
Federal Awarding Agency Name:  {To be completed when contract is drafted.}  
	
Contractor a Business Associate?  Yes	Contractor a Qualified Service Organization?  Yes	
Contractor subject to Iowa Code Chapter 8F?   No	Contract Includes Software (modification, design, development, installation, or operation of software on behalf of the Agency)? No	

1.9 Additional Terms.  The Contractor shall comply with the following: