ACC Phase II Draft RFP Stakeholder Comment Form Responses
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TimestampI understand my comments will be visible to the public after submission.First NameLast NameOrganizationHow would you describe your role?Please provide your overall impressions of the RFP (no character limit)How clear were the requirements in this section? [Contractor’s General Requirements]Please provide your comments regarding the Contractor’s General Requirements section (provide citation or topic area):How clear were the requirements in this section? [Personnel]Please provide your comments regarding the Personnel section (provide citation or topic area):How clear were the requirements in this section? [4) Regional Accountable Entity]Please provide your comments regarding the Regional Accountable Entity section (provide citation or topic area):How clear were the requirements in this section? [Member Enrollment and Attribution]Please provide your comments regarding the Member Enrollment and Attribution section (provide citation or topic area):How clear were the requirements in this section? [Member Engagement]Please provide your comments regarding the Member Engagement section (provide citation or topic area):How clear were the requirements in this section? [Grievances and Appeals]Please provide your comments regarding the Grievances and Appeals section (provide citation or topic area):How clear were the requirements in this section? [Network Development and Access Standards]Please provide your comments regarding the Network Development and Access Standards section (provide citation or topic area):How clear were the requirements in this section? [Health Neighborhood and Community]Please provide your comments regarding the Health Neighborhood and Community section (provide citation or topic area):How clear were the requirements in this section? [Population Health Management and Care Coordination]Please provide your comments regarding the Population Health Management and Care Coordination section (provide citation or topic area):How clear were the requirements in this section? [Provider Support and Practice Transformation]Please provide your comments regarding the Provider Support and Practice Transformation section (provide citation or topic area):How clear were the requirements in this section? [Primary Care Alternative Payment Methodology (Primary Care APM)]How clear were the requirements in this section? [Primary Care Alternative Payment Methodology (Primary Care APM)]How clear were the requirements in this section? [Capitated Behavioral Health Benefit]Please provide your comments regarding the Capitated Behavioral Health Benefit section (provide citation or topic area):How clear were the requirements in this section? [Data, Analytics and Claims Processing Systems]Please provide your comments regarding the Data, Analytics and Claims Processing Systems section (provide citation or topic area):How clear were the requirements in this section? [Outcomes, Quality Assessment and Performance Improvement Program]Please provide your comments regarding the Outcomes, Quality Assessment and Performance Improvement Program section (provide citation or topic area):How clear were the requirements in this section? [Compliance]Please provide your comments regarding the Compliance section (provide citation or topic area):How clear were the requirements in this section? [Start-up and Closeout Periods]Please provide your comments regarding the Start-up and Closeout Periods section (provide citation or topic area):How clear were the requirements in this section? [Additional Statement of Work Activities]Please provide your comments regarding the Additional Statement of Work Activities section (provide citation or topic area):How clear were the requirements in this section? [Compensation]Please provide your comments regarding the Compensation section (provide citation or topic area):
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11/8/2016 13:04:00I agree and wish to continueSkipBarberCAFCAAdvocateSomewhat unclearNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNot ClearAre the child welfare and DYC residential programs being rolled into capitation? I see the RCCO will be responsible for Residential (5.12.5.7.1.5) but can not determine if this is simply the residential that that the BHO's are responsible for categorically eligible children under the CMHTA or does this include the youth currently receiving treatment through Child Welfare and youth corrections that have fee for service medicaid. Can you clarify?No opinionNo opinionNo opinionNo opinionSomewhat clearNo opinion
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12/1/2016 12:14:19I agree and wish to continueProspective BidderSomewhat clearNot Clearunder section 5.2.12.1.3.2.1 - "The CFO shall have the following qualifications: master's degree in accounting or business administration" would you consider adding or a "certified public accountant" or equivalent professional certification/licensure.
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12/6/2016 11:04:20I agree and wish to continueKerrySwensonMount Saint VincentProviderRegarding when wraparound can be used.

6.2 WRAPAROUND PROGRAM FOR CHILDREN AND YOUTH WITH SIGNIFICANT MENTAL HEALTH CONDITIONS
6.2.3.1 The Contractor shall administer the Wraparound Program for children and youth from birth to age twenty-one (21) who are assessed as likely to benefit from the Program and who meet all of the following Medical Necessity criteria:
6.2.3.1.3 The child or youth is taking multiple psychotropic medications outside of recommended guidelines and/or is identified as having a high likelihood of any of the following:
6.2.3.1.3.1 Placement in a Residential Child Care Facility;
6.2.3.1.3.2 A psychiatric hospitalization; or
6.2.3.1.3.3 Commitment in the Youth Corrections system

My concern is that this almost requires a child to FIRST be put on multiple psychotropics BEFORE wraparound can be provided. I realized that there is the “and/or” piece, but to have this as the beginning statement in this section is concerning to me as it seems to give medications priority. If it was dropped down to one of the other criteria, it would appear to give multiple psychotropics the equal consideration.

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12/14/2016 8:27:15I agree and wish to continueEdHaginsMidwestern Colorado Mental Health Center ProviderLike a lot of efforts it is an evolution from where we've been to where we would like to be as a state. Clearly a lot of work has been put into it. Clearly not perfect, but how could it be. As long as we all keep working together to make it great for all stakeholders, clients, providers, taxpayers, etc, then in the end I think we'll continue to be a progressive state when it comes to health care. Somewhat clearSomewhat clearSomewhat unclearSomewhat unclearSomewhat clearVery clearVery clearVery clearSomewhat clearThe document references covered diagnosis and yet we haven't seen what that list looks for this RFP. That is an important factor in terms of this benefit, particularly when it comes to Autism Spectrum Disorders. While I think this ought to be opened up, it could be very costly to the system and there is a workforce shortage in terms of skilled professionals.Somewhat clearCCAR is mentioned but what about the DII to combine the DACOD and CCAR?No opinionNo opinionNo opinionSomewhat clearDon't recall if this is where this comment goes...in terms of the 6 behavioral health sessions for primary care, why is this not also an option the BH side of the house to increase access? This could be beneficial in schools, with law enforcement, the homeless, and mental health centers in general.No opinion
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12/14/2016 8:27:40I agree and wish to continueEmilyRaischUnite USProspective Technology PartnerGreat initiative, well written, only suggestions are around being more specific in a few areas. No opinionVery clearNo opinionNo opinionNo opinionNo opinionNo opinionSomewhat clearVery happy to see community and social service providers incorporated into the project. Would suggest a single technology platform to be used to manage referrals and cooperation between healthcare and health neighborhood providers. Health neighborhood and community report should include information on number of referrals received, sent, and outcomes. Somewhat clear5.9.4.1.1 Care Coordination Activity Report should include data on outcomes (positive/negative/neutral) of interventions provided by various service providers as well as time cases take from open to close.5.10.5.2 Member Provider Directory should be structured in a way that allows members to refer directly to other members. No opinionNo opinionSomewhat clear5.13.2.1.2.3 and 5.13.2.1.4 The care coordination tool should be bidirectional between medical and non-medical providers. All referrals should be closed-loop, and outcomes should be tracked between medical and non-medical (Health Neighborhood) providers. Finally cooperation and communication between medical and non-medical providers should be facilitated in a HIPAA compliant manner via the tool. Somewhat clear5.14.3.7.1 and 5.14.4.8.1.1.2.8 Healthy Neighborhood outcome measures should include number of referrals and cases between all providers. Number of services accessed and outcomes of cases (positive/negative/neutral) at providers should be tracked.No opinionNo opinionNo opinionNo opinion
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12/14/16I agree and wish to continueEarlDella BarcaBehavioral Healthcare, Inc.Prospective BidderSomewhat clearThere are a few sections that have some inconsistencies or that could be explained further:

(1) Section 5.15.3 states "Chief Executive Officer", but, to be consistent with other sections, I believe it should say Program Officer (5.2.12.1.1)

(2) Section 5.15.5.3 states "Contractor shall comply with the Department policies related to recoveries of overpayments." Is there a place where these policies are housed? Does this refer to regulations?

(3) Section 5.15.10.1 requires a Fraud, Waste, and Abuse Compliance Report every 6 months, but Section 5.15.10.2 states that the report is quarterly. Section 5.15.22.6 also states 6 months.

(4) Section 5.15.5.2.7.6 states that service verification notices should go to "all or a sample of Members who receive services". Can this be clarified? Is it all or a sample? All would likely be extremely burdensome to the RAE and overwhelming to members. If these verification notices are to be mailed, that creates a large administrative burden on the RAE and the members would likely be unhappy receiving these notices in the mail each time they seek a service.
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12/21/2016 12:07:51I agree and wish to continueMoeKellerMental Health Coloradoadvocacy organization for individuals with a mental health conditionThe contract has a requirement for providers to offer medical advanced directives. we feel that psychiatric advanced directives should also be included for those clients who wish to write one. ( p. 57)

The RAE should not be allowed to contract 100% of its provider services to just one agency. ( no sole sourcing). Many networks, especially in the rural areas of the state, are locked out of providing services locally due to current practice. Having multiple contacts with a variety of networks will open up more provisions of services to those in need across the state.
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1214/16I agree and wish to continueBernardHeath, Jr., Ph.D,Axis Health SystemProspective bidder, provider and community healthcare organizationAxis Health System greatly appreciates this opportunity to provide feedback regarding the Regional Accountable Entity (RAE) for the Accountable Care Collaborative draft RFP. As the only organization in Colorado to be a member of both the Colorado Community Health Network (CCHN) and the Colorado Behavioral Healthcare Council (CBHC), as a BHO owner/provider, and as a leading organization in the State and the nation in care integration, we are in a unique position to provide such feedback.

Principles of Intent. There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is both understandable and appropriate to a point. Yet, I would hope this perspective constitutes but a portion of the principles that govern the design and content of this RFP. Axis’ response desires to take advantage of this important opportunity to fearlessly design a system to support leading edge, best possible care for our Medicaid residents of Colorado. We have learned from the care design of the foundation contracts, and we aspire to a bolder vision of what could be possible.

Preservation of BHO gains. There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract in all regions, which has been so successful. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require provider ownership (or partial ownership) of the contract as is specified in an LSLPN license (4.1.2.2). A contract ownership position not only encourages the most effective, efficient and creative local design of care (making the very best uses of local resources as called for in 3.2.3.3, “regional communities are in the best position to make the changes that will cost-effectively optimize the health and quality of care for all Members”) but it also ensures that this structure will remain throughout the term of the RAE.

Deliverables. This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. We would suggest that a combined HCPF clinical and data team (with provider input if desired) review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes. There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes. HCPF may want to start with these measures, but we would suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.

Contract term. The initial term of the contract (1.2.2) is for one year. This transformation from RCCO to RAE will constitute a substantial evolution and require much of the contractor and provider network. We recommend that the initial contract be for a period of 3 years to allow the RAE to mature in its network, reporting and care delivery structures.
Somewhat clear5.1.10.2 This is an overreach. There needs to be an allowance for development of internally used instruments, procedures, data structures, training material, etc. that is used not only for this contract but for other regional patients’ care. We are happy to have HCPF and Medicaid patients benefit from our smart, creative staff, but they are in the end our staff and our communities’ staff and our whole community should benefit.

Somewhat unclear5.2.3 et. al. The requirements in this section have moved over the line into micromanagement. The truth is that setting granular requirement only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. We suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2 The 40% requirement is very difficult to understand in its implications. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.Very clearNo comments.Very clear5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.

New Idea Leon Festinger’s theory of Cognitive Dissonance and a raft of subsequent research have shown consistently that people more greatly value care/services that cost them effort or dollars over those services that are free…even if it is the same service. Additionally, there is a substantive waste of funds/resources in every community mental health center and community health center as a result of appointments that are no-showed. We can fill slots that are canceled (where we have advance notice that the appointment will not be kept) but no-shows result in a tremendous waste of resources. Medicaid allows for a nominal failed appointment fee but does not require it. HCPF currently does not allow such a fee. I would propose that this RFP allow, at the option of the RAE and the provider, a $1 - $5 no-show fee. Research shows that it is not the amount of the fee that results in changed behavior, but the fact of the fee so a nominal fee that will have minimal impact on access in general would work effectively and would increase patient engagement while reducing program cost. This would NOT be applied to a cancelation of an appointment.

5.5.1.1.4 We particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention. We know that this is where the low hanging fruit and long term costs savings will be found.

5.5.3.10.1.2 Colorado recently passed the Aid in Dying legislation, which in concert with advance directives puts us with 5 other states at the forefront of end-of-life planning for those who wish to do so. HCPF is, I am sure, aware of the prohibition of using Federal funds (including those through HRSA supported Community Health Centers [CHC] like Axis) for the purpose of compassionate ending of life. As Axis is unique in our State in terms of being designated both a Community Mental Health Center (CMCH) and a CHC, we may be able to (and we desire to try to) become one of the few organizations that will be able to offer these services. We would request your assistance/guidance in developing these services not within, but as a resource for, Region 1 in a manner that is consistent with both the intent of Colorado law and Federal law.
Somewhat clear5.6.1 Grievances are an important part of both quality improvement and patient engagement. Axis has a robust, active policy that encourages the filing of grievances and supports patients in doing so. Staff are an active part of this process which is evidence that it is not viewed internally as a “Gotcha” process. For this process to work, HCPF must trust the process and require that all grievances must contain sufficient information to be actionable. Anonymous complaints that do not contain sufficient information to back-track the issue and determine the problem, if any, are not helpful nor do they improve the system and should not be accepted. Use of external Ombudspersons and legal proceedings are necessary and valuable only after internal resolution has failed. Internal resolution should be the stated goal and those grieving should not be allowed to jump to external adjudication over the internal process. To do so sends the message that the internal process is not to be trusted. NO PROVIDER is ever so lacking in principle and judgement as to do anything remotely like engaging in retribution. That is an unfounded fear.Somewhat clear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. We urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care.

5.7.2.1.8 This section calls for universal screening tools. It is unclear from this statement whether the requirement is use of screening tools that are universally used across the country, or universally used within the treatment setting. We recommend that the wording be something along the line of, “…uses population based screening tools, screening the entire population of the site to determine need”. This is an important distinction as screening only those patients for conditions they appear to have misses more than twice the number of patients with the condition but without the initial appearance of it.

5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.4 Is this section actually intending to say, ”…shall provide for extended hours…on evenings and/or weekends and/or alternatives for emergency…”?

5.7.4.10 When HCPF is determining a “sufficient number of providers” we hope and expect that HCPF looks at a large practice of 15 providers as having 15 providers available, not as 1 provider.

5.7.4.13 We suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear5.8.2 Increasing Member access to timely and appropriate Medicaid services and benefits is critically important to improving population health. It is unclear whether this section is encouraging the broadest linkages with community resources or opening the door to “any willing provider”. We hope that it is the former – encouraging broad linkages. In that regard, stronger financial incentives and contractor proof of existing strong and positive community linkages will be very important. We have come to understand that the most important focus of improved access is not adding providers, but engaging enrollees active participation in their own healthcare in prevention and early intervention. With that in mind it brings us back to care integration which both engages patients best, and diminishes stigma most for behavioral health issues.

5.8.3.8 DSRIP is an interesting pilot established with good intent. Axis does not believe this to be a worthwhile endeavor given concerns about unanticipated consequences and the limitations of being a voluntary pilot. Further, it would appear that the new Administration in Washington would not be willing to continue with this program. We advise it’s deletion from the final draft.

5.8.3.12-13 Axis is very pleased to see the explicit inclusion of oral health as a critical component of healthcare. Nice job and thank you.
Somewhat unclear5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances (as opposed to an insurance company simply claiming they will contract with local providers). This also means that funding needs to be tied to true population health outcomes.

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes hundreds of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.
Very clear5.10.6.2 Axis suggests that this section be modified to read, “The Contractor shall offer training to its Network providers at least every six (6) months on one of the following topics:” to prevent confusion that all topics must be available every 6 months.Very clear5.11.1 From Axis’ standpoint, this is but a very small step from a traditional PPS model to preparing organizations for a more value based payment methodology. It does not introduce risk, nor does it move from unit of service, encounter based adjudication.Very clear5.12.1 Having the Contractor receive the Capitated Payment will not preserve the existing BHO alignment of funding and care incentive in Region 1. If the subcontract is a sub capitation contract it will preserve sub capitation as a payment structure but not a model of care with included risk and population based management. Consequently, it will not actually preserve what HCPF sees as benefits under the existing BHO structure. It may adjust some of what it sees as downsides, but it doesn’t create a structure to preserve the upside – the alignment of incentive. Additionally, there is no guarantee that the sub capitation will continue beyond the initial contract period.
5.12.5.4 The six session and “low acuity” provisions give the illusion of increased access to care and embracing of the “no wrong door” concept, but it is an illusion. Behavioral health enrolls clients by “episode”. The low acuity designation may work by episode. However, as a Community Health Center (CHC a.k.a. FQHC) we enroll for the life span and no patient is always “low acuity” – their level changes depending on experience, trauma, etc. Further, what presents in a CHC or Behavioral Health setting as low acuity (and by the way there is no consistent professional designation of low acuity) is often not. Presenting problems have a way of peeling back into a constellation of issues. In consequence it will be the rule more than the exception that someone initially treated in a CHC for six sessions will need more care and more intense care than the CHC setting is capable of providing. Focusing on allowable services is convenient, but perpetuates FFS volume based services rather that population health value based care.

This structure, therefore, will promote not integration, but fragmentation of care; six sessions here for what appears to be a low acuity behavioral health issue, then subsequent sessions there when it turns out to be a more demanding issue, then referral back here for chronic care management. A better solution is a strong formal and informal, collaborative arrangement that brings both aspects of healthcare around the patient, regardless of setting (and regardless of acuity), that is so integrated as to make the patient unaware that there is more than one system at work.

5.12.9.1 The problem with reimbursing FAQHs the encounter rate is that it is more expensive, reimbursing a higher rate based on CHC medical base rates which are higher than behavioral health base rates. It would be more fiscally responsible for there to be no CHC limits (other than CHC competence for the care) but have reimbursement based on something like the average of behavioral health site’s cost for that care.

5.12.12 This section beats a path to contractual inconsistency. We cannot support the intent of increasing value based, whole person, integrated care by using a retrospective FFS accountability structure. If we deliver care rather than prescribed and coded services, that care will at times be creative and not be translatable to a service code, but will directly result in improved individual and population health. (I am happy to provide examples should that be helpful to you.) In a truly integrated setting such as that of Axis, we will never get to an 89% MLR; an 89% costing out of prescribed and coded services as many of the services will not be codable. Either this contract needs to switch accountability to population based health indicators only and/or population cost only, or an accommodation needs to be made for such fully (and documented) integrated sites/care as that provided at Axis.

5.12.13 See response to 5.5.1.2 proposing a nominal fee for no-shows only.
Somewhat clear5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well.Somewhat clear5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. A measure such as “number of psychiatric bed days used” is attractive to measure because it is discretely visible and measurable. It is, however, a very poor measurement because it does not inform care. It does not help us know what actions we should or could be taking to change the outcome. Measuring suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

Axis applauds HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. We would like to suggest that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that better and better correlate with actual improved population health and consequent reduced per capita cost. We ask, too, that the Department be sensitive to the burden that disparate reports and report timing put on local data collection and administrative staff – pulling funds away from direct care and increasing base cost for operation. To the extent that the principle of “minimal necessary” can be applied to data extraction and alignment can be applied to the timing of reports, we would greatly appreciate it.

5.14.7.1 As previously noted in section 5.6.1, anonymous complaints are entirely unhelpful. The expressed fear of retaliation is absolutely without foundation or merit. Retaliation is thoroughly unacceptable, easily visible, and entirely un-intelligent. We ask HCPF to add something like the following to this section, “All QOC concerns will be encouraged to use the Contractor’s process for resolution. No QOC concern shall be considered valid unless accompanied by actionable details allowing for competent investigation, remediation and follow-up.” These issues are the responsibility of the Contractor, should not need to be resolved by the State, and should be effectively addressed at the direct care level.
Somewhat clear5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.Very clear No CommentsSomewhat clear No CommentsSomewhat clear No Comments.
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12/14/16I agree and wish to continueGretchenMcGinnisColorado AccessProspective BidderColorado Access strongly supports the state’s vision and goals for the ACC Phase II program and appreciates the opportunity to provide feedback, especially about potential new services. In particular, the state’s move to a single contractor for each region, combining the physical health and behavioral health programs, will enable unprecedented collaboration, synergies of efforts, increased efficiencies, and alignment of incentives; this decision will allow the ongoing evolution of Colorado’s healthcare system into a truly integrated model and accelerate the pace of moving toward alternative payment methodologies. The draft RFP is well developed, addresses the broad array of critical components necessary to achieve the program’s aims, and has clearly incorporated stakeholder input. The emphases on member-centeredness, community and provider involvement, flexibility, innovation, and phased implementation of payment reform will promote the ultimate success of the program and drive the outcomes intended by the state.

A potential limitation of the draft RFP is that it is quite prescriptive in some areas, such as personnel requirements. The program will be stronger and more efficient if the RAEs can more flexibly address some aspects of program staffing and other implementation details in collaboration with the State (5.2).
Colorado Access supports the state’s model that conceptualizes the Patient Centered Medical Home as the hub of an integrated delivery system and the key driver to improvements in the quality and experience of care, population health, and reducing overall healthcare costs. The draft RFP contains several elements that attempt to increase member linkage and engagement to PCMPs and to increase accountability of both the RAE and the PCMPs for those members; Colorado Access supports this framework. Additionally, the draft RFP attempts to link PCMPs more closely with a single RAE. This approach has the potential advantage for practice sites of decreasing complexity and reducing their administrative burden in dealing with several RAEs’ potentially variable requirements, tools, and reporting mechanisms. This intended benefit, while laudable, may not achieve its intended outcome, as many provider systems have practice sites in multiple regions. Those systems and their centralized leadership, data systems, and administrative infrastructure which support the practice sites would still need to engage with multiple RAEs. The medical and clinical staff, too, may work at various sites with a system, and thus be in effect participating in multiple RAEs.


Colorado Access recommends that the attribution model be further developed and made more robust. As currently proposed, it has several potentially problematic limitations and unintended consequences, as well as many that are unknown at this time. The proposed attribution algorithm focuses on primary care claims and does not account for other sources of members’ health care such as behavioral health and specialists. This has the potential to assign a member to a RAE in one region while inadvertently disrupting existing behavioral health network access and specialty care relationships that are active in another. The adverse impacts of this method could be greatest for members who are high utilizers or have chronic/complex conditions, the very population most in need of coordination and most likely to incur high health care costs. These are illustrative examples of typical member scenarios that could arise in the proposed methodology:
#1 Bobby is a foster child living in Adams County, currently RCCO and BHO Region 3. Bobby goes to Denver Health for primary care and Aurora Mental Health for behavioral health services, which is his primary treatment need, and point of contact with the health care system. Under the proposed attribution methodology, Bobby’s assignment would move from Region 3 to Region 5 (Denver). This would in turn require Region 5 and Denver Health to coordinate with Aurora Mental Health Center, Adams County child welfare services, and other local educational and community services involved with the member.
#2 Maria lives in western Adams and receives long-term services and supports from the SEP responsible for that region and behavioral health services from Community Reach Center. Due to her a chronic complex medical condition requiring specialized treatment, she receives the majority of her medical care at an academic medical center in Region 3. However, when she occasionally needs primary care services, she accesses a clinic near her home that is in Broomfield County. Under the proposed methodology, Maria would be assigned to Region 6, resulting in that region being responsible for care coordination (including coordination with the SEP in another region) and performance and quality metrics.

The proposed attribution methodology could be improved by being more member-driven and making use of upstream opportunities, and better methods for attributing and engaging members with PCMPs. Simply attributing new or unattributed members to PCMPs without engaging the member at the point of Health First Colorado enrollment, offering choices, etc. is unlikely to achieve the stated aims.

Another potential challenge with the proposed attribution methodology is the requirement for the RAEs to manage a risk-based behavioral health benefit, including utilization management, claims processing, and financial controls. These functions are dependent on accurate and timely eligibility data and actuarially sound rates based on a defined population and historical utilization. Both the administrative and financial management responsibilities of the behavioral health capitation aspect of the RAE would be complicated by a more volatile population, churn among regions, accuracy of regional assignment data, claims errors, etc.

The proposed attribution methodology also carries some risk of misaligning incentives. If there is significant financial interest in RAEs ability to achieve certain performance, clinical, and financial goals, then attracting, engaging, and attributing healthier members is incentivized, while referring higher cost or more complex members to other RAEs would be incentivized. The fluidity of the attribution methodology does not provide safeguards against this, or hold RAEs and their PCMPs sufficiently accountable for the outcomes of their regions as a whole.

Recommendations:
1. If the State decides to adopt the model of assigning members to a RAE based on where their PCMP practices are located, with each practice site assigned geographically to a region, we recommend that the state work collaboratively with the successful bidders to develop a more robust attribution algorithm that includes the totality of the members’ healthcare utilization and other factors, including primary care, physical health, specialists, behavioral health, and social determinants such as foster care involvement. Consideration should be given to some limited exceptions to this assignment method for certain populations that may not be well served by it, such as children in foster care.
2. Developing a more member-centered approach to attribution collaboratively with the successful bidders could increase member engagement and meaningful attribution, especially if the approach was further upstream (e.g. at the point of enrollment in Health First Colorado), and not solely based on claims.
3. If the proposed attribution methodology is adopted, we recommend that any reassignment of members from one RAE to another occur only prospectively such that state payments to RAEs, RAEs’ PCMP payments, behavioral health claims payments, and incentive payments are not re-adjusted and re-processed retroactively.
4. We recommend that consideration be given to continuing with some version of the current system of assigning members to RAEs based on their county of residence. Modifications could include assigning the PCMPs to RAEs based on address and requiring that the RAEs collaborate to adopt common requirements and reporting tools, as appropriate, in order to minimize complexity for providers.
Colorado Access strongly supports the goal of increasing access to behavioral health services in primary care settings and to creating sustainable funding mechanisms to support this model. However, using standard fee-for-service reimbursement models for billable behavioral health services would not adequately fund behavioral health integration in primary care settings other than FQHCs. Integrated care models involve significant amounts of non-billable activity on the part of behavioral health clinicians to fully implement a team-based, population health approach. Integrated care expansion has been driven to-date by grants, start-up funds, and, in some regions, BHO and CMHC support.

Providing up to 6 visits of behavioral health services in a primary care setting is reasonable. However, details about how this is administered would have to be determined and could be very complicated, such as defining an episode of care, or counting visits across multiple providers. Members might lose and then regain eligibility, change assignments between RAEs, or receive behavioral health services in several primary care settings that are in different RAEs. Tracking the benefit, defining the start/stop of a time interval, and adjudicating behavioral health claims would be challenging.

Colorado Access supports the RAEs’ responsibilities for broad engagement with other social service, governmental, educational, criminal justice, refugee, public health, and community organizations. The populations and funding for these agencies are based on geographic regions and catchment areas, however, while the RAE in a given region would serve members living across multiple geographic areas (in the proposed attribution method). This misalignment would weaken the RAEs’ ability to partner with these entities and dilute the impact of any investments in them.

Recommendations:
1. An alternative model to the six-visit proposal would be for HCPF to pay an enhanced rate for FFS BH services provided in non-FQHC primary care settings to reflect the higher per-unit costs of providing care in this model.
2. Consideration may be given to leaving the primary care behavioral health services in the BH capitation program but to require the RAEs to invest in the development and program costs of primary care integration build-out. This could include requirements that BH providers in primary care settings be included in the RAE’s network and claims be paid without network restriction, or prior authorization.
Colorado Access supports the department’s aims of transitioning to alternative payment models for primary care. However, it will ultimately be important for value based reimbursement to outweigh volume based FFS. This will be more challenging to do in practices with low attribution rates without corresponding APMs from other payers.Colorado Access supports the direction of the state in its performance measurement approach. Several key performance indicators are strongly evidence-based, and will help achieve the program’s aims. Others, however, have less evidence or have been shown through solid evidence not to be effective, such as annual adult well check visits. Some of the KPIs are easily quantifiable and may be reasonably expected to change over the program’s evaluation intervals. Some, however, have multiple determinants (many well beyond the influence of the RAE) and would be expected to change very slowly over time, such as population levels of obesity. Others are program development and process measures that would need to have meaningful and methodologically sound metrics for performance developed collaboratively with the successful bidders.
Recommendations:
1. The department should work collaboratively with the successful bidders and other stakeholders to refine the KPIs and develop sound metrics, methodologies, and baselines. KPIs need to be developed in a manner that reasonably allows the RAE to achieve the $4 PMPM withhold.
2. In the first measurement period, earning back the withheld payments should be reasonably readily achievable. This allows RAEs to make the investment in KPIs to be able to achieve improvements in subsequent years.
3. KPIs should align with existing measures and incentives in other programs, structures, and initiatives rather than be unique to the ACC.
4. Additional consideration should be given to the cost of care, which is ultimately critical to the long-term sustainability of the ACC program. This may be especially important as many of the proposed KPIs are not likely to quickly reduce cost of care.
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12/20/2016 14:38:31I agree and wish to continueDanaKennedyColorado Network of Health AlliancesSocial Service/Community OrganizationThe Colorado Network of Health Alliances is a statewide, membership coalition of health alliances across Colorado. The following comments were collected through an iterative and inclusive process including key informant interviews and Network discussions to garner feedback and reach agreement from the 23 member health alliances. Through building consensus, the following comments represents areas where we feel the RFP can be strengthened to best serve its members and meet the needs of patients and communities throughout Colorado. Somewhat clearAttention and accommodation are needed for the differing needs of rural and metropolitan communities. Lack of transportation is a barrier to access and should be addressed in the RFP. We support increased funding and flexibility for transportation in rural areas. Time and distance network requirements should reflect the challenges and needs for both primary care and behavioral health providers.
(Access to Care Standards 5.7.4)
Somewhat clearHealth Neighborhoods should reflect the availability of providers. The ability of RAEs to fund non-traditional providers should be considered (paramedicine, telemedicine and telehealth).
(Health Neighborhood and Community 5.8)

Stronger language requiring RAEs to use existing local collaborations to discourage duplication of efforts. Health alliances have governance and relationships already in place to build health neighborhoods and align and streamline processes across systems of care.
(Health Neighborhood and Community 5.8.3)
Somewhat clearEncourage flexibility in payment of care coordination funds to allow compensation to non-traditional organizations and community agencies that perform care coordination (for example, promotores or promotoras).
(Care Coordination 5.9.3 and Financial Support 5.10.9)
Somewhat clearTo be in compliance with federal parity regulations, SUD should be treated like other chronic behavioral and physical conditions. The absence of an inpatient benefit for SUD restricts treatment options for members.
(Integration of Primary Care and Behavioral Health Services 3.3.13 and Capitated Behavioral Health Benefit 5.12)

Covered diagnosis restrictions for behavioral health services impose significant barriers to treatment. More thought should be put into how we can ensure access with capitation.
(Integration of Primary Care and Behavioral Health Services 3.3.13 and Capitated Behavioral Health Benefit 5.12)

More consideration should be given to the unique needs of those with serious mental illness.
(Integration of Primary Care and Behavioral Health Services 3.3.13 and Capitated Behavioral Health Benefit 5.12)
Somewhat clearExisting health alliances are trusted neutral bodies and can convene providers and agencies around data sharing initiatives.
(Data, Analytics and Claims Processing Systems 5.13)
Somewhat clearUtilize existing health alliances to facilitate community and member engagement in meaningful ways to address social determinants of health. Alliances and other trusted community voices should be used to build local Performance Improvement Advisory Committees.
(Advisory Committees and Learning Collaboratives 5.14.9)
Somewhat clearBrokering case management to eliminate conflicts of interest may not be possible in rural communities due to workforce limitations.
(Brokering of Case Management Agencies 6.4)
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12/21/2016 15:53:49I agree and wish to continueMurrayWillis, MDColorado Society of AnesthesioloigstsAdvocateThe Colorado Society of Anesthesiologists (CSA) would like to submit the following response to the Request for Information. With over 700 physician members the CSA represents the interests of the practicing anesthesiologists in the state of Colorado. The Perioperative Surgical Home is a concept that has been developed by the American Society of Anesthesiologists (ASA) to address the need for increased care coordination with the goal of improving patient safety, quality care, and achieving cost efficiencies in the health care system.

The American Society of Anesthesiologists has been at the forefront of the development of a new delivery of care concept called the “Perioperative Surgical Home”. The purpose of this idea is to create a medical care construct that improves health outcomes and ultimately creates significant savings in the long term. This care model would dramatically increase coordination of the perioperative care of the patient, from the time a decision is made to have a surgical procedure, through the hospital course of treatment, and then through the postsurgical rehabilitation period. The improvements in patient care are accomplished by utilizing the anesthesiologist’s unique position at the center of the surgical continuum.

Initial studies have demonstrated significant improvements in the patient experience of health care and decreased costs. These goals are achieved by early patient engagement, targeted preoperative testing, intraoperative efficiencies, reduction in postoperative infections, fewer transfusions, shortened hospital stays, coordinated post-procedural care, and fewer hospital readmissions. These objectives are realized when anesthesiologists are actively engaged in the entire continuum of perioperative care.

We believe that the Perioperative Surgical Home concept addresses the stated goal of the Accountable Care Collaborative to provide “a client and family-centered, whole-person approach that improves health outcomes and ensures savings”. The health care team is incentivized to improve the perioperative process through a payment methodology that covers both facility and physicians for the episode of care. Examples of possible payment structures can range from fee for service to bundled payments with the opportunity to share in savings or bonuses for meeting quality and cost-saving metrics.

We look forward to the opportunity to discuss this innovative care management model with the ACC. The CSA is committed to working collaboratively with the ACC to improve the delivery of health care to the Medicaid patient population.

For more detail, the ASA website link is: https://www.asahq.org/psh/about%20psh/an%20overview

Murray S. Willis, M.D.
mswillis@comcast.net
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12/23/2016 9:17:24I agree and wish to continueDanielDartingSignal Behavioral Health NetworkSubstance Use Disorder Services Network OrganizationWe understand and appreciate the significant work and visioning that went into this document and the plan for the future. We are invested in helping to improve and shape it as the process moves forward.

We have concerns about how infrequently substance use disorder (SUD) is mentioned or integrated into the larger plan. Numerous studies have shown that investing in appropriate SUD treatment and other services reduces future medical costs. For example, the White House’s Office of National Drug Control Policy points out that for every $1 spent on SUD treatment, $4 are saved in other healthcare costs (https://www.whitehouse.gov/sites/default/files/ondcp/Fact_Sheets/investing_in_treatment_5-23-12.pdf)

Additionally, the SUD benefit appears to remain unchanged in the new RAE. It lacks a daily rate for withdrawal management (detox). Even more concerning, residential substance use services are completely lacking in the benefit. Lastly, recovery support services do not appear to be included either. Supporting patients in their recovery, after treatment, will help to reduce the likelihood of re-admissions and improve the long-term health of the Medicaid Member.

Even lacking those more expansive services, substance use Managed Service Organizations (MSOs) are able to help reach Medicaid Members (and other individuals) with services, like residential services, etc., lacking in the benefit now. Requiring and empowering the RAE to substantively coordinate with their MSO(s) will improve care delivery, access, and outcomes for clients.

Under 3.3.15.3, mention is made of behavioral health capitated payment, with the RAE as the responsible entity for assuming all mental health optimization for Members. No mention of substance use optimization (p. 25). This is a significant oversight, especially since such SUD optimization would realize savings overall.
Somewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat unclear5.6.8.1.1: Substance use service data will not be shared with the Ombudsman for Medicaid Managed Care (p. 67). Our assumption is that is due to 42 CFR Part 2. What impact will that exclusion have on the appropriate valuing of SUD services?Somewhat unclear5.7.3.1: Managed Service Organizations manage a statewide substance use disorder treatment system for Colorado. There are 7 MSO regions. As regional entities MSOs support the delivery, expansion, and quality delivery of the entire continuum of SUD treatment. Under the Network Development and Access Standards: Establishing a Network, MSOs are not included (p. 68), though other similar healthcare delivery networks are listed.

If one of the goals of the RAE is to implement coordination of services to prevent duplication and overuse of low value services, and fragmentation of care (as discussed on p. 25), MSOs should be included as an entity that the RAEs must work with to ensure benefit continuity and access to services not otherwise included in the Medicaid SUD benefit.

Further, as noted in the RFP, RAEs will need to have strong integrations into child welfare system and individuals involved in correction (p. 23). MSOs have experience with both; this is another reason to include connections with the MSO system and RAEs under Network Development and Access Standards.
Somewhat clear5.8.3.8: DSRIP is briefly mentioned, again as an afterthought it seems. The RFP generally admonishes Contractors to work with hospitals on implementing DSRIP-supported programs and with the establishment of interventions and performance goals. No mention is made of how this workflow will be implemented or funded. (p.79)Somewhat clear5.9.3.12: Care Coordination is mentioned frequently throughout the RFP draft. There is mention made of the RAE’s being required to work with existing entities to deliver specialty care coordination across funding sources, treatment options, and systems (p. 86). For SUD, MSOs have a mandate to perform such coordination, regardless of payer. Interacting directly with the MSO in terms of care coordination would be an appropriate directive for the RAE.Somewhat clearSomewhat unclearSomewhat unclearHow will payment alignment work with FQHCs and CMHCs. This seems complex, but is barely mentioned. (see also, 3.3.15.1.3, p. 25)Not ClearThe degree of information systems changes that will be coinciding with this RFP, which bidders will be required to support and interact with (but will not exist measurably in advance of the bid or RAE roll-out) is marked.Somewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat unclearKPIs and PMPM for Care management is unclear in terms of how it will be calculated. Can the Department elaborate?
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12/23/2016 11:06:31I agree and wish to continueShellyBurkeAxis Health SystemCommunity Mental Health Center/Community Health CenterThe RFP is quite heavily focused on the PCMP role which is actually the smallest aspect of the contract as it is attempting to bring together Behavioral Health and Care Coordination services. These services are quite different and this consolidation, while well intended doesn't align well with what is intended to be achieved.Somewhat unclearThis section included a lot deliverables that appear rigidly defined and applied and don't set the stage for the individual community health status and outcome measurements that may need to vary by region. Somewhat unclearPrescriptive in nature and drifts into management and organizational structure of respondent vs. staying focused on contract deliverables.Somewhat clearThe intention to consolidate is clear and the incentive and structure does not appear aligned to deliver the intent.Somewhat clearAttribution has been awkward, hard to track and hard to manage to with the current RCCO structure. There is little improvement in RFP to address and this will likely need further evolution before the volatility of this and accuracy of the attribution are truly improved.Very clearRFP focus on prevention, intervention, wellness are all important areas of focus for any reformed healthcare approach that can improve patient health outcomes and impact the total cost of care over a reasonable timeframe.Somewhat clearGrievance and appeals are an important patient right and they must be structured constructively in order to ensure accurate feedback and actionable items can be identified. Anonymous reporting rarely results in anything constructive and yet involves a lot of resources and time. All involved would benefit from a more clear directive for all involved in patient care and payment when direct feedback is required as a first step.There is a balance to be found between network adequacy and qualified providers held to a consistent standard of performance, documentation and accountability. This RFP as structured does not address these issues and appears to be more focused on "willing providers". Quality of care and measurability of outcomes requires there to be clearly defined criteria and accountability for providers to participate and be evaluated on efficacy both administrative and clinically.Somewhat unclearCollaboration across specialties and coordination of resources are important in the modern world of healthcare.Somewhat unclearPopulation Health management is a critical aspect for modernizing healthcare. The issue again is how to qualify providers, systems or clinics as capable of addressing what the screening will identify as the population's needs. It is not sufficient to screen and identify, the intervention and treatment capacity must be aligned to serve the patient's needs and ultimately impact the total cost of care. Community linkages have been created through local relationships - they will not be created or maintained by an insurance company who "contracts" for services.Very clearTraining requirements need some additional review, consideration and clarification.Very clearPrimary Care APM is at its essence a repackaging of how payments are made from the PPS approach to paying a provider monthly for expected patient encounters vs. actual per encounter billing with a y/e reconciliation for encounters and costs that will affect the future year's monthly payments. This doesn't introduce risk/reward as an essential step forward. It may allow for some innovation in patient service development.Very clearThe approach is clearly defined. The intention is not. The structure as proposed is intended to split low acuity care and services and high acuity care and services while preserving the capitation structure for this high acuity care. The methodology outlined doesn't set the stage for successful population based management or maintaining the risk/reward that is essential to capitation. This delineation does not promote integration of care in the way that it I think is intended and will likely increase fragmentation of care and disruption in the care delivery and increase the care complexity that will negatively impact the patient and likely unduly burden the providers. Somewhat clearThis section appeared to be additive to what already exists for the ACC and the BHOs, as such seems unwieldy for both the contractor and HCPF. Volume of data and reporting requirements, unless significantly reduced are not designed currently to add real value to the optics of improved patient outcomes. Somewhat clearIndicated involvement of Contractor in establishing performance measures/indicators is very much appreciated. Somewhat unclearAdditional clarity here is required.Very clearSomewhat unclearSomewhat unclearThere is a lot in this section and it isn't laid out in a way that clearly identifies what the structure will really be nor how it will be calculated across the disparate services and providers as identified in this RFP.
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12/29/2016 12:58:41I agree and wish to continuePatriciaYeager, Ph.D. CEOThe Independence Center (Colorado Springs)AdvocateA shotgun wedding between behavioral health and physical health without the moonshine! LTSS ought to at least be a bridesmaid to this union as these are people in the home usually every day, if not several times a day. With some training and a structure, LTSS providers can assist with monitoring daily health and sending out an early signal for changing health conditions that need attention.

I appreciate the tension between too many requirements and too little. However, when it comes to disability (and senior) cultural competency and functional access to medical offices, clinics and diagnostic units, more is required so that our sickest and most functionally impacted people (of all ages) may benefit and have a better quality of life.
Somewhat unclearNeed to add a key position:
5.2. 12 Personnel Availability
Each RAE needs its own (1.0 FTE) Americans with Disabilities Act (ADA) Coordinator in compliance with Title II of the ADA. This person shall oversee all disability access and competency projects and services and shall serve as the contact person for members and providers who want disability access and competency information, have questions, or need to report lack of access issues.
1. Must have a bachelor’s degree in relevant field
2. Must have 3-5 years’ experience working with people with a wide variety of disabilities
3. Prefer a person with a disability
4. Prefer a person who holds certification as an ADA coordinator (federally, The ADA Network trains and certifies people in this arena)
No opinionNot ClearNot detailed enough for a bidder to know how to serve people with disabilities

here are three sections that need more information regarding serving people with disabilities:

5.5.2.6.4 Alternative formats for written communication
The ADA calls for print fonts that are sans serif and a minimum of 14 point font or larger for persons with low vision. Alternate formats should include electronic formats as well.

5.5.3.3.1.1 Member communication
The call center or customer service center must have the capability of receiving and sending texts so that those who are deaf, adults who become deaf later in life, severely hard of hearing or who are speech impaired or non-verbal can communicate independently with the call center. TTY/TTDs will not be compatible with telephone technology by 2021. Check with the Public Utilities Commission on this date. Text and email are already primary ways to conduct “telephonic” communications with the overall deaf, hard of hearing, and speech impaired community.

5.5.3.5 Member Rights
5.5.3.5.2.6 The right to obtain available and accessible services including disability accessible and competent services. State how and who the member should call to make and resolve complaints. (The ADA coordinator)
A statement of commitment to providing disability accessible and competent care by the contractor is needed.
Not ClearFor too long, the health care sector has ignored or paid lipservice to the needs of people with disabilities of all ages. The Medicare-Medicaid "Dually" Eligible population consumes a large part of the healthcare dollars but do not have good health outcomes. Part of this is because the trip to the doctor is hellish for most people with disabilities- an ambulance ride to the ED only when one is very ill because doctors offices are not equipped for the most basic accessible exam , healthcare staff are not so welcoming and transit is very difficult. I urge our Medicaid program to take this opportunity to require contractors to do a self evaluation and correction plan over the 7 years of this contract. The State is a Title II entity under the Americans with Disabilities Act so a "self-evaluation and transition plan" process as required of Title II entities would be an appropriate way to identify an accessible and geographically dispersed network of healthcare for persons with disabilities. With each Contractor surveying its region and creating a transition plan, HCPF would then monitor the contractors' progress on their plans. Network Development and Access Standards are at the heart of this issue. Here are my suggestions for how to operationalize the goal of a network of healthcare providers (medical offices, clinics and diagnostic services) so that persons with disabilities of all ages can truly have a better and more cost effective health outcome

5.7.4 Access to Care Standards
A standard needs to be added that states Contractor shall ensure that there are disability accessible and competent healthcare providers that demonstrate network adequacy across the contractor’s geographic area. HCPF’s DCCT spells out physical, program and cultural competency requirements.

5.7.7 Ensure network compliance with Americans With Disabilities requirements for physical and programmatic access.
This boilerplate language needs a specific process that each RAE will use to demonstrate that it has complied with this regulation. The State should have a consistent approach to monitoring whether or not it has an accessible medical network of services to demonstrate that the State has complied with this requirement for Medicaid funding from CMS. Such a process may protect the RAE and the State from failing to meet the needs of people with functional limitations (disabilities) of all ages. I propose the following process which has been agreed upon, in principle between the state Medicaid agency and the current RCCOs.
This is a self-evaluation and transition plan process as put forth in Title II of the ADA for state and local governmental entities. Title II entities are required to have an ADA coordinator.
1. RCCOs will survey their medical facilities using the instrument already approved by CMS and HCPF (see the DCCT put together by stakeholders with HCPF and approved by CMS in 2015). The three pillars of this program are architectural access, program access and disability cultural competency.
2. Divide their medical facilities (medical offices, clinics and diagnostic centers) into three groups:
a. Those currently serving Medicaid-Medicare patients
b. Those who could serve them (interested, easily made accessible)
c. Those who are in inaccessible facilities and unable to be made “readily accessible” (ADA does not require more than what is reasonable)
3. Using the DCCT and a trained evaluator, assess the three pillars and, for each facility, create a document that details access features available, those features missing, cost to cure the issue and projected date. Determine priority for which facilities are to be updated and which facilities are to be left alone due to not meeting the readily accessible criteria. Members with disabilities will not be referred there.
4. Create a transition plan with the above information, adding who will be responsible for making sure the access features are installed. This process should take no more than 18 months.
5. Over the next 5 years (or end of RAE contract) the RAEs will fund and make the changes to those practices so that in 5 years Colorado has a geographically dispersed, accessible healthcare system.
6. Included in the plan will be an assessment of program access and cultural competency. Set a date and identify who will be responsible for making sure policies and procedures addressing these barriers will be funded and implemented. These policies and training changes must be implemented within 12 months of the creation of the plan.
7. Publish and update disability friendly healthcare locations through website and social media as well as print and through the RAEs' customer care call center for information.

5.7.5 Network Adequacy
5.7.5.1.2 Thank you for this provision requiring the contractor to ensure physical access, reasonable accommodations and accessible equipment. Should add training to enhance disability cultural competency of all healthcare providers.
Not ClearWe know from our pilot work in Colorado Springs with HCPF's access tool, DCCT, that providers need support in understanding disability access and basic etiquette towards those with functional limitations. Our experience with surveying 9-12 practices was very positive and they were very open to our suggestions and training. With that experience the following changes for this section are strongly urged:
5.10 Provider Support
5.10.3 Add Disability access and competency support to the list of support offered to Network providers

5.10.5.2.4 Community based resources such as….services supporting seniors and people with functional limitations (disabilities) of all ages,

5.10.8 Practice Transformation
5.10.8.3 The contractor shall offer expertise and resources necessary for practice transformation ranging from ….to comprehensive practice redesign, including disability competency services and training.

Not ClearPlease make explicit the inclusion of people with disabilities in performance improvement programs. Improving services for persons with disabilities often improves services for everyone. Services become "universally designed" or inclusive and usable by everyone.

5.14.9.2. Program Improvement Advisory Committees (PIAC)
Add as people with disabilities as a type of member to be included on the PIAC.

Not ClearThere is a whole system of work that goes on to prevent people with IDD or mental health issues from going into a nursing home or other institution inappropriately. But it appears that no such system is in place for persons with disabilities or seniors. With the cost of Medicaid nursing homes between $6900 and $8000 a month, and knowing that most people do not want to be in an institution and that health outcomes are iffy at best, this is an opportunity to prevent people from going into a nursing home inappropriately. Lets expand the notion of who can live in the community with supports, so that community based organizations are not paid to later move that person back into the community after they have lost their home, possessions, pets, transportation and social network. Contractors that inappropriately place people in nursing homes or institutions should be fined.

6.3 Pre Admission Screening and Resident Review (PASRR) General Requirements
6.3.1 A similar process shall be used to ensure people with disabilities and seniors are not placed inappropriately in a community or nursing facility and that these individuals receive services to enhance their ability to live independently in the community. A financial penalty shall be levied against contractors who inappropriately place people in nursing homes or other institutions who, with appropriate supports (health, ADLs, etc.) could thrive in the community.
Not ClearAdding persons with disabilities and seniors to a PASSR type process. Also adding two comments to the Appendix

7.5.3 PASRR Administration
7.5.3.1 The Department shall pay the Contractor a maximum of $XXXX annually for administering PASSR based on the proportion of the Contractor’s enrolled members who may have an intellectual and/or development disability or mental illness diagnosis; or who are persons with a disability or a senior, and who have been admitted into a nursing facility in the previous State Fiscal Year.

Did not see a place to make comments on the Appendix:
Appendix K Practice Support Tools and Resources
Under Example Medical Management Techniques
Add to list: Disability access and cultural competency tools, including DCCT (Colorado Access tool), program access sample policies and cultural competency training

Appendix M Primary Care APM (page 1 of 15)
Add Disability Access and Cultural Competency to the Primary Care Alternative Payment Framework
Definition for:
Basic: architectural/structural access for persons with disabilities, accessible exam table and scale, communications processes (sign language), in place and easy to access, alternatives to print for materials and prescriptions



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1/3/2017 10:50:58I agree and wish to continueAshleyBrock-BacaOffice of Behavioral HealthState agencyGenerally, I think the accountability of the RAEs to the community needs to be increased and formalized. Specifically, the RAE needs to be held accountable for the service provider network and the availability and accessibility of behavioral health services. Many communities currently report that it is virtually impossible to get the BHOs to pay for respite care for families of children with serious mental health challenges, and that getting intensive in-home therapy is extremely difficult. Similarly, accessing substance abuse services for youth is very difficult. Many communities resort to using other payors, when Medicaid should pay for the service. HCPF should hold the RAEs more accountable for a broad, diverse network of service providers across geographic regions of the state.

I strongly support the additional statement of work for the RAEs to oversee a High-Fidelity Wraparound paid for with Medicaid dollars. I encourage the Department to fund this additional statement of work in order to support cross-system efforts to better care for children and youth with serious behavioral health challenges who have complex needs.
Very clearNo opinionSomewhat clearNo opinionNo opinionNo opinionSomewhat unclearNo opinionNo opinionNo opinionNo opinionSomewhat clearThe general focus on system-involved children is appropriate and beneficial. I would like to see more specifics to operationalize the care (especially behavioral health care) for children in the foster care system or those who are involved in juvenile justice. For example, specifying the screening requirements and time frames and providing incentive payments will ensure timely screenings for children entering the system. Requiring that all EPSDT screenings include behavioral health screenings would also improve this section.

Consider how the Department can improve rapid access to behavioral health services. For example, allowing six sessions of behavioral health care for low acuity needs without prior approval in the primary care setting is a good start, but children and youth are more likely to receive behavioral health care in a school-based setting or in a behavioral health specialty clinic or mental health center. Please allow these six sessions to be provided in any setting.

I also want to re-iterate my general comments about increasing the behavioral health provider network, specifically for children and youth providers. Colorado families need greater access to intensive in-home therapy, respite care, peer support, family advocacy, trauma-specific treatment, and youth substance abuse services in order to prevent out of home placements. Services must also be culturally and linguistically appropriate for families. The Department must hold the RAEs more accountable for a broad, diverse provider network, and the Department should provide a formalized mechanism for communities to hold the RAEs accountable for the provider network and the accessibility and quality of services.

Using key performance indicators to track behavioral health expenditures of high-utilizing children and youth will help the RAEs manage costs. The following are suggested:
• Children entering foster care receive health and behavioral health screens within specified timeframes
• Lengths of stay for children in residential treatment facilities are reduced by some specified percentage
• Placements in out-of-home treatment facilities (e.g., psychiatric hospitals and psych inpatient units, PRTFs, RTFs) are reduced by some specified percentage
• Youth suicide rates are decreased by some specified percentage
No opinionNo opinionNo opinionNo opinionSomewhat clearI strongly support the Additional Statement of Work for High-Fidelity Wraparound. Funding this additional statement of work will support cross-system efforts to better care for children and youth with serious behavioral health challenges who have complex needs.

Here are my suggestions for improving the clarity and specificity of the RFP regarding this section:

Section 6.2.1 regarding administering a Wraparound program - The RAEs should be able to subcontract the administration of the high-fidelity wraparound to a community agency if desired, rather than managing it themselves. It is desired that the RAEs help create an infrastructure for wraparound that could be expanded in the future to children/youth with CHIP and private insurance, or whose wraparound services are being paid for by an agency such as child welfare or probation. This may be easier with a subcontractor than if the RAEs themselves are managing the wraparound process.

Section 6.2.3.1.3 regarding eligibility – ANY child welfare placement should be included, as well as any corrections involvement (not just juvenile justice) for young adults 18-21, and youth who are homeless or lack stable housing.

Section 6.2.3.2 any child welfare, DYC, or adult corrections (for the 18-21 age group) placement within 180 days of discharge or release should be included when considering appropriate children and youth for high-fidelity wraparound

Section 6.2.3.3.2 regarding children in placement – Children should not quickly lose eligibility for wraparound if they are placed in a facility. The goal of wraparound is to move children from out-of-home placements into home and community based settings. If a child is in wraparound and is admitted to a facility, the care coordination responsibility should remain with the wraparound process for a specified period of time (for example, 150 days), while every effort is made to transition to a home or community based setting.

Section 6.2.5.2 - an estimate of 1,000 to 2,000 children and youth is likely an underestimate; the number may be closer to 4,000, but I suppose this is a starting point.

Section 6.2.6.1 regarding the network of providers who will offer high-fidelity wraparound – there should be a stated preference that government agencies or non-profits closely associated with Collaborative Management Programs provide the high-fidelity wraparound care coordination whenever possible, although having a broad, flexible network that includes other providers is desirable for times of high demand. Organizations who are members of the Collaborative Management Program are ideally suited to coordinate care for children and youth involved in multiple systems such as child welfare and juvenile justice. Additionally, the RFP should specify the types of services that are required for children and youth with behavioral health challenges to live successfully in the community. Essential community-based services include intensive in-home services, crisis response, respite care, day treatment, outpatient therapy (individual, family, and group), trauma-specific treatment, psychiatric medication management and review, substance use services, step-down services, family peer support, flex funds, and mentors.

Section 6.2.6.1.3 regarding peer support providers – this is an essential part of wraparound, and peer support should be available to every family in wraparound.

Section 6.2.7.2 regarding measuring fidelity – this is very important, and fidelity should be assessed with the team member, facilitator, family and youth versions of the Wraparound Fidelity Index – EZ version or another similar tool. Fidelity should be at or above 85%. Facilitators and programs with less than 85% fidelity should use coaching, supervision, and other supports to address fidelity.

Section 6.2.7.3.1 regarding the four phases of wraparound – the engagement phase is absolutely critical and is much more than an assessment of medical necessity – don’t leave this out. Also, the transition phase is more than “monitoring and follow-up” – it is ensuring that the family’s goals have been met and that the family has a plan and resources in place to meet their needs for future challenges. Please do not allow providers or administrators to water down the Wraparound process. Wraparound must be done to fidelity in order to achieve the best outcomes - the research shows a clear relationship between fidelity to the wraparound process and child/youth/family improvement on the CANS.

Section 6.2.7.4.1 regarding the assessment – the CANS and the Strengths, Needs, and Cultural Discovery are both essential parts of the assessment.

Section 6.2.7.5.1 regarding peer support – peer support providers should receive appropriate training approved by the State of Colorado and either have, or be in pursuit of, certification as a peer support provider. They should also receive coaching and supervisory support appropriate for their role.

Section 6.2.8.1.5 regarding services – intensive in-home therapy is essential, and respite care is also very critical for families to be able to maintain children and youth in the home.

Section 6.2.8.1.8 regarding reporting to the CMP and child welfare – a formal relationship with joint accountability should be established between the RAE and the CMP in all CMP counties. A representative of the RAE should be on the Interagency Oversight Group in all CMP counties. An MOU should be in place between the RAE and the CMP regarding the high-fidelity wraparound program in each CMP county.

Section 6.2.8.1.11 regarding ratios – the ratio of families to care coordinator should be no higher than 10:1 per 1.0 FTE care coordinator, and no higher than 20:1 per 1.0 FTE peer support provider. Part-time staff caseloads must be pro-rated.
No opinion
17
1/3/2017 11:32:07I agree and wish to continueJeannieRitterMental Health Center of DenverAdvocateAs a Mental Health Ambassador in the community, I would like to thank the Department for making strides towards some of our key priorities and the priorities of other child health advocates and experts:
• Increasing access to behavioral health care for children by removing six visits from the Behavioral Health capitation (that is defined by covered diagnosis)
• Better coordinating between behavioral health systems and physical health systems
• Acknowledging the key role the broader Community plays in the health of children and families and articulating a role for the RAE in investing in and supporting the Community.
Medicaid is the single largest investment (in State and Federal dollars) that we make in the residents of Colorado and as an advocate etc. I am committed to partnering with the Department to help make those funds as impactful as possible. I and other child and family advocates and experts have a number of specific comments on the RFP language to help improve the 9 billion dollar Medicaid system for children and families through 2025. The most important changes we are suggesting are:
• Remove EPSDT early intervention and prevention services from the behavioral health capitation and have it offered Fee-for-Service within the State Plan
• Have entry into the Statewide Behavioral Health Network governed by an independent third party (i.e. the state, a governor appointed committee, a third-party vendor) to ensure an adequate and appropriate behavioral health network
• Ensure RFP language clearly allows the RAE to invest in the non-medical Community because non-medical services play a critical role in the health of children and families on Medicaid.
• Strengthen the Alternative Payment Methodology criteria to maximize the impact of that payment change
• Give the State Program Improvement Advisory Committee control over the Flexible Funding pool to ensure it is allocated in a way that corresponds with community priorities
• Make the Wraparound a required component of the contract
While we focus most of our energy in on areas where we seek changes, we would also like to thank the Department for the thoughtful work and inclusive process that went into the development of this RFP. The RFP is well written and contains many components advocated for by child health experts that have potential to have a significant positive impact on Medicaid enrolled children and families. We especially want to thank the Department for:
• Incorporating the All Kids Covered recommendation to focus on children and youth in foster care in addition to those at risk of out-of-home placement.
• Focusing on special populations requiring additional attention including “children involved with the child welfare system, individuals transitioning out of institutions and correctional facilities, and children at risk for out-of-home placement.”:
• Including the All Kids Covered recommendation that the RFP include criteria that supports respecting clients’ language and cultural preferences. We respectfully request that all references to cultural preference, competence, or humility be replaced with “responsiveness” because responsiveness implies an action on the part of providers and others in the health care system.
• We also are grateful for the requirements regarding translation and interpretation services that ensure members receive services and information in their language of choice.
• Requiring the RAE contract with providers who represent diverse racial and ethnic communities
• Including criteria to include afterhours care and develop individual care plans for people with complex needs.
• Including the community section that identifies the many non-healthcare needs a client may have and recognizes the importance of RAE engagement in non-healthcare services.
• Removing six behavioral visits from the behavioral health carve-out.
• Including robust measures for monitoring well-being, especially maternal depression screenings, dental visits, and developmental screenings.
• Focusing on youth taking psychotropic medications
We appreciate the effort that went into this document and are eager to support the Department in continuing to refine the program design.
Sincerely-
Jeannie Ritter

Recommendation—Staffing: The scope and scale of the ACC is significant. We recognize the technical complexity and volume of work for the Department of Health Care Policy and Financing to effectively administer and oversee this program. We fully support Departmental requests for additional staffing and especially requests for staffing with the appropriate level of expertise. The functions the Department of Health Care Policy and Financing must perform in order to ensure that the program runs smoothly requires expert level staff, hiring this level of staff requires appropriate compensation. We support the Department in those requests.

Winnable Battles: The RFP should clearly list the winnable battles for which the RAE is held accountable. We recommend that the RFP focus on the following strategies:
• Increase the percent of mothers who are appropriately screened and treated for depression
• Decrease untreated dental decay and decay experience in children.
• Increase access to and utilization of tobacco cessation services tailored for pregnant and postpartum women.
• Increase use of long-acting, reversible contraceptive methods.
In general, we recommend that many of the aspirational goals in the RFP be narrowed, prioritized and defined. We recognize that the capacity of both our providers and the RAEs is finite and by prioritizing we will be more likely to be successful in all endeavors.

Community Goal: We are deeply grateful for the inclusion of a Community section. We recommend removing from 3.2.3.3., “to support care teams and care coordination” from the program’s description so that the sentence reads “It differs from a capitated managed care program by investing directly in Community infrastructure.”
Rationale: Community, per the Department’s definition, is the sphere of services beyond healthcare that has the majority of impact on health. Care teams and coordination are within the health neighborhood so this statement is confusing. We support RAE investment in community infrastructure and supports (including the social determinants of health) and believe removing this statement will allow for more innovation and more strategic investments in the broader Community.

Coordination with Department of Education: We recommend adding the Department of Education to the list of Colorado state agencies with whom the RAE should coordinate in section 3.3.10.

Oral Health and Person and Family-Centeredness: We recommend revising 3.3.3.11.1. to add oral health and language to emphasize that services should be person and family-centered. The sentence should read, “Members will have their medical, behavioral, and oral health care needs met and will receive Community supports in a person and family-centered way.”

Continuum of Services: We recommend replacing the sentence at 3.3.12.4, “The next iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of services for special populations,” with “This iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of a fully coordinated continuum of services for individuals and their families, including but not limited to:”
Rationale: Children and their families require a broader continuum of services than the current ACC supports, both for the child and the whole family. ACC Phase II should clearly articulate this goal. Further, adding the language “including, but not limited to” recognizes that there are other populations that may require special services and attention over the course of the contract.
Very clearContinuum of Services: We recommend replacing the sentence at 3.3.12.4, “The next iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of services for special populations,” with “This iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of a fully coordinated continuum of services for individuals and their families, including but not limited to:”
Rationale: Children and their families require a broader continuum of services than the current ACC supports, both for the child and the whole family. ACC Phase II should clearly articulate this goal. Further, adding the language “including, but not limited to” recognizes that there are other populations that may require special services and attention over the course of the contract.

RAE Communication: We recommend removing 5.1.8.2.4.9.
Rationale: RAE collaboration and coordination with members, providers and other stakeholders is core to their role. We do not want to inhibit the RAEs ability to communicate because that could impair their ability to collaborate and be effective in serving Medicaid enrollees. RAEs will be leaders in their communities and so have an important role to play as leaders in conversations about health. These non-routine conversations and messages will be important to improving the health of Medicaid enrollees.

Provider Directory: We recommend that the provider directory be up to date, interactive, and accessible and include provider type.
Rationale: Provider type is a crucial piece of information to ensure that the contacted provider will serve the client’s need. Provider lists in PDF or other formats are difficult for clients to utilize. A dynamic and searchable provider directory that enables a client to filter the list and find a provider that is close, will take new members, and is appropriate for their age/gender and other needs is an important mechanism for supporting access.
Very clearKey Personnel Expertise: At least one of the key personnel in an administrative leadership position should have behavioral health expertise and at least one of the key personnel in an administrative leadership position should have pediatric expertise.
Somewhat clearReduce Churn: We note the negative impact of changing providers/care settings has on a client’s consistent access to care, continuity of care, and a provider’s ability to manage a client’s care effectively. We recognize and appreciate the Department’s ongoing efforts to work with providers to ensure that they are able to provide continuous comprehensive care for their clients. Somewhat unclearHealth Needs Survey Timing: We recommend the health needs survey occurs post-enrollment.
Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. In addition, the data may be less reliable because Medicaid enrollees may be less likely to respond accurately. We are also concerned that urgent needs identified through the Peak application process will not be responded to within an appropriate timeframe. Additionally, we wonder how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports.

Health Needs Survey Design: We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. Determining whether a child-bearing age female enrollee is pregnant should be a priority of the survey, in order to facilitate rapid referral to appropriate health services and community resources. We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.
Rationale: Currently, the goal of the survey is unclear.

Healthy Communities: Are Healthy Communities onboarding all members rather than just kids and families? We recommend that the state delineate roles and responsibilities so that it is clear what those roles and responsibilities are statewide. We also recommend that Healthy Communities remain focused on children and their families, which is their area of expertise.
Rationale: Clear delineation of roles and responsibilities will allow for reasonable apportionment of funds and ensure that services are not duplicative but complimentary.
No opinionNo opinionN/ASomewhat clearTelehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform.

RECOMMENDATION: THIRD PARTY CREDENTIALING FOR THE STATEWIDE BEHAVIORAL HEALTH NETWORK
Current Language: 5.7.3.1 “The Contractor shall establish and maintain a statewide network of behavioral health providers that spans inpatient, outpatient, laboratory, and all other covered mental health and substance use disorder services.”

BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.

Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.

Network Access: The standard for children’s primary care to provider ratio (in 4.7.4.11.) should be revised from 2,500 to 1,200. At a minimum, the standard should be equal for children and adults. The ratios of necessary mental health providers should be broken out by child and adult. In addition, network adequacy should also include consideration of people who have to utilize non-traditional modes of transportation or public transportation. RAEs should do an initial analysis of accessibility based on public transportation. We know the Medicaid population has higher mental health needs than the general population. In order to assure access to care for 25% of the pediatric population, we recommend a ratio of pediatric mental health providers to child enrollees of one practitioner per twelve hundred (1,200) twelve hundred members.
Rationale: The Pediatric Primary Care ratio is not adequate. Children have many more primary care visits than adults. Children’s mental health needs differ from those of adults and providers of mental health services to children should be trained to provide those services. The driving distance standards fail to acknowledge accessibility for many Medicaid clients who do not have vehicles.
RECOMMENDATION: ACCESS STANDARDS
Current Language: 5.7.4.13.5.2 “Non-urgent, Symptomatic Behavioral Health Services – within seven (7) days of a Member’s request. Administrative intake appointments or group intake processes are not considered a treatment appointment for non-urgent, symptomatic care.”

Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2. should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.
Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.

Network Adequacy Reporting: For all network access reporting, we recommend pediatric data and access should be separate from adult data and access.
We recommend that the network adequacy plan should include reporting on the race and ethnicity of the provider to determine whether the contractor is meeting the goals of 5.7.1.3.
Rationale: Separating data that reports on access for adults and children is necessary to determine network adequacy for each group.
Somewhat clearN/ASomewhat unclearRAE Directory: We recommend adding the following language, “The RAE directory should include resources to support women and families who are experiencing pregnancy-related depression and anxiety, including the Postpartum Support International phone number and website, and other community resources.”
Rationale: There is a wealth of evidence, including from Harvard University’s Center on the Developing Child and the American Academy of Pediatrics, around the long-term negative impact of pregnancy-related depression and anxiety on child health and development. Identifying women with pregnancy-related depression and anxiety and quickly connecting them with care can have a long-term positive impact on Medicaid enrollees. Babies of mothers who are treated for pregnancy-related mood issues have better health and developmental outcomes, are more likely to attend well-child visits, and have decreased emergency and urgent care utilization. These resources and supports should be accessible and available to women during pregnancy, at infant well-child visits, and at post-partum follow-up visits.

Care Coordination Definition: We recommend revising the 2.1.12. definition of care coordination so that it is more client centric and better addresses the function of care coordination as it relates to whole person needs. The sentence should read, “The process of collaborating with a Client to identify needs and viable solutions, create a care plan and then execute the care plan. A care plan may include physical health care, behavioral health care, functional LTSS supports, oral health, specialty care, housing supports, school participation, food resources, employment supports, transportation options, and other medical and community services.”
Rationale: The definition of Care Coordination noted several times in the RFP is very medically focused. The list of providers is comprised of all medical providers. We recommend clarifying that Care Coordination necessitates supporting clients in accessing the full range of services they require to maximize their potential. We also recommend changing this language to be more client-centered so that the clients have some agency in the coordination of their own care.

RECOMMENDATION: POPULATION HEALTH MANAGEMENT
Population Health Management: We recommend that the population health management plan include prevention, early intervention and the full spectrum of population health management services. We recommend that the plan be required to be review by experts in the populations and strategies outlined. Evidence of that review could be a requirement of the proposal submission.
Somewhat clearScreening Tools: We recommend specifically identifying developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines.

Provider Training: Provider support should include training providers in best practices related to caring for children and families including completing post-partum depression screening multiple times during the child’s first year and screening for ACEs annually as well as other early childhood mental health competencies. In addition, we recommend that behavioral health providers working with young children have the Colorado Infant/Early Childhood Mental Health Endorsement.
Somewhat clearPreventive Behavioral Health Visits: We recommend that the highest tier of the Alternative Payment Methodology include preventive behavioral health visits for children.
Rationale: The preventive behavioral health visit should be linked with well-child visits (at least 2 per year in the first three years and annually beginning at age 4), provided in collaboration with physical health services, and include: 1) child behavioral health and family psychosocial screening and identification; 2) anticipatory guidance around development, behavior, relational health between the child and caregivers/parents; 3) identification and discussion of environmental influences on well-being; and 4) address identified needs, provide intervention, triage, and connect families to necessary resources. Behavioral health preventive care plans must be integrated with physical health care plans with care teams functioning collaboratively to support optimal health and well-being. This preventive visit could also identify clients who require care coordination/care management services.

QUESTIONS: ALTERNATIVE PAYMENT METHODOLOGY
1. 24 Hour EHR Access: Who is the access to? Providers? Or providers and clients? What does Asynchronous communication mean?
2. Please clarify what a shared care plan: patient is.

Recommendation- Ensure Alternative Payment Methodology Tiers Maximize Potential for Improving Clinical Care:
• The Criteria for Enhanced level should be revised:
1. Health Neighborhood Care Coordination: Recommend moving hospital and ER follow up to Enhanced and away from Advanced.
2. Behavioral Health Integration: Having Behavioral Health providers in health settings should be moved from Advanced to Enhanced.
• The criteria for the Advanced level should include
1. Access to and continuity of care:
1. Advanced practices should offer direct to patient telehealth. This could be defined broadly including email and phone access. Many conditions do not require in-person visits and would significantly reduce the burden on families if care were provided by phone
2. Advanced practices should also be able to offer group prenatal care referrals to their clients. Group prenatal care has been shown to reduce low birthweight births and preterm births and is a promising practice to help reduce disparate infant mortality rates among minority racial and ethnic groups
2. Team Based Care: Team-based care should include lay health workers/non-traditional health workers/navigators etc.
3. Care Management: This should include an assessment of family needs and social needs (i.e. does the caregiver/parent have a medical home? Are all social needs met?)
4. Health Neighborhood: The practice must be engaging a community base care coordination tool where information is shared across medical and social needs. In addition, practices must be supporting patients in accessing dental care.
5. Behavioral Health Integration: Co-location is not integration. Documentation in a single EHR and other metrics of meaningful integration must be met. This includes being able to capture behavioral health utilization from within the physical health practice.
6. Quality Improvement: The practice must be engaged in regular reportable quality improvement activities and demonstrate improvement in designated patient populations.
Somewhat clearRecommendation Health and Behavior Codes: We recommend that the health and behavior codes be added as a fee-for-service benefit. Addition of six behavioral health visits out of primary care does not replace the need for health and behavior codes to address behavioral health aspects of acute and chronic medical conditions.
Rationale: Health and behavior codes would enable clinicians to provide necessary counseling and treatment for medical conditions and diagnoses (e.g., weight management/obesity, asthma, congenital anomalies, developmental diagnoses, feeding disorders, sleep disorders) that can have long-term effects for healthcare costs and outcomes. These behavioral health interventions need to be delivered within health care settings by licensed behavioral health providers (or license-eligible trainees under the supervision of a licensed clinician) billing health and behavior codes on a medical diagnosis, not a mental health diagnosis. For example, counseling an adolescent on weight management is a high value activity that will result in significant long-term savings to many systems.
RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”
Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).
We recommend that those six visits be able to be offered in community based programs and all medical sites. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.
We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.
We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
PRIORITY RECOMMENDATION: PREVENTION/EARLY INTERVENTION
Current Language: 5.12.5.7.1 “The Contractor shall provide or arrange for the following 1915(b)(3) Waiver services to Members in at least the scope, amount and duration proposed in the Uniform Service Coding Standards (USCS) Manual. All 1915(b)(3) services provided to children/youth from age 0 to 21, except for respite and vocational rehabilitation, are included in the State Plan as Expanded EPSDT services: Vocational Services, Intensive Case Management, Prevention/Early Intervention, Clubhouse and Drop-in Centers, Residential, Assertive Community Treatment, Recovery Services, Respite Services.
Somewhat unclearCare Coordination Tool: We recommend that the care coordination tool be required to not only collect information but also transmit information across medical and non-medical systems including oral health care providers, EPSDT, Early Intervention Colorado, home visitation programs, school-based health clinics, the Colorado Department of Education, Colorado Department of Human Services, Colorado Department of Public Health and Environment, the immunization registry, and child care and early learning settings.
The care coordination tool should potentially be accessible to clients as well as healthcare providers.
We recommend that the RAEs collaborate on a statewide tool that can interface with all electronic medical records.
Rationale: If the function of this tool is to enhance care coordination (rather than just track it) then it must be able to transmit information in order to support the delivery of care.
Somewhat clearSomewhat clearFlexible Funding Pool: We recommend adding the following language: “The use of the Flexible Funding Pool funds will be approved by the Statewide Program Improvement Advisory Committee. The funds must be used to encourage innovative upstream interventions that address risk and protective factors as well as the social determinants of health .”
Rationale: The State PIAC’s authority over spending the flexible funds would ensure that these funds are used to strategically meet community needs.
No opinionSomewhat clearWraparound: We strongly recommend the inclusion of the Wraparound Additional Statement of Work. We recommend insuring that financial incentives for this component of the work align with the expected delivery of services and outcomes.
18
1/3/2017 14:55:17I agree and wish to continueDorothyPerryHealth SolutionsProviderOne concern about bidding on this contract is the risk factor for behavioral health. The BH capitation money is going to be the vast majority of revenue in this contract. The contractor is being asked to provide 24 required services, yet more than half of them involve time and other resources that are outside the amount of credit to be given under the coding system, in addition to the
substantial number of administrative requirements under this contract (see list below). At the same time, The Department is reducing administrative costs to 11 percent. If this 11 percent is not met, there are financial penalties, both immediate regarding the payback, and long term regarding the following years rate setting. So in effect, there are double penalties. Any BH performance incentive monies we may earn are not paid out until nine months into the next fiscal year, so are of little help in managing the financials of a contractor or to provide incentives a provider organization. If the contractor fails at this contract, it is the contractors money in the insurance reserve that The Department will access to take over this contract. How can this contract be developed so that it is a win - win for Medicaid members and providers and contractors, rather than doling out significant administrative tasks that will result in penalties due to the effect on the MLR for the contractor?

Medicaid Accountable Care Collaborative Administrative Deliverable's & Frequency: Type & Reference Number

Effective Date Deliverable's
5.15.22.13; 5.15.22.14; 5.2.15.8; 5.2.15.1; 5.16.3.4; 5.1.8.2.4.1; 5.1.9.2.1
5.2.15.3; 5.5.9.2; 5.10.10.2; 5.10.10.4; 5.12.15.1; 5.15.22.1; 5.16.3.7; 5.9.5.1
Total = 15

Operational Date Deliverable's
5.5.9.4.1; 5.7.6.3
Total = 2

HCPF Request Deliverable's
5.15.22.2; 5.2.15.2; 5.15.22.18; 5.1.8.2.4.7; 5.10.10.1; 5.15.22.8; 5.15.22.11; 5.15.22.20; 5.5.9.5.1; 5.15.22.13; 5.15.22.14; 5.15.22.15; 5.14.11.3; 5.14.11.4
Total = 14

From HCPF request
5.5.9.5.1; 5.15.22.13; 5.15.22.14; 5.15.22.15; 5.14.11.3; 5.14.11.4
Total = 5

Change Deliverable's
5.9.5.2; 5.2.15.5; 5.2.15.4; 5.7.6.4; 5.5.9.3
Total = 5

Discovery Deliverable's
5.15.22.17; 5.15.22.22.1; 5.15.22.7; 5.15.22.4; 5.15.22.12; 5.15.22.19; 5.15.22.21; 5.15.22.16
Total = 8

Receipt/Notification Deliverable's
5.15.22.17; 5.15.22.22; 5.15.22.22.1; 5.2.15.7; 5.2.15.6
Total = 5

Termination Deliverable's
5.15.22.5; 5.5.9.6.1; 5.16.3.5; 5.16.3.6; 5.15.22.5
Total = 5

Quarterly Deliverable's
5.14.11.5; 5.14.11.6; 5.12.15.5; 5.15.22.9; 5.7.6.2; 5.15.22.23; 5.9.5.3;
5.12.15.2; 5.15.22.23.2.1
Total = 9

Monthly Deliverable's
5.13.3.1; 5.12.15.4; 5.11.4.1; 5.5.9.1; 5.8.7.1; 5.9.5.4; 5.15.22.6; 5.15.22.3
Total = 8

Annual Deliverable's
5.1.8.2.4.4; 5.1.9.3.1; 5.7.6.1; 5.10.10.2; 5.10.10.3; 5.10.10.4; 5.13.3.2; 5.15.22.1; 5.15.22.23.1; 5.16.3.8; 5.12.15.3; 5.14.11.1; 5.14.11.2; 5.15.22.11.2.1;
5.15.22.10
Total = 15
Grand Total Deliverable's = 86
Minus Start Up Deliverable's = 69

Somewhat clear(1) The contractor is being asked to improve care and treatment outcomes while reducing costs, yet you have administrative requirements such as Communication Plans/Update and Business Continuity Plans/Updates in this section that take time and resources away from the primary objectives. Is this a value added requirement that will significantly contribute to improved care and treatment outcomes? (2) In previous contracts the state had language about ownership of all software, programs, etc., yet the state had to modify these requirements due to private sector proprietary ownership rights. Will need to address this once again? Most provider organizations, and many potential contractor organization, do business other than Medicaid. It is common practice to streamline IT programs across the board for these organizations to improve organizational flow and consistency. Why would you have a right to these programs and software that include Medicaid, but also other lines of business? (3) What is the purpose of extending contracts from 5 years up to 7, with extensions? For those company's that bid and loose, that's a very long time until the contract can be bid on again. You are inserting micromanagement of key personnel when a portion of this contract is at risk. If a contractor has selected an individual who they believe can assist them in successfully managing this contract, and you assert control and not allow this person to be hired, you are enhancing the risk of the contractor. If the contractor fails due to decisions by The Department, what compensation will you provide? Each contractor should be allowed to make their own decisions regarding personnel and HCPF can manage the contractors based on KPIs and other performance measures.Somewhat unclear(1) Regarding, 'Members shall be enrolled with the Contractor based on the location of the PCMP practice site to which the Member is attributed . . .' It is a somewhat common practice to seek some medical care in more urban areas. For example, people in Trinidad seek care in Pueblo, people in Pueblo seek care in Colorado Springs, and people in Colorado Springs seek care in Denver. Yet generally all their other accessed resources are often local (social services, behavioral health, dentistry, vision care, school-based services, housing, food services, etc.). We recognize your intent is to centralize care based services around PCMPs, yet that model usually only works fluidly in dense urban areas such as Denver. What about those who live outside of Denver? We respectively request this provision be reconsidered. (2) The previous Medicaid BH contracts have screamed consumer choice - choice of provider, choice of services, advanced directives, etc. Yet in this contract you say The Department will determine attribution and may move a member's attribution without the members consent. Our suggestion is that you base a members attribution on their county of residence, and allow the consumer to choose if they want their attribution moved to another location.Somewhat clearSAASomewhat clear(1) The Member Health Needs Survey is another new administrative costs when we are being asked to reduce administrative expenditures. There will be costs associated with data transmission, collating, processing, distribution, and evaluation of these surveys. Is there true, discernible value added to patient care by doing this service? (2) This is a new administrative cost regarding the 15 language tagline requirement required by the Affordable Care Act. Does this require that if you publish a tagline in Arabic, for example, and the member wants their benefit handbook in that language, that the contractor is required to do so? Or is the 15 languages only limited to taglines? We have concerns regarding significant cost for written translations, proof readers in these languages to verify translations are accurate, and printing costs. Somewhat clear(1) Overriding a contractors decision regarding provider complaints puts the contractor at greater risk in successfully managing this contract. If you have an at-risk contract, as with the BH section of this contract, then The Department should not be able to put the contractor at potentially greater risk by overriding their decisions. (2) Our current BHO has received grievances due to not allowing enough providers into our regional network. Yet when we calculate the number of providers needed based on 5.7.4.11.4, we are exceeding that number. Will these numbers be adhered to in the next contrac? We respectfully suggest that you manage the contractors based on performance goals that may include Member satisfaction surveys and verifiable utilization/access data.Somewhat clear(1) Regarding the Social Determinants of Health, it requires 'The Contractor shall be responsible for knowing, understanding and implementing initiatives to build local communities to optimize Member health and well-being, particularly for those Members with complex needs that receive services from a variety of agencies.' Putting this in as contract requirement is a daunting task. Those in healthcare know and understand how important the social determinants are to health outcomes, yet little is accomplished regarding this on a large scale due to private and public sector not prioritizing this or not being able to pay for this. This contract seems to offers no remuneration for this, and implementing these initiatives is not a billable service, AND at the same time we are supposed to reduce our administrative costs. Can grant money be used for these types of programs rather than expecting it under the contract so the Member, the community and the contractor can all achieve success? (2) In section 5.12.5.7.1.5 it defines residential services as any type of twenty-four hour psychiatric care, excluding room and board, provided in a non-hospital, non-nursing home setting, where the contractor provides supervision in a therapeutic environment. In the current BHO contract, SUD residential services are not a covered benefit. Does 'psychiatric care' mean only those with mental health disorders, or does it also include SUD conditions, as SUD disorders are included in the Diagnostic and Statistical Manual as a type of psychiatric condition? Is SUD residential services a covered benefit?Somewhat clear5.8.7.1; Health Neighborhood and Community Report; Admin: New administrative requirement; requires ‘Creation of new Health Neighborhood and Community forums.’ Neighborhoods include hospitals, LTSS providers and local public health agencies, but of interest is that you do not list CBHC. BH has been shown repeatedly in the literature to reduce medical healthcare costs, more than most any other intervention. In addition, this is an additional administrative responsibility at a time when you are suggesting reducing administrative costs to 11 percent. This task will take innumerable hours and resources that are not billable. How will the contractor be compensated for this undertaking?Somewhat clear5.9.5.1; Population Health Management Plan; Admin: New administrative requirement; requires the Contractor shall have a comprehensive approach to population health management that uses data to stratify the population and offers a range of interventions to support Members at all life stages and levels of health. This is element important and meaningful, yet again this is an immense administrative task and you expect us to add this while while our administrative costs are limited to 11 percent. Although four percentage points can be added to the contractors administrative portion, how reasonable is this during the initial two years or so of this contract when contractors are developing programming, provider networks, and building a culture of accountability among its providers? Could the 11 percent be phased in so that in year one it is 15%, year two 14%, year three 13%, etc. Regarding 5.9.5.1 (Population Health Updates); 5.9.5.2 (Stratification Report); and 5.9.5.4 (Care Coordination Reports): these are more evidence of increased administrative costs.Somewhat clear5.10.10.3 (Practice Support Plan); 5.10.10.3 (Connectivity Assessments); and 5.10.10.4 (Provider Payment Report) are evidence of administrative expenses and resources. In the draft it is written that the Contractor shall distribute, in aggregate, at least thirty percent (30%) of the Contractor’s administrative PMPM payments received from the Department to their PCMP network and Health Neighborhood. The Contractor shall share incentive payments earned for performance with PCMP Network Providers and other Health Neighborhood participants as appropriate. This is meaningless information for a contractor who is attempting to decide if bidding on this contract is feasible as the total amount of the Administrative PMPM is not provided. Thus, a potential contractor cannot assess if 30% of it is an adequate incentive for their group of PCMPs. Somewhat clearSomewhat clearThe low acuity, six session element of this contract seems to have good intent, yet there is potential for poor patient care. How will it be decided if the person is at a level of acuity that warrants referral to a specialty BH professional? If an individual has a partial arterial blockage, they are not expected to see their PCMP until they actually experience cardiac arrest, they are referred to a cardiologist for early intervention and full spectrum care and treatment, and then may follow up with their PCMP after their treatment is concluded for general medical care and monitoring. If an individual is dealing with depression or early stages of alcoholism, is The Department suggesting that the individual wait until suicide is attempted or the individual is seen in an ED for alcohol poisoning before s/he is referred to a full spectrum licensed BH provider? The Department seems to be implying that behavioral health issues are somehow less complicated than other healthcare issues and do not require full spectrum specialty care. Suggest that there be incentives for PCMPs to collaborate with BH providers, rather than minimizing the potential severity of behavioral health conditions.Somewhat clearSomewhat clear(1) 5.14.11.3 Performance Improvement Projects: The Contractor shall create a Regional PIAC: Regional PIACs will require extensive administrative time and resources to recruit, communicate with, provide meeting preparation, leasing meeting space, meeting deliberations, meeting follow-up, etc. with two separate groups (1) members and caregivers; and (2) providers and community partners. This is high level request from The Department with indeterminate outcomes. How will The Department ensure that adequate administrative funding is available for these tasks? How will The Department determine if this is a value added addition to the Medicaid contract? (2) For members who are high utilizers the draft RFP suggest that members can be 'locked in' to one provider and/or one pharmacy. Once these members are locked into a provider, the provider and the contractor may be penalized via affected performance data regarding utilization and/or outcomes. How will The Department make sure that locking in a member will not disproportionately affect just a few providers and that these types of members will be spread-out providing some fairness. (3) In some areas it is common practice among some providers to 'fire' patients from primary medical care due to noncompliance with treatment plans. Will the practice of 'firing' patients for treatment non-compliance be allowed under this contract?Somewhat clearSomewhat clearSomewhat clearNot ClearNeed financial data for potential contractors to assess if bidding is feasible.
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1/3/2017 17:48:04I agree and wish to continueSaritaReddyGreeley Center for IndependenceProviderIt was informative and gave our staff a sense of the bigger picture pertaining to HCPF's vision for access to healthcare for Coloradans. For those of us who have not been here all that long, it was great to get the history too.Very clearThe requirements are clear. However, we feel that enrolling Members based on the location of the Provider office, rather than the home address of the Member (5.4.5) is likely to increase the difficulty members will have in getting information and access to personnel who can help them navigate the complexities of the system. Structures that are meant to help Members with access such as the Health Neighborhoods will be defined in a way that makes more sense for Providers than for Members under this methodology. Our opinion is that if we truly want Members to engage, the system should be as easy as possible for them to navigate.
We also feel that there may be confusion with RAE enrollments changing every time the choice for a new PCMP is exercised (5.4.9). Additionally, if transition service protocols from RAE to RAE are not standardized (the RFP indicates that each RAE will develop these independently), the goal of seamless transitions may not be easily met (5.4.9.2). All of these issues would be resolved if RAE enrollment was predicated on the Member's address.
Very clearAgain - the section is clear. However, the responsibilities underlined in these sections (5.5.1; 5.5.2; 5.5.3) would be so much more easily achieved if Members were assigned to a RAE based on where they live. There would be continuity of communication if the Member stayed in the same RAE regardless of where he/she chose to see a doctor.
Section 5.5.4 refers to Marketing. Does this mean RAEs are going to be competing for Members, and therefore spending resources on that effort?
Somewhat clearWe believe that efforts to increase Member access to timely and appropriate services and benefits (5.8.2) will be more successful if RAE enrollment is based on Member address. RAE staff would more easily be able to build relationships with Members and/or the Providers who serve them.
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1/4/2017 11:48:23I agree and wish to continueChristyDoddOral Health ColoradoAdvocateAs an oral health advocate and parent, I would like to thank the Department for making strides towards some of my key priorities and the priorities of other child health advocates and experts:
• Increasing access to behavioral health care for children by removing six visits from the Behavioral Health capitation (that is defined by covered diagnosis)
• Better coordinating between behavioral health systems and physical health systems
• Acknowledging the key role the broader Community plays in the health of children and families and articulating a role for the RAE in investing in and supporting the Community.
Medicaid is the single largest investment (in State and Federal dollars) that we make in the residents of Colorado and as a parent and advocate I am committed to partnering with the Department to help make those funds as impactful as possible. I and other child and family advocates and experts have a number of specific comments on the RFP language to help improve the 9 billion dollar Medicaid system for children and families through 2025. The most important changes we are suggesting are:
• Remove EPSDT early intervention and prevention services from the behavioral health capitation and have it offered Fee-for-Service within the State Plan
• Have entry into the Statewide Behavioral Health Network governed by an independent third party (i.e. the state, a governor appointed committee, a third-party vendor) to ensure an adequate and appropriate behavioral health network
• Ensure RFP language clearly allows the RAE to invest in the non-medical Community because non-medical services play a critical role in the health of children and families on Medicaid.
• Strengthen the Alternative Payment Methodology criteria to maximize the impact of that payment change
• Give the State Program Improvement Advisory Committee control over the Flexible Funding pool to ensure it is allocated in a way that corresponds with community priorities
• Make the Wraparound a required component of the contract
While we focus most of our energy in on areas where we seek changes, we would also like to thank the Department for the thoughtful work and inclusive process that went into the development of this RFP. The RFP is well written and contains many components advocated for by child health experts that have potential to have a significant positive impact on Medicaid enrolled children and families. We especially want to thank the Department for:
• Incorporating the All Kids Covered recommendation to focus on children and youth in foster care in addition to those at risk of out-of-home placement.
• Focusing on special populations requiring additional attention including “children involved with the child welfare system, individuals transitioning out of institutions and correctional facilities, and children at risk for out-of-home placement.”:
• Including the All Kids Covered recommendation that the RFP include criteria that supports respecting clients’ language and cultural preferences. We respectfully request that all references to cultural preference, competence, or humility be replaced with “responsiveness” because responsiveness implies an action on the part of providers and others in the health care system.
• We also are grateful for the requirements regarding translation and interpretation services that ensure members receive services and information in their language of choice.
• Requiring the RAE contract with providers who represent diverse racial and ethnic communities
• Including criteria to include afterhours care and develop individual care plans for people with complex needs.
• Including the community section that identifies the many non-healthcare needs a client may have and recognizes the importance of RAE engagement in non-healthcare services.
• Removing six behavioral visits from the behavioral health carve-out.
• Including robust measures for monitoring well-being, especially maternal depression screenings, dental visits, and developmental screenings.
• Focusing on youth taking psychotropic medications
We appreciate the effort that went into this document and are eager to support the Department in continuing to refine the program design.

Recommendation—Staffing: The scope and scale of the ACC is significant. We recognize the technical complexity and volume of work for the Department of Health Care Policy and Financing to effectively administer and oversee this program. We fully support Departmental requests for additional staffing and especially requests for staffing with the appropriate level of expertise. The functions the Department of Health Care Policy and Financing must perform in order to ensure that the program runs smoothly requires expert level staff, hiring this level of staff requires appropriate compensation. We support the Department in those requests.
RECOMMENDATION: WINNABLE BATTLES
Current Language: 2.1.21 “Colorado’s 10 Winnable Battles – Public health and environmental priorities that have known, effective solutions focusing on healthier air, clean water, infectious disease prevention, injury prevention, mental health and substance use, obesity, oral health, safe food, tobacco and unintended pregnancy. The initiative is overseen by the Colorado Department of Public Health and Environment.”
Recommendation—Winnable Battles: The RFP should clearly list the winnable battles for which the RAE is held accountable. We recommend that the RFP focus on the following strategies:
• Increase the percent of mothers who are appropriately screened and treated for depression
• Decrease untreated dental decay and decay experience in children.
• Increase access to and utilization of tobacco cessation services tailored for pregnant and postpartum women.
• Increase use of long-acting, reversible contraceptive methods.
In general, we recommend that many of the aspirational goals in the RFP be narrowed, prioritized and defined. We recognize that the capacity of both our providers and the RAEs is finite and by prioritizing we will be more likely to be successful in all endeavors.
Rationale:. There are many strategies listed in the Winnable Battles documents and the RAEs will not have the resources to focus on all of them. Providing more clarity on priorities and expectations will ensure that the RAEs dedicate their efforts where they can effectively intervene and make the largest difference for children and families. The strategies we have highlighted above are within the scope of work of the RAEs and have strong evidence supporting their effectiveness at improving the health of children and families.
RECOMMENDATION: COMMUNITY GOAL
Current Language: 3.2.3.3 “It differs from a capitated managed care program by investing directly in Community infrastructure to support care teams and Care Coordination.”
PRIORITY Recommendation—Community Goal: We are deeply grateful for the inclusion of a Community section. We recommend removing from 3.2.3.3., “to support care teams and care coordination” from the program’s description so that the sentence reads “It differs from a capitated managed care program by investing directly in Community infrastructure.”
Rationale: Community, per the Department’s definition, is the sphere of services beyond healthcare that has the majority of impact on health. Care teams and coordination are within the health neighborhood so this statement is confusing. We support RAE investment in community infrastructure and supports (including the social determinants of health) and believe removing this statement will allow for more innovation and more strategic investments in the broader Community.
RECOMMENDATION: COORDINATION WITH DEPARTMENT OF EDUCATION
Current Language: 3.3.10 “In order to maximize impact and minimize redundancies, the Program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, and Corrections,..”
Recommendation—Coordination with Department of Education: We recommend adding the Department of Education to the list of Colorado state agencies with whom the RAE should coordinate in section 3.3.10.
Rationale: The Department of Education is core to a child’s continuum of services and community of care. We would also like to note that for this coordination to be effective, it requires state leadership in addition to the RAE’s investment of time and resources.

3.3.8 Please include dental to read: In addition, the RAE will have responsibility for ensuring timely and appropriate access to Medically Necessary services offered by the full range of Medicaid providers in the Health Neighborhood, including specialty, hospital, dental and home-based care, to meet the health and functioning needs of Members. Please add dental to the list of Medically Necessary services the RAE is responsible for ensuring timely and appropriate access to.

RECOMMENDATION: COORDINATION WITH DEPARTMENT OF EDUCATION
Current Language: 3.3.10 “In order to maximize impact and minimize redundancies, the Program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, and Corrections,..”
Recommendation—Coordination with Department of Education: We recommend adding the Department of Education to the list of Colorado state agencies with whom the RAE should coordinate in section 3.3.10.
Rationale: The Department of Education is core to a child’s continuum of services and community of care. We would also like to note that for this coordination to be effective, it requires state leadership in addition to the RAE’s investment of time and resources.

RECOMMENDATION: ORAL HEALTH AND PERSON AND FAMILY-CENTEREDNESS
Current Language: 3.3.11.1 “Members will have their medical and behavioral health care needs met and receive Community supports in a seamless way.”
Recommendation—Oral Health and Person and Family-Centeredness: We recommend revising 3.3.3.11.1. to add oral health and language to emphasize that services should be person and family-centered. The sentence should read, “Members will have their medical, behavioral, and oral health care needs met and will receive Community supports in a person and family-centered way.”
Rationale: Oral health is not implicit in the statement “medical and behavioral” and is crucial for whole person health. Stipulating that care must be person and family-centered is more encompassing and inclusive than “seamless” as a key goal for the program.
RECOMMENDATION: CONTINUUM OF SERVICES
Current Language: 3.3.12.4 “The next iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of services for special populations: children involved with the child welfare system, individuals transitioning out of institutions and correctional facilities, and children at risk for out-of-home placement.”
Recommendation—Continuum of Services: We recommend replacing the sentence at 3.3.12.4, “The next iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of services for special populations,” with “This iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of a fully coordinated continuum of services for individuals and their families, including but not limited to:”
Rationale: Children and their families require a broader continuum of services than the current ACC supports, both for the child and the whole family. ACC Phase II should clearly articulate this goal. Further, adding the language “including, but not limited to” recognizes that there are other populations that may require special services and attention over the course of the contract.
Somewhat clearRecommendation—Deliverables: We recommend that all deliverables in section 5.1.6. (especially population health strategy) be posted online within thirty days of the Department’s receipt in order to support transparency and the advisory process. Reports should be structured in ways that are easily understood by members, network providers, stakeholders, and the public at large.
Rationale: Publicly sharing deliverables will ensure that the program is transparent and that advocates can effectively assist the Department in monitoring the program.
RECOMMENDATION: RAE COMMUNICATION
Current Language: 5.1.8.2.4.9. The contractor shall not engage in any non-routine communication with any Member, any provider, the media or the public without the prior written consent of the Department.
Recommendation—RAE Communication: We recommend removing 5.1.8.2.4.9.
Rationale: RAE collaboration and coordination with members, providers and other stakeholders is core to their role. We do not want to inhibit the RAEs ability to communicate because that could impair their ability to collaborate and be effective in serving Medicaid enrollees. RAEs will be leaders in their communities and so have an important role to play as leaders in conversations about health. These non-routine conversations and messages will be important to improving the health of Medicaid enrollees.
RECOMMENDATION: PROVIDER DIRECTORY
Current Language: 5.5.3.7.1.6 “Provider directories and contact information, including the names, locations, telephone numbers, and non-English languages spoken by current contracted providers, as well as identification of providers that are not accepting new Medicaid Members.”
Recommendation—Provider Directory: We recommend that the provider directory be up to date, interactive, and accessible and include provider type.
Rationale: Provider type is a crucial piece of information to ensure that the contacted provider will serve the client’s need. Provider lists in PDF or other formats are difficult for clients to utilize. A dynamic and searchable provider directory that enables a client to filter the list and find a provider that is close, will take new members, and is appropriate for their age/gender and other needs is an important mechanism for supporting access.

Very clearRECOMMENDATION: EXPERTISE
Current Language: 5.2.12
• Program Officer
• Chief Financial Officer
• Chief Clinical Officer
• Quality Improvement Director
• Health Information Technology and Data Director
• Utilization Management Director
Recommendation-Key Personnel Expertise: At least one of the key personnel in an administrative leadership position should have behavioral health expertise and at least one of the key personnel in an administrative leadership position should have pediatric expertise.
Rationale: Since the bulk of the dollars in the contract are dedicated to behavioral health, it is crucial that the leadership group include deep behavioral health expertise. Since the needs of children and youth are fundamentally different than the needs of adults, pediatric expertise in the leadership group is necessary to ensure that the programs serve both. Ideally, expertise in pediatric behavioral health would also exist within the leadership team
Very clearVery clearRECOMMENDATION: HEALTH NEEDS SURVEY
Very clearCurrent Language: 5.5.5 “The Department has developed a Health Needs Survey to be completed by Clients during enrollment to capture some basic information about a Member’s individual needs. The Health Needs Survey is a brief set of questions capturing important and time-sensitive health information (Appendix H Health Needs Survey) that shall be used by the Contractor to inform Member outreach and Care Coordination activities.
Recommendation—Health Needs Survey Timing: We recommend the health needs survey occurs post-enrollment.
Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. In addition, the data may be less reliable because Medicaid enrollees may be less likely to respond accurately. We are also concerned that urgent needs identified through the Peak application process will not be responded to within an appropriate timeframe. Additionally, we wonder how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports.
Recommendation—Health Needs Survey Design: We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. Determining whether a child-bearing age female enrollee is pregnant should be a priority of the survey, in order to facilitate rapid referral to appropriate health services and community resources. We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.
Rationale: Currently, the goal of the survey is unclear.
RECOMMENDATION: HEALTHY COMMUNITIES
Current Language: 5.5.6.2 “The Contractor shall collaborate with Healthy Communities contractors in the Contractor’s Region for onboarding Members to Medicaid and the Program. Healthy Communities will have contracted responsibilities to onboard Members to Medicaid and the Program through outreach, navigation support of Medicaid benefits, and education on preventive services, particularly services for children and families.”
Recommendation—Healthy Communities: Are Healthy Communities onboarding all members rather than just kids and families? We recommend that the state delineate roles and responsibilities so that it is clear what those roles and responsibilities are statewide. We also recommend that Healthy Communities remain focused on children and their families, which is their area of expertise.

5.5.2.6.5.1 The Contractor shall write all published information provided to Members, to the extent possible, at the sixth (6th) grade level, unless otherwise directed by the Department (Literacy rates for the US state that 14% of Americans cannot read and additionally 21% of those who can read, read below a 5th grade level) I recommend that all information be provided to Members at a 4th grade level to ensure that it can be easily understood even if a child is translating it for a parent.
RECOMMENDATION: ACCESS TO CARE STRATEGIES
Current Language: 5.7.1.5 “The Contractor may use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers from diverse backgrounds.”
Recommendations—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform.
RECOMMENDATION: PCMP CRITERIA
Current Language: 5.7.2.1.8 Criteria for a PCMP, “Has adopted and regularly uses universal screening tools including behavioral health screenings, uniform protocols, and guidelines/decision trees/algorithms to support Members in accessing necessary treatments.”
Recommendation—PCMP Criteria: We recommend that the PCMP network requirement for providers to use universal screening tools should explicitly call out developmental screenings for children under age six.
Rationale: Developmental Screening is a fundamental part of high quality care for pediatrics and periodic screenings using a standardized tool are included in best practice guidelines. Early detection of developmental delays helps children receive the interventions they need to ensure their healthy development.

RECOMMENDATION: THIRD PARTY CREDENTIALING FOR THE STATEWIDE BEHAVIORAL HEALTH NETWORK
Current Language: 5.7.3.1 “The Contractor shall establish and maintain a statewide network of behavioral health providers that spans inpatient, outpatient, laboratory, and all other covered mental health and substance use disorder services.”
PRIORITY Recommendation—BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.

RECOMMENDATION: DEFINE BEHAVIORAL HEALTH PROVIDER
Current Language: 5.7.4.10 “The Contractor’s behavioral health network shall have a sufficient number of providers so that each Member has their choice of at least two (2) behavioral health providers within their zip code or within thirty (30) minutes of driving time from their location, whichever area is larger.”
Recommendation—Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.

RECOMMENDATION: PROVIDER RATIOS
Current Language: 5.7.4.11 “Adult primary care providers: One (1) practitioner per eighteen hundred (1,800) adult Members. Mid-level adult primary care providers: One (1) practitioner per twelve hundred (1,200) adult Members. Pediatric primary care providers: One (1) PCMP Provider per twenty-five five hundred (2,500) child Members. Mental Health Providers: One (1) practitioner per fifteen hundred (1,500) Members.”
Recommendation—Network Access: The standard for children’s primary care to provider ratio (in 4.7.4.11.) should be revised from 2,500 to 1,200. At a minimum, the standard should be equal for children and adults. The ratios of necessary mental health providers should be broken out by child and adult. In addition, network adequacy should also include consideration of people who have to utilize non-traditional modes of transportation or public transportation. RAEs should do an initial analysis of accessibility based on public transportation. We know the Medicaid population has higher mental health needs than the general population. In order to assure access to care for 25% of the pediatric population, we recommend a ratio of pediatric mental health providers to child enrollees of one practitioner per twelve hundred (1,200) twelve hundred members.
Rationale: The Pediatric Primary Care ratio is not adequate. Children have many more primary care visits than adults. Children’s mental health needs differ from those of adults and providers of mental health services to children should be trained to provide those services. The driving distance standards fail to acknowledge accessibility for many Medicaid clients who do not have vehicles.
RECOMMENDATION: ACCESS STANDARDS
Current Language: 5.7.4.13.5.2 “Non-urgent, Symptomatic Behavioral Health Services – within seven (7) days of a Member’s request. Administrative intake appointments or group intake processes are not considered a treatment appointment for non-urgent, symptomatic care.”
PRIORITY Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2. should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.
Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.
RECOMMENDATION: NETWORK ADEQUACY REPORTING
Current Language: 5.7.5 “The Contractor shall submit a Network Report to the Department on a quarterly basis.”
Recommendation—Network Adequacy Reporting: For all network access reporting, we recommend pediatric data and access should be separate from adult data and access.
We recommend that the network adequacy plan should include reporting on the race and ethnicity of the provider to determine whether the contractor is meeting the goals of 5.7.1.3.
Rationale: Separating data that reports on access for adults and children is necessary to determine network adequacy for each group.

5.7.4 Access to Care Standards
Add Serve all Oral Health Needs

5.7.4.7.1 PCMP Network Time and Distance Standard
5.7.4.9 Behavioral Health Network Time and Distance Standards
Need to include an Oral Health Network Time and Distance Standards so that members do not have to drive more than 1 hour in a Frontier County to find dental coverage
No opinionCurrent Language: 5.8.4.5 “The Contractor shall have and maintain a centralized regional resource directory listing all Community resources available to Members and share the information with providers and Members.”’
Recommendation—RAE Directory: We recommend adding the following language, “The RAE directory should include resources to support women and families who are experiencing pregnancy-related depression and anxiety, including the Postpartum Support International phone number and website, and other community resources.”
Very clearCurrent Language: 5.10.5.2.3 “Clinical resources, such as screening tools, clinical guidelines, practice improvement activities, templates, trainings and any other resources the Contractor has compiled. “
Recommendation—Screening Tools: We recommend specifically identifying developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines.
RECOMMENDATION: PROVIDER TRAINING
Current Language: 5.10.6 “The Contractor shall, at a minimum, develop trainings based on subject matter expertise and host forums for ongoing training regarding the Program and the services the Contractor offers.”
Recommendation—Provider Training: Provider support should include training providers in best practices related to caring for children and families including completing post-partum depression screening multiple times during the child’s first year and screening for ACEs annually as well as other early childhood mental health competencies. In addition, we recommend that behavioral health providers working with young children have the Colorado Infant/Early Childhood Mental Health Endorsement.
No opinionNo opinionNo opinionRecommend that there are Oral Health KPI's included in this sectionNo opinionNo opinionNo opinionRecommendation 3.3.15.4.2—Flexible Funding Pool: We recommend adding the following language: “The use of the Flexible Funding Pool funds will be approved by the Statewide Program Improvement Advisory Committee. The funds must be used to encourage innovative upstream interventions that address risk and protective factors as well as the social determinants of health .”
Recommendation 5.10.9.1—Administrative Payments: We recommend adding the following language: “At least some of those funds must be distributed to Health Neighborhood beyond PCMPs.” We also recommend that the Department continue to seek ways to ensure that the funding in the Medicaid program is aligned with the areas where there is the greatest return on investment and that there continues to be increases in resources allocated to primary care (including primary behavioral health care) and decreases in investments in secondary and tertiary care.
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1/4/2017 15:07:49I agree and wish to continueChristyDoddOral Health ColoradoAdvocateNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionSomewhat clear5.7.4.7.1 PCMP Network Time and Distance Standard Please add Access to Oral Health.
I feel this would be a good place to align the new Department of Regulatory Agency Division of Insurance 3CCR702-4 standards which states:
Section 6 Dental Network Adequacy Standards
A. The following measurement standards shall be used to assess network adequacy of a carrier’s dental networks. The goals will be based on the provider type, the county designation as defined in Appendix A, and the driving distances specified below.
B. The carrier shall attest for its Colorado service areas
Dental
Large Metro & Metro Counties 10 miles from client
Micro Rural & CEAC 100 miles from client
No opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinion
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1/5/2017 7:28:49I agree and wish to continueCarlNassarHeart-Centered CounselingProviderI wanted to write this short letter to share two recommendations regarding the recent RFP:

1. First, I’d recommend Larimer and Weld County remain together in a single region;

2. Second, I’d request that the State take over credentialing for all RAEs, allowing a single credentialing process for providers.

Reasons follow:

1. Given the free movement of members for care between Weld and Larimer counties, it seems that members would be best served by a single Medicaid RAE as opposed to two RAEs covering the two counties.

2. Also, as a provider with behavioral health offices in both regions, a separation of regions in turn requires paneling of each provider with both RAEs, as members may come from Larimer or Weld to any of our locations in both counties.

3. Additionally, in the case of a division of Weld and Larimer counties into two RAEs, our providers would also be required to constantly track each client’s PCP locations, monitoring for changes, as a member’s change of PCPs from, say, one in Weld to one in Larimer, would in turn trigger a change RAEs and require billing to a different RAE.

Summary:

Due to the concerns stated above, for both members and our team of providers, we would like to express our preference and our hope that Larimer and Weld county remain united as a single region, supported by a single RAE.

I also suggest that the State take over credentialing for all of the RAEs and make it part of the existing enrollment process for Medicaid providers.

Thank you for your consideration of these requests.
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1/5/2017 14:11:31I agree and wish to continueShera LeeMatthewsDOCTORS CAREAdvocate on behalf of Provider/SafetyNet ClinicDoctors Care embraces the spirit of the ACC 2.0 RFP because it supports patient centered care and the concept of the healthy neighborhood.
However, Access to care must be in the forefront of ACC 2.0. This is a major problem today and while the state aims to provide these future quality services for the client; we can’t succeed in our deliverables when we have inadequate numbers of providers, specialists, mental health centers, and substance use. This has resulted in lack of access and timely care for the client. ACC 2.0 also has the potential to achieve wonderful goals; but can also place barriers and increased pressure to perform on a limited number of contractors. We can’t drive away current/future contractors by making requirements too daunting to receive basic reimbursement at the current levels. Today, revalidation and the reduced payment for E&M visits in 2016 have already resulted in reduced numbers of providers/contractors. The department and the RAE’s must focus on growing and maintaining access to care, but also be flexible in these goals to assure participants are receiving reimbursement in a fair and equitable setting for all, from small to large, rural and in other care settings. We can’t achieve a patient centered care home without all of these participants providing access to care.

Somewhat clearCOMMENT on 3.3.12.1:
Care Coordination is currently offered by many entities and a person centered approach is already applied. The department should be sensitive to not duplicating current efforts, but coordinate with these entities and allow flexibility to utilize these efforts offered in the community. Enabling sharing of these efforts and assessments should be a key responsibility of the Department and the RAE.

COMMENT on 3.3.13.2.2:
6 PCP Visits: We applaud the support of integration of behavioral healthcare in the primary care setting and the ability to bill for these low acuity services. Related to the treatment in this primary care setting, many providers partner with community mental health centers. They provide masters level counselors or social workers that are not licensed, but supervised. To facilitate billing for these low acuity behavioral health services, we ask that these unlicensed, supervised masters level mental health staff be included in this billing coverage within the primary care setting, not just the community mental health centers.

COMMENT ON 5.14.4.8.1.1.1
I. Data Reporting: specifically KPIs should have separate measures and data for children versus adults.
II. Past data collection experiences should be considered related to those successes/failures when adjusting or choosing the new KPI's. (i.e. Overall well visits for ages 3-9 showed little improvement with past KPI)

COMMENT on 5.4.8.2:
The attribution system level that reviews claims history for PCMP assignment should consider well visits as weighted or solely in the system. If a client visits an urgent care frequently, this should not hold the weight of where the clients is seeking well care or non-urgent care

COMMENT ON 5.7.2.1.10
Hours: Weekly extended hours for small/medium practices, rural settings and schools can cause a financial burden to the practice and may not be sustainable. We suggest a more flexible standard of one day per month or quarter for extended hours.

COMMENT on 5.7.2.1.3:
Practitioner Definition: It is critical to include (not omit) the PA, Physician Assistant on the practitioner list for a provider license. Physician Assistants extend access to many, if not most of the Medicaid patients we serve!

COMMENT ON 5.7.3.3
Mental Health Access: Based on timely access to and providing a variety of professional services, the contractor should include the private practice Medicaid practitioner (in addition to the Community Mental Health Center). RAE’s must be encouraged to expand credentialing to private practice.

Somewhat clearSomewhat clearSomewhat clearCOMMENT on 5.4.8.2:
The attribution system that reviews claims history for PCMP assignment should consider well visits as weighted or solely in the system. If a client visits an urgent care frequently, this should not hold the weight of where the clients is seeking well care or non-urgent care
Somewhat clearSomewhat clearSomewhat clearSomewhat clear
Somewhat unclearSomewhat unclearSomewhat unclearSomewhat unclearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clear
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1/5/2017 16:22:27I agree and wish to continueAdvocateNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
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1/5/2017 18:29:52I agree and wish to continueCarlClarkMental Health Center of DenverProspective BidderI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document. However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

The HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
No opinion 5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
No opinion5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionNo opinion5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
No opinion5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.
No opinion5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
No opinion5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
No opinion5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
No opinionNo opinion5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
No opinion5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.No opinionNo opinion6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
No opinion7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
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1/5/2017 19:27:23I agree and wish to continueProviderNo opinionLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
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1/6/2017 3:06:44I agree and wish to continueKateNilesprivate practice; NASW repAdvocateSomewhat unclearSomewhat clearNot ClearSomewhat clearSomewhat clearSomewhat clearSomewhat unclearNot ClearSomewhat unclearSomewhat clearSomewhat clearSomewhat clearSomewhat unclearSomewhat clearSomewhat clearVery clearSomewhat clearSomewhat clear
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1/6/2017 8:28:18I agree and wish to continueAdvocateSomewhat clearVery clearSomewhat clearVery clearNo opinionSomewhat clearNo opinionSomewhat clearSomewhat clearSomewhat clearSomewhat clearVery clear
Six Visits Parameters:
The six behavioral health psychotherapy sessions should be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician), and should be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting the care should be provided in an integrated way with integrated charting.
The “low-acuity” terminology should be eliminated; it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

The six visits limit should be per episode of care; "episode" should be determined by the treating provider. Appendix N should be revised so the reference to six visits per fiscal year is removed.
Somewhat clearSomewhat clearSomewhat clearNo opinionNo opinionVery clear
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1/9/2017 9:26:48I agree and wish to continueAdvocateNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionNo opinionLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
No opinionNo opinionNo opinionNo opinionNo opinionNo opinion
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1/9/2017 11:43:55I agree and wish to continueJeffTuckerMental Health Center of DenverHealthcare AdministratorI generally support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a spectrum of care across different settings. I recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

In particular, Human Resources practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership/potential infringement upon contractor’s intellectual property is also concerning.

Additionally, I see a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. I recommend that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and resources should be allocated.

3.3.12.2 I wonder whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.

Somewhat clear 5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Would strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Would strike this section; issue of overreach.

5.1.10.2.3 Would strike this section.

5.1.10.2.4 Would strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
Somewhat clearGenerally, over-broad reach and over-controlling requirements:
5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and certifications in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
Somewhat clearSomewhat clear5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
Somewhat unclear5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.

Somewhat unclear5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vice/versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
Somewhat unclear5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
Somewhat unclear5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect until well after the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
Somewhat clearSomewhat unclear5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like an overly strict timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and recruiting staff to do this would be nearly impossible. I suggest meeting compliance/adherance at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an overload of information.
Somewhat unclear5.13.1.4.2.5 Define ownership of findings - should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I suggest the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
Somewhat unclear5.15.5.2.6 I question if “up to and including termination” is enough. The federal government already has punishable guidelines.No opinionSomewhat clear6.3.6.1 Clarify the purpose of the 17,000 statement. This might be a very large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
Somewhat clear7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
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1/9/2017 13:04:48I agree and wish to continueWilliamMilnorMental Health Center of DenverProviderI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

The HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
Somewhat clear 5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
Somewhat clear5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionSomewhat clear5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
Somewhat unclear5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.


Somewhat unclear5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
Somewhat clear5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
Somewhat clear5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
No opinionSomewhat clear5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
Somewhat clear5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.No opinionSomewhat clear6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
Very clear7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
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1/9/2017 14:17:18I agree and wish to continueKathleenMcInnisSouthwestern Colorado AHECSocial Service/Community OrganizationObviously, the Department has put into this document, a lot of thought and research and I appreciate the willingness to take comments on this RFP. As a community health and public health organization, we are committed to partnering with other local, regional, and state partners, including the Department, to make a difference for our communities' health and health outcomes. Including a section related to Community Goals is very important to addressing health disparities, social determinants of health, and barriers to care, all of which have a significant impact in the health outcomes of individuals and the community. I would like to see a requirement of the RAE to include real commitments and investments in community infrastructure (physical, financial, etc.) and a requirement to partner with local/regional organizations (public/private health, oral health providers, schools, community organizations) to best meet the needs of patients/families and maximize impact, without duplication of effort.Somewhat clearSection 5.1.6. All deliverables in section 5.1.6. (especially population health strategy) should be posted online within 30 days of the Department’s receipt in order to support transparency and the advisory process. Reports should be structured in ways that are easily understood by members, network providers, stakeholders, and the public at large.
Rationale: Publicly sharing deliverables will ensure that the program is transparent and that advocates can effectively assist the Department in monitoring the program.
No opinionReduce Churn: We were happy to see and appreciate the Department’s ongoing efforts to work with providers to ensure that they are able to provide continuous comprehensive care for their clients. We understand the negative impact that changing providers/care settings has on a client’s consistent access to care, continuity of care, and a provider’s ability to manage a client’s care effectively. No opinionSection 5.5.5. We recommend the health needs survey be given post-enrollment.
Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. In addition, the data may be less reliable because Medicaid enrollees may be less likely to respond accurately. We are also concerned that urgent needs identified through the Peak application process will not be responded to within an appropriate timeframe. Additionally, we wonder how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports. We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.

No opinionNo opinionRecommendations—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform. Geographic barriers are only a piece of the larger issues related to accessing care.
RECOMMENDATION: THIRD PARTY CREDENTIALING FOR THE STATEWIDE BEHAVIORAL HEALTH NETWORK
5.7.3.1 Recommendation—BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.

RECOMMENDATION: DEFINE BEHAVIORAL HEALTH PROVIDER
5.7.4.10 5 Recommendation—Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want/need a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.


No opinionNo opinionRECOMMENDATION: CARE COORDINATION DEFINITION
2.1.12 Care Coordination – Definition: The deliberate organization of Client care activities between two or more participants (including the Client and/or family members/caregivers) to facilitate the appropriate delivery of physical health, behavioral health, functional LTSS supports, oral health, specialty care, and other services. Care Coordination may range from deliberate provider interventions to coordinate with other aspects of the health system to interventions over an extended period of time by an individual designated to coordinate a Member’s health and social needs
Recommendation—Care Coordination Definition: We recommend revising the 2.1.12. definition of care coordination so that it is more client centric and better addresses the function of care coordination as it relates to whole person needs. The sentence should read, “The process of collaborating with a Client to identify needs and viable solutions, create a care plan and then execute the care plan. A care plan may include physical health care, behavioral health care, functional LTSS supports, oral health, specialty care, housing supports, school participation, food resources, employment supports, transportation options, and other medical and community services.”
Rationale: The definition of Care Coordination noted several times in the RFP is very medically focused. The list of providers is comprised of all medical providers. We recommend clarifying that Care Coordination necessitates supporting clients in accessing the full range of services they require to maximize their potential. We also recommend changing this language to be more client-centered so that the clients have some agency in the coordination of their own care.
No opinionNo opinionNo opinionRecommendation—Health and Behavior Codes: We recommend that the health and behavior codes be added as a fee-for-service benefit. Addition of six behavioral health visits out of primary care does not replace the need for health and behavior codes to address behavioral health aspects of acute and chronic medical conditions.
Rationale: Health and behavior codes would enable clinicians to provide necessary counseling and treatment for medical conditions and diagnoses (e.g., weight management/obesity, asthma, congenital anomalies, developmental diagnoses, feeding disorders, sleep disorders) that can have long-term effects for healthcare costs and outcomes. These behavioral health interventions need to be delivered within health care settings by licensed behavioral health providers (or license-eligible trainees under the supervision of a licensed clinician) billing health and behavior codes on a medical diagnosis, not a mental health diagnosis. For example, counseling an adolescent on weight management is a high value activity that will result in significant long-term savings to many systems.
RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
3.3.13.2.2 Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).
We recommend that those six visits be allowed to be offered in clinical (within primary care practice), public, private, or community-based settings or within the home. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.
We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
Rationale: We want to be sure that behavioral health care is provided by someone appropriately credentialed and does not become an expansion of the scope of primary care medical providers. And best meets the needs of the clients.
No opinionRECOMMENDATION: CARE COORDINATION TOOL
5.13.2.1.1 Recommendation—Care Coordination Tool: We recommend that the care coordination tool be required to not only collect information but also transmit information across medical and non-medical systems including oral health care providers, EPSDT, Early Intervention Colorado, home visitation programs, school-based health clinics, the Colorado Department of Education, Colorado Department of Human Services, Colorado Department of Public Health and Environment, the immunization registry, and child care and early learning settings.
The care coordination tool should potentially be accessible to clients as well as healthcare providers.
We recommend that the RAEs collaborate on a statewide tool that can interface with all electronic medical records and a concerted effort should be made to share care coordination information across organizations to maximally benefit the clients and reduce duplication of services and effort.
Rationale: If the function of this tool is to enhance care coordination (rather than just track it) then it must be able to transmit information in order to support the delivery of care.

No opinion5.14.4.8.1.1.1 Recommendation—Number and Types of KPIs: We recommend fewer than 9 KPIs and an attempt to move towards social measures (ie. housing status, food security) and clinical outcomes-based KPIs over the course of the contract. We recommend that as the Department evolves the measures, they continue to identify measures that are specific (not composites of many measures) and that are developmentally-relevant and age appropriate.
Rationale: Too many measures dilutes focus. Clarity in measures and accessible goals bring both administrative efficiencies and clinical efficacy.
No opinionNo opinionNo opinionNo opinion
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1/9/2017 15:00:17I agree and wish to continueKyleCovellAdvocateLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
Somewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
Somewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clear
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1/9/2017 15:07:41I agree and wish to continueTerriHurstColorado Criminal Justice Reform CoalitionAdvocate1.) Throughout the RFP, the use of the phrase “individuals transitioning out of…correctional facilities” is used and identified as a special population. In addition, in Section 5.9.3.10 the use of the phrase “Medicaid-eligible individuals transitioning out of the criminal justice system” is identified as a population that care coordination activities should be occurring with. While the use of these phrases throughout the RFP draft is a step in the right direction, neither phrase is clear or comprehensive. It is assumed the Department is interested in identifying and working with Medicaid-members who are involved in the criminal justice system, which CCJRC applauds and appreciates.
There are a variety of ways that people may be involved in the criminal justice system (ex: incarcerated in prison or jail, transition/diversion in community corrections, probation, parole, pretrial, etc.). Use of the phrase, “individuals transitioning out of…..correctional facilities” only identifies people being released from jail, prison, or community corrections facilities, but excludes people on probation, which is the largest group of people who are justice-involved. All Medicaid-eligible members who are involved in the criminal justice system, regardless of their status, should be considered a special population given the high rates of chronic health and behavioral health conditions that many justice involved people experience.
Use of the phrase, “Medicaid-eligible individuals transitioning out of the criminal justice system” taken literally, excludes almost everyone who is justice-involved unless they are ready to be “off-paper” or no longer under any form of supervision. This terminology would mean that the vast majority of justice involved people would not have access to care coordination services or other supports until they were close to completing their sentence. This would be a complete oversight as justice involved people could greatly benefit from care coordination to medical, behavioral and other social support services while they are still under supervision. In fact, access to health and behavioral health care services has been shown to reduce involvement with the criminal justice system.
Given the ambiguity in the two aforementioned phrases, CCJRC suggests the Department use “people involved in the criminal justice system” throughout the RFP. This is a more comprehensive and inclusive phrase that will ensure that any Medicaid member involved in the criminal justice system is considered a special population and will have access to care coordination supports.

2.) The Health Needs Survey raises questions and needs clarification:
• What happens if a Member doesn’t want to complete the survey?
• It would be better suited for a RAE care coordinator to conduct a health needs survey versus an insurance broker or enrollment specialist.
• An option to complete the survey through a patient portal should also be offered.
• The length of the survey may be a deterrent to it being completed. A suggestion is to create a two or three question assessment that can help identify any immediate needs.

3.) Lack of mention or inclusion of oral health.

4.) Lack of mention or inclusion of substance use disorder services.

5.) Access to care standards should not solely be based on time & distance.

6.) There is an overall lack of accountability in this draft RFP. If one of the deliverables is not met or if there is an issue with the contractor, what sort of oversight can be expected from the Department? Stronger language should be added that states that the Department will conduct annual audits and that Members and providers can rely on the Department to enforce contract requirements.

7.) There are also a lot of reports and plans that are required of the Contractors. Making these documents readily available to the public would increase transparency and accountability.

8.) It is unclear in this draft RFP how some of the provisions are to be operationalized, in particular only allowing PCMP practice sites to be contracted with only one Regional Accountable Entity (RAE).
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3.3.12.2. Once a Client is enrolled in the Program, the Department will conduct a brief Health Needs Survey through PEAK and/or the Department’s Enrollment Broker. The Health Needs Survey will be used to help PCMPs and RAEs identify a Member and family’s potential immediate needs.

Comment:
• What happens if a Member doesn’t want to complete the survey?
• It would be better suited for a RAE care coordinator to conduct a health needs survey versus an insurance broker or enrollment specialist.
• An option to complete the survey through a patient portal should also be offered.
• The length of the survey may be a deterrent to it being completed. A suggestion is to create a two or three question assessment that can help identify any immediate needs.

3.3.12.4. The next iteration of the Accountable Care Collaborative Program will include efforts to improve the coordination and delivery of services for special populations: children involved with the child welfare system, individuals transitioning out of institutions and correctional facilities, and children at risk for out-of-home placement.

Comment:
• Instead of “individuals transitioning out of…correctional facilities,” CCJRC suggests the phrase “people involved in the criminal justice system” be used. This is a more comprehensive and inclusive phrase that will ensure that any Medicaid member involved in the criminal justice system is considered a special population and will have access to care coordination supports.
• There should be specific measures and guidelines as to how the RAE’s are expected to connect and provide services to justice involved people.
• Every justice involved Member should be assigned a care coordinator or peer specialist once they are enrolled in Medicaid and assigned to a RAE.
• Emphasis should be placed on connecting justice involved populations to the RAE, not necessarily a PCMP.
• RAE care coordinators should be required to provide in-reach services to people leaving prisons or jails to ensure needs are being identified and appointments are being made with a behavioral or health care provider prior to an individual being released.
• RAE care coordinators should be trained and proficient in understanding the nuances and complexity of the criminal justice system.

3.3.13.2.1. The Department will rely less on the use of a covered diagnosis as a requirement for accessing Medically Necessary covered behavioral health services. Covered diagnoses will continue to be used to identify inpatient hospitalizations, emergency department visits, laboratory tests, and specific outpatient and alternative behavioral health services that will be reimbursed through the behavioral health benefit.

Comment:
• What is the list of covered diagnoses that will be used? Appendix N does not clarify what the covered diagnoses are.
• A Medicaid-member should be able to receive any medically necessary behavioral health service regardless of their diagnosis. There should not be “carved out” services specific to one’s diagnosis, especially emergency room visits, laboratory tests and specific outpatient and alternative behavioral health services.
• A Medicaid-member should also not have to have a “primary diagnosis” in order to receive services, in particular regarding behavioral health. A person with a co-occurring disorder, meaning they have a substance use disorder (SUD) and a mental illness, should be able to receive care regardless of whether the SUD diagnosis is considered primary or if the mental health diagnosis is primary.

3.3.13.2.2. The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.

Comment:
• How is the “low acuity” condition determined? Is this based on an assessment?
• If someone uses their 6 sessions, but still requires more services and they are not approved under the capitation benefits, then what?
• Does this comply with parity?
Somewhat clear5.1.6. Deliverables
Comment:
• What happens if a deliverable is not met? Where is the accountability?
• Identified deliverable reports and plans should be made public.

5.1.11. Performance Reviews
5.1.11.1. The Department may conduct performance reviews or evaluations of the Contractor in relation to the work performed under the Contract.
Comment:
• The Department “may” conduct a performance review is very light language. Performance reviews, accountability and oversight language should be strengthened to say that “The Department will conduct performance reviews and evaluations.”
• Performance reviews should be made public.
No opinionNo opinionSomewhat unclear5.4. Member Enrollment and Attribution
5.4.5. Members shall be enrolled with the Contractor based on the location of the PCMP Practice Site to which the Member is attributed (e.g., if a Member lives in Region 3, but is attributed to a PCMP Practice Site in Region 5, the Member will be enrolled to the Contractor in Region 5). The PCMP attribution effective date will be the same as the RAE enrollment date.
Comment:
• What about people who are homeless or do not have a permanent address? How are they attributed to a RAE?
• Connection with a RAE case manager/care coordinator is more important than being attributed to a PCMP. It should be accepted and anticipated that some people will be unattributed to a PCMP. The most important thing is for a Medicaid-member to be connected to a RAE. It should be seamless for a person to get care regardless of who or where their PCMP is located.
Somewhat clear5.5.3.5. Member Rights
Comment:
• What if a person feels like their rights in this section have been violated and ignored? What is their recourse?

5.5.5. Health Needs Survey
Comment:
• What happens if a Member doesn’t want to complete the survey?
• It would be better suited for a RAE care coordinator to conduct a health needs survey versus an insurance broker or enrollment specialist.
• An option to complete the survey through a patient portal should also be offered.
• The length of the survey may be a deterrent to it being completed. A suggestion is to create a two or three question assessment that can help identify any immediate needs.

5.5.9.1. Member Engagement Report
Comment:
• These reports should be made public.
Not ClearThere should be one grievance process for both physical & behavioral health services, even if they are covered capitated services.

5.6.2. The Contractor shall assist Members in following the Department’s procedures for handling Appeals of physical health adverse benefit determinations.
Comment:
• I assume this covers the 6 low-acuity behavioral health services too?
• Again, there should be one grievance process for both behavioral and physical health services regardless if they are capitated services or not.
Somewhat unclear5.7.1.8. The Contractor’s networks shall provide the Contractor’s Members with a reasonable choice of providers.
Comment:
• Please define “reasonable” choice of providers.

5.7.3.3. The Contractor shall enter into contracts with any willing and qualified Community Mental Health Center in the state to enable Member choice and promote continuity of care.
Comment:
• Language should be added here that states “contracts shall be offered to any willing and qualified behavioral health provider in the state.”

5.7.3.4. Behavioral Health Provider Credentialing and Re-credentialing
Comment:
• Behavioral health credentialing standards should be interpreted and implemented equally in all 7 RAE’s. If a provider meets credentialing standards, they should be offered a contract.
• The Department needs to create guidelines and an appeals process for providers who are denied a contract with a RAE, in particular if the provider meets the credentialing standards, but is denied a contract offer or told that the RAE has an adequate network.

5.7.4. Access to Care Standards
5.7.4.7. Access Monitoring Review Plan
Comment:
• Given that the Access Monitoring Review Plan is not final nor comprehensive since it did not assess the capitated behavioral health provider network, it should not be referenced here or used as the base for access to care standards.
• Behavioral Health Network Time and Distance Standards – In addition to time and distance, network adequacy should also be based on the length of time it takes a Medicaid member to access behavioral health services (i.e. schedule an appointment for treatment services).

5.7.4.13.5. The additional timeliness standards apply only to the Capitated Behavioral Health Benefit:
Comment:
• Medicaid members should have clear guidance of what to do if they are unable to reach a behavioral health provider in the expected time, distance and access to care standards.
• What happens if the timeliness standards aren’t met? What sort of accountability do the RAE’s have to meet these standards?

5.7.4.13.5.2.1. Administrative intake appointments or group intake processes are not considered a treatment appointment for non-urgent, symptomatic care.
Comment:
• A timeframe needs to be established for administrative intake appointments.

5.7.4.13.5.3. The Contractor shall not place Members on waiting lists for initial routine service requests.
Comment:
• “Initial routine service requests” needs to be defined and there needs to be accountability measures if these services are not provided or if a person is placed on a waiting list.

5.7.5. Network Adequacy Plan and Report
Comment:
• The Network Adequacy Plan should be available to stakeholders and the public.
Somewhat clear5.8.3.8. The Contractor shall collaborate with hospitals to implement the DSRIP Program, a Section 1115 waiver program that, if granted, will give Colorado Medicaid the opportunity to tie hospital payments to performance. DSRIP gives the Department another tool to connect hospitals to the Health Neighborhood and align hospital incentives with the goals of the Accountable Care Collaborative Program.
Comment:
• Language should be added to this section that states the Contractor shall work with the Department in any sort of waiver process given that there are many different waivers the state could pursue over the next 7 years.

5.8.7.1. Health Neighborhood and Community Report
Comment:
• The Health Neighborhood and Community Report should be made public and posted on the Department’s website.
Somewhat unclear5.9.3. Care Coordination
Comment:
• Language in this section is very vague.
• Care coordination is extremely important for people involved in the criminal justice system in helping them understand and navigate the health care system and every Medicaid-member who is involved in the criminal justice system should have an identified care coordinator to work with.

5.9.3.10. The Contractor shall ensure that Care Coordination is provided to Members who are transitioning between health care settings and populations who are served by multiple systems, including but not limited to children involved with child welfare, Medicaid-eligible individuals transitioning out of the criminal justice system, Members receiving LTSS services, and Members transitioning out of institutional settings.
Comment:
• Instead of “Medicaid-eligible individuals transitioning out of the criminal justice system” CCJRC suggests the use of the phrase “people involved in the criminal justice system.” This is a more comprehensive and inclusive phrase that will ensure that any Medicaid member involved in the criminal justice system is considered a special population and will have access to care coordination activities.
• Use of the phrase, “Medicaid-eligible individuals transitioning out of the criminal justice system” taken literally, excludes almost everyone who is justice-involved unless they are ready to be “off-paper” or no longer under any form of supervision. This terminology would mean that the vast majority of justice involved people would not have access to care coordination services or other supports until they were close to completing their sentence. This would be a complete oversight as justice involved people could greatly benefit from care coordination to medical, behavioral and other social support services while they are still under supervision. In fact, access to health and behavioral health care services has been shown to reduce involvement with the criminal justice system.
No opinionNo opinionSomewhat unclear5.12.6.1. The Contractor shall provide covered services in an amount, duration, and scope that is no less than the amount, duration, and scope furnished under Fee-for-Service Medicaid.
Comment:
• If the low-acuity behavioral health sessions are capped at 6, does that mean the Capitated Sessions could be capped too?

5.12.6.4. The Contractor may place appropriate limits on a service:
Comment:
• “Appropriate limits” needs to be defined. Also, does this section comply with parity?

5.12.6.9. If the Contractor is unable to provide covered behavioral health services to a particular Member within its network, the Contractor shall adequately and timely provide the covered services out-of-network at no cost to the Member.
Comment:
• “Adequately and timely” should be defined.
No opinionSomewhat clear5.14.4.9. Capitated Behavioral Health Benefit Pay for Performance
Comment:
• There needs to be performance standards and metrics focused specifically on substance use disorder services such as number of providers providing M.A.T. services or number of members transitioning from detox services to treatment services.
No opinionNo opinionNo opinionNo opinion
35
1/9/2017 15:12:36I agree and wish to continueSharonRaggioMind Springs HealthProvider 3. General Impressions

The decision to build off of the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. I fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.

Principles of Intent:

There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is understandable and appropriate to a point. Mind Springs’ desires to take advantage of this important opportunity to design a system to support leading edge, best possible care for our Medicaid residents of North West Colorado. We have learned from the care design of the foundation contracts (both the RCCO and the BHO, but also the PRIME contracts), and we aspire to a bolder vision of what could be possible. True integration is not adequately articulated in this draft RFP.

Preservation of BHO gains:

There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract, nor given enough attention to the development of services for people with a serious mental illness. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward. This may not prove beneficial to maintaining the gains currently seen.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require CMHC provider to have “skin in the game” and require contracting with the CMHCs to incentivize the current robust B-3 services, service locations (especially in rural areas), services to people with serious mental illness, and alternatives to hospitalization.

Payment Strategies:
The RFP should clearly lay the path for a system focused on maximizing independence, local control, and stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. I would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, I believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers. Where are the hospital systems in this RFP? Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado’s rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder:

One important area in need of service enhancement, and currently lacking from the draft RFP, is Substance Use Disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. I ask HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase.

Non-Medical Partners:

Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort. Does HCPF have agreements in place with these other entities to use resources to support the aim of this RFP, that any bidder or provider can count upon for success in the intention of this RFP? As an example, I offer differences learned with Mind Springs participating in both the OBH crisis RFP and the HCPF I/DD Pilot. Both of the opportunities involve a crisis system, however at times expectations, data, and requirements needed to be clarified as they were at odds between the state agencies. The good news is that these issues were resolved, however the point is that having state agreement between state departments to support the RFP would have been helpful.

Deliverables:

This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. It is suggested that a combined HCPF clinical and data team review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes:

There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes for individuals or for the population. HCPF may want to start with these measures, but suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.
Somewhat clearSomewhat unclear5.2.3 et. al. The requirements in this section are an over reach. Setting granular requirements only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. I suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.

Include language for the RAE to allow a subcap and risk sharing for the management of services under the 1915(b) waiver, which creates a system which adequately involves providers in care management and incentives quality care at the lowest level.
Very clear
Mandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.
The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations. Consider a regional attribution methodology rather than a practice-based methodology.
Very clear5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.


5.5.1.1.4 I particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention.
Somewhat clear
5.6.1 Grievances are an important part of both quality improvement and patient engagement. Typically grievances start at the practice site and the practice staff are an active part of this process. Unfortunately, today, some grievances by pass the local practice and go straight to the state. For the grievance process to be impactful, HCPF must define the process and then allow it to work. It is suggested it be required that all grievances contain sufficient information to be actionable and start at the practice level. Use of external Ombudspersons and legal proceedings are necessary and valuable only after the defined process is followed.
Somewhat clear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.


5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear5.8.2 Increasing Member access to timely and appropriate Medicaid services and benefits is critically important to improving population health. It is unclear whether this section is encouraging the broadest linkages with community resources or opening the door to “any willing provider”. I believe from other comments HCPF has made it is the former – encouraging broad linkages. In that regard, stronger financial incentives and contractor proof of existing strong and positive community linkages will be very important. I firmly believe the most important focus of improved access is not adding providers, but engaging enrollees’ active participation in their own healthcare in prevention and early intervention.

5.8.3.8 DSRIP is an interesting pilot established with good intent. With a significant question being the new Administration in Washington’s willingness to continue with this program, how will HCPF address this issue in the final RFP? It seems today that DSRIP should be deleted, as it seems unlikely to happen. Pls re-think the role of hospitals.

A specific definition describing the difference between health neighborhood and population health would be helpful. Additionally, addressing the use of tele-health, especially in rural areas such as Region 1, might be helpful.
Somewhat unclear5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances. This also means that funding needs to be tied to true population health outcomes. Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes multiple of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.

It is also suggested the state crisis system and the MSOs be specifically included in this section as important participants for population health. Additionally, HCPF may wish to clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.

Very clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.

Very clear5.11.1 I would hope that PRIME can be expanded.Very clearRetaining behavioral health capitation is critically important and aligns well with the goals of the ACC to advance payment models and delivery systems toward greater efficiency and effectiveness. However, there remains substantial concerns with exactly how this will be executed and the resulting impacts. ACC Phase II must seek to strengthen existing systems of care that have evolved over decades to meet the needs of diverse populations across urban, rural and frontier Colorado. Specific attention must be given to ensure that access to services is expanded without sacrificing quality and scarce healthcare resources. Maintaining covered diagnosis restrictions for capitated behavioral health services preserves the significant barriers to treatment Colorado has struggled with in recent years. More thought must be given to how capitation can be preserved while ensuring comprehensive access to high quality care.

Depending on how the capitation rate setting process occurs, there could be significant challenges posed by shifting lower acuity services (and, therefore, populations) to fee-for-service. Managing risk for a population primarily consisting of those with the most serious and chronic needs is difficult, and the associated risk premium must recognize this difficulty.

There is also concern that allowing for the six visits in primary care in a FFS environment has the potential to sacrifice quality treatment in favor of "access" due to lack of guidelines about the content and therapeutic quality in these sessions. Careful consideration and controls should be implemented to ensure both quality and cost efficiency. This provision has the potential to actually hinder integration and may result in more co-location growth with the addition of mechanisms for volume-based behavioral health billing in primary care practices. If this new financial mechanism for primary care is in place to treat less acute patients, there is concern that this could exacerbate the workforce challenges already felt in community behavioral health settings as more clinicians would opt to work in more lucrative primary care settings with less acute clients. As written, the RFP perpetuates disproportionate financing and administrative burden to working in community behavioral health.

Additionally, simply paying for 6 visits in a primary care setting does not necessarily result in integration. More often it results in co-location and has the potential to create different challenges, requiring more oversite from the RAE as the capitation portion of the benefit is accessed.

The RFP also provides for Inpatient hospitalization services under capitation only for primary mental health diagnoses. This raises concerns that there will not parity for SUD. Covering SUD residential services under the Medicaid benefit could create significant medical cost offsets.
Overall, more consideration should be given to the unique needs of those with serious and persistent mental illness and difficult co-occurring conditions.

Additional clarification is necessary around the definition of “low acuity.” It is difficult to know how a client will be determined to be low acuity in the absence of a full client assessment in primary care settings. It is also unclear what constitutes an “episode of care” and how the threshold of six visits per episode was determined. Are there requirements for what level/type of provider can deliver these six sessions?

If individuals with low acuity behavioral health needs are no longer included under the risk-based behavioral health managed capitation program, how will the Department ensure that new capitation rates are sufficiently adjusted to reflect the shift toward higher risk of the high needs population that will continue to seek services under the capitation program?

Clarification should be provided on how risk arrangements with providers and 1915(b)(3) services will be included in rate-setting.

How will Medicaid programs be coordinated with funding streams from other State Agencies? For example, how will MSOs, funded under the Department of Human Services, be engaged and aligned?

How will the six visit per episode of care provision for behavioral health be funded? Is this paid for by a reduction in behavioral health capitation rates, or paid for using medical cost offset anticipated by addressing lower acuity behavioral health needs in primary care settings?

Clarification should be provided under the Culturally Responsive section about what determines a “qualified interpreter.”
Somewhat clear5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well. Somewhat clear5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. Process measures typically are required, but do not meet this aim. Measuring things like suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

I applaud HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. It is suggested that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that increase alignment and inform/correlate with actual improved population health and consequent reduced per capita cost.
Somewhat clear5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.Very clearno commentsSomewhat clearIt is important to consider how the connection to child welfare can be strengthened in the next iteration of the ACC. This system is minimally referenced in the draft RFP and deserves additional consideration. Somewhat clear
There should be additional resources available for SUD services and expanding the benefit must include significant dollars to address the pain points currently being felt by hospitals and other areas of the health delivery system.

How will the Department ensure that earning a sufficient operating margin is possible so that RAEs and providers can reinvest in enhancing services and infrastructure to continue evolving our health system toward greater efficiency and improved outcomes?

The RFP indicates that the ACC will evolve payment by aligning provider rate-setting methodologies across provider types so that they are aligned and mutually reinforcing (FQHCs, CMHCs, primary care). Please elaborate on how this will be achieved and how this alignment will reward improved outcomes, beyond meeting process measures, across provider types.

How will the proposed structure create opportunities for shared savings realized on the medical side that result from enhanced focus on behavioral health, integrated care, population health strategies and care management?
36
1/9/2017 15:20:53I agree and wish to continueAmyGallagherWhole Health LLCProviderThe decision to build off of the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. I fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.

Principles of Intent:

There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is understandable and appropriate to a point. Mind Springs’ desires to take advantage of this important opportunity to design a system to support leading edge, best possible care for our Medicaid residents of North West Colorado. We have learned from the care design of the foundation contracts (both the RCCO and the BHO, but also the PRIME contracts), and we aspire to a bolder vision of what could be possible. True integration is not adequately articulated in this draft RFP.

Preservation of BHO gains:

There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract, nor given enough attention to the development of services for people with a serious mental illness. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward. This may not prove beneficial to maintaining the gains currently seen.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require CMHC provider to have “skin in the game” and require contracting with the CMHCs to incentivize the current robust B-3 services, service locations (especially in rural areas), services to people with serious mental illness, and alternatives to hospitalization.

Payment Strategies:
The RFP should clearly lay the path for a system focused on maximizing independence, local control, and stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. I would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, I believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers. Where are the hospital systems in this RFP? Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado’s rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder:

One important area in need of service enhancement, and currently lacking from the draft RFP, is Substance Use Disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. I ask HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase.

Non-Medical Partners:

Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort. Does HCPF have agreements in place with these other entities to use resources to support the aim of this RFP, that any bidder or provider can count upon for success in the intention of this RFP? As an example, I offer differences learned with Mind Springs participating in both the OBH crisis RFP and the HCPF I/DD Pilot. Both of the opportunities involve a crisis system, however at times expectations, data, and requirements needed to be clarified as they were at odds between the state agencies. The good news is that these issues were resolved, however the point is that having state agreement between state departments to support the RFP would have been helpful.

Deliverables:

This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. It is suggested that a combined HCPF clinical and data team review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes:

There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes for individuals or for the population. HCPF may want to start with these measures, but suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.

Somewhat clearNo commentSomewhat unclear5.2.3 et. al. The requirements in this section are an over reach. Setting granular requirements only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. I suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.

Include language for the RAE to allow a subcap and risk sharing for the management of services under the 1915(b) waiver, which creates a system which adequately involves providers in care management and incentives quality care at the lowest level.
Very clear
Mandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.
The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations. Consider a regional attribution methodology rather than a practice-based methodology.
Very clear5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.


5.5.1.1.4 I particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention.
Somewhat clear5.6.1 Grievances are an important part of both quality improvement and patient engagement. Typically grievances start at the practice site and the practice staff are an active part of this process. Unfortunately, today, some grievances by pass the local practice and go straight to the state. For the grievance process to be impactful, HCPF must define the process and then allow it to work. It is suggested it be required that all grievances contain sufficient information to be actionable and start at the practice level. Use of external Ombudspersons and legal proceedings are necessary and valuable only after the defined process is followed.Somewhat clear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.
5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear
5.8.2 Increasing Member access to timely and appropriate Medicaid services and benefits is critically important to improving population health. It is unclear whether this section is encouraging the broadest linkages with community resources or opening the door to “any willing provider”. I believe from other comments HCPF has made it is the former – encouraging broad linkages. In that regard, stronger financial incentives and contractor proof of existing strong and positive community linkages will be very important. I firmly believe the most important focus of improved access is not adding providers, but engaging enrollees’ active participation in their own healthcare in prevention and early intervention.

5.8.3.8 DSRIP is an interesting pilot established with good intent. With a significant question being the new Administration in Washington’s willingness to continue with this program, how will HCPF address this issue in the final RFP? It seems today that DSRIP should be deleted, as it seems unlikely to happen. Pls re-think the role of hospitals.

A specific definition describing the difference between health neighborhood and population health would be helpful. Additionally, addressing the use of tele-health, especially in rural areas such as Region 1, might be helpful.
Somewhat unclear5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances. This also means that funding needs to be tied to true population health outcomes. Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes multiple of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.

It is also suggested the state crisis system and the MSOs be specifically included in this section as important participants for population health. Additionally, HCPF may wish to clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.
Very clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.
Very clearHope that PRIME can be expandedVery clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.
Somewhat clear5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well. Somewhat clear
5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. Process measures typically are required, but do not meet this aim. Measuring things like suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

I applaud HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. It is suggested that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that increase alignment and inform/correlate with actual improved population health and consequent reduced per capita cost.
Somewhat clear5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.Very clearno commentSomewhat clearIt is important to consider how the connection to child welfare can be strengthened in the next iteration of the ACC. This system is minimally referenced in the draft RFP and deserves additional consideration. Somewhat clearThere should be additional resources available for SUD services and expanding the benefit must include significant dollars to address the pain points currently being felt by hospitals and other areas of the health delivery system.

How will the Department ensure that earning a sufficient operating margin is possible so that RAEs and providers can reinvest in enhancing services and infrastructure to continue evolving our health system toward greater efficiency and improved outcomes?

The RFP indicates that the ACC will evolve payment by aligning provider rate-setting methodologies across provider types so that they are aligned and mutually reinforcing (FQHCs, CMHCs, primary care). Please elaborate on how this will be achieved and how this alignment will reward improved outcomes, beyond meeting process measures, across provider types.

How will the proposed structure create opportunities for shared savings realized on the medical side that result from enhanced focus on behavioral health, integrated care, population health strategies and care management?
37
1/9/2017 15:29:36I agree and wish to continueJaneBinghamMind Springs HealthProviderThe decision to build off of the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. I fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.

Principles of Intent:

There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is understandable and appropriate to a point. Mind Springs’ desires to take advantage of this important opportunity to design a system to support leading edge, best possible care for our Medicaid residents of North West Colorado. We have learned from the care design of the foundation contracts (both the RCCO and the BHO, but also the PRIME contracts), and we aspire to a bolder vision of what could be possible. True integration is not adequately articulated in this draft RFP.

Preservation of BHO gains:

There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract, nor given enough attention to the development of services for people with a serious mental illness. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward. This may not prove beneficial to maintaining the gains currently seen.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require CMHC provider to have “skin in the game” and require contracting with the CMHCs to incentivize the current robust B-3 services, service locations (especially in rural areas), services to people with serious mental illness, and alternatives to hospitalization.

Payment Strategies:
The RFP should clearly lay the path for a system focused on maximizing independence, local control, and stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. I would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, I believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers. Where are the hospital systems in this RFP? Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado’s rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder:

One important area in need of service enhancement, and currently lacking from the draft RFP, is Substance Use Disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. I ask HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase.

Non-Medical Partners:

Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort. Does HCPF have agreements in place with these other entities to use resources to support the aim of this RFP, that any bidder or provider can count upon for success in the intention of this RFP? As an example, I offer differences learned with Mind Springs participating in both the OBH crisis RFP and the HCPF I/DD Pilot. Both of the opportunities involve a crisis system, however at times expectations, data, and requirements needed to be clarified as they were at odds between the state agencies. The good news is that these issues were resolved, however the point is that having state agreement between state departments to support the RFP would have been helpful.

Deliverables:

This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. It is suggested that a combined HCPF clinical and data team review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes:

There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes for individuals or for the population. HCPF may want to start with these measures, but suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.
Somewhat clearno commentsSomewhat unclear
5.2.3 et. al. The requirements in this section are an over reach. Setting granular requirements only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. I suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.

Include language for the RAE to allow a subcap and risk sharing for the management of services under the 1915(b) waiver, which creates a system which adequately involves providers in care management and incentives quality care at the lowest level.
Very clearMandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.
The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations. Consider a regional attribution methodology rather than a practice-based methodology.
Somewhat clear
5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.


5.5.1.1.4 I particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention
Somewhat clear5.6.1 Grievances are an important part of both quality improvement and patient engagement. Typically grievances start at the practice site and the practice staff are an active part of this process. Unfortunately, today, some grievances by pass the local practice and go straight to the state. For the grievance process to be impactful, HCPF must define the process and then allow it to work. It is suggested it be required that all grievances contain sufficient information to be actionable and start at the practice level. Use of external Ombudspersons and legal proceedings are necessary and valuable only after the defined process is followed.Somewhat clear
5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.


5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear
5.8.2 Increasing Member access to timely and appropriate Medicaid services and benefits is critically important to improving population health. It is unclear whether this section is encouraging the broadest linkages with community resources or opening the door to “any willing provider”. I believe from other comments HCPF has made it is the former – encouraging broad linkages. In that regard, stronger financial incentives and contractor proof of existing strong and positive community linkages will be very important. I firmly believe the most important focus of improved access is not adding providers, but engaging enrollees’ active participation in their own healthcare in prevention and early intervention.

5.8.3.8 DSRIP is an interesting pilot established with good intent. With a significant question being the new Administration in Washington’s willingness to continue with this program, how will HCPF address this issue in the final RFP? It seems today that DSRIP should be deleted, as it seems unlikely to happen. Pls re-think the role of hospitals.

A specific definition describing the difference between health neighborhood and population health would be helpful. Additionally, addressing the use of tele-health, especially in rural areas such as Region 1, might be helpful.
Somewhat unclear5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances. This also means that funding needs to be tied to true population health outcomes. Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes multiple of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.

It is also suggested the state crisis system and the MSOs be specifically included in this section as important participants for population health. Additionally, HCPF may wish to clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.
Very clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.
Somewhat clear5.11.1 I would hope that PRIME can be expanded.Very clearRetaining behavioral health capitation is critically important and aligns well with the goals of the ACC to advance payment models and delivery systems toward greater efficiency and effectiveness. However, there remains substantial concerns with exactly how this will be executed and the resulting impacts. ACC Phase II must seek to strengthen existing systems of care that have evolved over decades to meet the needs of diverse populations across urban, rural and frontier Colorado. Specific attention must be given to ensure that access to services is expanded without sacrificing quality and scarce healthcare resources. Maintaining covered diagnosis restrictions for capitated behavioral health services preserves the significant barriers to treatment Colorado has struggled with in recent years. More thought must be given to how capitation can be preserved while ensuring comprehensive access to high quality care.

Depending on how the capitation rate setting process occurs, there could be significant challenges posed by shifting lower acuity services (and, therefore, populations) to fee-for-service. Managing risk for a population primarily consisting of those with the most serious and chronic needs is difficult, and the associated risk premium must recognize this difficulty.

There is also concern that allowing for the six visits in primary care in a FFS environment has the potential to sacrifice quality treatment in favor of "access" due to lack of guidelines about the content and therapeutic quality in these sessions. Careful consideration and controls should be implemented to ensure both quality and cost efficiency. This provision has the potential to actually hinder integration and may result in more co-location growth with the addition of mechanisms for volume-based behavioral health billing in primary care practices. If this new financial mechanism for primary care is in place to treat less acute patients, there is concern that this could exacerbate the workforce challenges already felt in community behavioral health settings as more clinicians would opt to work in more lucrative primary care settings with less acute clients. As written, the RFP perpetuates disproportionate financing and administrative burden to working in community behavioral health.

Additionally, simply paying for 6 visits in a primary care setting does not necessarily result in integration. More often it results in co-location and has the potential to create different challenges, requiring more oversite from the RAE as the capitation portion of the benefit is accessed.

The RFP also provides for Inpatient hospitalization services under capitation only for primary mental health diagnoses. This raises concerns that there will not parity for SUD. Covering SUD residential services under the Medicaid benefit could create significant medical cost offsets.
Overall, more consideration should be given to the unique needs of those with serious and persistent mental illness and difficult co-occurring conditions.

Additional clarification is necessary around the definition of “low acuity.” It is difficult to know how a client will be determined to be low acuity in the absence of a full client assessment in primary care settings. It is also unclear what constitutes an “episode of care” and how the threshold of six visits per episode was determined. Are there requirements for what level/type of provider can deliver these six sessions?

If individuals with low acuity behavioral health needs are no longer included under the risk-based behavioral health managed capitation program, how will the Department ensure that new capitation rates are sufficiently adjusted to reflect the shift toward higher risk of the high needs population that will continue to seek services under the capitation program?

Clarification should be provided on how risk arrangements with providers and 1915(b)(3) services will be included in rate-setting.

How will Medicaid programs be coordinated with funding streams from other State Agencies? For example, how will MSOs, funded under the Department of Human Services, be engaged and aligned?

How will the six visit per episode of care provision for behavioral health be funded? Is this paid for by a reduction in behavioral health capitation rates, or paid for using medical cost offset anticipated by addressing lower acuity behavioral health needs in primary care settings?

Clarification should be provided under the Culturally Responsive section about what determines a “qualified interpreter.”
Somewhat clear
5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well.
Somewhat unclear
5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. Process measures typically are required, but do not meet this aim. Measuring things like suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

I applaud HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. It is suggested that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that increase alignment and inform/correlate with actual improved population health and consequent reduced per capita cost.
Somewhat clear
5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.
Very clearno comments
Somewhat clearIt is important to consider how the connection to child welfare can be strengthened in the next iteration of the ACC. This system is minimally referenced in the draft RFP and deserves additional consideration. Somewhat clearThere should be additional resources available for SUD services and expanding the benefit must include significant dollars to address the pain points currently being felt by hospitals and other areas of the health delivery system.

How will the Department ensure that earning a sufficient operating margin is possible so that RAEs and providers can reinvest in enhancing services and infrastructure to continue evolving our health system toward greater efficiency and improved outcomes?

The RFP indicates that the ACC will evolve payment by aligning provider rate-setting methodologies across provider types so that they are aligned and mutually reinforcing (FQHCs, CMHCs, primary care). Please elaborate on how this will be achieved and how this alignment will reward improved outcomes, beyond meeting process measures, across provider types.

How will the proposed structure create opportunities for shared savings realized on the medical side that result from enhanced focus on behavioral health, integrated care, population health strategies and care management?
38
1/9/2017 15:37:32I agree and wish to continueFeliciaRomeroMind Springs HealthProviderThe decision to build off of the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. I fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.

Principles of Intent:

There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is understandable and appropriate to a point. Mind Springs’ desires to take advantage of this important opportunity to design a system to support leading edge, best possible care for our Medicaid residents of North West Colorado. We have learned from the care design of the foundation contracts (both the RCCO and the BHO, but also the PRIME contracts), and we aspire to a bolder vision of what could be possible. True integration is not adequately articulated in this draft RFP.

Preservation of BHO gains:

There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract, nor given enough attention to the development of services for people with a serious mental illness. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward. This may not prove beneficial to maintaining the gains currently seen.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require CMHC provider to have “skin in the game” and require contracting with the CMHCs to incentivize the current robust B-3 services, service locations (especially in rural areas), services to people with serious mental illness, and alternatives to hospitalization.

Payment Strategies:
The RFP should clearly lay the path for a system focused on maximizing independence, local control, and stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. I would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, I believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers. Where are the hospital systems in this RFP? Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado’s rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder:

One important area in need of service enhancement, and currently lacking from the draft RFP, is Substance Use Disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. I ask HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase.

Non-Medical Partners:

Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort. Does HCPF have agreements in place with these other entities to use resources to support the aim of this RFP, that any bidder or provider can count upon for success in the intention of this RFP? As an example, I offer differences learned with Mind Springs participating in both the OBH crisis RFP and the HCPF I/DD Pilot. Both of the opportunities involve a crisis system, however at times expectations, data, and requirements needed to be clarified as they were at odds between the state agencies. The good news is that these issues were resolved, however the point is that having state agreement between state departments to support the RFP would have been helpful.

Deliverables:

This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. It is suggested that a combined HCPF clinical and data team review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes:

There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes for individuals or for the population. HCPF may want to start with these measures, but suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.
Not Clearno comments
Somewhat unclear5.2.3 et. al. The requirements in this section are an over reach. Setting granular requirements only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. I suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear
5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.

Include language for the RAE to allow a subcap and risk sharing for the management of services under the 1915(b) waiver, which creates a system which adequately involves providers in care management and incentives quality care at the lowest level.
Very clearMandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.
The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations. Consider a regional attribution methodology rather than a practice-based methodology.
Very clear5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.


5.5.1.1.4 I particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention.
Somewhat clear
5.6.1 Grievances are an important part of both quality improvement and patient engagement. Typically grievances start at the practice site and the practice staff are an active part of this process. Unfortunately, today, some grievances by pass the local practice and go straight to the state. For the grievance process to be impactful, HCPF must define the process and then allow it to work. It is suggested it be required that all grievances contain sufficient information to be actionable and start at the practice level. Use of external Ombudspersons and legal proceedings are necessary and valuable only after the defined process is followed.
Somewhat clear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.


5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear5.8.2 Increasing Member access to timely and appropriate Medicaid services and benefits is critically important to improving population health. It is unclear whether this section is encouraging the broadest linkages with community resources or opening the door to “any willing provider”. I believe from other comments HCPF has made it is the former – encouraging broad linkages. In that regard, stronger financial incentives and contractor proof of existing strong and positive community linkages will be very important. I firmly believe the most important focus of improved access is not adding providers, but engaging enrollees’ active participation in their own healthcare in prevention and early intervention.

5.8.3.8 DSRIP is an interesting pilot established with good intent. With a significant question being the new Administration in Washington’s willingness to continue with this program, how will HCPF address this issue in the final RFP? It seems today that DSRIP should be deleted, as it seems unlikely to happen. Pls re-think the role of hospitals.

A specific definition describing the difference between health neighborhood and population health would be helpful. Additionally, addressing the use of tele-health, especially in rural areas such as Region 1, might be helpful.
Somewhat unclear5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances. This also means that funding needs to be tied to true population health outcomes. Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes multiple of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.

It is also suggested the state crisis system and the MSOs be specifically included in this section as important participants for population health. Additionally, HCPF may wish to clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.
Very clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.
Very clearI hope that PRIME can be expandedVery clearRetaining behavioral health capitation is critically important and aligns well with the goals of the ACC to advance payment models and delivery systems toward greater efficiency and effectiveness. However, there remains substantial concerns with exactly how this will be executed and the resulting impacts. ACC Phase II must seek to strengthen existing systems of care that have evolved over decades to meet the needs of diverse populations across urban, rural and frontier Colorado. Specific attention must be given to ensure that access to services is expanded without sacrificing quality and scarce healthcare resources. Maintaining covered diagnosis restrictions for capitated behavioral health services preserves the significant barriers to treatment Colorado has struggled with in recent years. More thought must be given to how capitation can be preserved while ensuring comprehensive access to high quality care.

Depending on how the capitation rate setting process occurs, there could be significant challenges posed by shifting lower acuity services (and, therefore, populations) to fee-for-service. Managing risk for a population primarily consisting of those with the most serious and chronic needs is difficult, and the associated risk premium must recognize this difficulty.

There is also concern that allowing for the six visits in primary care in a FFS environment has the potential to sacrifice quality treatment in favor of "access" due to lack of guidelines about the content and therapeutic quality in these sessions. Careful consideration and controls should be implemented to ensure both quality and cost efficiency. This provision has the potential to actually hinder integration and may result in more co-location growth with the addition of mechanisms for volume-based behavioral health billing in primary care practices. If this new financial mechanism for primary care is in place to treat less acute patients, there is concern that this could exacerbate the workforce challenges already felt in community behavioral health settings as more clinicians would opt to work in more lucrative primary care settings with less acute clients. As written, the RFP perpetuates disproportionate financing and administrative burden to working in community behavioral health.

Additionally, simply paying for 6 visits in a primary care setting does not necessarily result in integration. More often it results in co-location and has the potential to create different challenges, requiring more oversite from the RAE as the capitation portion of the benefit is accessed.

The RFP also provides for Inpatient hospitalization services under capitation only for primary mental health diagnoses. This raises concerns that there will not parity for SUD. Covering SUD residential services under the Medicaid benefit could create significant medical cost offsets.
Overall, more consideration should be given to the unique needs of those with serious and persistent mental illness and difficult co-occurring conditions.

Additional clarification is necessary around the definition of “low acuity.” It is difficult to know how a client will be determined to be low acuity in the absence of a full client assessment in primary care settings. It is also unclear what constitutes an “episode of care” and how the threshold of six visits per episode was determined. Are there requirements for what level/type of provider can deliver these six sessions?

If individuals with low acuity behavioral health needs are no longer included under the risk-based behavioral health managed capitation program, how will the Department ensure that new capitation rates are sufficiently adjusted to reflect the shift toward higher risk of the high needs population that will continue to seek services under the capitation program?

Clarification should be provided on how risk arrangements with providers and 1915(b)(3) services will be included in rate-setting.

How will Medicaid programs be coordinated with funding streams from other State Agencies? For example, how will MSOs, funded under the Department of Human Services, be engaged and aligned?

How will the six visit per episode of care provision for behavioral health be funded? Is this paid for by a reduction in behavioral health capitation rates, or paid for using medical cost offset anticipated by addressing lower acuity behavioral health needs in primary care settings?

Clarification should be provided under the Culturally Responsive section about what determines a “qualified interpreter.”
Somewhat clear
5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well.
Somewhat clear5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. Process measures typically are required, but do not meet this aim. Measuring things like suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

I applaud HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. It is suggested that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that increase alignment and inform/correlate with actual improved population health and consequent reduced per capita cost.
Somewhat clear5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.Very clearno commentsSomewhat clearIt is important to consider how the connection to child welfare can be strengthened in the next iteration of the ACC. This system is minimally referenced in the draft RFP and deserves additional consideration. Somewhat clearThere should be additional resources available for SUD services and expanding the benefit must include significant dollars to address the pain points currently being felt by hospitals and other areas of the health delivery system.

How will the Department ensure that earning a sufficient operating margin is possible so that RAEs and providers can reinvest in enhancing services and infrastructure to continue evolving our health system toward greater efficiency and improved outcomes?

The RFP indicates that the ACC will evolve payment by aligning provider rate-setting methodologies across provider types so that they are aligned and mutually reinforcing (FQHCs, CMHCs, primary care). Please elaborate on how this will be achieved and how this alignment will reward improved outcomes, beyond meeting process measures, across provider types.

How will the proposed structure create opportunities for shared savings realized on the medical side that result from enhanced focus on behavioral health, integrated care, population health strategies and care management?
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1/9/2017 16:08:02I agree and wish to continueBethColeCDHS/OECState Agency RepresentativeI think it's very comprehensive.Somewhat clearSomewhat clearSomewhat clearVery clearVery clearVery clearSomewhat clear5.7.2.1.12 - add "and/or recognize plans created for children and families enrolled in early intervention". On 5.7.3 - There needs to be some requirement that an ACC must have a certain portion of social emotional providers with experience/certification in infant and toddler mental health, or there needs to be a provision for an EI mental health provider to be able to provide services, if the ACC doesn't have one in network. 5.7.4.14.1 - what is the process for this? 5.7.5.1.3 - add early intervention providers. 5.7.4.11 - should read "provider per twenty-five hundred" (this is an edit). On the chart on p. 74, the top row should read "Mental Health Provider; serving infants and children" (added infants).Somewhat clearThere needs to be some requirement to include (or be allowed to contract with) providers who see children in early intervention. Section 5.8.6.1.5 - if LTSS providers are specifically mentioned, then early intervention providers should also be listed.Somewhat clear5.9.1.1 should include screenings, especially developmental screenings and screenings for postpartum depression. 5.9.3.10 - add early interventionSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearSomewhat clearVery clearVery clearHow will the wraparound program work with other programs that the child and family may be involved with (like EI)?Somewhat clear
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1/9/2017 16:16:03I agree and wish to continueJay FlynnMental Heath Center of DenverProviderThe proposal seems to be a bit inflexible and intrusive in it's expectation and control over the contractor's business practice. The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.Very clearI have concerns with the departments claim to ownership rights of the contractors work product. 5.1.10.2.2 Strike this section; issue of overreach.

Very clearThis section raises concern about infringement on a contractor’s business.

5.2.3 The organizational chart should be more limited to a list of executive staff and management positions. is a more reasonable expectation. The contractor can keep their own lists of contacts..
Very clearNoneVery clearIs there any room for member choice? Very clearPlease make it clear which documents are included and which languages are prevalent. This will be a big financial undertaking.

5.5.2.6.4.1 and 5.5.2.6.4.2 Please further define “significant”; 15 language rmay not be necessary in all regions. This is a huge cost. .

5.5.2.6.5.2 How this will function with 15 different languages Documents would be voluminous. 5.5.2.6.8 requires that the contractor needs an 18 pt font size, which is onerous.

5.5.2.6.8 Is required for all 15 languages.
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5.5.3.6.1.5.1 Please Include behavioral health.

5.5.3.6.1.5.2 Please include behavioral health in addition to physical health here.
Very clearPlease better define "real time" Very clear5.7.4.4.1 Define if Community Crisis Connection satisfies this requirement.

5.7.4.9 The time and distance standards are somewhat unreasonable. The maximum time should not be the same as the maximum distance. Urban counties have traffic in different areas of the city at different times of the day should be considered.

5.7.4.10 Please show how driving time will be calculated. Additionally, most of the urban population uses public transportation and driving time is not relevant. .
5.7.4.13.5.1 How will you define“emergency behavioral health care.”

5.7.4.13.5.2 if an appointment is offered and declined is the standard met.

5.7.5.1.8 This is an overreaching incursion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 This is intrusive.
Very clear5.8.3.5.2 Please make it clear the provider will be paid FFS or if payment comes under the capitated benefit if the consultation is with a specific behavioral health care provider. If it is this way, please show how the provider will be compensated for providing the service. 5.8.3.11 Please strike this section. .
5.8.4.2 Please show the payment/reimbursement procedure for this service.

5.8.4.4 Please show the reimbursement procedure for this service

Somewhat clear3.6 It will be tough to implement non-duplication of coordination at both the RAE and specialty provider levels. Please better define the precise requirements for linking and organizing. Are the mental health centers are a “special population provider.”
Also, how will electronic information be imported?
Very clearMostly looked good 5.10.7.4. It would be helpful for the Department to provide Contractors and Network Providers a scheduled, timed forecast for meeting the requirements that show the current state of HITT. These should not go into effect immediately when the as starts, as the HIEs do not offer a method of exchanging CFR Part 2 information with consent at scale .
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Somewhat clearSomewhat clear5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 The PCMP should allow for a specialty BH provider within the PCMP clinic to bill and receive FFS as well, even if billed by the specialty BH , rather than the PCP.

5.12.5.5 Community Support is not on this list. It is currently allowed under the state plan. it should be included as mental health centers provide most of these services now.

5.12.5.5.16.7 This should be changed to “The Contractor will cover Emergency Services when the emergency room provider, hospital, or fiscal agent does not notify the Contractor”

5.12.5.5.16.11.1 This seems like a difficult timeline.

5.12.5.7.1.2 Averaging of service intensity could be done at the program level, not the individual level, when determining that community-based services meet case management requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 The addition of additional services which include supported education programs and the return to higher education would be helpful

5.12.5.7.1.6 This is quite expensive and hiring staff to work this would be nearly impossible. It would be better to meet a fidelity rate of 70%.

5.12.5.7.1.7 Make it clear if community locals include mental health clinic locations and residential facilities.

Somewhat clear5.13.2.2.3.6 This seems to mean no Center data shall be submitted to APCD, as it all currently falls within 42 CFR Part 2. The state could address these inequities by figuring performance measures while leaving out behavioral health data.

Somewhat clear5.14.4.8.1.1.2.4 Please define engagement within the primary care and specialty environments. Also, 4 sessions in first 45 days of treatment will not fit the entire populations’ needs, it is too intensive.
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5.14.4.9.1.1.1 What are base standards.

5.14.4.9.1.1.3 There are no outcomes under, only process measures here.

5.14.4.9.1.2.2 Make it clear how 90% accuracy is calculated.

5.14.5.6.1 large practices will require a full corrective action plan, and if so, define how “serious” is calculated. This seems difficult.

5.14.8.3.1 Make it clear if the review will cover the whole med record for the person or only those documents related to the services and encounters are being reviewed.
Very clearLooks fineVery clearLooks fineSomewhat clear6.3.10.1 The Provider doesn’t own the nursing facilities. Make it clear if this will prevent the nursing facility from taking persons with behavioral health issues, decreasing a resource.
Very clearThe reporting requirements are too frequent here.
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1/9/2017 17:18:32I agree and wish to continueRoyStarksMental Health Center of DenverSocial Service/Community OrganizationI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

The HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
No opinion 5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
No opinion5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionNo opinion5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
No opinion5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.
No opinion5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
No opinion5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
No opinion5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
No opinionNo opinion5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
No opinion5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.No opinionNo opinion6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
No opinion7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
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1/10/2017 8:00:47I agree and wish to continueMichelleHoyMind Springs HealthProviderThe decision to build off of the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. I fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.

Principles of Intent:

There is a sense in this draft RFP of an effort to plug perceived holes in the BHO contract implementation and RCCO contract implementation. That is understandable and appropriate to a point. Mind Springs’ desires to take advantage of this important opportunity to design a system to support leading edge, best possible care for our Medicaid residents of North West Colorado. We have learned from the care design of the foundation contracts (both the RCCO and the BHO, but also the PRIME contracts), and we aspire to a bolder vision of what could be possible. True integration is not adequately articulated in this draft RFP.

Preservation of BHO gains:

There is a wise desire in this RFP to maintain that which has proven to work for our State. Yet, in transferring the BHO contract to the RAE, HCPF has not fully preserved the full-risk nature of the BHO contract, nor given enough attention to the development of services for people with a serious mental illness. In Region 1, with a likely bid from a large insurance entity as single contractor, the full risk structure is transferred to the insurance company, not the existing owner/provider structure as is the case with the BHO (under LSLPN license). Thus, Region 1 providers as RAE subcontractors will have a different role and very different alignment of risk/reward. This may not prove beneficial to maintaining the gains currently seen.

At the discretion of the insurance company the subcontract would likely be a FFS or an enhanced FFS contract which no longer aligns funding and care to incentivize and generate the best health outcomes. This would functionally move Region 1 in the opposite direction intended; from value to volume. Insurance company sub-capitation for a single organization would be difficult and both the risk and gain sharing would be truncated.

If we are to truly preserve the full-risk nature of the contract with the BHOs then the RAE contract should require CMHC provider to have “skin in the game” and require contracting with the CMHCs to incentivize the current robust B-3 services, service locations (especially in rural areas), services to people with serious mental illness, and alternatives to hospitalization.

Payment Strategies:
The RFP should clearly lay the path for a system focused on maximizing independence, local control, and stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. I would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, I believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers. Where are the hospital systems in this RFP? Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado’s rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder:

One important area in need of service enhancement, and currently lacking from the draft RFP, is Substance Use Disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. I ask HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase.

Non-Medical Partners:

Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort. Does HCPF have agreements in place with these other entities to use resources to support the aim of this RFP, that any bidder or provider can count upon for success in the intention of this RFP? As an example, I offer differences learned with Mind Springs participating in both the OBH crisis RFP and the HCPF I/DD Pilot. Both of the opportunities involve a crisis system, however at times expectations, data, and requirements needed to be clarified as they were at odds between the state agencies. The good news is that these issues were resolved, however the point is that having state agreement between state departments to support the RFP would have been helpful.

Deliverables:

This RFP contains substantial deliverables tied to their respective sections, but not coordinated in timing or data use across sections. This will put a huge demand on HCPF to monitor the substance, timing and frequency of the required reports and will require much time and programming to deliver. It is suggested that a combined HCPF clinical and data team review the universe of deliverables to see if accountability can be assured with a smaller and more streamlined and coordinated set of deliverables.

Outcomes:

There are a large array of KPIs and outcome measures that appear to be drawn from disparate documents, federal accountability requirements and previous contracts. The intent is to support contract accountability and to document improved health outcomes. Both purposes are important and legitimate. Few of these measures will correlate as much as hoped with functional contract accountability and with actual health outcomes for individuals or for the population. HCPF may want to start with these measures, but suggest convening a joint HCPF/Contract Provider committee to evaluate their accuracy and utility beginning 6 months into the contract in order to pare down, streamline and ensure that the measures used are of most functional value.

Somewhat clearno commentsSomewhat unclear5.2.3 et. al. The requirements in this section are an over reach. Setting granular requirements only limits the flexibility to meet the intent as no prescribed structure ever ensured a specific function. I suggest language that clarifies intent and desired outcomes, but does not prescribe specific processes.

5.2.14.2
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted. Clarification, specifically of its intent, and structure would be helpful.
Somewhat clear5.3.2.1 Simply saying that the RAE will administer two managed care authorities as one integrated program in no way assures any meaningful level of integration. Is side by side “integrated”? The intent of the term “integration” would benefit from some additional clarity.

Include language for the RAE to allow a subcap and risk sharing for the management of services under the 1915(b) waiver, which creates a system which adequately involves providers in care management and incentives quality care at the lowest level.
Very clearMandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.
The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations. Consider a regional attribution methodology rather than a practice-based methodology.
Very clear5.5.1.2 The person- and family-centered approach is consistent with care integration and much appreciated.


5.5.1.1.4 I particularly appreciate the specific emphasis on prevention, wellness, and by extension, early intervention.
Somewhat clear5.6.1 Grievances are an important part of both quality improvement and patient engagement. Typically grievances start at the practice site and the practice staff are an active part of this process. Unfortunately, today, some grievances by pass the local practice and go straight to the state. For the grievance process to be impactful, HCPF must define the process and then allow it to work. It is suggested it be required that all grievances contain sufficient information to be actionable and start at the practice level. Use of external Ombudspersons and legal proceedings are necessary and valuable only after the defined process is followed.Somewhat clear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.


5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear5.7.1.8 Better care and lower cost comes from responsible managed care. The draft RFP at points appears to expect the Contractor to accept any provider that desires to be part of the RAE (e.g. 5.7.2.3) yet at other points notes the responsibility of the RAE to determine its own network to meet deliverables and this section’s expectations. One cannot manage care and include any willing provider. I urge HCPF, as it evaluates responses to the RFP and later practice consistency with contract requirements, to resist the desire to require inclusion of any willing provider as an effort to head off provider complaints of exclusion. RAE’s need HCPF’s support in establishing their networks to meet the contract requirements. HCPF can trust the considerable contract deliverables to ensure both the breadth of care and timely access to that care. Further, tele-health needs to be a defined consideration, especially in rural areas.


5.7.3.4.1.1 If this section is mandating NCQA (or JCAHO) accreditation of all Network Providers this will be neither an appropriate nor attainable goal. Not only is this process expensive and extremely time consuming, it is not altogether relevant to our contract goals nor is there any evidence that such accreditation correlate with improved health outcomes. Clarification here would be welcome.

5.7.4.13 I suggest that this section should more accurately and appropriately read, “The Contractor shall ensure that its network is sufficient so that services are offered/available to Members on a timely basis…”.
Somewhat unclear
5.9.1.2 As suggested in this section, population health management will be at the core of any success that results from the RAE system. Effective population health management needs to be informed not just by the State data, but also and importantly from local data and familiarity with the population – another way to say that contract applicants need to have already built strong and broad community linkages and alliances. This also means that funding needs to be tied to true population health outcomes. Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?

5.9.2.2.4 Requiring a description of each intervention the Contract will offer is impractical, likely not possible, and would constitute an unmanageable burden on HCPF to monitor. Treatment is a fluid process that balances patient need, capacity, timing and available resources. It is not like saying that for this car we will need a new alternator. Within each provider there are sometimes multiple of staff and thousands of permutations of interventions. We suggest that the plan required by HCPF be at a higher value level so as to be manageable to evaluate and sufficiently fluid to be effective.

It is also suggested the state crisis system and the MSOs be specifically included in this section as important participants for population health. Additionally, HCPF may wish to clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.
Very clearFinancial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.
Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.
Very clearI would hope that PRIME can be expandedVery clear
Retaining behavioral health capitation is critically important and aligns well with the goals of the ACC to advance payment models and delivery systems toward greater efficiency and effectiveness. However, there remains substantial concerns with exactly how this will be executed and the resulting impacts. ACC Phase II must seek to strengthen existing systems of care that have evolved over decades to meet the needs of diverse populations across urban, rural and frontier Colorado. Specific attention must be given to ensure that access to services is expanded without sacrificing quality and scarce healthcare resources. Maintaining covered diagnosis restrictions for capitated behavioral health services preserves the significant barriers to treatment Colorado has struggled with in recent years. More thought must be given to how capitation can be preserved while ensuring comprehensive access to high quality care.

Depending on how the capitation rate setting process occurs, there could be significant challenges posed by shifting lower acuity services (and, therefore, populations) to fee-for-service. Managing risk for a population primarily consisting of those with the most serious and chronic needs is difficult, and the associated risk premium must recognize this difficulty.

There is also concern that allowing for the six visits in primary care in a FFS environment has the potential to sacrifice quality treatment in favor of "access" due to lack of guidelines about the content and therapeutic quality in these sessions. Careful consideration and controls should be implemented to ensure both quality and cost efficiency. This provision has the potential to actually hinder integration and may result in more co-location growth with the addition of mechanisms for volume-based behavioral health billing in primary care practices. If this new financial mechanism for primary care is in place to treat less acute patients, there is concern that this could exacerbate the workforce challenges already felt in community behavioral health settings as more clinicians would opt to work in more lucrative primary care settings with less acute clients. As written, the RFP perpetuates disproportionate financing and administrative burden to working in community behavioral health.

Additionally, simply paying for 6 visits in a primary care setting does not necessarily result in integration. More often it results in co-location and has the potential to create different challenges, requiring more oversite from the RAE as the capitation portion of the benefit is accessed.

The RFP also provides for Inpatient hospitalization services under capitation only for primary mental health diagnoses. This raises concerns that there will not parity for SUD. Covering SUD residential services under the Medicaid benefit could create significant medical cost offsets.
Overall, more consideration should be given to the unique needs of those with serious and persistent mental illness and difficult co-occurring conditions.

Additional clarification is necessary around the definition of “low acuity.” It is difficult to know how a client will be determined to be low acuity in the absence of a full client assessment in primary care settings. It is also unclear what constitutes an “episode of care” and how the threshold of six visits per episode was determined. Are there requirements for what level/type of provider can deliver these six sessions?

If individuals with low acuity behavioral health needs are no longer included under the risk-based behavioral health managed capitation program, how will the Department ensure that new capitation rates are sufficiently adjusted to reflect the shift toward higher risk of the high needs population that will continue to seek services under the capitation program?

Clarification should be provided on how risk arrangements with providers and 1915(b)(3) services will be included in rate-setting.

How will Medicaid programs be coordinated with funding streams from other State Agencies? For example, how will MSOs, funded under the Department of Human Services, be engaged and aligned?

How will the six visit per episode of care provision for behavioral health be funded? Is this paid for by a reduction in behavioral health capitation rates, or paid for using medical cost offset anticipated by addressing lower acuity behavioral health needs in primary care settings?

Clarification should be provided under the Culturally Responsive section about what determines a “qualified interpreter.”
Somewhat clear5.13.1.4.1.2 This contract requires more than an understanding of and capability of managing HIPAA (Health Insurance Portability and Accountability Act) standard transactions, it must be capable of managing 42 CFR Part II (governing substance use services) and FERPA (Family Educational Rights and Privacy Act) for school-based health service transactions as well. Somewhat clear
5.14.4.2 The selection of Key Performance Indicators, Outcome Measures, and Quality Measurement Criteria is deceptively tricky. Useful and effective indicators, measures and criteria must have one aspect in common; they must directly inform care. Process measures typically are required, but do not meet this aim. Measuring things like suicidal ideation or levels of depression are good measures as they inform the care we need to provide.

I applaud HCPF’s plan to involve the Contractor in developing performance indicators, outcome measures and quality measurement criteria. If the contractor includes community providers, we have much to contribute and are perfectly happy to have the Department determine the final measurement criteria. It is suggested that once established, the Department does not view the measures as cast in stone. Regardless of success on the chosen measure, we should all be actively looking for measurements that increase alignment and inform/correlate with actual improved population health and consequent reduced per capita cost.
Somewhat clear
5.15.7.1 We understand the intent of addressing “provider-preventable conditions”, but the contract needs a clear definition of this.
Very clearNo commentsSomewhat clearIt is important to consider how the connection to child welfare can be strengthened in the next iteration of the ACC. This system is minimally referenced in the draft RFP and deserves additional consideration. Somewhat clearThere should be additional resources available for SUD services and expanding the benefit must include significant dollars to address the pain points currently being felt by hospitals and other areas of the health delivery system.

How will the Department ensure that earning a sufficient operating margin is possible so that RAEs and providers can reinvest in enhancing services and infrastructure to continue evolving our health system toward greater efficiency and improved outcomes?

The RFP indicates that the ACC will evolve payment by aligning provider rate-setting methodologies across provider types so that they are aligned and mutually reinforcing (FQHCs, CMHCs, primary care). Please elaborate on how this will be achieved and how this alignment will reward improved outcomes, beyond meeting process measures, across provider types.

How will the proposed structure create opportunities for shared savings realized on the medical side that result from enhanced focus on behavioral health, integrated care, population health strategies and care management?
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1/10/2017 8:08:43I agree and wish to continueChipSouthernGreenwoodpediatricsPractice Administrator3.3.12.1 Current Language – Population Health Management and Care Coordination Services: “Ideally, Care Coordination will be provided face-to-face by individuals with strong ties to the Community who can develop ongoing relationships with Members.”
3.3.12.1 Recommendation – Population Health Management and Care Coordination Services: The delegation of care coordination was a critical component of the RCCOs. The RFP should explicitly state that the RAE has the authority and is encouraged to delegate care coordination to a PCP so that care coordination can be accomplished “close to the patient and family.” The absence of this language in the RFP fails to recognize the delegation of care coordination as a “best practice” learned from the implementation of ACC 1.0.
3.3.12.12.1 Current Language – Integration of Primary Care and Behavioral Health Services: “The Department will rely less on the use of a covered diagnosis as a requirement for accessing Medically Necessary covered behavioral health services.”
3.3.12.12.1 Recommendation – Integration of Primary Care and Behavioral Health Services: This language is broad and overly vague. The current requirement of a covered diagnosis for infants and young children has had a chilling effect on the ability of children to access and receive needed behavioral health services through the current BHO delivery system. Under ESPDT, children are required to receive necessary treatment for behavioral health services and any limitation on the amount, scope and duration for medically necessary services undermines the intended statutory purpose of EPSDT and should not be so restrictive for infants and young children.
4.2 Organizational Experience
4.2 Recommendation – Organizational Experience: Offerors should be limited to Colorado-based nonprofit organizations. In the alternative, strong preference should be given to Colorado-based nonprofit organizations in the assessment and scoring of the proposals. Simply requiring 89% Medical Loss Ratio is insufficient. Offerors should have the requisite knowledge of Colorado’s unique communities, their current resources, challenges and strengths in order to successfully implement their solution for that particular community. The RAE should be expected to have experience in the type of population, health care and geography (that is, a frontier county versus an urban county) for which they apply. We also need diversity among the Offerors. To maintain this diversity, we encourage the Department to limit the number of RAE regions for which an Offeror can submit a response to three regions.
5.2.12 Current Language: Key Personnel
• Program Officer
• Chief Financial Officer
• Chief Clinical Officer
• Quality Improvement Director
• Health Information Technology and Data Director
• Utilization Management Director
5.2.12 Recommendation-Key Personnel Expertise: At least one of the key personnel in an administrative leadership position should have behavioral health expertise and that the CCO, Quality Improvement Director or Utilization Management have pediatric expertise.
Rationale: Since the bulk of the dollars in the contract are dedicated to behavioral health, it is crucial that the leadership group include deep behavioral health expertise. Since the needs of children and youth are fundamentally different than the needs of adults, pediatric expertise in the leadership group is necessary to ensure that the programs serve both. Ideally, expertise in pediatric behavioral health would also exist within the leadership team. Additionally, since nearly one-half of Medicaid members, it is critically important that there be expertise by personnel who have actually provided primary care for children.
5.4.5 Current Language – Member Attribution: “Members shall be enrolled with the Contractor based on the location of the PCMP Practice Site to which the member is attributed (for example, if a Member lives in Region 3, but is attributed to a PCMP Practice Site in Region 5, the member will be enrolled to the Contractor in Region 5). The PCMP attribution effective date will be the same as the RAE enrollment date.”

5.4.8.1 Current Language: Member Attribution: “If a Member has previously chosen a PCMP within the Program, that attribution is retained and the Members will be enrolled into the RAE region where the PCMP Practice Site is located.”

5.4.8.2 Current Language: Member Attribution: “If a member has not selected a PCMP previously, the Department will use the system assignment process outlined in Appendix F Enrollment and Attribution to attribute the Member to a PCMP. The Member will be enrolled into the RAE region where that PCMP Practice Site is located.

5.4.5, 5.4.8.1, 5.4.82 Recommendation – Member Attribution: We note the negative impact of changing providers/care settings has on a client’s consistent access to care, continuity of care, and a provider’s ability to manage a client’s care effectively. We recognize and appreciate the Department’s ongoing efforts to work with providers to ensure that they are able to provide continuous comprehensive care for their clients. The final attribution process should be developed and finalized in consultation with providers and/or practice managers. There may need to be minor alterations to the attribution plan in different regions. For example, in Region 5, the attribution process currently favors Denver Health in a way that disrupts the care of families in other clinics and practices. The attribution process may have to be different in frontier counties in which health care resources may be less available and are organized differently than in urban settings. The currently proposed attribution methodology does not account for regional differences.
5.4.8.2.1 Current Language – Attribution Review: “On a quarterly basis, the Department will review the attributions of members who were attributed using the system assignment process. If a stronger PCMP relationship can be determined, using the Department’s attribution methodology, the Member will be reattributed.”
5.4.8.2.1 Recommendation – Attribution Review: The proposed process totally discounts the preferences and wishes of the Member and diminishes the person-center approach to care the Department hopes to achieve. The attribution process should be family- and patient-respectful and one that promotes continuity of care. A notation should be made in the patient portal and the Member should be asked at their next visit to select a PCMP in a customer-friendly process (responsive re-attribution system) that promotes continuity and the preferences of the Member.
5.7.1.5 Current Language – Access to Care Strategies: “The Contractor may use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers from diverse backgrounds.”
5.7.1.5 Recommendations—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform.
5.7.3.1 Current Language - Behavioral Health Network Administration: “The Contractor shall establish and maintain a statewide network of behavioral health providers that spans inpatient, outpatient, laboratory, and all other covered mental health and substance use disorder services.”
5.7.3.1 Recommendation—BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.
5.7.4.10 Current Language – Behavioral Health Provider: “The Contractor’s behavioral health network shall have a sufficient number of providers so that each Member has their choice of at least two (2) behavioral health providers within their zip code or within thirty (30) minutes of driving time from their location, whichever area is larger.”
5.7.4.10 Recommendation—Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.
5.7.4.11.3 Current Language – Network Access and Provider Ratios : “Adult primary care providers: One (1) practitioner per eighteen hundred (1,800) adult Members. Mid-level adult primary care providers: One (1) practitioner per twelve hundred (1,200) adult Members. Pediatric primary care providers: One (1) PCMP Provider per twenty-five five hundred (2,500) child Members. Mental Health Providers: One (1) practitioner per fifteen hundred (1,500) Members.”
5.7.4.11.3 Recommendation—Network Access and Provider Ratios: The standard for children’s primary care to provider ratio (in 4.7.4.11.) should be revised from 2,500 to 1,200. At a minimum, the standard should be equal for children and adults. The ratios of necessary mental health providers should be broken out by child and adult. In addition, network adequacy should also include consideration of people who have to utilize non-traditional modes of transportation or public transportation. RAEs should do an initial analysis of accessibility based on public transportation. We know the Medicaid population has higher mental health needs than the general population. In order to assure access to care for 25% of the pediatric population, we recommend a ratio of pediatric mental health providers to child enrollees of one practitioner per twelve hundred (1,200) twelve hundred members.
Rationale: The Pediatric Primary Care ratio is not adequate. Children have many more primary care visits than adults. Children’s mental health needs differ from those of adults and providers of mental health services to children should be trained to provide those services. The driving distance standards fail to acknowledge accessibility for many Medicaid clients who do not have vehicles.
5.7.4.13.5.2 Current Language – Behavioral Health Access Standards: “Non-urgent, Symptomatic Behavioral Health Services – within seven (7) days of a Member’s request. Administrative intake appointments or group intake processes are not considered a treatment appointment for non-urgent, symptomatic care.”
5.7.4.13.5.2 Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2 should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.
Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.
5.10.5.2.3 Current Language – Screening Tools: “Clinical resources, such as screening tools, clinical guidelines, practice improvement activities, templates, trainings and any other resources the Contractor has compiled. “
5.10.5.2.3 Recommendation—Screening Tools: We recommend specifically identifying developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines.
Recommendation—Preventive Behavioral Health Visits: We recommend that the highest tier of the Alternative Payment Methodology include preventive behavioral health visits for children.
Rationale: The preventive behavioral health visit should be linked with well-child visits (at least 2 per year in the first three years and annually beginning at age 4), provided in collaboration with physical health services, and include: 1) child behavioral health and family psychosocial screening and identification; 2) anticipatory guidance around development, behavior, relational health between the child and caregivers/parents; 3) identification and discussion of environmental influences on well-being; and 4) address identified needs, provide intervention, triage, and connect families to necessary resources. Behavioral health preventive care plans must be integrated with physical health care plans with care teams functioning collaboratively to support optimal health and well-being. This preventive visit could also identify clients who require care coordination/care management services.
QUESTIONS: ALTERNATIVE PAYMENT METHODOLOGY
1. 24 Hour EHR Access: Who is the access to? Providers? Or providers and clients? What does Asynchronous communication mean?
2. Please clarify what a shared care plan: patient is.
Recommendation- Ensure Alternative Payment Methodology Tiers Maximize Potential for Improving Clinical Care:
• The Criteria for Enhanced level should be revised:
1. Health Neighborhood Care Coordination: Recommend moving hospital and ER follow up to Enhanced and away from Advanced.
2. Behavioral Health Integration: Having Behavioral Health providers in health settings should be moved from Advanced to Enhanced.
• The criteria for the Advanced level should include
1. Access to and continuity of care:
1. Advanced practices should offer direct to patient telehealth. This could be defined broadly including email and phone access. Many conditions do not require in-person visits and would significantly reduce the burden on families if care were provided by phone
2. Advanced practices should also be able to offer group prenatal care referrals to their clients. Group prenatal care has been shown to reduce low birthweight births and preterm births and is a promising practice to help reduce disparate infant mortality rates among minority racial and ethnic groups
2. Team Based Care: Team-based care should include lay health workers/non-traditional health workers/navigators etc.
3. Care Management: This should include an assessment of family needs and social needs (i.e. does the caregiver/parent have a medical home? Are all social needs met?)
4. Health Neighborhood: The practice must be engaging a community base care coordination tool where information is shared across medical and social needs. In addition, practices must be supporting patients in accessing dental care.
5. Behavioral Health Integration: Co-location is not integration. Documentation in a single EHR and other metrics of meaningful integration must be met. This includes being able to capture behavioral health utilization from within the physical health practice.
6. Quality Improvement: The practice must be engaged in regular reportable quality improvement activities and demonstrate improvement in designated patient populations.

General Comment on Timelines and Changes in Reimbursement (Section 5.11): FQHC’s are reimbursed at cost and therefore more able to fund changes in processes and infrastructure than private practices. More than half of children on Medicaid are in medical homes in private practice settings; the current reimbursement is primarily fee-for-service and an inadequate PMPM that fails to sufficiently cover the expense of implementing new processes or infrastructure. To successfully implement these changes as outline in the RAE RFP, a practice needs adequate, consistent income for two years. RAEs should be required to provide long-term, consistent, achievable financial support to medical homes to implement necessary changes in infrastructure and processes. The PCMP receives $2 PMPM for meeting certain criteria and can earn another $2.50 (total of $4.50) for meeting certain other value-based criteria.
For track one: Reimbursement and PMPMs to private practice medical homes under ACC 2.0 as currently structured would be less than the reimbursement and PMPMs were under ACC 1.0 initially. The reimbursement plus PMPMs for 2.0 needs to be at least as high as 1.0 was for private practice medical homes to be successful. For ACC 2.0 to be effective, the “higher” FFS reimbursement given for meeting certain criteria would need to be equivalent to Medicare rates. And instead of $2 PMPM baseline, the baseline needs to be $3 PMPM. Success also requires that the criteria for the higher level of reimbursement referred to in the ACC 2.0 proposal remains the same for two years: the fee-for-service remains the same for the first two years and the $3 PMPM is locked in for two years. The criteria for qualifying for portions of the additional $2.50 need to be consistent for 2 years as well. The PCMP would have to be notified of changes to the fee-for-service at least 18 months in advance.

For track two: The criteria and PMPM would need to remain the same (predictable) for two years and be agreed upon by the Department and the PCMP.
Recommendation—Health and Behavior Codes: We recommend that the health and behavior codes be added as a fee-for-service benefit. Addition of six behavioral health visits out of primary care does not replace the need for health and behavior codes to address behavioral health aspects of acute and chronic medical conditions.
Rationale: Health and behavior codes would enable clinicians to provide necessary counseling and treatment for medical conditions and diagnoses (e.g., weight management/obesity, asthma, congenital anomalies, developmental diagnoses, feeding disorders, sleep disorders) that can have long-term effects for healthcare costs and outcomes. These behavioral health interventions need to be delivered within health care settings by licensed behavioral health providers (or license-eligible trainees under the supervision of a licensed clinician) billing health and behavior codes on a medical diagnosis, not a mental health diagnosis. For example, counseling an adolescent on weight management is a high value activity that will result in significant long-term savings to many systems.
3.3.13.2.2 Current Language – Six Behavioral Health Visits: “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”
3.3.13.2.2 Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).
If the service is provided in a clinical setting, the care should be provided in an integrated way that includes integrated charting.
We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.
We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
Rationale: We want to be sure that behavioral health care is provided by someone appropriately credentialed and does not become an expansion of the scope of primary care medical providers.
5.12.5.6.2 Current Language: Primary Diagnosis: The Contractor’s responsibility for all inpatient hospital services is based on the primary diagnosis that requires inpatient level of care and is being managed within the treatment plan of the Member.
5.12.5.6.2 Recommendation—Primary Diagnosis: The RFP describes a Medicaid delivery system that continues to rely on covered diagnoses; which features a primary diagnosis requirement very similar to the current system. Without a change to this requirement, children will continue to be denied services they need whenever their primary diagnoses are physical in nature— including those diagnoses related to autism, Substance Use Disorders (SUD), or developmental/intellectual disabilities. It would be best if the Regional Accountable Entities (RAEs) have a requirement to cover behavioral health services in all settings, irrespective of whether other diagnoses are present and in compliance with EPSDT statutes and regulations.
Rationale: Without a change, this continues to perpetuate many of the same issues that Medicaid clients are currently experiencing. The reasons are twofold. First if the BHO determines a lower level of care is appropriate, but that level of care isn't immediately available, the BHO may make the child wait until the lower level of care is available, rather than approving access to the higher level of care that is available immediately. Second, because BHOs often make treatment decisions, rather than a rendering provider getting to make the decision about what's medically necessary / the correct intervention, patient treatment and placement beyond stabilization and screenings often has to wait until the managed care organization weighs in. This can mean many hours in an ER or other situations (e.g., returning home and waiting for an “opening” in the approved level of care) that are not ideal for a client.
5.12.6.9 Current Language – Out of Network Services: “If the Contractor is unable to provide covered behavioral health services to a particular Member within its network, the Contractor shall adequately and timely provide the covered services out-of-network at no cost to the Member.”
5.12.6.9 Recommendation—Out of Network Access Requirements:. We recommend removing the “adequately and timely language” at 5.12.6.9. and adding, “ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers” so the section reads, “If the Contractor is unable to provide covered behavioral health services to a particular Member within its network, the Contractor shall ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers at no cost to the Member.”
Rationale: Limits to the network should not be a reason for failure to meet the timeliness standards. It is up to the Contractor to ensure network adequacy and approve access to care when the network does not meet a Member’s needs.
5.12.5.7.1 Current Language – Prevention/Early Intervention: “The Contractor shall provide or arrange for the following 1915(b)(3) Waiver services to Members in at least the scope, amount and duration proposed in the Uniform Service Coding Standards (USCS) Manual. All 1915(b)(3) services provided to children/youth from age 0 to 21, except for respite and vocational rehabilitation, are included in the State Plan as Expanded EPSDT services: Vocational Services, Intensive Case Management, Prevention/Early Intervention, Clubhouse and Drop-in Centers, Residential, Assertive Community Treatment, Recovery Services, Respite Services.
5.12.5.7.1 Recommendation—Move BH Prevention/Early Intervention to Fee For Service: We recommend the State remove Early Intervention and Prevention from the behavioral health capitation and offer it as a state plan service, in addition to the six visits discussed above, and define the behavioral health early intervention and prevention services required.
These services include activities such as:
1) Screening, identification, triage, intervention, and referral when concerns or delays are identified using standardized screening protocols; Specifically, postpartum depression screening, developmental screenings, ACES and MCHATS should be reimbursed in the frequency that is clinically recommended and at appropriate reimbursement levels.
2) Health promotion services that support the development of nurturing relationships between caregivers/parents and children, provide anticipatory guidance and support around typical developmental issues, and help address psychosocial complexity before it impacts well-being;
3) Prevention efforts that provide a higher level of services and supports to families identified as being at risk or vulnerable because of child, family, or environmental factors that could negatively impact development; and
4) Early childhood behavioral health intervention services provided by a qualified workforce of behavioral health professionals for those families identified as having complex needs and/or with identified adversity and behavioral health needs.
5) Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
Rationale: Early Intervention and Prevention services for children are not presently being offered adequately, and the proposed RFP does not change the offering. In addition, the focus on the provision of high-acuity services in the next iteration of the capitation makes the future network potentially even less effective at Prevention and Early Intervention. Prevention and Early Intervention services may be better provided by providers outside of the specialty behavioral health network since this work requires specialization and training beyond the scope of what licensed behavioral health professionals are required to have and the services are often delivered in community settings including primary care, early care and education, social service programs (e.g., WIC offices), and homes (e.g., home visiting). This should include opening H codes as a fee-for-service billing mechanism to allow for assessment of need/suitability for services, psycho-education and counseling around health and well-being, group-based service delivery, and community engagement, all without requiring a behavioral health diagnosis.
3.3.15.4.2 Current Language – Allocation of Flexible Funding Pool : “Flexible Funding Pool: This pool will be created from any monies not distributed for KPIs and will be used to reinforce and align evolving program goals.”
3.3.15.4.2 Recommendation—Flexible Funding Pool: We recommend adding the following language: “The use of the Flexible Funding Pool funds will be approved by the Statewide Program Improvement Advisory Committee. The funds must be used to encourage innovative upstream interventions that address risk and protective factors as well as the social determinants of health .”
Rationale: The State PIAC’s authority over spending the flexible funds would ensure that these funds are used to strategically meet community needs.
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1/10/2017 9:38:08I agree and wish to continueAaronTurner-PhiferURACAccreditation OrganizationURAC supports Colorado’s efforts to further integrate the delivery system and enhance care coordination. This RFP is a positive step that builds on the great work already achieved by the Regional Care Collaborative Organizations. As an organization focused on driving out the cost of poor quality from the delivery system, URAC recommends that the Department of Health Care Policy and Financing (DHCPF) consider clearly aligning Regional Accountable Entity (RAE) requirements with other efforts underway that will reduce administrative burden for the RAEs and their network of providers. URAC encourages DHCPF to utilize the quality work completed by national accrediting organizations that is relied on by other public and private payers.

CMS currently recognizes accreditation, including URAC accreditation, to augment oversight of Medicare Advantage plans and Qualified Health Plans operating on Health Insurance Marketplaces. CMS provides states with the ability to use accreditation to demonstrate compliance with certain External Quality Review requirements. The final rule implementing the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) recognized four accreditors, including URAC, who are authorized to certify Patient Centered Medical Homes (PCMH). By utilizing the work of accreditors, DHCPF can align its requirements with national quality standards to ensure Coloradans receive the highest level of care while reducing the burden on the RAEs and their network of providers.
At a minimum, URAC encourages the Dept. to consider providing additional weight to an offeror’s score if they can demonstrate they are accredited in an area that aligns with the goals of the Accountable Care Collaborative (ACC) and specific RFP requirements.

URAC stands ready to work with DHCPF to leverage existing quality standards in a manner that allows you to deliver high quality care to Coloradans while limiting the administrative burden placed on the RAEs and providers.
Very clearPlease see previous comment about the potential use of accreditation which may fall under the RFP Section concerning Contractor's General Requirements. No opinionVery clearWhile the Mandatory Qualifications in in the Offeror’s Experience (Section 4) are clear, URAC encourages DHCPF to consider a requirement that offerors maintain accreditation thus ensuring quality best practices are utilized and implemented by RAEs. A majority of states recognize/utilize accreditation to augment their oversight of Medicaid managed care organizations.

However, given that RAEs are not like other traditional Medicaid managed care organizations, the DHCPF should consider other accreditation programs that validate the quality of organizational efforts to implement best practices. URAC’s Clinical Integration Accreditation standards address governance, use of clinical guidelines, data sharing, and quality measure reporting. These standards ensure effective, shared responsibility among members focusing on improving the quality of care delivered to patients.

URAC encourages DHCPF to consider providing additional weight to scores for offeror’s that have made an investment to meet national best practices that align with the goals of the ACC and specific elements of the RFP.
No opinionNo opinionNo opinionNo opinionNo opinionNo opinionSomewhat clearThe final rule issued by CMS implementing MACRA identified four accreditors, including URAC, eligible to certify PCMHs. The finale rule also indicated that commercial insurance and Medicaid programs were also eligible to certify PCMHs if they met certain national standards and included 500 practices. Those physicians/groups that had achieved PCMH certification from one of these entities are eligible to receive full credit under the Clinical Practice Improvement Activities category of the Merit-based Incentive Payment System (MIPS) established by MACRA. The Improvement Activities section constitutes 15% of a physician/group’s total score. URAC encourages DHCPF to work with CMS to seek approval as a Medicaid program eligible to certify PCMHs. This would allow RAE’s participating physicians to receive an elevated Medicaid PMPM and receive full credit under the Improvement Activities category of MIPS. This alignment would certainly reduce the burden on practices and may even encourage increased participation by providers. No opinionNo opinionNo opinionVery clearPer CFR 438.360, in place of a Medicaid review by the state or its External Quality Review Organization (EQRO), states can use information gathered from a national accrediting organization or from Medicare to show compliance with certain external quality review activities. This provision is meant to ease the administrative burden on the state and the managed care entities by avoiding duplication of activities. URAC encourages DHCPF to review the potential benefit of utilizing information from accreditation in lieu of conducting the following mandatory EQR-related activities: compliance review, validation of performance improvement projects, and validation of performance measures. Should any RAEs achieve accreditation, this may be a useful resource to reduce the administrative burden they face. No opinionNo opinionNo opinionNo opinion
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1/10/2017 10:55:44I agree and wish to continueRebeccaAlderferBen and Lucy Ana Walton FundFoundationWe would like to thank the Department for making strides towards some of our key priorities by:
• Increasing access to behavioral health care for children and families by removing six visits from the Behavioral Health capitation (that is defined by covered diagnosis)
• Better coordinating between behavioral health systems and physical health systems
• Including robust measures for monitoring well-being, especially maternal depression screenings and developmental screenings

Medicaid is the single largest investment (in combined State and Federal dollars) that we make in the residents of Colorado and we are committed to partnering with the Department to help make those funds as impactful as possible. We have a number of specific comments on the RFP language to help improve the $9 billion Medicaid system for pregnant and postpartum women and their children through 2025. The most important changes we are suggesting are:
• Prioritizing the determination of whether a child-bearing age female enrollee is pregnant or in the first year postpartum in order to facilitate rapid referral to appropriate health services and community resources
• Focusing care coordination activities on women who screen positive for pregnancy-related depression and anxiety
• Including resources in the RAE directory to support women and families who are experiencing pregnancy-related depression and anxiety
• Specifically identifying developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines
• Including training for providers in best practices related to caring for children and families, including completing pregnancy-related depression screening multiple times during pregnancy and during the child’s first year, and providing guidance around documentation of screening results and appropriate billing procedures for each type of setting
• Requiring that for children under six, the wellness KPI indicator should be developmental screening, and for pregnant and postpartum women, the measure should be receipt of a depression screen
• Requiring that the behavioral health engagement KPI measure age and stage appropriate behavioral health screening, specifically encouraging pregnant and postpartum women to receive a depression screen
• Removing EPSDT early intervention and prevention services from the behavioral health capitation and have it offered Fee-for-Service within the State Plan

While we focus most of our energy in on areas where we seek changes, we would also like to thank the Department for the thoughtful work and inclusive process that went into the development of this RFP. The RFP is well written and contains many components advocated for by maternal and child health experts that have potential to have a significant positive impact on Medicaid-enrolled pregnant and postpartum women and their children. We appreciate the effort that went into this document and are eager to support the Department in continuing to refine the program design.

Winnable Battles: The RFP should clearly list the winnable battles for which the RAE is held accountable. We recommend that the RFP focus on the following strategies:
• Increase the percent of mothers who are appropriately screened and treated for depression.
• Decrease untreated dental decay and decay experience in children.
• Increase access to and utilization of tobacco cessation services tailored for pregnant and postpartum women.
• Increase use of long-acting, reversible contraceptive methods.
In general, we recommend that many of the aspirational goals in the RFP be narrowed, prioritized and defined. We recognize that the capacity of both our providers and the RAEs is finite and by prioritizing we will be more likely to be successful in all endeavors.

Rationale: There are many strategies listed in the Winnable Battles documents and the RAEs will not have the resources to focus on all of them. Providing more clarity on priorities and expectations will ensure that the RAEs dedicate their efforts where they can effectively intervene. The strategies we have highlighted above are within the scope of work of the RAEs and have strong evidence supporting their effectiveness at improving the health of children and families.
No opinionSection: 5.5.3.7.1.6
Recommendation—Provider Directory: We recommend that the provider directory be up to date, interactive, and accessible and include provider type.
Rationale: Provider type is a crucial piece of information to ensure that the contacted provider will serve the client’s need. Provider lists in PDF or other formats are difficult for clients to utilize. A dynamic and searchable provider directory that enables a client to filter the list and find a provider that is close, will take new members, and is appropriate for their age/gender and other needs is an important mechanism for supporting access.
No opinionNo opinionNo opinionNo opinionSection: 5.5.5
Recommendation—Health Needs Survey Timing: We recommend the health needs survey occurs post-enrollment.

Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. We are also concerned that urgent needs identified at the time of application by an eligibility technician or through the PEAK application process will not be responded to within an appropriate timeframe. The questions within the Health Needs Survey may also go beyond what is legally allowed by the Centers for Medicare & Medicaid Services to be required on a Medicaid application, and exceed what is allowable for other assistance programs incorporated within the PEAK application (e.g. SNAP, Colorado Works, and subsidies through Connect for Health Colorado). Additionally, we are concerned with how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports. Finally, because the majority of Coloradans eligible for Medicaid are already enrolled in the program, conducting the Health Needs Survey at the time of application will not capture the health needs of the majority of people enrolled with the RAE.

Recommendation—Health Needs Survey Design: We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. Determining whether a child-bearing age female enrollee is pregnant or in the first year postpartum should be a priority of the survey, in order to facilitate rapid referral to appropriate health services and community resources. Specifically, we recommend that Question 4 in Appendix H be asked of ALL child-bearing age female clients, and that it be followed by a question that reads as follows: “Have you given birth in the last 12 months?” We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.

Rationale: Identifying behavioral health, physical health, and social needs of pregnant women and women in the first year postpartum should be a priority upon enrollment. Regional Accountable Entities should be responsible for the screening and for referring women to appropriate resources based upon screening results.
No opinionNo opinionSection 5.7.1.5

Recommendation—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including psychiatric and other consultation services for providers and direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to build capacity and reduce barriers to accessing care.”

Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform. For providers, access to psychiatric and other specialty providers through phone or video consultation makes these services more readily available for clients in all parts of the state.

Section 5.7.4.13.5.2

Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2. should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.

Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.
No opinionNo opinionSection: 5.8.4.5
Recommendation—RAE Directory: We recommend adding the following language, “The RAE directory should include resources to support women and families who are experiencing pregnancy-related depression and anxiety, including the Postpartum Support International phone number and website, and other community resources.”

Rationale: There is a wealth of evidence, including from Harvard University’s Center on the Developing Child and the American Academy of Pediatrics, around the long-term negative impact of pregnancy-related depression and anxiety on child health and development. The effects of maternal depression are linked to “reductions in young children’s behavioral, cognitive, and social and emotional functioning.” Children raised by clinically depressed mothers are at risk for later mental health problems, social adjustment difficulties, and difficulties in school. One study also found that women suffering from maternal depression had health care costs that were 90 percent higher than those of non-depressed women. Identifying women with pregnancy-related depression and anxiety and quickly connecting them with care can have a long-term positive impact on Medicaid enrollees. Babies of mothers who are treated for pregnancy-related mood issues have better health and developmental outcomes, are more likely to attend well-child visits, and have decreased emergency and urgent care utilization. These resources and supports should be accessible and available to women during pregnancy, at infant well-child visits, and at post-partum follow-up visits.

RECOMMENDATION: Care Coordination
Recommendation—Care Coordination for Pregnancy-related Depression: We recommend that the Contractor be incentivized to focus on care coordination activities for women who screen positive for pregnancy-related depression and anxiety, enabling those women to receive necessary treatment and support. These care coordination services should include referring women who screen positive for pregnancy-related depression to medical and community resources, following-up with those women to determine whether they were able to access those resources, and informing the health care provider who documented the positive screen of the services the women was offered and whether she was able to access those resources.

No opinionRECOMMENDATION: SCREENING TOOLS
Section: 5.10.5.2.3
Recommendation—Screening Tools: We recommend specifically identifying that the RAE should maintain and provide a list of Medicaid-approved developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines and that the RAE should support the use of these tools.

RECOMMENDATION: PROVIDER TRAINING
Section: 5.10.6
Recommendation—Provider Training: Provider support should include training providers in best practices related to caring for children and families including completing pregnancy-related depression screening multiple times during pregnancy and during the child’s first year. The contractor should also provide guidance around documentation of screening results and appropriate billing procedures for each type of setting.

No opinionNo opinionRECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Section: 3.3.13.2.2
Recommendation—Six Behavioral Health Visits:
We strongly support the availability of six behavioral health sessions without a covered behavioral health diagnosis as this is the primary way that the draft RFP contemplates expanding access to behavioral health services in the next iteration of the ACC program. This program change is especially important for children who may not yet have a covered diagnosis but could benefit from behavioral health services. Allowing these six behavioral health visits in primary care settings will dramatically improve access to these services for Medicaid clients. We are confident that with care coordination and data support provided by the RAEs, information from these visits will be able to be shared across health care providers as necessary and appropriate while protecting patient privacy.
We recommend eliminating the “low-acuity” terminology because it is subjective and unclear. Further, we support the delivery of the right type of care in the appropriate setting and think that any issue that can be treated in a primary care setting over a defined period of time should be allowed to be treated in these visits, regardless as to the acuity of the issue. A client could have an acute but short-term need that could be met by these services.

We also recommend specifying that these visits allow for dyadic visits for a caregiver and baby together when mother demonstrates symptoms of depression or anxiety.

We also recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

Therefore, please adjust the language as follows: The Department will increase access to behavioral health interventions by encouraging the delivery of behavioral health within primary care settings by a license-eligible behavioral health practitioner. Behavioral health treatment, including dyadic behavioral health intervention for infants and young children with their parents present, delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.
We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.

RECOMMENDATION: OUT OF NETWORK SERVICES
Section: 5.12.6.9
Recommendation—Out of Network Access Requirements: We recommend removing the “adequately and timely language” at 5.12.6.9. and adding, “ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers” so the section reads, “If the Contractor is unable to provide covered behavioral health services to a particular Member within its network, the Contractor shall ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers at no cost to the Member.”
Rationale: Limits to the network should not be a reason for failure to meet the timeliness standards. It is up to the Contractor to ensure network adequacy and approve access to care when the network does not meet a Member’s needs.

RECOMMENDATION: PREVENTION/EARLY INTERVENTION
Section: 5.12.5.7.1
Recommendation—Move BH Prevention/Early Intervention to Fee For Service: We recommend the State remove Early Intervention and Prevention from the behavioral health capitation and offer it as a state plan service, in addition to the six visits discussed above, and define the behavioral health early intervention and prevention services required.
These services include activities such as:
1) Screening, identification, triage, intervention, and referral when concerns or delays are identified using standardized screening protocols; Specifically, postpartum depression screening, developmental screenings, ACES and MCHATS should be reimbursed in the frequency that is clinically recommended and at appropriate reimbursement levels;
2) Health promotion services that support the development of nurturing relationships between caregivers/parents and children, provide anticipatory guidance and support around typical developmental issues, and help address psychosocial complexity before it impacts well-being;
3) Prevention efforts that provide a higher level of services and supports to families identified as being at risk or vulnerable because of child, family, or environmental factors that could negatively impact development; and
4) Early childhood behavioral health intervention services provided by a qualified workforce of behavioral health professionals for those families identified as having complex needs and/or with identified adversity and behavioral health needs.
5) Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
Rationale: Early Intervention and Prevention services for children are not presently being offered adequately, and the proposed RFP does not change the offering. In addition, the focus on the provision of high-acuity services in the next iteration of the capitation makes the future network potentially even less effective at Prevention and Early Intervention. Prevention and Early Intervention services may be better provided by providers outside of the specialty behavioral health network since this work requires specialization and training beyond the scope of what licensed behavioral health professionals are required to have and the services are often delivered in community settings including primary care, early care and education, social service programs (e.g., WIC offices), and homes (e.g., home visiting). This should include opening H codes as a fee-for-service billing mechanism to allow for assessment of need/suitability for services, psycho-education and counseling around health and well-being, group-based service delivery, and community engagement, all without requiring a behavioral health diagnosis.
No opinionNo opinionRECOMMENDATION: WELLNESS KPI SPECIFICITY
Section: 5.14.4.8.1.1.2.3
Recommendation—Wellness KPI Definition: We recommend that the wellness visits measure KPI be more specific: Most adults and older children should be measured for visits, but for children under six, the indicator should be developmental screening, and for pregnant and postpartum women, the measure should be receipt of a depression screen.

Rationale: Developmental and depression screenings occur within the context of a wellness visit and so would capture both the presence of a wellness visit and the quality of that visit for these key populations. This also allows for a focus on pregnancy-related depression screening, in alignment with several other state initiatives. Children six months of age who had documentation of a maternal depression screening for the mother is a State Innovation Model (SIM) quality measure. The state’s 2016-2020 Maternal and Child Health Needs Assessment identified women’s mental health including pregnancy-related depression as a priority area. The state has also identified maternal depression as a component of one of Colorado’s ten winnable battles: mental health and substance abuse. The U.S. Preventive Services Task Force recommends universal screening for depression in pregnant and postpartum women, noting that even studies of the effect of screening plus “minimal additional intervention” have shown reductions in postpartum depression at follow-up.

RECOMMENDATION: BEHAVIORAL HEALTH ENGAGEMENT
Section: 5.14.4.8.1.1.2.4
Recommendation—Behavioral Health Engagement KPI: Rather than behavioral health engagement, we recommend measuring age and stage appropriate behavioral health screening, specifically encouraging pregnant and postpartum women to receive a depression screen.

Rationale: Since behavioral health engagement is already held to payment under the capitation, it makes sense to have “medical” portion of the funding tied to those indicators influenced by medical factors. As with the recommended measure above, this change would also allow for a focus on pregnancy-related depression screening, in alignment with several other state initiatives. Children six months of age who had documentation of a maternal depression screening for the mother is a State Innovation Model (SIM) quality measure. The state’s 2016-2020 Maternal and Child Health Needs Assessment identified women’s mental health including pregnancy-related depression as a priority area. The state has also identified maternal depression as a component of one of Colorado’s ten winnable battles: mental health and substance abuse. The U.S. Preventive Services Task Force recommends universal screening for depression in pregnant and postpartum women, noting that even studies of the effect of screening plus “minimal additional intervention” have shown reductions in postpartum depression at follow-up.
No opinionNo opinionNo opinionNo opinion
46
1/10/2017 11:01:53I agree and wish to continueGerry BrewSummitStone Health PartnersProviderOverall Comments
SummitStone Health Partners (SHP) appreciates and shares many of the Department’s goals for ACC Phase II. We look forward to opportunities to build on the successes of the Medicaid programs and to move toward greater alignment where that meets the goals to better serve clients and effectively utilize public dollars for the benefit of Coloradans in need. We are likewise grateful for the Department’s pledge to a thoughtful stakeholder process to guide this alignment in consideration of the impressive complexity of the current healthcare landscape and tremendous resources dedicated each year to the U.S. healthcare system.
This commitment to stakeholder engagement is exemplified by the Department’s decision to preserve the 1915 waiver, and the full-risk nature of the contract with the BHOs that has allowed the community behavioral health system in Colorado to pay for services in Institutes of Mental Disease, build a full array of services to meet the needs of individuals, and respond to the local community. This decision to build off the successful managed, risk-based capitation system for behavioral health is important, and demonstrates the state’s commitment to advance the healthcare payment continuum toward better models of care for Colorado’s Medicaid population. We fully support the goals of the ACC that direct Colorado toward expanding integrated care, expanding mechanisms for value-based care, and strengthening the role of communities to innovate and improve care delivery systems.
SHP thanks the Department for the opportunity to provide input on the draft RFP and help illuminate the full range of externalities that may result from the ACC model as proposed.
The draft RFP includes a number of significant changes to the current administrative and financing system for behavioral health services that could significantly impact Colorado’s behavioral health safety net, including potentially negative impact on individuals experiencing the most serious behavioral health challenges. To avoid a disruption in care, certain key aspects of the existing program must be adequately addressed and included in the final RFP.
Institutes of Mental Disease (IMD): An IMD is defined under Section 1905 of the Social Security Act as a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases. It is estimated that 65% of psychiatric beds in Colorado are in IMDs. Colorado currently has a waiver under Section 1915(b) of the Social Security Act which allows HCPF to utilize a managed care payment model for mental health care, instead of a fee-for-service payment model. HCPF has determined that under a capitated payment model, payments with respect to a Medicaid participant may continue despite the treatment of that participant at an IMD. This provides a workaround which allows IMDs in the state to receive federal funds despite the historical prohibitions in Section 1905. This workaround is only available so long as a waiver is in place and so long as the state continues to use a managed care payment model for mental health services. Given the extreme need for inpatient services, and to better meet the needs of the community, it is important that this IMD exclusion continue in the Final RFP.
1915(b)(3) Waiver Services: Similar to the IMD issue, there are a broad range of alternative services made possible because of the 1915 (b)(3) waiver, which is possible because of Colorado’s mental health managed care program. Waiver services include: Vocational Services; Intensive Case Management; Prevention/Early Intervention Activities; Clubhouse and Drop-in Centers; Residential (including ATU); Assertive Community Treatment; Peer Support and Recovery Services; and Respite Services. SHP believes that Medicaid members with behavioral health needs benefit greatly from these services and by keeping the 1915 waiver and risk-based behavioral health managed care, HCPF is on the right path to support the systems that have developed these services. However, the draft RFP does not sufficiently speak to how the Community Mental Health Center system, and other local behavioral health providers, will be required elements in the delivery of care and management of the ACC program. While the RFP indicates that the RAE will be responsible for developing mechanisms to engage a broad range of community partners, SHP believes that additional language that supports the involvement and decision making ability of these critical community stakeholders must be explicitly addressed in the next phase of the ACC program. Without this, it will be impossible for the ACC to achieve its goal that members will have their medical and behavioral health care needs met and receive community supports in a seamless way.
Payment Strategies: For ACC Phase II, HCPF has a goal that Medicaid members receive physical and behavioral health services through a more integrated value-based payment structure. Without an ability to advance physical healthcare payment to align with the current behavioral health capitation system, there must be deliberate care to ensure the new program builds on the current value of Colorado’s BHO, while enhancing services to more individuals than have been traditionally covered under the current program. SHP believes that to accomplish the overall goals that both HCPF and the behavioral health community wish to achieve, a managed care model where providers share risk is the best choice for Medicaid members, providers, and payers. SHP values the efficiency, quality, and flexibility that the current mental health managed care program has afforded providers and members.
The RFP should clearly lay the path for a system focused on maximizing independence, local control, stewardship of tax dollars, while achieving the Triple Aim. While adding fee-for-service behavioral health services for “low acuity” individuals will likely mean additional resources available in the community, there is concern that this approach will shift resources away from behavioral health and into primary care in a manner that will simply incentivize higher volume of services rather than investing in outcomes and achievements.

The negative consequences of shifting resources from the behavioral health capitation program to FFS in the primary care setting are significant. This may be exacerbated by the RFP’s proposal of financial holdbacks for the already underfunded behavioral health system. We would prefer to see ACC Phase II focus on expanding behavioral health benefits to better meet the full continuum of need for all Medicaid populations. Furthermore, we believe a more productive strategy overall for achieving the Triple Aim requires solutions targeted where the majority of healthcare spending is occurring, without detriment to smaller elements of the healthcare system such as behavioral health, oral health, DD/IDD providers, long-term care and specialty providers. Nationally, expenditures for hospital care constitute nearly one third of $3 trillion in total health spending – which is far and away the largest driver of spending. That trend is consistent with what we see in Colorado, with 32.6% of all Medicaid payments - $2.8 billion - going to the $9 billion hospital system. While there is certainly outstanding need in some of Colorado rural, critical access hospitals, it is hard to determine how this proposed ACC approach will significantly curb hospital-based expenditures. The draft RFP should describe more precisely how this initiative will incentivize better connections through all systems of care, and specifically how the ACC will reduce expenditures in our largest healthcare cost centers without harming smaller, community-based systems.

Substance Use Disorder: One important area in need of service enhancement, and currently lacking from the draft RFP, is substance use disorders (SUD). HCPF states that the term “behavioral health” is meant to convey both mental health and SUD services, but there are several distinct differences among the two types of care that should be addressed in a comprehensive delivery system reform effort. The draft RFP is silent on the Managed Service Organizations (MSO) and how this significant network of providers will interact with the RAEs. For example, the RFP speaks to the requirement of care coordination and the RAE having the ability to bridge multiple delivery systems and state agencies, though MSOs are never explicitly indicated. This is a strong competency of the current MSOs system, and would enhance the program by adding an entity well-versed in the various types of substance use providers and the complex needs of individuals in need of substance use services. It is also critical that the RFP consider a comprehensive strategy for SUD, rather than a myopic focus on the opioid epidemic. SHP asks HCPF to expand on their concept for including SUD care delivery in their plans for ACC Phase II.
Non-Medical Partners: Overall, it is clear the Department’s has a vision to improve population health and reduce healthcare expenditures through greater integration of physical and behavioral health through the use of team-based care and care coordination. Although much of this can be accomplished through the Medicaid system, many other state-supported systems that affect population health and healthcare spending, such as public health, housing and environment, criminal justice, behavioral health crisis services, and human services must be explicitly addressed in ACC Phase II if Colorado is to achieve the overall goals of this reform effort.

Again, SHP is appreciative of this opportunity for open and honest dialogue around the future of the ACC – the core of Colorado’s Medicaid program. The next iteration of the Accountable Care Collaborative will be a major initiative that will have resounding impacts for years to come. Thoughtful, strategic discourse with the careful inclusion of all stakeholders in Medicaid planning is imperative to our collective success and achievement of better outcomes, reduced costs, and improved patient satisfaction.




Very clearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?

No Comments.

What operational concerns and potential consequences are there for implementing the section/requirements as written?

No Comments.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?

No Comments.

Please specify what the Department could modify to improve the section/requirements

No Comments.
Somewhat clearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
Requirements reflect significant state department oversight and potential micromanaging which seems to devalue local control and community-based variations, stated intentions of the ACC. This pertains to an intrusive role in staffing decisions, personnel transitions/approvals (meeting or exceeding qualifications) and prior-approval on hiring decisions.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
Operational efficiency and workforce maximization are at stake. While accountability is important, the expectations of this section subsume local control and minimize the importance of outcomes in favor of process. The 40% limitation on subcontracting may also have major implications for how both medical and non-medical partners are involved, depending on how this limitation is interpreted.

Please specify what the Department could modify to improve the section/requirements.

The language should suggest qualifications, hiring and transition processes but should avoid creating an intrusive government role in local decisions, instead focusing on holding contractors accountable to outcomes.

Additional clarity would be helpful for the 40% limit on subcontracting services. For example, is this for clinical services or just ASO type agreements (provider agreements not subcontracts).

Somewhat unclearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
Aligning physical and behavioral healthcare financing and delivery of care is a worthy goal of the ACC and HCPF. It is imperative that the RAE build on the extensive managed care history of the behavioral health services program, and important to note that simply stating that one entity will administer both PCCM and PIHP authorities will not directly correlate to successful integration and systems transformation.

What operational concerns and potential consequences are there for implementing the section/requirements as written?

No Comment.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?

No Comment.

Please specify what the Department could modify to improve the section/requirements.
Include language for the RAE, at risk for the management of services under the 1915(b) waiver, that creates a system which adequately involves providers in care management, and maximizing resources through payment such as including sub-capitation payments to local providers.

Not ClearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?

Mandatory enrollment of all full benefit Medicaid clients is critical to achieving the overall goals of the ACC Phase II. Requirements related to attribution and enrollment within this section may present challenges and deserve additional analysis to ensure goals related to continuity of care and client choice are achieved.

What operational concerns and potential consequences are there for implementing the section/requirements as written?

The difference between using PCMP attribution (practice location dependent) vs. Medicaid member location has a major impact on providers that may be located close to a RAE region border. Building on this, it is important to know if PCMP attribution will be based on each individual practice site or at the organizational level. For example, would a provider with multiple practice sites that overlaps multiple RAE regions have patients enrolled in just one RAE, or would patients that are in each practice site be enrolled in the RAE in that region?

There are significant concerns for some related to the enrollment projections for the various regions. Distribution across the seven regions is highly disparate and could pose challenges managing care for diverse populations.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
The rationale for the proposed attribution methodology and enrollment projections is critical.

Please specify what the Department could modify to improve the section/requirements.
Consider a regional attribution methodology rather than a practice-based methodology.


Not ClearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
The emphasis on person and family-centered approaches to care is extremely appreciated and aligns very well with the overall goals of ACC Phase II. Cultural and linguistic responsiveness are paramount to good care and the focus on promotion of health and wellness will result in better outcomes across the healthcare system in Colorado.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
It is important to note that meeting best standards for cultural and linguistic competency can be costly, and that rate setting processes must adequately account for this so that a very high bar can be set for meeting these deliverables.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
Regarding promotion of member health and wellness, it is unclear how this section might relate to the broader system of community partners dedicated to prevention and wellness programs. In order to avoid duplication of efforts, this section may represent an opportunity to specifically call out collaboration with local public health agencies and other prevention/wellness focused agencies.

Please specify what the Department could modify to improve the section/requirements.

The Department should specifically address expectations for appropriately meeting the needs of Colorado’s deaf and hard of hearing population. The quality of interpretation and support services is highly variable, particularly for reliable support to those in need of behavioral health services. Additional information and suggested best practices can be obtained by contacting the Colorado Daylight Partnership. More generally, direct engagement with community stakeholders in the development of support materials should be emphasized.

The Department should consider adding language under the Marketing section that encourages RAEs to distribute information about the Statewide Behavioral Health Crisis Line and Services System.




Very clearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
No comment.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
No comment.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
No comment.

Please specify what the Department could modify to improve the section/requirements
No comment.

Not ClearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
The array of named providers is important to include and support the overall goals of the ACC. However, it is critical that the MSOs and regional contractors for behavioral health crisis services be addressed in some capacity to ensure a robust continuum of services meeting all levels of behavioral health needs are available.

Regarding access to care standards, it is important to note that rural and metropolitan communities have different needs. Transportation is a significant issue. Consideration should be given in the time and distance network requirements, for both primary care and behavioral health providers.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
Without mention of how the MSOs and behavioral health crisis services, it is difficult to know how the ACC will effectively support clients with these needs. These are often high acuity, high cost populations and without additional specificity on how these systems will be involved, Colorado will continue to rely on emergency departments and the criminal justice system as an inappropriate safety net for these clients. Inclusion is critical, particularly given the Governor's investments in SUD and developing a robust crisis services system.

Access to care must appropriately address transportation challenges and time and distance standards indicated for rural and frontier counties may be unreasonable expectations given current workforce shortages.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
The Department should clarify its analysis of how federal block grant dollars for behavioral health may overlap or connect to the ACC program.
Please specify what the Department could modify to improve the section/requirements.
Name MSOs and regional behavioral health crisis providers as components of RAE networks and required partners. Provide additional justification to potential bidders for time and distance standards, and indicate the role that telehealth may play in meeting network adequacy.

Somewhat unclearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
The emphasis on establishing health neighborhoods and building community solutions is critical to achieving the goals of the ACC. The language within this section that requires referral processes, promotion of coordination tools, and collaboration is important. However, without stronger financial incentives, shared with the community partners, it is unlikely that the health neighborhood model and anticipated outcomes will be realized.

Local control is mentioned, but an advisory group (on medical side) is not the path toward local control
What operational concerns and potential consequences are there for implementing the section/requirements as written?

Upstream and non-traditional providers outside of the medical community may be undervalued as the RFP is currently written. This ultimately limits the extent of enhanced health outcomes that the ACC can help realize.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
A specific definition describing the difference between health neighborhood and population health would be helpful.
Please specify what the Department could modify to improve the section/requirements
Strengthen financial mechanisms and requirements of RAEs to fund non-traditional providers such as nurse practitioners, physician assistants, public health entities, telehealth providers, and other community partners.

We recommend stronger language requiring RAEs to use local collaborations to discourage duplication of efforts. Existing health alliances, for example, have governance and relationships already in place to build health neighborhoods and align and streamline processes across systems of care.


Somewhat unclearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
While a population health management approach and care coordination are integral to achieving the overall goals of the ACC, there are major challenges to realizing these goals given concerns with attribution methodology and transient populations. It will also be difficult to achieve population health goals when funding is not tied to the achievement of outcomes at this level.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
Difficult to set population health goals, particularly in the metro area, when there is transients utilization of various services across regions.
What part of the section/requirements needs specific additional clarification in the draft RFP as written?
Will there be real opportunities to invest in, and support, population health strategies, when funding is not tied to outcomes at this level?
Please specify what the Department could modify to improve the section/requirements
Not ClearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
The focus on practice transformation activities, and building in financial incentives to Network Providers, is well aligned with the overall goals of the ACC. Ensuring these financial incentives will be extended to Health Neighborhood participants is important to achieving ACC goals.

Language that supports leveraging existing resources to avoid duplication and burden on practices is appreciated and may be expanded in some areas to ensure optimal efficiency. There are additional resources that should be considered that will ensure Providers are aware of the full continuum of supports available to members.
What operational concerns and potential consequences are there for implementing the section/requirements as written?
Financial incentives for practice transformation activities are critical as an incremental step toward rewarding enhanced health outcomes. Because of the significant role proposed for RAEs in their communities, it is important that the opportunity to assume risk and earn financial incentives is extended to Health Neighborhood participants and not just Network Providers. While such payment arrangements should be negotiated locally, the optional nature of including Health Neighborhood participants may limit the extent to which this actually happens.

It is not clear how RAEs will be able to comply with requirements to facilitate clinical information sharing with regional HIEs given that this is not currently possible for all client data.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
The Provider Training section requires the Contractor to develop trainings for various topics. Clarification should be added that indicates the RAEs may use existing trainings to educate their Provider Networks. For example, on the topics of cultural responsiveness, population health, and administration of the CCAR, there are many excellent, existing resources and it would be unnecessarily duplicative to ask the RAE to develop something new.

Please specify what the Department could modify to improve the section/requirements
Information about the statewide behavioral health crisis system should be included in the array of existing community-based resources provided to Network Providers.

Similar to language in the Practice Transformation section, include statement that the Contractor shall use existing trainings in the region and the state and coordinate with existing training providers, when appropriate, to reduce duplication of efforts and overburdening practices.

Somewhat unclearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
No comments.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
No comments.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
No comments.
Please specify what the Department could modify to improve the section/requirements
No comments.

Not ClearRetaining Somewhat unclearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
No comments.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
No comments.

What part of the section/requirements needs specific additional clarification in the draft RFP as written? No comments.

Please specify what the Department could modify to improve the section/requirements
Include language recognizing that existing health alliances are trusted neutral bodies and can convene providers and agencies around data sharing initiatives.
Not ClearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
The ongoing commitment to quality and performance improvement aligns very well with the overall goals of ACC Phase II. Performance Improvement Projects specifically focused on integration, including reverse integration models, will help create better models of care for patients with diverse needs.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
There is a general concern that this section overemphasizes process measures rather than tying value to outcomes. For example, behavioral health engagement as a Key Performance Indicator is a measure of utilization and does not measure improvement in functioning, symptom severity, or other tangible health outcome.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
How will the Department ensure a robust, community-informed set of KPIs are identified that will emphasize outcomes over process metrics?

Specific to behavioral health engagement as a Key Performance Indicator, additional clarification should be added for how this measure will be defined and implemented.

Please specify what the Department could modify to improve the section/requirements
Consider additional language encouraging that existing health alliances be utilized to facilitate community and member engagement in meaningful ways to address social determinants of health. Also support leveraging these health alliances to build local Performance Improvement Advisory Committees.
Very clearHow well does the section/requirements align with the overall goals of Accountable Care Collaborative Phase II?
No comments.

What operational concerns and potential consequences are there for implementing the section/requirements as written?
No comments.

What part of the section/requirements needs specific additional clarification in the draft RFP as written?
No comments.

Please specify what the Department could modify to improve the section/requirements
No comments.


Very clear
Not ClearNot Clear
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1/10/2017 12:26:07I agree and wish to continueAnitaRichColorado Children's Healthcare Access ProgramAdvocateGood work in trying to summarized the project and the work that needs to be done.Somewhat clear3.3.12.1 Recommendation – Population Health Management and Care Coordination Services: The delegation of care coordination was a critical component of the RCCOs. The RFP should explicitly state that the RAE has the authority and is encouraged to delegate care coordination to a PCP so that care coordination can be accomplished “close to the patient and family.” The absence of this language in the RFP fails to recognize the delegation of care coordination as a “best practice” learned from the implementation of ACC 1.0.

3.3.12.12.1 Recommendation – Integration of Primary Care and Behavioral Health Services: This language is broad and overly vague. The current requirement of a covered diagnosis for infants and young children has had a chilling effect on the ability of children to access and receive needed behavioral health services through the current BHO delivery system. Under ESPDT, children are required to receive necessary treatment for behavioral health services and any limitation on the amount, scope and duration for medically necessary services undermines the intended statutory purpose of EPSDT and should not be so restrictive for infants and young children.

4.2 Organizational Experience
4.2 Recommendation – Organizational Experience: Offerors should be limited to Colorado-based nonprofit organizations. In the alternative, strong preference should be given to Colorado-based nonprofit organizations in the assessment and scoring of the proposals. Simply requiring 89% Medical Loss Ratio is insufficient. Offerors should have the requisite knowledge of Colorado’s unique communities, their current resources, challenges and strengths in order to successfully implement their solution for that particular community. The RAE should be expected to have experience in the type of population, health care and geography (that is, a frontier county versus an urban county) for which they apply. We also need diversity among the Offerors. To maintain this diversity, we encourage the Department to limit the number of RAE regions for which an Offeror can submit a response to three regions.
Somewhat clear5.2.12 Recommendation-Key Personnel Expertise: At least one of the key personnel in an administrative leadership position should have behavioral health expertise and that the CCO, Quality Improvement Director or Utilization Management have pediatric expertise.
Rationale: Since the bulk of the dollars in the contract are dedicated to behavioral health, it is crucial that the leadership group include deep behavioral health expertise. Since the needs of children and youth are fundamentally different than the needs of adults, pediatric expertise in the leadership group is necessary to ensure that the programs serve both. Ideally, expertise in pediatric behavioral health would also exist within the leadership team. Additionally, since nearly one-half of Medicaid members, it is critically important that there be expertise by personnel who have actually provided primary care for children.
Somewhat clearSomewhat clear5.4.5, 5.4.8.1, 5.4.82 Recommendation – Member Attribution: We note the negative impact of changing providers/care settings has on a client’s consistent access to care, continuity of care, and a provider’s ability to manage a client’s care effectively. We recognize and appreciate the Department’s ongoing efforts to work with providers to ensure that they are able to provide continuous comprehensive care for their clients. The final attribution process should be developed and finalized in consultation with providers and/or practice managers. There may need to be minor alterations to the attribution plan in different regions. For example, in Region 5, the attribution process currently favors Denver Health in a way that disrupts the care of families in other clinics and practices. The attribution process may have to be different in frontier counties in which health care resources may be less available and are organized differently than in urban settings. The currently proposed attribution methodology does not account for regional differences.

5.4.8.2.1 Recommendation – Attribution Review: The proposed process totally discounts the preferences and wishes of the Member and diminishes the person-center approach to care the Department hopes to achieve. The attribution process should be family- and patient-respectful and one that promotes continuity of care. A notation should be made in the patient portal and the Member should be asked at their next visit to select a PCMP in a customer-friendly process (responsive re-attribution system) that promotes continuity and the preferences of the Member.

Somewhat unclear5.5.2.1 Recommendation – Cultural Responsiveness: In general, this section is a "check the box" approach to the complexities of cultural responsiveness. It is extremely limiting and even misleading, in part because it isn't clear what the reach of the requirements is intended to be. To what extent can these CONTRACTOR requirements actually be mirrored in the cultural responsiveness where care is actually delivered - i.e. in the clinics and medical homes in all seven regions?

Further, 42 CFR 438.206 - Availability of services - stipulates that "The State must also ensure that MCO, PIHP and PAHP provider networks for services covered under the contract meet the standards developed by the State in accordance with § 438.68." There are no standards for cultural-responsiveness, especially not at the medical home or provider level where it matters most.

Lastly, people from different cultural backgrounds cannot be lumped in with people of "different genders, sexual orientations, and disabilities." This is a sloppy premise that leads to an entire section of the RFP titled "Cultural Responsiveness" (5.5.2) being vague, very difficult to assess at any level, and beyond the reach of any real attempt at regulation. Its language speaks to requirements that would place unrealistic expectations on so many providers, especially those in small private practice settings.

5.5.2.2.2 Recommendation Member Demographics: While many people of different cultural backgrounds may experience socioeconomic challenges, cultural difference does not automatically indicate a lower standard of living, education, etc. The language of this RFP inadvertently encourages Contractors to stereotype people in this way. Socioeconomic challenges should be addressed separately from cultural differences.

5.5.2.4 and 5.5.4.1 Recommendation – Health Literacy and Readily Accessible Information: Section 108 addresses access to assistive technologies for people with disabilities, i.e., TTY protocols, captioning, software accessibility. Section 104 of the Rehabilitation Act addresses the rights of any person who has a physical or mental impairment which substantially limits one or more of such person's major life activities. To suggest that cultural and language differences be addressed under these federal acts is not itself culturally responsive.

The needs of patients and families with different culturally-based expectations of health care, who may nor may not be fluent in English, are not actually addressed through these sections/acts. Examples:
• TTY protocols would only be relevant to cross-cultural patient interactions if the patient is deaf or hard of hearing.
• Audible descriptions of visual content might be useful for a patient from a different cultural background if he/she is blind and if the descriptions are in his/her native language.
• Speaking a mother tongue other than English is not a speech impairment.

NOTE: This section addresses "electronic information and services" but does not address in any way the growing challenges of E-health literacy. E-health literacy is a barrier to equal access to care compounding the already staggering problem of low health literacy in this country.

5.5.3.7.1.8 Recommendation – Health First Colorado Nurse Advice Line: The Medicaid Nurse Advice Line for Members is anathema to the concept of medical home and medical neighborhood. The definition of a medical home includes 24 by 7 telephone care (triage and advice) and the criteria for provider participation in the ACC 2.0 should include this responsibility. Marketing the Medicaid Nurse Advice Line for Medicaid Members through the RAEs and through Health First Colorado gives the wrong message to Medicaid members. The RAEs, the Member’s Medicaid card and Health First Colorado web site and representatives should promote the concept of accessing care through the medical home, not the Medicaid Nurse Advice Line. The Medicaid Nurse Advice Line for Medicaid Members does not communicate with the patient’s medical home with any information about telephone encounters with the patients attributed medical home. This is a serious breach of continuity. Colorado Medicaid could promote the Medicaid Nurse Advice Line for patients or families that don’t have a medical home yet; however, if Medicaid Members (or their parents), who have a medical home, call The Medicaid Nurse Advice Line, the Medicaid Nurse Advice Line should be required to communicate to the attributed PCMP, the medical home, details of the telephone encounter with the attributed member.

5.5.5 Recommendation—Health Needs Survey Timing: We recommend the health needs survey occurs post-enrollment.
Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. In addition, the data may be less reliable because Medicaid enrollees may be less likely to respond accurately. We are also concerned that urgent needs identified through the Peak application process will not be responded to within an appropriate timeframe. Additionally, we wonder how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports.
5.5.5 Recommendation—Health Needs Survey Design: We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. The currently proposed survey is not pediatric focused. The survey needs to be focused on the needs of children at a variety of ages and development stages from birth to 21. It also needs to include the needs of the parents in relationship to their children. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. Determining whether a child-bearing age female enrollee is pregnant should be a priority of the survey, in order to facilitate rapid referral to appropriate health services and community resources. We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.
Rationale: Currently, the goal of the survey is unclear. If the survey is not designed properly, it will have to be redone by the PCMP. The potential for a higher quality survey exists if it is actually administered by someone who actually is going to take responsibility for the care. One possible solution is to have the Healthy Communities personnel embedded within the RAEs to serve as a coordination point with internal RAE care coordinators or outreach staff.


Very clearSomewhat clear5.7.1.5 Recommendations—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform.

5.7.2.1.8 Recommendation—PCMP Criteria: We recommend that the PCMP network requirement for providers to use universal screening tools should explicitly call out developmental screenings for children under age six. However, each of these terms needs a definition. The RFP doesn’t address how the RAE will document compliance and check on the quality of the instruments. Our recommended language change is as follows: “The RAE will collaborate with PCMPs to develop clinical practice guidelines appropriate to the population served. As an aside, the Department needs to consider reimbursement for behavioral health screenings before the PCMP should be required to use them.
Rationale: Developmental Screening is a fundamental part of high quality care for pediatrics and periodic screenings using a standardized tool are included in best practice guidelines. Early detection of developmental delays helps children receive the interventions they need to ensure their healthy development

5.7.3.1 Recommendation—BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.

5.7.4.10 Recommendation—Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.

5.7.4.11.3 Recommendation—Network Access and Provider Ratios: The standard for children’s primary care to provider ratio (in 4.7.4.11.) should be revised from 2,500 to 1,200. At a minimum, the standard should be equal for children and adults. The ratios of necessary mental health providers should be broken out by child and adult. In addition, network adequacy should also include consideration of people who have to utilize non-traditional modes of transportation or public transportation. RAEs should do an initial analysis of accessibility based on public transportation. We know the Medicaid population has higher mental health needs than the general population. In order to assure access to care for 25% of the pediatric population, we recommend a ratio of pediatric mental health providers to child enrollees of one practitioner per twelve hundred (1,200) twelve hundred members.
Rationale: The Pediatric Primary Care ratio is not adequate. Children have many more primary care visits than adults. Children’s mental health needs differ from those of adults and providers of mental health services to children should be trained to provide those services. The driving distance standards fail to acknowledge accessibility for many Medicaid clients who do not have vehicles.

5.7.4.13.5.2 Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2 should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.
Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.


Very clear5.8.4.5 Recommendation—RAE Directory: We recommend adding the following language, “The RAE directory should include resources to support women and families who are experiencing pregnancy-related depression and anxiety, including the Postpartum Support International phone number and website, and other community resources.”
Rationale: There is a wealth of evidence, including from Harvard University’s Center on the Developing Child and the American Academy of Pediatrics, around the long-term negative impact of pregnancy-related depression and anxiety on child health and development. Identifying women with pregnancy-related depression and anxiety and quickly connecting them with care can have a long-term positive impact on Medicaid enrollees. Babies of mothers who are treated for pregnancy-related mood issues have better health and developmental outcomes, are more likely to attend well-child visits, and have decreased emergency and urgent care utilization. These resources and supports should be accessible and available to women during pregnancy, at infant well-child visits, and at post-partum follow-up visits.

2.1.12 Recommendation—Care Coordination Definition: We recommend revising the 2.1.12 definition of care coordination so that it is more client centric and better addresses the function of care coordination as it relates to whole person needs. The sentence should read, “The process of collaborating with a Client to identify needs and viable solutions, create a care plan and then execute the care plan. A care plan may include physical health care, behavioral health care, functional LTSS supports, oral health, specialty care, housing supports, school participation, food resources, employment supports, transportation options, and other medical and community services.”
Rationale: The definition of Care Coordination noted several times in the RFP is very medically focused. The list of providers is comprised of all medical providers. We recommend clarifying that Care Coordination necessitates supporting clients in accessing the full range of services they require to maximize their potential. We also recommend changing this language to be more client-centered so that the clients have some agency in the coordination of their own care.

5.9.2 Recommendation—Population Health Management: We recommend that the population health management plan include prevention, early intervention and the full spectrum of population health management services. We recommend that the plan be required to be review by experts in the populations and strategies outlined. Evidence of that review could be a requirement of the proposal submission.

5.9.3.4 Recommendation – Person Centered Approach to Care Coordination: We recommend that the Department specifically require the Contractor to focus care coordination activities on women who screen positive for pregnancy-related depression and anxiety, enabling those women to receive necessary treatment and support and closing the referral loop with the woman’s provider.

5.9.3.10 Recommendation – Care Coordination Transitions: Additional populations and other circumstances in need of transitional planning need to be included and stated in the RFP. Examples include, but are not limited to, young adults transitioning out of pediatric care, special needs children transitioning between primary and specialty care, children/families receiving behavioral health services or hospitalizations.
Recommendation—Care Coordination for Developmental Delays Pregnancy-related Depression: We recommend that the Contractor be incentivized to focus on care coordination activities for children who screen positive for a developmental delay and women who screen positive for pregnancy-related depression and anxiety, enabling these children and women to receive necessary treatment and support. These care coordination services should include referring affected children and women to medical and community resources, following-up with these families to determine whether they were able to access those resources, and informing the health care provider who documented the positive screen of the services the family or woman was offered and whether the family was able to access those resources.

Somewhat clear5.10.5.2.3 Recommendation—Screening Tools: We recommend specifically identifying developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines.

5.10.6 Recommendation—Provider Training: Provider support should include training providers in best practices related to caring for children and families including completing post-partum depression screening multiple times during the child’s first year and screening for ACEs annually as well as other early childhood mental health competencies. In addition, we recommend that behavioral health providers working with young children have the Colorado Infant/Early Childhood Mental Health Endorsement.

Somewhat clearRecommendation—Preventive Behavioral Health Visits: We recommend that the highest tier of the Alternative Payment Methodology include preventive behavioral health visits for children.
Rationale: The preventive behavioral health visit should be linked with well-child visits (at least 2 per year in the first three years and annually beginning at age 4), provided in collaboration with physical health services, and include: 1) child behavioral health and family psychosocial screening and identification; 2) anticipatory guidance around development, behavior, relational health between the child and caregivers/parents; 3) identification and discussion of environmental influences on well-being; and 4) address identified needs, provide intervention, triage, and connect families to necessary resources. Behavioral health preventive care plans must be integrated with physical health care plans with care teams functioning collaboratively to support optimal health and well-being. This preventive visit could also identify clients who require care coordination/care management services.
QUESTIONS: ALTERNATIVE PAYMENT METHODOLOGY
1. 24 Hour EHR Access: Who is the access to? Providers? Or providers and clients? What does Asynchronous communication mean?
2. Please clarify what a shared care plan: patient is.
Recommendation- Ensure Alternative Payment Methodology Tiers Maximize Potential for Improving Clinical Care:
• The Criteria for Enhanced level should be revised:
1. Health Neighborhood Care Coordination: Recommend moving hospital and ER follow up to Enhanced and away from Advanced.
2. Behavioral Health Integration: Having Behavioral Health providers in health settings should be moved from Advanced to Enhanced.
• The criteria for the Advanced level should include
1. Access to and continuity of care:
1. Advanced practices should offer direct to patient telehealth. This could be defined broadly including email and phone access. Many conditions do not require in-person visits and would significantly reduce the burden on families if care were provided by phone
2. Advanced practices should also be able to offer group prenatal care referrals to their clients. Group prenatal care has been shown to reduce low birthweight births and preterm births and is a promising practice to help reduce disparate infant mortality rates among minority racial and ethnic groups
2. Team Based Care: Team-based care should include lay health workers/non-traditional health workers/navigators etc.
3. Care Management: This should include an assessment of family needs and social needs (i.e. does the caregiver/parent have a medical home? Are all social needs met?)
4. Health Neighborhood: The practice must be engaging a community base care coordination tool where information is shared across medical and social needs. In addition, practices must be supporting patients in accessing dental care.
5. Behavioral Health Integration: Co-location is not integration. Documentation in a single EHR and other metrics of meaningful integration must be met. This includes being able to capture behavioral health utilization from within the physical health practice.
6. Quality Improvement: The practice must be engaged in regular reportable quality improvement activities and demonstrate improvement in designated patient populations.

General Comment on Timelines and Changes in Reimbursement (Section 5.11): FQHC’s are reimbursed at cost and therefore more able to fund changes in processes and infrastructure than private practices. More than half of children on Medicaid are in medical homes in private practice settings; the current reimbursement is primarily fee-for-service and an inadequate PMPM that fails to sufficiently cover the expense of implementing new processes or infrastructure. To successfully implement these changes as outline in the RAE RFP, a practice needs adequate, consistent income for two years. RAEs should be required to provide long-term, consistent, achievable financial support to medical homes to implement necessary changes in infrastructure and processes. The PCMP receives $2 PMPM for meeting certain criteria and can earn another $2.50 (total of $4.50) for meeting certain other value-based criteria.
For track one: Reimbursement and PMPMs to private practice medical homes under ACC 2.0 as currently structured would be less than the reimbursement and PMPMs were under ACC 1.0 initially. The reimbursement plus PMPMs for 2.0 needs to be at least as high as 1.0 was for private practice medical homes to be successful. For ACC 2.0 to be effective, the “higher” FFS reimbursement given for meeting certain criteria would need to be equivalent to Medicare rates. And instead of $2 PMPM baseline, the baseline needs to be $3 PMPM. Success also requires that the criteria for the higher level of reimbursement referred to in the ACC 2.0 proposal remains the same for two years: the fee-for-service remains the same for the first two years and the $3 PMPM is locked in for two years. The criteria for qualifying for portions of the additional $2.50 need to be consistent for 2 years as well. The PCMP would have to be notified of changes to the fee-for-service at least 18 months in advance.

For track two: The criteria and PMPM would need to remain the same (predictable) for two years and be agreed upon by the Department and the PCMP.
Somewhat unclearSee word document sent separately.Somewhat clear5.14.4.8.1.1.1 Recommendation—Number and Types of KPIs: We recommend fewer than 9 KPIs and an attempt to move towards social measures (ie. housing status, food security) and clinical outcomes-based KPIs over the course of the contract. We recommend that as the Department evolves the measures, they continue to identify measures that are specific (not composites of many measures) and that are developmentally-relevant and age appropriate.
Rationale: Too many measures dilutes the focus. Clarity in measures and accessible goals bring both administrative efficiencies and clinical efficacy.
Somewhat clearSee answers sent on separate sheet.Somewhat clearVery clearVery clearSomewhat clear3.3.15.4.2 Recommendation—Flexible Funding Pool: We recommend adding the following language: “The use of the Flexible Funding Pool funds will be approved by the Statewide Program Improvement Advisory Committee. The funds must be used to encourage innovative upstream interventions that address risk and protective factors as well as the social determinants of health .”
Rationale: The State PIAC’s authority over spending the flexible funds would ensure that these funds are used to strategically meet community needs.
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1/10/2017 13:03:10I agree and wish to continueSocial WorkerLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
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1/10/2017 13:27:43I agree and wish to continueTracyMarrsJudi's HouseSocial Service/Community OrganizationNo opinionNo opinionNo opinionLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.

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1/10/2017 13:48:59I agree and wish to continueJeffZayachBoulder County Public HealthLocal Public HealthIt is difficult to see how this version truly integrates multiple aspects of a local community system and assures these components are structured and funded in a way that will support the vision of ACC 2.0. There needs to be a stronger focus on integrating services so that systems do not go back or stay in a co-located system. We would like to see a stronger focus on how payments will move the system more toward integration, including public health and human services in a way that client and health outcomes are improved and supported.Somewhat clearIt would be helpful to better understand how this effort will continue to be supported through administration changes (federal or state) that could threaten this system as the investments in these areas form local partners is significant in order to accomplish aligned goals. In addition, we recommend that all deliverables in section 5.1.6. (especially population health strategy) be posted online within thirty days of the Department’s receipt in order to support transparency and the advisory process.No opinionSomewhat clearThis section seems to lack clarity in terms of how much commitment there is to Substance Use Disorder services. Not ClearThe attribution by PCMP severely limits our ability at the local level to effectively manage population health in a social determinants of health model in the RAE region. We suggest that the attribution to a RAE be by the county of residence. This system, I believe, is in alignment with how Medicaid clients get current services for the most part.Very clearNo opinionSomewhat unclearUnder 5.7.1.3 add “Eligible Local Public Health Agencies”. Under 5.8.3.10
add “… including supporting and building on existing data sharing initiatives within the community and providing de-identified data sets to Health Neighborhood partners so we can accomplish the goals of the RAE.” Under 5.8.3.13 change “Explore appropriate funding…” to “Ensure appropriate funding approaches…” If the RAEs and LPHAs are engaging in specific collaborative activities, the RAE should bear some responsibility in ensuring that there is adequate funding for partners to fully participate. LPHAs have very little unallocated discretionary funding to use in order to fully engage with RAE-focused activities. LPHAs and other, existing community partners cannot be expected to immediately align funding sources to be able to support their role in partnership with a RAE. Identifying community need, defining effective interventions, and then intentionally appropriately funding and implementing those interventions is necessary if the RAE is to be successful.

We also suggest adding the following language: “Ensure LPHA's are engaged as the primary source for assuring core public health services are delivered, as defined in 6CCR-1014-7.”

Because LPHAs are required to assure a set of core public health services, they should be consulted first by RAEs looking for providers for those related services. The RAE would not be restricted to only using the LPHA as a provider, but they should be supported as a primary resource for those services that they are delivering and responsible for.

Last, it should be made clearer that Substance Use Disorder services be included in the integrated behavioral health continuum of care.

Somewhat clearUnder 5.8.4.5 the Community section should, in general, more clearly articulate the possible ways that a RAE could support the community outside of clinical care. For example: Clinical programs screen and refer for social determinants, participating in community coalitions and deepening engagement, coordinating community initiatives, implementing on-site interventions (ie on-site foodbank or enrollment for SNAP/WIC), modeling health behaviors (e.g. own cafeteria has healthy policies), intentional hiring from disadvantaged neighborhoods, and community advocacy & policy engagement.

Under 5.8.4.5.1 add that if created by the RAE, the resource directory should be available for use by all Health Neighborhood members, even those who do not bill Medicaid.

Under 5.8.4.9 Existing language "As hospitals serve as an anchor for many Communities, the Contractor shall engage with hospitals to perform community health needs assessments and to develop and implement strategies to reduce health inequities and disparities in the Community." Edit this to state: “… to perform community health needs assessments without disrupting or duplicating existing relationships.” Both non-profit hospitals and local public health agencies have requirements to perform community health needs assessments. Organizations completing needs assessments at the local level should work toward alignment and not duplicate those assessments and collaborate on implementation plans. Public Health’s role is to bring community partners together around these efforts. While new partners are often welcomed, they should enter the partnership in a non-competitive manner with an eye toward adding to rather than disrupting the existing work.

Under 5.8.5.1 add “Colorado Health Assessment and Planning System (CHAPS) process of local public health assessments and community health improvement plan development and implementation as defined in CRS 25-1-505.”

Under 5.8.6.1 We cannot find a reference to “Community Forums” in other sections of the RFP. If it exists, language should include a requirement to use existing community forums where possible. Many existing community partners are hosting community forms and engaging community members and patients. The RAE should align with not compete or duplicate these existing local activities.

Under 5.8.6.1.10 Collaboration with Local Public Health Agencies; this report should be shared with the Local Public Health Agencies on which the RAE is reporting.

In general we also recommend that there be an increased emphasis on working with the child welfare system and criminal justice system. In addition, it is not clear, and should be emphasized, how REA's are expected to work in coordination with hospitals and DSRIP efforts.

Not Clear5.9.2.2.1 add: “We recommend that the population health management plan include prevention, early intervention and the full spectrum of population health management services. We recommend that the plan be required to be review by experts in the populations and strategies outlined. Evidence of that review could be a requirement of the proposal submission."

5.9.2 as noted earlier attribution should be based on geographic location of residence so they get the benefit of coordinated population health management and wrap around social determinant services within the county of residence.

5.9.2.4 edit this existing language: "The Contractor shall engage Members and Network Providers in developing and revising its Population Health Management Plan, share the final plan with Network Providers, and assist them in delivering Care Coordination, wellness activities and other population health interventions based on the Population Health Management Plan." with this:
“… shall engage Members, Network Providers and Health Neighborhood partners…” Again, if there are health neighborhood partners who are critical to the delivery system that do not bill Medicaid for services, they should still be provided with the plan in order to ensure wrap around social determinants supports that align across the community.

5.9.3. Add new line: “The Contractor shall assure linkage with existing community care coordination relationships, as well as contracts established and successfully implemented in ACC Phase I.” Phase II should build upon the great work of ACC Phase I. While we don’t expect that contracts would be uniformly implemented from Phase I into Phase II, it would be highly disruptive to the local community connections if the previous care coordination relationships were dissolved.

5.9.3.7.7 Existing language is "Reduces duplication and promotes continuity by identifying a lead care coordinator for Members receiving Care Coordination from multiple systems"; add “and supports existing care coordination relationships.”
Somewhat clear5.10.7.4.5 It is imperative that we are able to acces and use substance abuse data in helping manage populations within the RAE. The Department should clarify how they will provide for the use ofr data under 42 CFR Part 2 which has been a difficulty at the local level.

5.10.9.1 Current Language: “The Contractor shall distribute, in aggregate, at least thirty percent (30%) of the Contractor’s administrative PMPM payments received from the Department to their PCMP network and Health Neighborhood.” We recommend adding the following language: “At least some of those funds must be distributed to Health Neighborhood beyond PCMPs.” We also recommend that the Department continue to seek ways to ensure that the funding in the Medicaid program is aligned with the areas where there is the greatest return on investment and that there continues to be increases in resources allocated to primary care (including primary behavioral health care) and decreases in investments in secondary and tertiary care as needs dictate.

Health and behavior codes would enable clinicians to provide necessary counseling and treatment for medical conditions and diagnoses (e.g., weight management/obesity, asthma, congenital anomalies, developmental diagnoses, feeding disorders, sleep disorders) that can have long-term effects for healthcare costs and outcomes. In order to meet the needs of the community, LPHAs, Human services organizations and other providers should be able to provide Medicaid clients who do not meet a diagnosed mental condition with behavior health intervention. Early Intervention and Prevention services for children are not presently being offered adequately, and the proposed RFP does not change the offering. In addition, the focus on the provision of high-acuity services in the next iteration of the capitation makes the future network potentially even less effective at Prevention and Early Intervention. Prevention and Early Intervention services may be better provided by providers outside of the specialty behavioral health network since this work requires specialization and training beyond the scope of what licensed behavioral health professionals are required to have and the services are often delivered in community settings including primary care, early care and education, social service programs (e.g., WIC offices), and homes (e.g., home visiting). This should include opening H codes as a fee-for-service billing mechanism to allow for assessment of need/suitability for services, psycho-education and counseling around health and well-being, group-based service delivery, and community engagement, all without requiring a behavioral health diagnosis.

5.13 It should be noted that local public health and human services agencies have an important role both in helping communities and community partners have access to and understand community-level health data through their formal role in community health assessment and planning. For LPHAs to be successful and valuable partners in improving the health of their communities (and to meet their statutory requirements), they need full access to de-identified data within the system (as legally permitted).

5.13.1.4.2.7 existing language states: "The Contractor shall support and encourage Network Provider use of the BIDM Web Portal." Edit to include: “… support and encourage Network Provider and Health Neighborhood partner use of the BIDM Web Portal, and will provide technical assistance on the use of the portal.”

Add new line: “The Contractor shall provide raw data exports, upon request and as needed, for Network Provider and Health Neighborhood partners engaged in formal community heath assessments within the region."

5.13.2.1.1 Current Language: “The Contractor shall possess and maintain an electronic Care Coordination Tool to support communication and coordination among members of the Provider Network and Health Neighborhood. The Contractor shall make it available for use by providers and care coordinators not currently using another tool.” We recommend that the care coordination tool be required to also transmit information across medical and non-medical systems including local public health agencies, human services agencies, and other local service providers that meet the intention of providing services that impact the social determinants of health (e.g. oral health care providers, EPSDT, Early Intervention Colorado, home visitation programs, school-based health clinics, the Colorado Department of Education, Colorado Department of Human Services, Colorado Department of Public Health and Environment, the immunization registry, housing, food, child care and early learning settings, etc.)

No opinionNot Clear5.12.5.4 There is a need for more clarity regarding where the offset for fee for services funding will come from.

It is also imperative that in an integrated services model that services are able to be offered in alternative settings such as schools and integrated service practices.

5.12.5.5.14 The social detox is a vital piece of the Substance Use Disorder continuum of care and should be fairly reimbursed at a per diem rate.

5.12.5.6.2.3 Parity for SUD clients does not exist and creates a significant road block for dually diagnosed clients. Unless this is addressed, clients will continue to over-utilize the emergency department.

Appendix N Special Connections should include SUD recovery services and appropriate coding.
Very clearSomewhat clear5.14.4.1 While it is good to ensure that the contractors are prepared for the performance measurement and reporting to be placed in the public domain, HCPF should make an outward commitment to publish the performance data in an easily accessible, online format.

5.14.4.8.1.1.1 We recommend fewer than 9 KPIs and an attempt to move towards social measures (ie. housing status, food security) and clinical outcomes-based KPIs over the course of the contract.

5.14.9.2.1.6 We agree that this is a sufficient way to ensure that LPHAs are included. The PIAC members should be made public on the RAE website so other LPHAs and community partners know who is representing their interests on the PIAC.

The Contractor should be required to share the learning and expertise gained from the Operational Learning Collaborative with community partners through presentations, active participation on community boards, etc.
Very clearVery clearVery clearNot ClearThe proposed fee for service model is not in alignment with where I though Colorado was headed and does not align with other payment reforms such as SIM.
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1/10/2017 14:38:05I agree and wish to continueBeckyOttemanSoutheast Health GroupProviderSoutheast Health Group is appreciative of this opportunity to provide feedback regarding the Accountable Care Collaborative Draft RFP. As the only Essential Community Provider in the rural/frontier region of southeastern Colorado who has delivered mental health services since 1957, behavioral health services (mental health and substance used disorder) since 2006, and physical healthcare services in a reverse-integration model (primary care providers on-site at our behavioral health locations) since 2013 we have a vested interest in making sure that our clients and communities continue to receive exceptional healthcare services supported by a system of local control from a contract that is designed to provide the appropriate funding, care design, measures and outcomes, and accountability to our clients and communities and HCPF within reasonable timelines and deliverables.

According to the Institute for Healthcare Improvement, 5 percent (5%) of the patient population generally represents 50 percent (50%) of total costs across all payers. This segment of the population is complex and dynamic. They struggle with chronic physical and mental illness, poverty, and social isolation. They make frequent use of the healthcare system and often have poor outcomes. Their care can be chaotic, wasteful, and stressful for both patients and health care staff. The standard care system is not working for this segment of the population.

The RFP is unclear about the role of the behavioral health centers as a key resource for these complex, highest cost patients. These same patients are often "fired" from PCP's for some form of noncompliance. The behavioral health system in Colorado is uniquely skilled to meet the needs of the most complex patients. While we support a "no wrong door" approach, we also would like to see language that recognizes the expertise and workforce required to successfully manage complex patients while improving outcomes and reducing cost of care.

A capitated, full-risk contract which has been so successful over the past 20+ years in saving the State millions of dollars and delivering exceptional care should be one of the many goals of a behavioral health RFP. Unfortunately, this ACC 2.0 Draft RFP is not a behavioral health RFP and does not lend itself to the preservation and continued innovation of a system that will help to maintain the existing owner/provider structure that has been important in bringing about the many successes and exceptional care design that our clients have become accustomed to receiving. Clarification is needed from HCPF to show that this RFP is not moving us backwards into a FFS system and away from best practice. A requirement of the RFP should be that the RAE contract must ensure that a provider-driven structure is utilized and focuses on what is best for the clients and communities in the region.
Somewhat clearSection 5.1.8.2.4.9 - In a rural/frontier environment where everyone knows everyone else, or is related to others in the community, conversations can happen at any time and at any place. Of course, we would never violate HIPAA and our own ethical code of conduct, but "non-routine communication" would need to be clarified by HCPF so we know what is meant by this term. Plus, what HCPF may deem to be "non-routine" and what we deem to be "non-routine" can greatly vary depending on the circumstances. Many different interpretations of this term/section may happen.

Section 5.1.10.2 - Southeast Health Group has multiple materials, programs, procedures, etc. that have been designed and developed internally to meet the requirements of different funding sources (OBH Block Grant, private grants, etc.) and different program and population needs. Many of these internally developed sources are used across systems and funding sources because of our integrated care model. Some type of exception or permission needs to be made available to approve the work the agency does in meeting the needs of our clients and communities.
Somewhat clearSections 5.2.3 thru 5.2.8 - Being micromanaged takes our focus away from providing effective and efficient services to a focus on our employees. Clients and their needs should always come first, not the needs of our agency, the RAE, or the State. Having to obtain written approval for Key Personnel positions and not reassigning individuals to positions that better use their strengths ties our hands and is the definition of being inflexible. Also, recruitment and retention of Key Personnel is not always possible in our rural/frontier region and can often take years to accomplish, thus the reason that staff may be reassigned quite often depending on the needs of the agency and the clients.

Section 5.2.14.2 - "The Contractor shall not subcontract more than forty percent (40%) of the total value of this contract." Is this even possible knowing that the RAE will have inpatient contracts and contracts for outpatient services? A lot more clarification is needed.
Somewhat clearSection 5.3.2.1 - What is HCPF's definition of an "integrated program"? There is not a definition of integration throughout the Draft RFP.Somewhat clearSection 5.4.5 - If clients will be attributed based on where their PCP is located and they can change their PCP at any time, there will have to be a lot of monitoring and tracking done and reported to agencies by HCPF. Also, many of our clients are referred to a doctor outside of our capitated region where the client's PFP is located because of our rural/frontier environment. Who will receive the capitated payment? I am afraid that the money will not follow the client, thus leaving the providers who are providing the most services unfunded or underfunded. Plus, this system of attribution will cause a lot of confusion for the client and for all of the agencies involved in the client's care.Very clearSection 5.5.5 - Even though the Draft RFP indicates that the Health Needs Survey developed by HCPF is a brief set of questions, this will still be a very time intensive requirement. One of the biggest complaints that is received from other agencies is about all of the paperwork that we require! During enrollment most all clients are already stressed or traumatized enough without adding more into the process for them to be seen by a provider.Somewhat clearSections 5.6.5.7 & 5.6.5.7.1 - Provider relations and client complaints should be handled at the local/regional level. There is always more to the story and the local providers and agencies are in the best position to develop a solution with the client that meets the needs of the client and is communicated to all agencies involved. Plus, some clients or family members will see the State's involvement as a way to bypass the local behavioral health center which will only complicate the situation even further. We encourage our clients to bring forward their concerns through our Patient Advocacy Program. By having our own staff involved in the solution we are able to improve the quality of our programs and patient engagement based on each concern and solution.Very clearNo Comments.Somewhat clearSection 5.8.3.1 - Surely, behavioral health providers and community mental health centers not being listed in this section as one of the Health Neighborhood Providers is an oversight on the part of the Department.Somewhat clearSection 5.9.2.2.4 - Asking for descriptions of each intervention is unrealistic and extremely time consuming. It is not clear how doing this will improve delivery of services and outcomes and reduce costs.Very clearNo CommentsVery clearNo CommentsSomewhat clearSection 5.12.5.4 - The six (6) sessions of low-acuity behavioral health services in a primary care setting per episode of care fragments the current system that is working. This gives primary care settings an open ticket to bill for 6 sessions and then transfer the client over to the behavioral health center when the client is noncompliant or difficult to manage. I can envision some primary care settings seeing the patient for 2 or 3 sessions and deciding that they no longer want to work with the client for a variety of reasons and ending their relationship with the patient without providing the appropriate warm hand-off to the behavioral health center. Not only does it fragment the system, but it does not encourage collaboration and eventually integration of services.

Section 5.12.12 - Requiring an MLR of 89% makes the assumption that all of the services that are provided by the behavioral health center have a code attached to them. This is not true and will have a huge impact on our ability to meet the MLR requirements. We provide many services that do not have a code attached to them as part of our community benefit. This seems to be more of a punishment rather than an incentive; especially for those agencies that provide care in an integrated system.
Somewhat clearNo CommentsSomewhat clearSection 5.14.7 - Quality of care concerns should be addressed at the local level where the care has taken place and not at the State level. The providers who have the relationship with the client need to be responsible for improving their quality of care. Any concerns that are brought forward help the agency improve performance. When the State gets involved it muddies the waters and confuses the client and the process.Somewhat clearNo CommentsVery clearNo CommentsSomewhat clearNo CommentsSomewhat clearNo Comments
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1/10/2017 15:19:33I agree and wish to continueKellieTeterDenver Public HealthSocial Service/Community OrganizationRecommendation—Staffing: The scope and scale of the ACC is significant. We recognize the technical complexity and volume of work for the Department of Health Care Policy and Financing to effectively administer and oversee this program. We fully support Departmental requests for additional staffing and especially requests for staffing with the appropriate level of expertise. The functions the Department of Health Care Policy and Financing must perform in order to ensure Contractor accountability and that the program runs smoothly requires expert level staff, hiring this level of staff requires appropriate compensation. We support the Department in those requests.

PRIORITY Recommendation—Winnable Battles: The RFP should clearly list the winnable battles for which the RAE is held accountable. We recommend that the RFP focus on the following strategies:
• Increase the percent of mothers who are appropriately screened and treated for depression.
• Decrease untreated dental decay and decay experience in children.
• Increase access to and utilization of tobacco cessation services tailored for pregnant and postpartum women.
• Increase use of long-acting, reversible contraceptive methods.
In general, we recommend that many of the aspirational goals in the RFP be narrowed, prioritized and defined. We recognize that the capacity of both our providers and the RAEs is finite and by prioritizing we will be more likely to be successful in all endeavors.
Rationale: There are many strategies listed in the Winnable Battles documents and the RAEs will not have the resources to focus on all of them. Providing more clarity on priorities and expectations will ensure that the RAEs dedicate their efforts where they can effectively intervene. The strategies we have highlighted above are within the scope of work of the RAEs and have strong evidence supporting their effectiveness at improving the health of children and families.
Recommendation—Deliverables: We recommend that all deliverables in section 5.1.6. (especially population health strategy) be posted online in their entirety, with confidential patient information removed, within thirty days of the Department’s receipt in order to support transparency and the advisory process. Reports should be structured in ways that are easily understood by members, network providers, stakeholders, and the public at large.
Rationale: Publicly sharing deliverables will ensure that the program is transparent and that advocates can effectively assist the Department in monitoring the program.

Recommendation—Provider Directory: We recommend that the provider directory be up to date, interactive, and accessible and include provider type.
Rationale: Provider type is a crucial piece of information to ensure that the contacted provider will serve the client’s need. Provider lists in PDF or other formats are difficult for clients to utilize. A dynamic and searchable provider directory that enables a client to filter the list and find a provider that is close, will take new members, and is appropriate for their age/gender and other needs is an important mechanism for supporting access.

Recommendation-Key Personnel Expertise: At least one of the Chief Clinical Officer, Quality Improvement Director, or Utilization Management Director must have behavioral health expertise and at least one of the Chief Clinical Officer, Quality Improvement Director, or Utilization Management Director must have pediatric expertise.
Rationale: Since the bulk of the dollars in the contract are dedicated to behavioral health, it is crucial that the leadership group include deep behavioral health expertise. Since more than 500,000 children are enrolled in the program, making up the largest demographic of Colorado Medicaid enrollees, and the needs of children and youth are fundamentally different than the needs of adults, pediatric expertise in key positions of the leadership group is necessary to ensure that the programs serve both. Ideally, expertise in pediatric behavioral health would also exist within the leadership team.
PRIORITY Recommendation—Health Needs Survey Timing: We recommend the health needs survey occurs post-enrollment.
Rationale: While we understand the operational opportunity and potential complications of doing the screening later in the process, the risks of deterring people from applying for Medicaid are significant. We are also concerned that urgent needs identified at the time of application by an eligibility technician or through the PEAK application process will not be responded to within an appropriate timeframe. The questions within the Health Needs Survey may also go beyond what is legally allowed by the Centers for Medicare & Medicaid Services to be required on a Medicaid application, and exceed what is allowable for other assistance programs incorporated within the PEAK application (e.g. SNAP, Colorado Works, and subsidies through Connect for Health Colorado). Additionally, we are concerned with how individuals who are not deemed eligible for Medicaid but who have identified needs will be connected to necessary resources, services, and supports. Finally, because the majority of Coloradans eligible for Medicaid are already enrolled in the program, conducting the Health Needs Survey at the time of application will not capture the health needs of the majority of people enrolled with the RAE.

PRIORITY Recommendation—Health Needs Survey Design: We recommend that the Health Needs Survey be a requirement of the RAE and be family and child oriented. We recommend that the screening be a triage tool to identify how quickly clients require outreach and by whom. Determining whether a child-bearing age female enrollee is pregnant or in the first year postpartum should be a priority of the survey, in order to facilitate rapid referral to appropriate health services and community resources. Specifically, we recommend that Question 4 in Appendix H be asked of ALL child-bearing age female clients, and that it be followed by a question that reads as follows: “Have you given birth in the last 12 months?” We recommend strategies for soliciting information from families so that heads of household do not have to provide duplicative information (e.g., family-level information) on each individual application but that the information of individual parents (for example) remains confidential.
We recommend that the community-level results of Health Needs Surveys be explicitly tied to the actions proposed in the population health strategy.
Rationale: Identifying behavioral health, physical health, and social needs of pregnant women and women in the first year postpartum should be a priority upon enrollment. Regional Accountable Entities should be responsible for the screening and for referring women to appropriate resources based upon screening results.

Recommendations—Telehealth: We recommend that the RAE consider telehealth broadly as a strategy to reduce barriers to access to the healthcare system. We recommend deleting the following sentence (5.7.1.5), The Contractor “May use mechanisms such as telemedicine to address geographic barriers to accessing clinical providers…” and adding, “The contractor should include the development of a broad telehealth capacity (including psychiatric and other consultation services for providers and direct to client phone, email and other communications to replace in person visits when clinically appropriate) within the network as a way to build capacity and reduce barriers to accessing care.”
Rationale: For Medicaid enrollees, especially children and families, with many competing demands on their time, money and energy, accessing a provider by phone or email is an important part of health care reform. For providers, access to psychiatric and other specialty providers through phone or video consultation makes these services more readily available for clients in all parts of the state.

Recommendation—BH Network Administration: We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE). This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.
Rationale: The goal of this change is to ensure an adequate network and avoid potential conflicts of interest. Having a third party entity perform credentialing would achieve the following:
• Reduce administrative burden on providers in contracting with multiple RAEs
• Remove conflicts of interest related to expanding the behavioral health network
• Remove potential negative consequences of having different RAE behavioral health networks
• Would ensure that the behavioral health network is adequate by ensuring that there is one broad statewide network.

Recommendation—Definition of BH Provider: We recommend that the term “behavioral health provider” be defined to clarify that the requirement of two behavioral health providers does not refer to individual clinicians or teams, but rather entirely separate brick and mortar entities so that access requirements are more clearly understood.
Rationale: Many clients and families want a choice other than the local CMHC. Clarification of this term would ensure that these criteria would give clients that meaningful choice in selecting a qualified behavioral health service.

Recommendation—Network Access: The standard for children’s primary care to provider ratio (in 4.7.4.11.) should be revised from 2,500 to 1,200. At a minimum, the standard should be equal for children and adults. The ratios of necessary mental health providers should be broken out by child and adult. In addition, network adequacy should also include consideration of people who have to utilize non-traditional modes of transportation or public transportation. RAEs should do an initial analysis of accessibility based on public transportation.
Rationale: The Pediatric Primary Care ratio is not adequate. Children have many more primary care visits than adults. The driving distance standards fail to acknowledge accessibility for many Medicaid clients who do not have vehicles.

Recommendation—Appropriate BH Follow-up: We recommend that 5.7.4.13.5.2. should also include, “and follow-up appointments at clinically optimal and indicated intervals.” We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.
Rationale: We appreciate the clarification that intake appointments do not fulfill the criteria for a first appointment. However, we are concerned that the first appointment will be made in a timely fashion and then, like now, the following appointments will be delayed due to insufficient numbers of clinicians.
PRIORITY Recommendation—RAE Directory: We recommend adding the following language, “The RAE directory should include resources to support women and families who are experiencing pregnancy-related depression and anxiety, including the Postpartum Support International phone number and website, and other community resources.”
Rationale: There is a wealth of evidence, including from Harvard University’s Center on the Developing Child and the American Academy of Pediatrics, around the long-term negative impact of pregnancy-related depression and anxiety on child health and development. The effects of maternal depression are linked to “reductions in young children’s behavioral, cognitive, and social and emotional functioning.” Children raised by clinically depressed mothers are at risk for later mental health problems, social adjustment difficulties, and difficulties in school. One study also found that women suffering from maternal depression had health care costs that were 90 percent higher than those of non-depressed women. Identifying women with pregnancy-related depression and anxiety and quickly connecting them with care can have a long-term positive impact on Medicaid enrollees. Babies of mothers who are treated for pregnancy-related mood issues have better health and developmental outcomes, are more likely to attend well-child visits, and have decreased emergency and urgent care utilization. These resources and supports should be accessible and available to women during pregnancy, at infant well-child visits, and at post-partum follow-up visits.

PRIORITY Recommendation—Care Coordination for Pregnancy-related Depression: We recommend that the Contractor be incentivized to focus on care coordination activities for women who screen positive for pregnancy-related depression and anxiety, enabling those women to receive necessary treatment and support. These care coordination services should include referring women who screen positive for pregnancy-related depression to medical and community resources, following-up with those women to determine whether they were able to access those resources, and informing the health care provider who documented the positive screen of the services the women was offered and whether she was able to access those resources.
PRIORITY Recommendation—Screening Tools: We recommend specifically identifying that the RAE should maintain and provide a list of Medicaid-approved developmental screening tools and behavioral health screening tools for children under age 6 and pregnancy-related depression screening tools for pregnant and postpartum women to promote adherence to clinical best practice guidelines and that the RAE should support the use of these tools.

PRIORITY Recommendation—Provider Training: Provider support should include training providers in best practices related to caring for children and families including completing pregnancy-related depression screening multiple times during pregnancy and during the child’s first year. The contractor should also provide guidance around documentation of screening results and appropriate billing procedures for each type of setting.
Recommendation—Preventive Behavioral Health Visits: We recommend that the highest tier of the Alternative Payment Methodology include preventive behavioral health visits for children.
Rationale: The preventive behavioral health visit should be linked with well-child visits (at least 2 per year in the first three years and annually beginning at age 4), provided in collaboration with physical health services, and include: 1) child behavioral health and family psychosocial screening and identification; 2) anticipatory guidance around development, behavior, relational health between the child and caregivers/parents; 3) identification and discussion of environmental influences on well-being; and 4) address identified needs, provide intervention, triage, and connect families to necessary resources. Behavioral health preventive care plans must be integrated with physical health care plans with care teams functioning collaboratively to support optimal health and well-being. This preventive visit could also identify clients who require care coordination/care management services.

QUESTIONS: ALTERNATIVE PAYMENT METHODOLOGY
1. 24 Hour EHR Access: Who is the access to? Providers? Or providers and clients? What does Asynchronous communication mean?
2. Please clarify what a shared care plan: patient is.


Recommendation- Ensure Alternative Payment Methodology Tiers Maximize Potential for Improving Clinical Care:
• The Criteria for Enhanced level should be revised:
1. Health Neighborhood Care Coordination: Recommend moving hospital and ER follow up to Enhanced and away from Advanced.
2. Behavioral Health Integration: Having Behavioral Health providers in health settings should be moved from Advanced to Enhanced.
• The criteria for the Advanced level should include
1. Access to and continuity of care:
1. Advanced practices should also be able to offer group prenatal care referrals to their clients. Group prenatal care has been shown to reduce low birthweight births and preterm births and is a promising practice to help reduce disparate infant mortality rates among non-white racial and ethnic groups.
2. Team Based Care: Team-based care should include lay health workers/non-traditional health workers/navigators etc.
3. Care Management/Care Coordination: This should include an assessment of family needs and social needs (i.e. does the caregiver/parent have a medical home? Are all social needs met?)
4. Health Neighborhood: The practice must be engaging a community-based care coordination tool where information is shared across medical and social needs. In addition, practices must be supporting patients in accessing dental care.
5. Behavioral Health Integration: Co-location is not integration. Documentation in a single EHR and other metrics of meaningful integration must be met. This includes being able to capture behavioral health utilization from within the physical health practice.
6. Quality Improvement: The practice must be engaged in regular reportable quality improvement activities and demonstrate improvement in designated patient populations.
PRIORITY Recommendation—Six Behavioral Health Visits:
We strongly support the availability of six behavioral health sessions without a covered behavioral health diagnosis as this is the primary way that the draft RFP contemplates expanding access to behavioral health services in the next iteration of the ACC program. This program change is especially important for children who may not yet have a covered diagnosis but could benefit from behavioral health services. Allowing these six behavioral health visits in primary care settings will dramatically improve access to these services for Medicaid clients. We are confident that with care coordination and data support provided by the RAEs, information from these visits will be able to be shared across health care providers as necessary and appropriate while protecting patient privacy.
We recommend eliminating the “low-acuity” terminology because it is subjective and unclear. Further, we support the delivery of the right type of care in the appropriate setting and think that any issue that can be treated in a primary care setting over a defined period of time should be allowed to be treated in these visits, regardless as to the acuity of the issue. A client could have an acute but short-term need that could be met by these services.
We also recommend specifying that these visits allow for dyadic visits for a caregiver and baby together when mother demonstrates symptoms of depression or anxiety.
We also recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).
Therefore, please adjust the language as follows: The Department will increase access to behavioral health interventions by encouraging the delivery of behavioral health within primary care settings by a license-eligible behavioral health practitioner. Behavioral health treatment, including dyadic behavioral health intervention for infants and young children with their parents present, delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.
We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.

Recommendation—Out of Network Access Requirements: We recommend removing the “adequately and timely language” at 5.12.6.9. and adding, “ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers” so the section reads, “If the Contractor is unable to provide covered behavioral health services to a particular Member within its network, the Contractor shall ensure provision of the service by a qualified clinician while meeting the same standards of timeliness as required of in-network providers at no cost to the Member.”
Rationale: Limits to the network should not be a reason for failure to meet the timeliness standards. It is up to the Contractor to ensure network adequacy and approve access to care when the network does not meet a Member’s needs.

PRIORITY Recommendation—Move BH Prevention/Early Intervention to Fee For Service: We recommend the State remove Early Intervention and Prevention from the behavioral health capitation and offer it as a state plan service, in addition to the six visits discussed above, and define the behavioral health early intervention and prevention services required.
These services include activities such as:
1) Screening, identification, triage, intervention, and referral when concerns or delays are identified using standardized screening protocols; Specifically, postpartum depression screening, developmental screenings, ACES and MCHATS should be reimbursed in the frequency that is clinically recommended and at appropriate reimbursement levels;
2) Health promotion services that support the development of nurturing relationships between caregivers/parents and children, provide anticipatory guidance and support around typical developmental issues, and help address psychosocial complexity before it impacts well-being;
3) Prevention efforts that provide a higher level of services and supports to families identified as being at risk or vulnerable because of child, family, or environmental factors that could negatively impact development; and
4) Early childhood behavioral health intervention services provided by a qualified workforce of behavioral health professionals for those families identified as having complex needs and/or with identified adversity and behavioral health needs.
5) Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
Rationale: Early Intervention and Prevention services for children are not presently being offered adequately, and the proposed RFP does not change the offering. In addition, the focus on the provision of high-acuity services in the next iteration of the capitation makes the future network potentially even less effective at Prevention and Early Intervention. Prevention and Early Intervention services may be better provided by providers outside of the specialty behavioral health network since this work requires specialization and training beyond the scope of what licensed behavioral health professionals are required to have and the services are often delivered in community settings including primary care, early care and education, social service programs (e.g., WIC offices), and homes (e.g., home visiting). This should include opening H codes as a fee-for-service billing mechanism to allow for assessment of need/suitability for services, psycho-education and counseling around health and well-being, group-based service delivery, and community engagement, all without requiring a behavioral health diagnosis.
Recommendation—Care Coordination Tool: We recommend that preference be given to bidders that provide a plan for or are positioned to move in the direction of universal interoperability with regard to the collection and sharing of information across medical and non-medical systems, including oral health care providers, EPSDT, Early Intervention Colorado, home visitation programs, school-based health clinics, the Colorado Department of Education, Colorado Department of Human Services, Colorado Department of Public Health and Environment, the immunization registry, and child care and early learning settings.
The care coordination tool should potentially be accessible to clients as well as healthcare providers.
We recommend that the RAEs collaborate on a statewide tool that can interface with all electronic medical records.
Rationale: We support the proposal for a care coordination tool that allows for the collection and sharing of information across systems, and recognize that such a tool must be interoperable with electronic medical records and other systems in order to function in a way that is useful across provider types. If the function of this tool is to enhance care coordination (rather than just track it) then it must be able to transmit information in order to support the delivery of care.
Recommendation—KPI Evolution: The current contract reads such that the KPIs would remain the same over the course of the contract. If the program is successful, ability to improve on some of the KPIs will likely plateau before seven years. After a reasonable period of percentage improvement, measures should become discrete benchmarks. Maintenance of benchmarks should be a prerequisite for future payment incentives. We recommend the following language, “Reimbursement to be based on percent improvement until a benchmark is met. At that time, those KPIs will become a prerequisite or gate for receiving any incentive payment and new KPIs will be added.”
A percent improvement for seven years does not allow for the possibility that some peak performance is reached. Keeping the KPIs static until 2025 does not allow the state to adjust for new priorities.

Recommendation—Number and Types of KPIs: We recommend fewer than 9 KPIs to allow for focus on the part of the RAEs and providers. We recommend that as the Department evolves the measures, they continue to identify measures that are specific and unique (not composites of many measures) and that are developmentally-relevant and age appropriate.
Rationale: Too many measures dilutes focus. Clarity in measures and accessible goals bring both administrative efficiencies and clinical efficacy.

Recommendation—Types of KPIs: We recommend that KPIs for RAEs and providers should be aligned with the criteria for Alternative Payment Methodology tiers, to allow for focus on the part of the RAEs and providers.
Rationale: Too many sets of measures dilute focus. Clarity in measures and accessible goals bring both administrative efficiencies and clinical efficacy.

PRIORITY Recommendation—Wellness KPI Definition: We recommend that the wellness visits measure KPI be more specific: Most adults and older children should be measured for visits, but for children under six, the indicator should be developmental screening, and for pregnant and postpartum women, the measure should be receipt of a depression screen.
Rationale: Developmental and depression screenings occur within the context of a wellness visit and so would capture both the presence of a wellness visit and the quality of that visit for these key populations. This also allows for a focus on pregnancy-related depression screening, in alignment with several other state initiatives. Children six months of age who had documentation of a maternal depression screening for the mother is a State Innovation Model (SIM) quality measure. The state’s 2016-2020 Maternal and Child Health Needs Assessment identified women’s mental health including pregnancy-related depression as a priority area. The state has also identified maternal depression as a component of one of Colorado’s ten winnable battles: mental health and substance abuse. The U.S. Preventive Services Task Force recommends universal screening for depression in pregnant and postpartum women, noting that even studies of the effect of screening plus “minimal additional intervention” have shown reductions in postpartum depression at follow-up.

PRIORITY Recommendation—Behavioral Health Engagement KPI: Rather than behavioral health engagement, we recommend measuring age and stage appropriate behavioral health screening, specifically encouraging pregnant and postpartum women to receive a depression screen.
Rationale: Since behavioral health engagement is already held to payment under the capitation, it makes sense to have “medical” portion of the funding tied to those indicators influenced by medical factors. As with the recommended measure above, this change would also allow for a focus on pregnancy-related depression screening, in alignment with several other state initiatives. Children six months of age who had documentation of a maternal depression screening for the mother is a State Innovation Model (SIM) quality measure. The state’s 2016-2020 Maternal and Child Health Needs Assessment identified women’s mental health including pregnancy-related depression as a priority area. The state has also identified maternal depression as a component of one of Colorado’s ten winnable battles: mental health and substance abuse. The U.S. Preventive Services Task Force recommends universal screening for depression in pregnant and postpartum women, noting that even studies of the effect of screening plus “minimal additional intervention” have shown reductions in postpartum depression at follow-up.

Recommendation—Flexible Funding Pool: We recommend adding the following language: “The use of the Flexible Funding Pool funds will be approved by the Statewide Program Improvement Advisory Committee. The funds must be used to encourage innovative upstream interventions that address risk and protective factors as well as the social determinants of health.”
Rationale: The State PIAC’s authority over spending the flexible funds would ensure that these funds are used to strategically meet community needs.
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1/10/2017 15:25:52I agree and wish to continueAngelaOakleyMental Health Center of DenverProviderI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

The HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
No opinion 5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
No opinion5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionNo opinion5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
No opinion5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.
No opinion5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
No opinion5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
No opinion5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
No opinionNo opinion5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
No opinion5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.No opinionNo opinion6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
No opinion7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
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1/10/2017 16:20:56I agree and wish to continueSocial Service/Community OrganizationLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
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1/10/2017 16:29:50I agree and wish to continueGinaGurreriJudi's HouseAdvocateLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
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1/10/2017 16:48:08I agree and wish to continueJessicaCarneyJudi's House/JAG InstituteEmployee Licensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
57
1/10/2017 17:01:55I agree and wish to continueShelleyMcKittrickCity of AuroraCity Homelessness Program DirectorIn general, the RFP is clear, if not conciseVery clearVery clearVery clear5.8.4.2 - add homeless services/housing to this section as we know that housing IS healthcare.
5.8.4.7 - excellent!
5.8.4.8 - Suggest: "The Contractor shall collaborate with Community organizations to gather information that will help to identify service gaps and needs and will share these identified gaps and services across the service providing continuum.
Very clearAdd: drop-in centers and libraries
58
1/10/2017 17:58:34I agree and wish to continueAlexandraMersJudi's HouseProviderNo opinionLicensed mental health clinicians and related trainees working in a community-based child and family grief care center should be able to provide and be reimbursed for grief care services provided to a child who has experienced a significant loss. The Department should consider designating community-based settings where licensed mental health clinicians and related trainees work as eligible to bill and be reimbursed for these services. Clinicians must be able to provide these services outside of the capitated behavioral health network.

RECOMMENDATION: SIX BEHAVIORAL HEALTH VISITS
Current Language: 3.3.13.2.2 “The Department will increase access to low acuity behavioral health interventions by encouraging the delivery of behavioral health within primary care settings. Low acuity behavioral health treatment delivered in primary care settings may be reimbursed Fee-for-Service for up to six (6) sessions per episode of care. These sessions will not require a covered behavioral health diagnosis. Additional sessions will require authorization from the RAE for reimbursement through the Capitated Behavioral Health Benefit.”

Recommendation—Six Visits Parameters:
We recommend that the six behavioral health psychotherapy sessions be provided by a licensed behavioral health clinician (or license-eligible trainees under the supervision of a licensed clinician).

We recommend that those six visits be able to be offered in community -based programs offered outside of capitated behavioral health networks. If the service is provided in a clinical setting, the care should be provided in an integrated way with integrated charting.

We recommend eliminating, “low-acuity” terminology because it is subjective and unclear and the only actual distinction is the duration of care provided and the location of the service. A client could have an acute but short-term need that could be met by these services.

We appreciate the wording that the six visits limit will be per episode of care. We would like to clarify that the episode is determined by the treating provider. We also recommend revising Appendix N so that the reference to six visits per fiscal year is removed.
59
1/11/2017 7:57:17I agree and wish to continueMarissaVanDoverMental Health Center of DenverSocial Service/Community OrganizationI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

The HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
No opinion5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
No opinion5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionNo opinion5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Somewhat unclear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”

No opinion5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.
No opinion5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
No opinion5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
No opinion5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.

No opinionNo opinion5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
No opinion5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.No opinion6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
No opinion7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
60
1/11/2017 9:21:27I agree and wish to continueTerriHamblenMental Health Center of Denver ProviderI support the intention of the RFP, particularly the focus on health and quality of care for all members as well as integration of a continuum of care across different settings. I sincerely recognize and appreciate the thought and effort which went into the creation of the document.
However, throughout the RFP there are instances of overreach as well as broad statements which are not clearly defined. It is essential that HCPF provides clear expectations to the contractor.

I believe that the HR practices in the RFP are highly restrictive and overreaching into contractor’s business practices.

Data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

Additionally, there seems to be a misalignment of funding, as there appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data with no consideration of inflation.

The RFP should also consider and make allowances for innovations which may arise after the contract goes into place.

The RFP would be greatly improved with an increased focus on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs.

The RFP is framed from the context of treating illness as opposed to a recovery framework of treating the whole person with a goal of recovery and well-being. As a result, mental health recovery services are conceptualized as something provided by peers. My recommendation is that the entire proposal be reframed to place a focus on recovery-focused delivery of services. As such, the mental health outcome measures need to focus on recovery and well-being as opposed to the current list of symptom reduction outcome measures. The focus also needs to recognize the appropriate credential for recovery focused work, which is the Certified Psychiatric Rehabilitation Practitioner as opposed to more licensed staff. While licensed staff serve a valuable role, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 The automatic enrollment will mean that people can choose an out-of-region PCMP and be assigned to a different RAE than their geographic “home” region, even if they receive one or two PCMP services a year and receive mental health center services once a week from a CMHC in their geographic home region.

3.3.6 Clearly define “basic minimum requirements” for behavioral healthcare.

3.3.8 The statement “Non-PCMP assessments inform subsequent interactions with Members” will require a technological component and thus resources should be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Low acuity behavioral health interventions should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis REGARDLESS OF LOCATION provided. It is important to offer prevention and early intervention services at multiple locations including schools, churches, community centers, etc and not just defined healthcare entities.

3.3.13.3 This will be a challenge for rural and frontier regions of the state in regards to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 Define the criteria for the different per-member per-month (PMPM) payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
Somewhat clear5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
Somewhat clear5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
Very clearVery clear5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Somewhat unclear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”


Somewhat clear6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.

Somewhat unclear5.7.3.4.2 I strongly recommend that all staff be credentialed (not just those with NPI numbers/ licensed staff) or at a minimum providers of psychiatric rehabilitation services be included in this section.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vise versa.

5.7.4.4.1 Clarify whether Community Crisis Connection satisfies this requirement.

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. In the Urban County columns, traffic in different areas of the city at various times of the day should be considered. For example, a 9 mile commute can take 30-50 minutes depending upon traffic.

5.7.4.10 Define how driving time will be determined - worst case rush hour or unimpeded by traffic. Also, considering most of our urban population (people we serve) uses public transportation, driving time is not very relevant. Additionally, in rural areas, two providers must be available. and in frontier areas this may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 DFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
Somewhat unclear5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
Somewhat unclear5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
Very clearSomewhat unclear5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
Somewhat unclear5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.Somewhat clearSomewhat unclear6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
Somewhat clear7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
61
1/11/2017 9:54:06I agree and wish to continueKristiMockMental Health Center of DenverChief Operating OfficerThe focus on health and quality of care for all members as well as integration of a continuum of care across different settings is a good thing.

Throughout the RFP there are a number of instances where it will be essential that HCPR provide clear expectations of the contractor. There is also overreach in some areas. For example, the HR practices in the RFP are very restrictive and reach into the contractor’s business practices. Additionally, data ownership and the potential infringement upon contractor’s intellectual property is also concerning.

There appears to be no funding stream for some of the required elements (examples: community activities - outreach and support, connecting systems, developing technology solutions, acting as the BHO for a population). It also appears the contract sets FY19 rates based on FY15 actuarial data without consideration of inflation or taking into account new and innovative technologies, treatment, relationships/collaborations that may come up after the contract is enacted.

An increased focus in the RFP on measurable outcomes and overall goals (recovery, resiliency, well-being, to what extent people are getting better) instead of a prescriptive approach to the implementation of programs and symptom reduction outcomes would greatly improve it. Recovery and well-being should be the hallmark as opposed to focusing on illness.

The focus also needs to recognize the appropriate credential for recovery focused work, which includes Certified Psychiatric Rehabilitation Practitioner as opposed to licensed staff. Licensed staff members serve a valuable and necessary role, however, much of the work of psycho-social rehabilitation is provided by bachelor level case managers, residential counselors, supported education and employment staff. The appropriate credential for these providers is the CPRP which provides staff with the education and skills to provide effective services. Also, there is a shortage of licensed providers currently and the financial implications of requiring more licensed staffing is significant.

3.3.5 Automatic enrollment will mean that people may choose a PCMP out-of-region and be assigned to a different RAE than their geographic “home” region, even if they receive only one or two PCMP services a year and receive weekly mental health center services from a CMHC in their geographic home region.

3.3.6 Please define “basic minimum requirements” for behavioral healthcare.

3.3.8 “Non-PCMP assessments inform subsequent interactions with Members” requires a technological component that requires that resources be allocated.

3.3.12.2 I question whether conducting the Health Needs Survey at the time of enrollment will foster people clearly and honestly responding.

3.3.13.2.1 CMHC-based services will still require a covered behavioral health diagnosis.

3.3.13.2.2 Behavioral health interventions that are low acuity should be reimbursed FFS for up to 6 sessions per episode and not require a covered behavioral health diagnosis regardless of the location at which they are provided. It is important to offer prevention and early intervention services at many different locations including schools, churches, community centers, etc. - defined healthcare entities should be just one of the acceptable locations.

3.3.13.3 Rural and frontier regions of the state will be significantly challenged with regard to program sustainability and availability of staffing.

3.3.14.5 Provider portals only, rather than an approach that includes both manual portal access and automated API access to interchange and BIDM, will be very cumbersome to manage at scale. RAEs must offer API access.

3.3.15.2 What is the criteria for the different PMPM payment amounts.

3.3.15.4 Define how much of the $4 PMPM will go towards Key Performance Indicators, Flexible Funding Pool and Public Reporting. Currently it appears that the funding will go towards the KPIs and if funding is left over there will be a flexible funding pool. The third category of public reporting funding is unclear.

3.3.15.4.1 Rate setting and performance indicators must take into account the differences in populations served between rural, suburban and urban mental health centers with particular attention to the higher acuity faced by urban centers.
No opinion5.1.10.2 The statements “the Department shall have all ownership rights” and “The Department shall have these ownership rights, regardless of whether the work product was developed by the Contractor or any Subcontractor for work product created in the performance of this Contract” infringe upon intellectual property rights.

5.1.10.2.1 Strike “or acquired by the Contractor on behalf of the Department, which are used in performance of the Contract.”

5.1.10.2.2 Strike this section; issue of overreach.

5.1.10.2.3 Strike this section.

5.1.10.2.4 Strike this section.

5.1.13.1 Regarding “The Department shall provide API access to its computer system so that the Contractor may access the system using standard web service interfaces,” it is essential to open up API access.
No opinion5.2.3 This section raises concern regarding infringement upon a contractor’s business practices. In the first sentence, strike the word “any” from “any activity related to the Contract.”

5.2.3 The organizational chart provided should be limited to a list of executive management staff and perhaps management positions (not individual people), and 60 days (instead of 30) is a more reasonable expectation. The contractor can maintain their own lists of contacts.

5.2.4 Strike this section; Sweeping infringement upon a contractor’s business practices.

5.2.5 Strike this section; Issue of overreach; Also, this is not sustainable. It would hamper the contractor’s ability to hire and fire key positions as well as recruit qualified candidates.

5.2.6 Strike this section, or at a minimum replace “equivalent to” with “similar to” in the sentence beginning “The replacement person shall have qualifications that are equivalent to…”

5.2.10 Strike this section; This is overly intrusive into the contractor’s business. Also, some of the regions are quite small, and this may not be possible.

5.2.11.2 This section must include provisions for vacations, sick time, other leave, etc.

5.2.13.2 Strike this section.

5.2.14.2 Strike this section; The contractor should not be limited on the amount of work that is subcontracted.

Add a section 5.2.14.4 “The subcontractor will utilize staff with the appropriate credentials including licensing and Certified Psychiatric Rehabilitation Practitioners in the provision of behavioral health services on ACT teams and for other psychiatric rehabilitation services.”
No opinionNo opinion5.4.8.2.1 Consult member on preference as to where they wish to be assigned.

5.4.8.3 Clarify formal notification process and level of comprehension.
Not Clear5.5.1.3 The councils now occur at the provider and contractor level.

5.5.2.4.1 Define “cultural responsiveness” and/or “cultural competence.” There are many requirements surrounding those two points, and contractors need a definition of achievement.

5.5.2.5.1 Define “timely.”

5.5.2.5.2 Clarify which documents are included and which languages are defined as “prevalent.” Financial supports are needed to conduct this extensive task.

5.5.2.5.2.1 Clarify how the contractor “shall assure.” For example, “the contractor shall contract with language vendors that vet competence.” This is complicated, and financial support and/or a rate differential for the added oversight and expense is needed.

5.5.2.5.3.1 Clarify which documents are included and which languages are defined as “prevalent.”

5.5.2.6.3 Strike “as directed by the Department or as”; This is over broad and leaves the contractor vulnerable to being held accountable to shifting expectations/diminished ability to meet directives.

5.5.2.6.4.1 and 5.5.2.6.4.2 Combine and simplify; Define “significant”; The 15 language regulation may not be necessary in all 7 regions (for example frontier areas). There is significant cost. There may be a technology program solution for those in frontier Colorado.

5.5.2.6.5.1 I recommend a 4th-6th grade level. Also, define how/ when the Department will “direct” this.

5.5.2.6.5.2 Clarify how this will work with 15 different language taglines; Documents would be pages long. Also 5.5.2.6.8 stipulates that the contractor needs an 18 pt font size version as well.

5.5.2.6.8 Clarify if this is required in all 15 languages.

5.5.2.6.9 I appreciate the value of doing this; however, define the logistics such as what “tested” means and how this might impact deadlines.

5.5.3.6.1.5.1 Include behavioral health in addition to “serious dysfunction of any bodily organ or part.”

5.5.3.6.1.5.2 Specify behavioral health in addition to physical health in this section.

5.5.3.7.1.5 Clarify type of training - links or actual.

5.5.3.7.1.8 Include Colorado Crisis Services information in addition to the Nurse Advice Line.

5.5.3.12.1 Clarify the turnaround time as well as how many times it will need to be negotiated (and sent back and forth). The process will be costly especially for smaller RAE’s.

5.5.4.3 Strike this or clarify that the advisory council will be representative of all areas - rural, frontier and urban. This seems especially onerous and time consuming as well as expensive to make adjustments based on an advisory council’s review.

5.5.5.2 Make the addition that “the department or its delegate shall provide file transfer protocol access in order to facilitate the daily data transfer.”

5.5.5.2.1 Define “regular.”

5.5.6.2.2 Make the addition that “The Department shall provide API or FTP access to the Salesforce data platform.”
No opinion5.6.2 Clarify the process for behavioral health.

5.6.5.7.1 In regards to “real time,” clarify how missed calls (“phone tag” incidents) will be handled.


No opinion5.7.3.4.2 All staff should be credentialed (not just those with NPI numbers/ licensed staff) In CMHC’s it is important to match tasks/treatment being performed with the appropriate staffing level – not all services need to be delivered by licensed personnel.

5.7.4.3 and 5.7.4.4 These sections should be consistent with 5.7.2.1.10 which uses 7:30 – 5:30 or vice versa.

5.7.4.4.1 Does Community Crisis Connection satisfy this requirement?

5.7.4.9 Most of the time and distance standards are unreasonable. The maximum time in minutes should not be the same as the maximum distance in miles. Drive times vary depending on location, weather and traffic.

5.7.4.10 How will drive time be determined - worst case rush hour/bad weather or unimpeded by traffic? In rural/frontier areas, the availability of two providers within some of the distances may not be possible.

5.7.4.13.5.1 Define “emergency behavioral health care.”

5.7.4.13.5.2 Clarify that if an appointment is offered and declined, the standard is met.

5.7.5.1.8 This is an inappropriate intrusion into the contractor’s business operations. Caseload size will vary greatly given the team model and levels of care.

5.7.5.1.9 Again, this is intrusive and not our care delivery model.
Not Clear5.8.2 Define “the promotion of healthy Communities.”

5.8.3.5.2 Clarify whether the provider will be paid FFS or if payment falls under the capitated benefit when the consultation is with a specialty behavioral health care provider. If the latter, define how the provider will be rewarded for providing the consultation.

5.8.3.9.1 The policies and sharing means must be 42 CFR Part 2 compliant.

5.8.3.11 Strike this section. Workable non-emergent transportation is difficult even in urban areas. This is not feasible in rural and frontier areas.

5.8.4.2 Define the payment/reimbursement mechanism for this service.

5.8.4.4 Define the payment/reimbursement mechanism for this service.

5.8.4.5 and 5.8.4.5.1 Combine these sections. Leverage existing resources, for example specify if MHUW’s 211 will satisfy this requirement. The conflict of “have and maintain” and “not duplicate” should be eliminated.
5.9.1.2 Specify how the Department will provide access to its data systems. I recommend the capability of a regular, automated data export to the Contractor’s data warehouse.

5.9.3.6 Care coordination (connecting people to team expertise) in principle is valuable. However, it will be difficult to operationalize non-duplication of care coordination at the RAE and specialty provider levels. Define the specific requirements for linking and organizing. Clarify if mental health centers are a “special population provider.” There likely is a significant IT cost to implement this.

5.9.3.6 There are different waivers for people with different vulnerabilities – blind, mental health, persons with cognitive and developmental disabilities.

5.9.3.7.4 Define “culturally competent.”

5.9.3.7.11 Must be 42 CFR Part 2 compliant.
Not Clear5.10.5.4 Make the addition that “The Department shall provide 270/271 benefits eligibility information regarding Member Medicaid coverage to Network Providers using modern electronic access methodologies (not dial-up modem).”

5.10.5.9 Add “, including psychiatric rehabilitation interventions and services” after “clinical and operational tools.”

5.10.6.2.9 Add “, including training for behavioral health providers on principles of recovery and psychiatric rehabilitation” after “population health.”

5.10.7.3.4 Deprecate the CCAR for the DII.

5.10.7.4.5 The Department needs to provide Contractors and Network Providers a “glide-path” to meeting these requirements that reflects the current state of HIT. I suggest these not go into effect immediately when the contract starts, because right now: a) the HIEs (QHN, CORHIO) do not offer a means of exchanging 42 CFR Part 2 compliant information with consent at scale (QHN is running a pilot, CORHIO is trying); and b) providers’ EHRs can calculate CQMs, but cannot reliably extract and send QRDA data electronically at scale [per Netsmart, no states at the current moment accept the exchange of QRDA data, so although the EHRs produce the files, no exchange has been set up].

5.10.7.4.5.1 and 5.10.7.4.5.2 The Department should also assess the capabilities of the regional HIEs.
5.12.4.4 Define “effective” so that the contractor and Department knows when the contract has been met.

5.12.5.4 I suggest that the PCMP should allow for a specialty behavioral health provider embedded within the PCMP clinic to bill and be reimbursed FFS as well, even if billed by the specialty behavioral health provider, rather than the PCP.

5.12.5.5 Community Support (H0036/H0037) is not on this list. It is currently allowable under state plan. I recommend that it be included as mental health centers provide many of these services currently.

5.12.5.5.16.7 I recommend this be changed to “The Contractor shall cover Emergency Services even when the emergency room provider, hospital, or fiscal agent does not notify the Contractor…”

5.12.5.5.16.11.1 This seems like a challenging timeline.

5.12.5.7.1.1 Specify Evidence Based Practice of the Individual Placement and Support model of supported employment services.

5.12.5.7.1.2 I suggest that the averaging of service level intensity be done at the program level, not the Member level, when determining that community-based services meet ICM requirements.

5.12.5.7.1.3 This should include attempts at outreach (H0023) that do not result in a successful direct encounter with Members (either face-to-face or on the phone).

5.12.5.7.1.4 Make the addition of “as well as additional services which include supported education programs and the return to higher education” following “club-like setting.”

5.12.5.7.1.6 Coverage 24/7/365 is extremely expensive and finding/recruiting staff to do this would be nearly impossible. I suggest meeting fidelity at a 75% level.

5.12.5.7.1.7 Clarify if “Community locations” include mental health clinic locations and residential facilities. Also make the addition of “Additional psychiatric rehabilitation services as provided by Certified Psychiatric Rehabilitation Practitioners” following “advocacy services.”

5.12.6.6 Replace “clear and specific criteria” with “general criteria.” Also, it will be very difficult to develop the discharge agreement in the electronic health record.

5.12.11.1.2.8 This and the above seem an excess of information to include in a third party ID report.
Not Clear5.13.1.4.2.5 Define ownership of findings, which should be the person conducting the analysis.

5.13.1.4.2.7 Make the addition that “The Department shall provide direct interface access to the BIDM to Network Partners, who shall not be limited in choice to receiving access through the Contractor or using a Web Portal.”

5.13.2.1 Specify who develops the tool and the components.

5.13.2.1.2.2 Also 42 CFR Part 2 compliant.

5.13.2.1.3.6 Please specify if the Care Coordinator notes are from the Contractor’s care coordinator or from coordinators at the entities providing care. If the latter, this is more resource intensive.

5.13.2.1.6 I support the reporting of information (instead of exchange of information).

5.13.2.2.3.2 Make the addition that “The Department shall provide back an 835-formatted response to the Contractor” following “data transfer protocol.”

5.13.2.2.3.6 This means no MHCD data shall be submitted to APCD, since it all currently falls under 42 CFR Part 2. The state should address the health inequities created by calculating performance measures while excluding behavioral health data.

5.13.2.2.3.7 Make the addition that “In the event the Department chooses to change format requirements for the Contractor, the Department shall give the Contractor 120 days’ notice to implement the changes.” [90 would also be acceptable]
Not Clear5.14.4.8.1.1.2.4 Better define “engagement” especially within the primary care, prevention and specialty environments. Also, OBH’s 4 sessions in first 45 days of treatment will not fit the entire Member populations’ needs – this is too intensive and prescriptive.

5.14.4.8.1.1.3.1-2 This is unsustainable. At some point a ceiling effect comes into play.

5.14.4.9.1.1.1 Clearly define “base standards.”

5.14.4.9.1.1.3 There are no outcomes below, only process measures.

5.14.4.9.1.2.2 Clarify how 90% accuracy is calculated.

5.14.5.6.1 For large practices, specify if one serious complaint will require a full corrective action plan, and if so, define how “serious” is determined. This seems burdensome.

5.14.8.3.1 Clarify if the review will cover the entire medical record for the Member or only those documents related to the services/encounters being reviewed.

5.14.10.1 Provide more clarity.
5.15.5.2.6 I question if “up to and including termination” is enough. The feds already have punishable guidelines.6.3.6.1 Clarify the purpose of the 17000 statement. This could be a large number.

6.3.10.1 The contractor doesn’t own the nursing facilities. Clarify if this will prevent the nursing facility from taking persons with behavioral health problems, thus decreasing a resource.
7.5.3.3 Require a monthly report (not weekly) and monthly invoice.
62
1/11/2017 10:09:47I agree and wish to continuePeterManettaColorado Association of Local Public Health OfficialsAdvocateComments on Section 8 Evaluation:
The following criteria should be used in evaluation RAE contract bids
- Nonprofit incorporation and/or governing board or ownership populated with patients, providers, or other community based organizations
- Parent company domiciled in Colorado
- Requirement that RAEs submit letters of support from major Medicaid providers, PCMPs, and BH providers who would participate in the BH network.
Somewhat unclear5.1.6
We recommend that all deliverables in section 5.1.6. (especially population health strategy) be posted online within thirty days of the Department’s receipt in order to support transparency and the advisory process.

Reports should be structured in ways that are easily understood by members, network providers, stakeholders, and the public at large. Publicly sharing deliverables will ensure that the program is transparent and that advocates can effectively assist the Department in monitoring the program.
No opinionNo opinionNo opinionSomewhat unclear5.5.6.2
Current Language: “The Contractor shall collaborate with Healthy Communities contractors in the Contractor’s Region for onboarding Members to Medicaid and the Program. Healthy Communities will have contracted responsibilities to onboard Members to Medicaid and the Program through outreach, navigation support of Medicaid benefits, and education on preventive services, particularly services for children and families.”

Are Healthy Communities onboarding all members rather than just kids and families? We recommend that the state delineate roles and responsibilities so that it is clear what those roles and responsibilities are statewide. We also recommend that Healthy Communities remain focused on children and their families, which is their area of expertise. Clear delineation of roles and responsibilities will allow for reasonable apportionment of funds and ensure that services are not duplicative but complimentary.
No opinionSomewhat clear5.7.1
Include: The Contractor's network shall contain a sufficient number of providers capable of providing care to Members with co-occurring behavioral health needs and intellectual or developmental disabilities.

5.7.3.1 (Specialty Behavioral Health Provider Network)
Current Language: “The Contractor shall establish and maintain a statewide network of behavioral health providers that spans inpatient, outpatient, laboratory, and all other covered mental health and substance use disorder services.”
We recommend that a third party entity conduct the credentialing and governance for one statewide network of behavioral health providers (rather than a different statewide network for each RAE).
This would mean that clinicians would have to be credentialed only once in order to provide behavioral health capitated services in any region.

5.7.4.13.5.2
Current Language: “Non-urgent, Symptomatic Behavioral Health Services – within seven (7) days of a Member’s request. Administrative intake appointments or group intake processes are not considered a treatment appointment for non-urgent, symptomatic care.”
We recommend that 5.7.4.13.5.2. should also include, “and follow-up appointments at clinically optimal and indicated intervals.”
We appreciate the change in language that group or intake appointments are not considered adequate engagement with the system and want to be sure that follow-up and ongoing care is provided in a timely fashion.

5.7.1.3
Current Language: “The Contractor shall ensure that its contracted networks are capable of serving all Members, including contracting with providers with specialized training and expertise across all ages, levels of ability, gender identities, and cultural identities. The Contractor’s networks shall include, but not be limited to, the following:”
Add “Eligible Local Public Health Agencies”


Somewhat unclearOverall Comment:
The Community section should, in general, more clearly articulate the possible ways that a RAE could support the community outside of clinical care. For example, we recommend adding:
- Clinical programs screen and refer for social determinants
- Participate in community coalitions in a robust manner, not just showing up to meetings
- Financing community initiatives
- Implementing on-site interventions (ie, on-site foodbank or enrollment for SNAP)
- As a health system, model health behaviors such as health food and beverage policies
- Intentional hiring from disadvantaged neighborhoods
- Community advocacy & policy engagement

5.8.3.2
Current Language: “The Contractor shall establish .....connections and improved processes.”
Edit to read: “… by supporting existing collaborations, including contracts established in ACC Phase I, and facilitating…”

5.8.3.10
Current Language: “The Contractor shall facilitate health data sharing among providers in the Health Neighborhood.”
Add “ including supporting and building on existing data sharing initiatives within the community and providing de-identified data sets to Health Neighborhood partners, as appropriate. This data sharing activity may require the Contractor to compel, incentivize and/or require sharing and integration of data from a variety of sources.”

5.8.3.13 through 5.8.3.13.3
Edit “Explore appropriate funding…” to state “Ensure appropriate funding approaches…”
If the RAEs and LPHAs are engaging in specific collaborative activities, the RAE should bear some responsibility in ensuring that there is adequate funding for both partners to fully participate. LPHAs do not have large amounts of discretionary funding to be able to fully engage with RAE-focused activities. LPHAs and other, existing community partners cannot be expected to immediately align funding sources to be able to support their role in partnership with a RAE. Identifying community need, defining effective interventions, and then intentionally not appropriately funding and implementing those interventions is wasteful and unethical.

Add “Ensure they are engaged as the primary source for core public health services, as defined in 6CCR-1014-7, unless they prefer to assure those services are provided by another community partner.”
Because LPHAs are required to provide a set of core public health services, they should be consulted first by RAEs looking for providers for those related services. The RAE would not necessarily be restricted to ONLY using the LPHA as a provider, but they should be supported as a primary resource for those services.

5.8.4.5 through 5.8.4.5.1
Current Language: “The Contractor shall have and maintain a centralized regional resource directory ... a regional resource directory.”

Add that if created by the RAE, the resource directory should be available for use by Health Neighborhood members who do not bill Medicaid.

5.8.4.9
Current Language: “As hospitals serve as an anchor .... disparities in the Community.”

Edit to state: “… to perform community health needs assessments without disrupting or duplicating existing relationships.”
Hospitals, local public health agencies, health alliances and many other community partners have been working diligently to partner and align with the non-profit hospital requirements on community health needs assessments. While new partners are often welcomed, they should enter the partnership in a non-competitive manner with an eye toward adding to rather than disrupting the existing work.

5.8.5.1
Current Language: “The Contractor shall... health care system, including:”

Add “Colorado Health Assessment and Planning System (CHAPS) process of local public health assessments and community health improvement plan development and implementation as defined in CRS 25-1-505.”

5.8.6.1
Current Language: “The Contractor shall submit a report to the ...Neighborhood and Community forums”

We were unable to find reference to “Community Forums” in other sections of the RFP. If it exists, it should include a requirement to use existing community forums where possible. Many existing community partners are hosting community forms and engaging community members and patients. The RAE should align with not compete with these existing local activities.

5.8.6.1.10
Collaboration with Local Public Health Agencies
This report must be shared with the Local Public Health Agencies on which the RAE is reporting.



Somewhat clear5.9.2.2
We recommend that the population health management plan include prevention, early intervention and the full spectrum of population health management services. We recommend that the plan be required to be reviewed by experts in the populations and strategies outlined. Evidence of that review could be a requirement of the proposal submission.

5.9.2.2.1
Current Language: “The Contractor’s ... as information is available.”

Add: “The contractor shall consult with local heath data experts, including but not limited to local public health agencies, to ensure that the selected methodology aligns with existing community data analysis as much as possible.”

5.9.2.4
Current Language: “The Contractor shall engage Members and Network Providers... Population Health Management Plan.”

Edit: “… shall engage Members, Network Providers and Health Neighborhood partners…”

Again, if there are health neighborhood partners who do not bill Medicaid for services, they should still be provided with the plan in order to ensure awareness and alignment across the community.

5.9.3.
Care Coordination
Add new line: “The Contractor shall support care coordination relationships and contracts established and successfully implemented in ACC Phase I.”

Phase II should build upon the great work of ACC Phase I. While we don’t expect that contracts would be uniformly implemented from Phase I into Phase II, it would be highly disruptive to the local community connections if the previous care coordination relationships were dissolved.

5.9.3.7.7
Current Language: “Reduces duplication and promotes continuity by identifying a lead care coordinator for Members receiving Care Coordination from multiple systems”

Add “and supports existing care coordination relationships.”

Somewhat clear5.10.9.1
Current Language: “The Contractor shall distribute, in aggregate, at least thirty percent (30%) of the Contractor’s administrative PMPM payments received from the Department to their PCMP network and Health Neighborhood.”

We recommend adding the following language: “At least some of those funds must be distributed to Health Neighborhood beyond PCMPs.” We also recommend that the Department continue to seek ways to ensure that the funding in the Medicaid program is aligned with the areas where there is the greatest return on investment and that there continues to be increases in resources allocated to primary care (including primary behavioral health care) and decreases in investments in secondary and tertiary care.
Somewhat clearThe criteria for the Advanced level should include: "Social Needs Screening and Referral"
Social needs screening and referral could be added as a requirement to be an advanced practice for the Alternative Payment Methodology. Social needs screening, referral and tracking could also be listed as one of the strategies the RAE should explore in the Community Section of the RFP.
Somewhat unclearOverall Comments: We recommend that the health and behavior codes be added as a fee-for-service benefit. Addition of six behavioral health visits out of primary care does not replace the need for health and behavior codes to address behavioral health aspects of acute and chronic medical conditions. Health and behavior codes would enable clinicians to provide necessary counseling and treatment for medical conditions and diagnoses (e.g., weight management/obesity, asthma, congenital anomalies, developmental diagnoses, feeding disorders, sleep disorders) that can have long-term effects for healthcare costs and outcomes. In order to meet the needs of the community, LPHAs and other providers should be able to provide Medicaid clients who do not meet a diagnosed mental condition with behavior health intervention. These interventions should be able to be billed on health and behavior codes on a medical diagnosis, not a mental health diagnosis. For example, counseling an adolescent on weight management or tobacco use is a high value activity that will result in significant long-term savings to many systems.


5.12.5.5.15.2
Change to: "The Contractor is financially responsible for all Medicaid services associated with a Member's outpatient hospital treatment, including all behavioral health and associated medical and facility services, labs, x-rays, supplies, and other ancillary services, when the procedure(s) is billed on a CMS-1500 and ANSI 837-P X12 claim form, and the diagnosis requiring the outpatient hospital treatment is a covered behavioral health diagnosis."

5.12.5.5.16.15
Change to: "The Contractor is financially responsible for Emergency Services which are rendered in the treatment of a diagnosis which is psychiatric in nature, even if physical health conditions are present or a medical procedure is provided."

5.12.5.5.16.16
Change to: "The Contractor is financially responsible for initial evaluation as part of Emergency Services rendered due to a behavioral or psychiatric emergency. If a behavioral or psychiatric emergency is determined by the treating provider to be due to the presence of an intellectual or developmental disability, the Contractor shall remain responsible until a clinically-appropriate transfer to an appropriate provider can be facilitated, or the behavioral or psychiatric emergency has ended."

5.12.5.5.16.17
Include: "The Contractor is not financially responsible for Emergency Services which are rendered in the treatment of a diagnosis which is determined by the treating provider to be not psychiatric in nature."

5.12.5.6.2
Change to: "The Contractor’s responsibility for inpatient hospital services is based on the diagnosis that requires inpatient level of care and is being managed within the treatment plan of the Member."

5.12.5.6.2.1
Change to: "The Contractor is financially responsible for the hospital stay when the Member’s diagnosis requiring the inpatient level of care is a covered psychiatric diagnosis, even when the psychiatric diagnosis includes some physical health procedures (including labs and ancillary services)."

5.12.5.6.2.2
Change to: "The Contractor is not financially responsible for inpatient hospital services when the Member's diagnosis requiring the inpatient level of care is physical in nature, even if a covered psychiatric condition is present."

5.12.5.6.2.4
Include: "The Contractor is financially responsible for hospital services rendered in the treatment of a diagnosis which is psychiatric in nature, even if the diagnosis requiring the inpatient level of care is physical in nature, or such services coincide with treatment for another non-covered diagnosis."

5.12.5.7.1
Current Language: “The Contractor shall.... Respite Services."

We recommend the State remove Early Intervention and Prevention from the behavioral health capitation and offer it as a state plan service, in addition to the six visits discussed above, and define the behavioral health early intervention and prevention services required.
These services include activities such as:
1) Screening, identification, triage, intervention, and referral when concerns or delays are identified using standardized screening protocols; Specifically, postpartum depression screening, developmental screenings, ACES and MCHATS should be reimbursed in the frequency that is clinically recommended and at appropriate reimbursement levels.
2) Health promotion services that support the development of nurturing relationships between caregivers/parents and children, provide anticipatory guidance and support around typical developmental issues, and help address psychosocial complexity before it impacts well-being;
3) Prevention efforts that provide a higher level of services and supports to families identified as being at risk or vulnerable because of child, family, or environmental factors that could negatively impact development; and
4) Early childhood behavioral health intervention services provided by a qualified workforce of behavioral health professionals for those families identified as having complex needs and/or with identified adversity and behavioral health needs.
5) Proactive efforts to educate and empower individuals to choose and maintain healthy life behaviors and lifestyles that promote positive behavioral health. Services include behavioral health screenings; educational programs promoting safe and stable families; senior workshops related to aging disorders; and parenting skills classes.
Early Intervention and Prevention services for children are not presently being offered adequately, and the proposed RFP does not change the offering. In addition, the focus on the provision of high-acuity services in the next iteration of the capitation makes the future network potentially even less effective at Prevention and Early Intervention. Prevention and Early Intervention services may be better provided by providers outside of the specialty behavioral health network since this work requires specialization and training beyond the scope of what licensed behavioral health professionals are required to have and the services are often delivered in community settings including primary care, early care and education, social service programs (e.g., WIC offices), and homes (e.g., home visiting). This should include opening H codes as a fee-for-service billing mechanism to allow for assessment of need/suitability for services, psycho-education and counseling around health and well-being, group-based service delivery, and community engagement, all without requiring a behavioral health diagnosis.


Somewhat clearOverall comments: It should be noted that local public health agencies have an important role both in helping communities and community partners have access to and understand community-level health data through their formal role in community health assessment and planning. For LPHAs to be successful and valuable partners in improving the health of their communities, they need full access to de-identified data within the system (as legally permitted).

5.13.1.4.2.7
Current Language: “The Contractor shall support and encourage Network Provider use of the BIDM Web Portal.”
Edit: “… support and encourage Network Provider and Health Neighborhood partner use of the BIDM Web Portal, and will provide technical assistance on the use of the portal.”

Add new line: “The Contractor shall provide raw data exports, upon request and as needed, for Network Provider and Health Neighborhood partners engaged in formal community heath assessments within the region.

5.13.2.1.1
Current Language: “The Contractor shall possess and maintain an electronic Care Coordination... another tool.”

We recommend that the care coordination tool be required to not only collect information but also transmit information across medical and non-medical systems including local public health agencies, oral health care providers, EPSDT, Early Intervention Colorado, home visitation programs, school-based health clinics, the Colorado Department of Education, Colorado Department of Human Services, Colorado Department of Public Health and Environment, the immunization registry, and child care and early learning settings.

The care coordination tool should potentially be accessible to clients as well as healthcare providers.
We recommend that the RAEs collaborate on a statewide tool that can interface with all electronic medical records.

Somewhat clear5.14.4.1
Current Language: “The Contractor shall participate ... the public domain.”

While it is good to ensure that the contractors are prepared for the performance measurement and reporting to be placed in the public domain, HCPF should make an outward commitment to publish the performance data in an easily accessible, online format.

5.14.4.8.1.1: Key Performance Indicators
The current contract reads such that the KPIs would remain the same over the course of the contract. If the program is successful, ability to improve on some of the KPIs will likely plateau before seven years. After a reasonable period of percentage improvement, measures should become discrete benchmarks. Maintenance of benchmarks should be a prerequisite for future payment incentives.

We recommend the following language, “Reimbursement to be based on percent improvement until a benchmark is met. At that time, those KPIs will become a prerequisite or gate for receiving any incentive payment and new KPIs will be added.”

A percent improvement for seven years does not allow for the possibility that some peak performance is reached. Keeping the KPIs static until 2025 does not allow the state to adjust for new priorities.

5.14.4.8.1.1.1
Current Language: The Contractor shall work to improve performance .... options offered by the Department.

We recommend fewer than 9 KPIs and an attempt to move towards social measures (ie. housing status, food security) and clinical outcomes-based KPIs over the course of the contract. We recommend that as the Department evolves the measures, they continue to identify measures that are specific (not composites of many measures) and that are developmentally-relevant and age appropriate.

5.14.4.8.1.3.1
Current Language: “The Contractor is responsible for improving network performance on core health and cost measures that will be reported publicly on a quarterly basis.”

We recommend adding the influenza vaccine to the list of public reporting measures.

5.14.9.2.1.6
Current Language: “Other individuals who can represent advocacy and Community organizations, local public health, and child welfare interests”

We agree that this is a sufficient way to ensure that LPHAs are included. The PIAC members should be made public on the RAE website so other LPHAs and community partners know who is representing their interests on the PIAC.

5.14.9.4: Operational Learning Collaborative
5.14.9.4.1
Current Language: “The Contractor shall participate in a monthly Department Operational Learning Collaborative to monitor and report on Contractor and Program activities including, but not limited to, the following.”

The Contractor should be required to share the learning and expertise gained from the Operational Learning Collaboratives with community partners through presentations, active participation on community boards, etc.


No opinionNo opinionNo opinionNo opinion
63
1/11/2017 10:54:34I agree and wish to continueAnnette KowalColorado Community Health Network (CCHN)Social Service/Community OrganizationIn general, the draft RFP outlines concepts that Colorado Community Health Network (CCHN) and our member organizations support as efforts to reform the state’s Medicaid system to improve health, lower costs, and provide a better patient experience for Medicaid members.
CCHN is the unified voice for Colorado’s 20 Federally Qualified Community Health Centers (CHCs or FQHCs) and their patients. FQHCs provide a health care home for more than 650,000 of their community members – more than one in eight people in Colorado – from 61 of the state’s 64 counties, including 25% of Medicaid enrollees - many of whom are Medicaid Accountable Care enrollees. As of October 2016 over 37% of those attributed in the ACC are attributed to a FQHC (not including RMHP PRIME), making FQHCs a key provider in the ACC and partner in achieving the state’s desired outcomes.
FQHCs have been integral to the ACC program from taking the first enrollees in 2011 to being foundational partners in forming the RCCO or serving in a governance role in several regions, and continue today to be leaders at both the local and state level through leadership roles in RCCOs and state appointed committees such as the Program Improvement Advisory Committee.
By design, FQHCs are unique health care providers run by community boards. At least 51% of FQHC board members are patients. This structure ensures that both patient needs and larger community needs are represented in FQHC clinical and financial operations.
Our comments outline specific areas of support and concern, or areas in need of clarification.

SUPPORT: CCHN expresses strong support for the general direction of the ACC as envisioned in the draft RFP. In particular, CCHN strongly supports the goals of the next phase: integration of physical and behavioral health, strengthening coordination of services, advancing team-based care and health neighborhoods, promoting member engagement, paying providers for the increased value they deliver, and ensuring greater accountability and transparency.

CONCERN/NEED CLARIFICATION: The elements outlined above set a great foundation for further transforming the Medicaid system, but there are areas that CCHN thinks need to be further developed to fully realize this vision. CCHN’s areas of concerns and areas in need of additional clarification are: maintenance of the current PCMP definition to ensure a focus on primary care provided by MDs/DOs, APNs and PAs; ensuring that PCMPs continue to receive at least comparable PMPM that exists currently including the opportunity to receive additional PMPM when serving in delegated care management contracts – this should not be limited by the proposed 40% subcontractor restriction and PCMPs responsible for care improvement and cost savings should be rewarded with shared savings and incentive payments; ensuring that staff and financial resources are sufficient for both the Department and RAE contractors to complete required deliverables, and that deliverables are meaningful, necessary and increase value; increased clarity on RAE’s authority to manage networks of medical providers, and ensuring the right incentives are in place between provider and patient responsibility to ensure appropriate use of the health care system.

On the whole CCHN and our members see much to be excited about in the vision outlined in the draft RFP. Thank you for your consideration of our comments. CCHN looks forward to continuing to partner with you on the development of ACC 2.0.
Somewhat clearSection 5.1 pages 33 - 40

Support
• Communications requirements (5.1.8.2.2) - CCHN appreciates the requirement that contractors maintain consistent communication, both proactive and responsive, with Network providers and other partners, and promote communication among Network providers.

Concern/needed clarifications:
•Contract term (1.2.3) – CCHN is concerned about the single year contract term. If allowable, the initial contract term should be 3 years with one year renewals after that time. This would allow contractors enough time to really implement this complicated system.

•RAE responsibilities (3.3.17) - The expansive list of potential future scope changes will make it difficult for the offeror to estimate whether the proposed PMPM will be adequate to do everything outlined in this section without additional dollars. CCHN wants to ensure that both the Department and the Contractor have the capacity to have strong partnerships with each other and providers, and the combination of the number of deliverables and the potential for changes threatens that. Clarify if revisions to the program will only occur as part of annual contract procurements.

•Offeror experience (4.2) - Clarify if the main offeror needs to have the experience requirements outlined, or if a combination of partners can have this experience.

•Transparency & Care Confidence – There should be transparency in the program that creates public confidence in the care being provided. The Department should consider public tools that demonstrate this such as KPI performance and/or RAE annual report cards.

•Evaluation (8.0) – The following criteria should be used in evaluation RAE contract bids
o Nonprofit incorporation and/or governing board or ownership populated with patients, providers, or other community based organizations
o Parent company domiciled in Colorado
o Requirement that RAEs submit letters of support from major Medicaid providers, PCMPs, and BH providers who would participate in the BH network.
Somewhat unclearSection 5.2 pages 40 - 46

Concern/needed clarifications:
•Key personnel (5.2.12) - Key personnel should include behavioral health expertise.

•Key personnel (5.2.12.1.1.1) The draft RFP states that the Program Officer shall work out of their office within the contracted region. While we believe ensuring a local presence of key personnel is important, there should be the opportunity to leverage those staff, rather than requiring duplication, in cases when a contractor wins multiple regions. While RAEs should be able to use the same local key personnel for multiple regions, these positions should be hired staff and not subcontracted.

•Subcontractors (5.2.14.2) – CCHN supports the integration of Medicaid mental and physical health funding to make primary, preventative and behavioral health services more efficient and patient centric. CCHN also supports one admin entity for ACC/RCCO and BHO functions. However, the subcontracting requirements in this section have led to several concerns:

o Additional clarification should be provided regarding what contracts and relationships with partners count against the 40% threshold for subcontracting. For example, it is CCHN’s assumption that all payments for behavioral health claims will not count as subcontracting, even if the RAE has a contractual relationship with another entity to process and pay those claims. In that situation, it is our understanding that only the funds associated with the delegation of the claims processing and payment will count as subcontracting, not the actual amounts paid to providers. Providing additional clarity around this is essential for providers and RAEs to understand their ability to execute delegated care contracts. Interested and qualified PCMPs should continue to be eligible for delegated care management contracts and these contracts should not be limited by the proposed 40% subcontract restriction.

o If delegated care coordination contracts count against the subcontractor requirement, we have concerns that this will impact the availability of non-behavioral health subcontracts for care coordination, and consequently the amount of care coordination happening at the point of care. This concern is based on the assumption that RAEs will subcontract out the bulk of their behavioral health funding to Community Mental Health Centers as is the case today between BHOs and CMHCs today. The RFP should specify that delegated care arrangements with providers do not count toward the requirement that a subcontractor can’t subcontract more than 40% of the total value of the contract.

o CCHN understands that this restriction on subcontracting is a current program requirement, but it isn’t clear if or how it has not been enforced. We believe the intent of this requirement is to ensure the integration of primary and behavioral health care, and that a carve out doesn’t remain by way of subcontracting, but this is not clear in the RFP. The intent behind this requirement should be more clearly articulated in the RFP and address how the state will monitor and assure adherence to this requirement.
Very clearSection 5.3 pages 46 – 47

Concerns/needed clarifications:

•Deliverables (5.3.2) - CCHN has concerns regarding the feasibility of the number of deliverables required of the RAEs with the level of funding provided, and the bandwidth of RAEs and the Department. With the much larger scope for RAEs (compared to RCCOs today), and the Department’s limited bandwidth. The Department should ensure that all compliance and deliverables are meaningful, necessary, and increase value. In light of this, CCHN is supporting the Department’s FY17-18 budget request for nearly five additional ACC phase II FTE. To increase transparency and understanding, throughout the RFP the Department should note deliverables that are requirements due to these federal authorities 1915(b) waiver and managed care authorities.

Very clearSection 5.4 pages 47-49

Support
• Member Enrollment (5.4.1) – CCHN and our members support mandatory ACC enrollment (except for PACE clients) with immediate attribution to a PCMP. This change will allow for PCMPs and RAEs to proactively engage with patients quickly after their enrollment in Medicaid.

• Member Attribution (5.8.2 and Appendix F) - CCHN is supportive of client enrollment and attribution which includes PCMP performance as an element of the system assignment methodology. However, the RFP does not define what “PCMP performance” will include. CCHN proposes that PCMP performance should include meeting the following requirements to be eligible for auto-assigned patients:
o Open to Medicaid patients (e.g. no waitlist)
o Have a care delegation agreement in place with the RCCO
o National PCMH recognition or meeting other TBD standards
o Meet a minimum threshold of Medicaid patients, or percent of overall practice.

Concern/need clarification:
• Member Attribution (5.4.10) This section includes information on the RAE’s ability to make changes to existing PCMP selection records based on member utilization patterns, and as such seems the most appropriate place to comment on the need for some mechanism of patient accountability related to attribution.
o Lock In - CCHN understands the Department’s interest in assuring patient choice and flexibility, but this needs to be balanced with patient responsibility to commit to receiving care from their chosen PCMP. Holding PCMPs and RAEs accountable for patient outcomes and utilization of more costly forms of care requires a level of patient responsibility that isn’t currently present in the system. While patients must have opportunities for PCMP changes based on things such as housing status or moving, we believe they should be locked into their assigned PCMP to ensure continuity of care and to better manage costs and improve health outcomes. This attribution should be at the site level as patients primarily seek care at one site, but providers may move between sites, particularly for large systems like FQHCs.
oAttribution/assignment to urgent care centers - We continue to have concerns with urgent cares serving as PCMPs. In addition we believe that the requirements to be a PCMP should not be changed from the existing requirements. We want to ensure urgent cares are truly able to meet PCMP criteria if they are assigned patients, and we don’t believe ERs should ever qualify as PCMPs. To accomplish this, the Department should consider prioritizing wellness codes in claims based attribution to ensure assignment to PCMPs rather than the most recent utilization (for example a member may access an urgent care for a sick visit, but still receive their wellness visits at a PCMP), use a longer look back for re-attribution (i.e. 18 or 24 months), and PCMP qualification by site versus simply parent organization designation.

• RAE attribution based on PCMP site location (5.4.5) - We understand the Department is likely proposing RAE enrollment based on PCMP location to help minimize the number of RAEs PCMPS with sites in multiple regions have to deal with, a concept CCHN has supported due to the administrative complexity of providers having different relationships, contracts, and expected work from different RCCOs. However the proposal to attribute clients by PCMP site location will not address our interest of multi PCMP site entities having to only play in one RAE, and causes several concerns including:
o Members who see a behavioral health provider in one region and a PCMP in another will impact the RAE’s ability to monitor utilization. Without the ability to see the full utilization of the patient, the RAE will have limited ability to recognize when duplicative services are offered and to maximize care coordination efforts,
o Additionally, using a behavioral health provider in a different RAE creates complications in ensuring that the correct RAE receives the behavioral health capitation for that patient.
o Finally, the fundamental principle of population health/social determinant risk management is that your geography dictates your risk levels, and much of social service eligibility and support is driven by geographic residency. We have concerns that disconnecting this geography from the RAE geography complicates rather than complements the wider concepts of population health/social determinants risk management.

•Enrollment broker (5.4.8.2.1 & 5.4.9) – The Department needs to ensure the enrollment broker is informing members of their PCMP attribution and RAE enrollment effectively and quickly. Member ability to select a PCMP through the enrollment broker needs to be easier, more modern, easily accessible (not fax), and with short wait times. The Department should hold the enrollment broker to these standards as part of their contract deliverables.
Somewhat unclearSection 5.5 pages 49 - 60

Concerns/needs clarified
• Member communication & handbook (5.5.3 & 5.5.3.6) - Both member communication and handbooks should describe clearly available medical and behavioral health services, and should be standardized across RAEs to allow easy comparability and use.

• Advance Directives (5.5.3.10) – CCHN supports access to Aid in Dying which was approved by Colorado voters in November and encourages the Department to pursue state-only Medicaid funds to ensure Medicaid members have access to these services if/when applicable.

• Health needs survey (3.3.12.2 & 5.5.5) – Additional clarity is needed on who will develop the health needs survey, when and by whom the survey will be conducted, and how data from the survey will be provided to PCMPs to identify a member and family’s potential immediate needs. The survey should be based on national best practices/standards, succinct, allow for risk stratification in deployment, and include a patient engagement and activation measure to use in goal setting and ensure that patient is interested and motivated in addressing a specific need from the outset. The survey should be completed as part of RAE (versus) initial enrollment. If PCMPs are responsible for administering the survey, additional PMPM should be associated with this work.

• Member Education of Medicaid Benefits (5.5.6.2) – The RFP specifies that the RAE will work with Healthy Communities within their region for onboarding Members to the program. FQHCs have experience working with Healthy Communities. The draft RFP appears to be expanding the scope of Healthy Communities beyond kids to engage with and onboard adults too. The RFP should clarify the future role of Healthy Communities.

• Promotion of member health and wellness (5.5.7) – Embedded in the current and proposed ACC there is a tension between provider responsibility to manage patient’s and the patient’s unrestricted options in how to utilize the health care system. Only if the two have aligned incentives, both negative and positive, can significant change to patient utilization and total cost of care be achieved. To meet the Department goal of assisting members effectively in utilizing Medicaid benefits and supporting members in becoming proactive participants in their health and well-being, clients should be locked-in to their assigned PCMP to ensure continuity of care and better manage costs and improve health outcomes. Lock-in must allow opportunities for PCMP changes based on clients housing status, moving, etc. If the Department isn’t willing to lock patients in then KPIs should be so heavily driven by patient compliance (i.e. number of BH visits in primary care, ED visits for ambulatory care-sensitive conditions).
Somewhat clearSection 5.6 pages 61 – 68

Support
• Network provider submitted problems to the RAE (5.6.5.7) – We appreciate that there are requirements for RAEs to document network provider submitted problems, the Department will review solutions, and could direct RAE to find different solutions or follow a specific course of action.

Concerns/needs clarified
Grievances (5.6.5) – All grievance processes should include the provision of sufficient information to be actionable and make appropriate changes to address areas of concern or offer counter information. This should include both the process for grievances filed with the Department against the Contractor, and those filed with the Contractor regarding providers.

Somewhat unclearSection 5.7 pages 68 - 78

Support
• Build on current Medicaid Network (5.7.1) – Support RAE’s building on current network of Medicaid providers in their creation, administration and maintenance of a PCMP network.

• Telemedicine (5.7.1.5) – Support use of telemedicine to address geographic barriers to accessing clinical providers, particularly specialists, but also broadly as a strategy to reduce barriers to access across the health care system to reduce barriers to accessing care.

• Non-urgent, symptomatic behavioral health services (5.7.4.13.5.2) – needs to occur within 7 days, and for low-acuity patients this can/should occur in the primary care setting.

Concerns/needs clarification
• Contradicting information (5.7.2.3) – Regarding network development the RFP both says that RAEs will have the ability to select PCMPs to contract with based on quality metrics, but in this section it also says that the contractor will contract with all PCMP sites. Additionally, because medical payments will continue to be paid directly by the state, it is not clear what authority the RAE has to refuse a contract to a PCMP. This issue is specific to medical as the behavioral health structure does provide the RAE’s the necessary leverage to refuse contracts. The state needs to decide if either RAEs will have to contract with all qualified PCMPs, or will be able to be more selective regarding PCMP contracts and be consistent throughout this section. Additionally, should the RAEs be able to be restrictive, it should be clear what authority that is under and in what conditions they can be restrictive.

• PCMP qualifications - CCHN supports access to high-quality, general and specialized care from a comprehensive and integrated provider network (5.7.1.2). However, we request that the Department ensure in the final RFP that the current PCMP definition is maintained in the next phase of the ACC. (5.7.2.1). We believe that over time the Department should make the qualifications for PCMPs more stringent while balancing both patient choice and access, and that in meantime high performing PCMPs should be eligible for auto attribution. Performance should include open to Medicaid, have care delegation agreement with the RAE, national PCMH recognition, and meet a minimum threshold of Medicaid patients or overall practices. 5.7.2.1.3 omits physician assistants and this provider should be added as a PCMP. The current PCMP definition includes Medicaid enrolled providers that are (1) an individual physician, advanced practice nurse or physician assistant with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology OR (2) a FQHC, RHC or other clinic or group practice with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics or obstetrics and gynecology. In the next phase of ACC PCMPs need to continue to be required to “act as the dedicated source of primary care for Members and capable of delivering the majority of members comprehensive primary, preventive, and sick medical care”. If RAEs are able to limit their networks, the criteria for exclusion must be public and clear. As noted under member attribution we continue to have concerns with urgent cares serving as PCMPs. We want to ensure urgent cares are truly able to meet PCMP criteria, and we don’t believe ERs should ever qualify as PCMPs. To accomplish this, the Department should consider prioritizing wellness codes in claims based attribution to ensure assignment to PCMPs rather than the most recent utilization (for example a member may access an urgent care for a sick visit, but still receive their wellness visits at a PCMP), use a longer look back for re-attribution (i.e. 18 or 24 months), and PCMP qualification by site versus simply parent organization designation.

• Specialty behavioral health providers (3.3.3 & 5.7.3) states that the RAE will manage a network of primary care physical providers and specialty behavioral health providers to ensure access to appropriate care for Medicaid Members. What is meant by specialty behavioral health providers? Will this responsibility include ensuring access to behavioral health providers in the primary care setting? CCHN would like the FQHC billing rule changed to allow an expanded list of behavioral health providers to bill for screenings, prevention and interventions at FQHCs The list of FQHC billable BH providers is consistent with providers that may bill Medicaid in private settings and includes the following providers: MD (psychiatrists), clinical psychologist (PhD and PsyD), LCSW, APRN (psychiatric nurse practitioner), RxN (psychiatric nurse with Rx authority – not NP but master level); LPC, LMFT, CACII & III (only for substance abuse treatment); LAC; MAC; and candidates for licensure including psychologist candidate, licensed professional counsel candidate, marriage and family therapist candidate and licensed social worker.

• The final RFP should ensure timeliness standards for credentialing of BH providers.

• Universal screening tools (5.7.2.1.8) – Screening tools need to be population based, and this should be clarified in the contract language to weed out providers who are less committed to a population based approach.

• Access to Care Standards (5.7.4) – The Department should describe how these were established, and RAEs should be able to document situations when there aren’t enough providers available to meet the standards. Standards should be based on providers and NOT require separate brick and mortar entities. Standards should be consistent among primary care and behavioral health, and specialty care and hospital standards should be included as critical components of network access. Additionally, clarification should be provided that standards regarding timely access to care are measured based on availability of treatment appointments, not patient choice on when to receive care.

Somewhat unclearSection 5.8 pages 78-83

Support
• Increasing number of specialists (5.8.3.3 & 5.8.3.4)

• Recognizing the importance of oral health and establishing relationships and communication channels with the Dental Benefit managed care vendor to promote member utilization of dental benefits (5.8.3.12)

Concerns/needs clarified
• Health Neighborhood and Community and the Social Determinants of Health (5.8.3 and 5.8.4) – These sections increase expectations regarding RAE engagement with other parts of the health care system, but do not empower the RAE to compel participation of the agencies they will be expected to work with. For example, 5.8.3.10 addresses the RAE’s responsibility to facilitate health data sharing among providers and does not address the role that the State’s HIE contractor will play in that process. As the Department considers these requirements to engage various aspects of the health system, consideration for feasibility should be made based on the leverage the RAE will have and what role the State will play in bringing the support of other state departments and contractors.

• Health Neighborhood – E-consult software (5.8.3.5.2) – The software described in this section sounds promising, but it isn’t clear what the cost to the RAE and/or PCMP will be to implement it. Further clarification on expectations regarding PCPM use and implementation costs would be beneficial.

• Health Neighborhood – Hospitals (5.8.3.8) – CCHN is supportive of incenting hospitals to promote a shared, proactive system that improves health and drives innovation. CCHN submitted comments specific to DSRIP in November and is generally supportive of this effort to further align the ACC with the hospital program. This portion of the RFP addresses the participation of RAEs in hospital community needs assessments, project selection, and project development, but what should be more explicit that these projects should be aligned with the hospital-related KPIs which PCMPs and RAEs will be held accountable to in phase two. RAE participation in a hospital focused process will not sufficiently align the system, and allow RAEs to move the dial on total cost of care and ED utilization. The DSRIP initiative and hospital projects should be aligned with the desired outcomes of the ACC.

• Substance Use Disorder (SUD) Services – SUD services are critical for many Medicaid members to see improved outcomes, decreased costs and general well-being. RAE coordination of SUD resources is an essential component in assuring prevention of duplication and overuse of services and fragmentation of care.

• Universal Release of Information – At an earlier meeting regarding ACC phase two, mention was made of the Department considering establishing a universal release of information methodology by which providers would be able to share pertinent patient information in a more streamlined fashion. This idea is not reflected in the draft RFP but is something CCHN and our members are highly supportive of. While we understand that there are some specific challenges regarding behavioral health, CCHN would support the Department’s efforts should a way to manage the challenges be found.

Somewhat unclearSection 5.9 pages 83 – 87

Concern/clarification needed:
•Population Health Management - Stratification (5.9.2.2) – The draft RFP allows each contractor to establish their own stratification process, which has been one of the administrative complexities for large primary care systems located in and working with multiple RCCOs. The current RCCO stratification models often are not meaningful at the primary care practice level, necessitating increases in transparency about how stratification is applied and how risk scores are compiled. This requirement necessitates an additional report to the state regarding how the RAE plans on stratifying their population. CCHN requests the Department consider having a single cross-state method for stratification created in partnership with PCMPs. This would create administrative simplicity both for providers in understanding which populations to target, and for the RAEs in having one less deliverable to provide.

•Care Coordination (5.9.3.5-10) – It is not clear throughout this section the level of authority that the RAE will have in the operations of a PCMP’s care coordination program. It is understandable for the RAE to ensure that the member’s needs are being meet, but the expectation cannot be for the RAE to dictate the specifics of a PCMP’s care coordination.
Very clearSection 87 – 93

Support:
• General Information and Administrative Support (5.10.5) – Generally CCHN supports the obligation of this section for a RAE to be a source of information for providers.
• Financial Support (5.10.9) – CCHN supports the requirement that stakeholders be given advance notice of all forums and shall have an opportunity to participate in and provide input toward the development of the incentive/admin payment strategy to PCMP network providers. This is in alignment with CCHN’s interest in the final RFP assuring there are consistent RAE requirements related to financing/financial management to ensure resources are largely invested in improving patient experience and outcomes. RAE governance structures should allow providers to participate in the decision making process associated with how these dollars will be distributed regionally. This is important in creating transparency on how funds are spent, and insuring that they are invested in a way that is meaningfully community-centered and aligned with the state’s goals. CCHN’s specific thoughts on PCMP PMPM included in section 21 on compensation.

Concern/clarification needed:
• Provider Training and Practice Transformation (5.10.6 and 5.10.8) – We support RAEs providing training and support to PCMPs, however it is important that trainings are meaningful, and not duplicative of other state efforts such as admin and practice transformation efforts through SIM. Trainings should be tailored to PCMP needs.
No opinionSection 5.11 pages 93 – 94

Support:
• Primary Care APM (5.11.1) - CCHN supports payment innovation that moves towards value based over volume based payment, which allows flexibility to design care teams and systems around patient needs, provides stable funding to providers with the opportunity to evolve to include risk/responsibility over time, is reliant on regular patient and provider performance data, and includes rewards for quality and controlling the total cost of care. CCHN appreciates and looks forward to the continued partnership with the Department in the development and piloting of a new APM for FQHCs that is a PMPM with a path for rewarding quality and incenting accountability and taking on risk over time for interested FQHCs.
Somewhat clearSomewhat unclear
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1/11/2017 11:00:47I agree and wish to continueAnnetteKowalColorado Community Health Network (CCHN)Social Service/Community OrganizationSomewhat clearSection 5.12 pages 94 – 109
Support:
• Behavioral Health Integration (5.12 generally) –
o FQHCs in Colorado all provide some level of integrated behavioral health care and have faced various challenges under the current carve out system. As such, CCHN is supportive of the integration of funding for Medicaid mental and physical health to make primary, preventative and behavioral health services more efficient and patient centric.
o The integration of the administrative entities of the BHO and RCCO into the RAE is an important step towards being able to monitor total patient utilization of behavioral and medical care, and emphasizing the importance of providing behavioral health services to all Medicaid clients at the point of care, regardless of whether a service is medical or behavioral health.
o Ensuring Medicaid members continue to have access to IMD facilities and 1915(b)(3) alternative services.
• Low-acuity Behavioral Health in Primary Care (5.12.5.4) – Research indicates that about 25% of all U.S. adults have a mental illness and that nearly 50% of U.S. adults will develop at least on mental illness during their lifetime. The current BHO penetration rates range from 12% to nearly 17%, supporting other studies which indicate that 50-65% of people in need of mental health services do not get seen. This indicates the need to make early identification and intervention more readily available in the primary care setting because it is where patients are more likely to present initially, and many will not follow through on a referral, meaning if they do not receive that care in the primary care setting, they may never receive it. While it is vital to ensure the sustainability of the current behavioral health system for the severe and persistently mentally ill, making early identification and access more supported in the primary care setting is the model which CHCs have demonstrated works to improve patient outcomes and reduce long term costs.
o The integration of the BHO and RCCO functions into the RAE is essential for making this successful. Under the current system BH providers at FQHCs regularly identify situations in which services are being duplicated, meaning provided both in primary care and the behavioral health system, which means resources are used on the same patient which could be utilized to provide additional access. By combining the administrative functions and ensuring that the RAE has access to both the behavioral health and medical data, the RAE will be able to identify these situations and work with providers on how to remove those duplications and ensure that the patient receives the best care for them in a reliable and consistent fashion.
o Additionally, the elimination of the required CCAR to receive behavioral health services is a positive step towards opening access to behavioral health services in the primary care setting. The experience of our members with the CCAR calls into question the value it adds to the system, leading CCHN to advocate that the CCAR should be removed as a requirement entirely, not just for low-acuity and select behavioral health services. While reviewing requirements for the value they add to patient care and the system, the lengthy intake process should also be evaluated.
• MLR (5.12.12) – CCHN supports accountability and transparency in RAE costs with the majority of RAE resources largely invested in improving patient experience and outcomes.

Concerns/clarification needed:
• FQHC and RHC Encounter Rates (5.12.9) – Given the confusion over FQHC payment for behavioral health services, CCHN is thankful for the explicit nature of this section. However, the current allowable behavioral health providers for FQHCs is far too restrictive to allow for sufficient hiring of the needed providers for these services. In the past this has been covered by the BHOs reimbursing for providers that are not explicitly outlined in the referenced statute, but due to both the allowance for some services outside of the behavioral health capitation and the restriction to the statute here, CCHN requests that the list of FQHC allowable behavioral health providers be expanded to include MD (psychiatrists), clinical psychologist (PhD and PsyD), LCSW, APRN (psychiatric nurse practitioner), RxN (psychiatric nurse with Rx authority – not NP but master level); LPC, LMFT, CACII & III (only for substance abuse treatment); LAC; MAC; and candidates for licensure including psychologist candidate, licensed professional counsel candidate, marriage and family therapist candidate and licensed social worker.

• Low-acuity Behavioral Health Services (Appendix O) – While the list of codes which the Department has proposed to reimburse as low-acuity behavioral health services in the primary care setting is a good start, it does not address many of the behavioral health services which are provided in an integrated primary care setting. We are in agreement with the state that ongoing treatment should be a part of the behavioral health capitation, but many patients are in need of assessment and treatment which is time sensitive, focused, and can be provided within the context of the primary care office in less than six visits. CCHN requests that in addition to the codes proposed as low-acuity the Department add codes related to screening for behavioral health and substance abuse issues and codes related to the intersection between medical and behavioral health, such as the Health and Behavioral assessment and intervention codes.

Somewhat unclearSection 5.13 pages 109 – 113

Concern/clarification needed:
•Central Role of Data and Analytics (5.13.1.7.1) – While there are cases, such as behavioral and substance abuse information protected by CRF 42, which prohibit the sharing of information between providers, the implication that the RAE would have the ability to decide when it is appropriate or not to allow a provider to access Member level data is contrary to the intent of the ACC and the needs of PCMPs. PCMPs need access to complete care and cost data for their patients across regions, and this cannot depend on the plan of each individual RAE. This data needs to be real-time in order to provide meaningful care coordination and the Department and RAE contractors need to prioritize actionable data for PCMPs.
•Care Coordination Tool (5.13.2) – Most CHCs already invested in care coordination tools so we are appreciative that the RFP specifies that providers and delegated care coordinators will be able to continue using their own tools. Because many of these tools are integrated within EHRs, building reports is costly, time consuming, and may be difficult for the provider, so reporting should be standardized, meaning not different depending on the RAE with whom the delegated contract is with, in order to ensure that provider are able to meet these requirements. Additionally, standards and measures of care coordination should recognize the different models necessitated when provided within a primary care setting compared to being provided by an outside entity for multiple PCMPs.
Somewhat clearSupport:
• Program Improvement Advisory Committees (5.14.9.2) – CCHN supports the standardization of administrative elements of the RAEs, such as the requirements regarding the engagement of stakeholder groups through the regional and state Program Improvement Advisory Committees.

Concerns/clarity needed:
• Performance Improvement Projects (5.14.3) – As with other areas where RAEs will be able to establish different priorities, these projects create a number of concerns, particularly for large providers who work with and are located in multiple regions. Further information is needed regarding how the Department will ensure that projects align with overall program goals, address needs of the communities and providers in the region, and align with the projects that hospitals will be engaging in as well. Added to participation in other initiatives, such as SIM, these projects could result in too many projects for PCMPs to be able to engage in meaningfully. Guiding principles around these projects should ensure that they align with other state efforts, including DSRIP and SIM.
• Key Performance Indicators (5.14.4.8.1.1) – The indicators outlined in this section do not align with those outlined by the Department in earlier communications. This is concerning as one of the requests of our members has been for consistency in KPIs over time in order to make meaningful improvement which is embedded in the system and therefore less likely to result in systems reverting back after the metric is removed. Specific to the metrics outlined here, we have several concerns and questions:
o Total cost of care (5.14.4.8.1.1.2.1) – This metric includes both physical and behavioral health, but excludes dental. As providers who believe in comprehensive care which includes oral health, we question the exclusion of dental costs from the metric.
o ED visits for ambulatory sensitive conditions (5.14.4.8.1.1.2.2) – CCHN recommends the removal of this metric. There is little data to support this metric, and multiple areas of concerns regarding it: the proliferation of free standing EDs, the lack of patient accountability or responsibility in the utilization of EDs in these situations, and the influence on this measure by coding, diagnosis, and provider behavior.
o Obesity (5.14.4.8.1.1.2.7) – While it is great to see a metric specifically aligned with the 10 Winnable Battles, this metric is significantly different in terms of the time required for interventions to result in meaningful differences. If only annual change is to be considered, the metric may not be sensitive enough to provide meaningful information or payment adjustment. This is supported by the statement in 5.14.4.8.1.3.1.2 that RAEs and providers play a critical but perhaps not determinative role in addressing this level of outcome. It may be more beneficial to seek improvements in other related health outcomes, such as controlled blood pressure and reductions in high blood pressure, which can be achieved more incrementally and do have more of a medically based intervention.
o Health Neighborhood (5.14.4.8.1.1.2.8) – The proposed metric looks only at consultations and compacts, not at visits with specialists. Even if consultations and compacts increase, the need for visits with specialists will be maintained, and true access to needed specialty care needs to include the ability to see a specialist when needed.
o Regional KPI (5.14.4.8.1.1.4) – In providing for RAEs to select a regional KPI, the RFP references a list to be provided by the Department which is not included in the KPI. Additional specificity regarding this list is needed and should be vetted with providers before finalized.
o Other KPIs (5.14.4.8.1.1.5) – With the increase from three KPIs to 9, the addition of this holding spot for RAEs to be required to work on additional KPIs is highly open ended and brings into question the ability of the RAEs to work on so many quality indicators with the resources available to them. It is unreasonable to expect the RAEs to have the capacity to take on additional work in this area when this is an area of work which will already be greatly expanded from the current contract.
• Flexible Funding Pool (5.14.4.8.1.2.1) – Similar to the comment on the Other KPI section, this appears to be additional work presented in a highly open ended format and without the guarantee that the funds available would support that work.
Somewhat clearSection 5.15 pages 126 – 145

Concerns/needs clarification
• Provider preventable conditions ( 5.15.7.1.1) needs to be defined in final RFP. It isn’t clear what this is or means.
• Credible allegations of fraud (5.15.5.2.11) – CCHN requests that the following additional provisions are included in the final RFP and ultimately in state regulations related to credible allegations of fraud
o Establish a definition of a credible allegation, including:
 More than one allegation made within an established time period
 Allegations are supported by credible evidence
 Reasonable assurance that the acts in question were willfully committed in an effort to obtain more benefits or payments than entitled to, and not due to unintentional billing mistakes.
o Establish a maximum length of time for which the State can suspend payments prior to making a final determination as to the credible allegation of fraud.
o Requirements that the notification of a credible allegation contain enough detailed information for the provider to respond to the specific allegation.
o Requirements that the state recertify to the provider at regular intervals that the fraud investigation is ongoing.
o Requirement to process suspended payments to a provider on a timely basis once the allegation has been resolved in favor of the provider.
Very clearSection 5.16 pages 145 – 149

No comments
No opinionSection 6.0 pages 149 – 160

No comments

Somewhat clearSection 7.0 pages 160 – 165
Concerns/needs clarification:
• PCMP PMPM (3.3.15.2 & 7.0) – PCMPs responsible for care improvement and cost savings should be rewarded with shared savings and incentive payments.
o The draft RFP is silent on care delegation arrangements. Many FQs and some other large practices receive PMPM from their RCCO for providing these services at the point of care and want to ensure they continue to have the opportunity to be reimbursed by RAEs for providing this important service in Phase II.
o How was the 30% minimum of RAE’s PMPM that must was distributed to the PCMP network and health neighborhood established?
o The 30% minimum should apply to the $4 Dept. withhold too.
o The optional $2 PCMP PMPM should be paid up front.
o The minimum $2 PCMP PMPM should be considered a minimum for larger practices as it is not likely enough to cover the costs of care coordination efforts for smaller providers. Consider an approach to the minimum PCMP PMPM which functions on a sliding scale dependent upon provider size and care coordination functions.
o The Department should encourage RAEs as much as possible to ensure that providers responsible for care improvement and cost savings are rewarded with shared savings and incentive payments. FQs care delegation roles is aligned with the Department’s’ interest stated in 3.3.12.1 that “ideally, care coordination will be provided face to face by individuals with strong ties to the community who can develop ongoing relationships with members”. The RAE should offer PMPM sufficient to support the reasonable costs of PCMP participation in the health neighborhood, care coordination and overall population health strategy of the region.
• KPIs (7.4.1) – HCPF should document how selected KPIs lower cost and improve health, and the data used to calculate KPIs should be readily available to PCMPs. Improvement as well as meeting benchmarks should be rewarded. As stated above PCMPs responsible for care improvement and cost savings should be rewarded with shared savings and incentive payments.
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1/11/2017 12:09:54I agree and wish to continueMaileenHamtoMental Health Center of Denver Diversity and Inclusiveness ProfessionalRFP needs consistent language when addressing cultural issues. Some places in the document use "cultural responsiveness" while others use the term "cultural proficiency." These terms mean different things. “Responsiveness” indicates a low bar, while competency presents a more challenging approach to addressing institutional and systemic racism embedded in the health care system. Somewhat clearSomewhat clearSomewhat clearSomewhat clear5.4.7: Incorporate other protected classes in the anti-discrimination statement, including:
• Language used at home
• Genetic information
• AIDS/HIV
• Military or veteran status
• Status as a victim of domestic violence, assault, or stalking

5.5.1.1.1: Revise: Responsiveness to Member and family/caregiver needs by incorporating best-practices in communication and cultural proficiency in service delivery

5.5.1.1.2: Revise: Utilization of various tools to communicate clearly and concisely in a manner that prioritizes linguistic access and cultural competency

Also specify “various tools” for communications, e.g. print, face-to-face, digital, et.al. Include acknowledgment of cost impacts.

5.5.1.2: Revise: The Contractor shall align Member engagement activities with the Department’s person- and family-centered approach that respects and values cultural competency, individual preferences, strengths, and contributions.

Somewhat clear5.5.2.2.2: “The medical risks associated with the Member population’s racial, ethnic and socioeconomic conditions.”

Need more clarification about how this will be implemented, given that previous sections place importance on a patient- / individual-centered approach. Need optimum balance between individualization and population health disparities, so we are not stereotyping diverse communities.

5.5.2.3: “The Contractor shall identify Members whose cultural norms and practices may affect their access to health care.”

Need more clarification about how this will be implemented, without adversely profiling or labeling diverse communities .

5.5.2.4 and 5.5.2.4.1: These section and sub-section appear to signify that all Member communications are to be conducted only in electronic format. This is inconsistent with Section 5.5.1.1.2, which calls upon “various tools” of communication for Members and their family/caregiver. Please clarify and/or expand the scope of information accessibility. Include acknowledgment of cost impacts.

5.5.2.5.2: “The Contractor shall make oral interpretation available in all languages and written translation available in each prevalent non-English language.”

Specify “prevalent non-English language.” Provide more guidance about what is considered prevalent, e.g. numbers or percentage of population served.

5.5.2.5.3: Under this section, there must be a separate sub-section for providing interpreter services for Deaf and Hard-of-Hearing individuals.

Section 5.5.2.5.3.1 only addresses “oral interpretation.”

Section 5.5.2.5.3.3 “appears” to include the Deaf and Hard-of-Hearing community, but there is no specific mention of ASL interpretation. The Deaf and Hard of Hearing community does not fall under communities of disability.

5.5.2.6.4.1 and 5.5.2.6.4.2: These two sub-sections appear contradictory. Sub-section 5.5.2.6.4.1 calls for translation in top 15 prevalent non-English languages, while 5.5.2.6.4.2 includes only the top two. Please clarify.

Also advocating against excusing small-sized publications from the translation requirement. More discussion necessary to uncover all potential problems with this approach. Include acknowledgment of cost impacts.

5.5.2.6.5.1: Change the language accessibility level to 4th grade. CMS recommends health literacy information to be written at 4th to 6th-grade level. It’s best practice to opt for more simple, easy-to-understand language.

https://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/downloads/toolkitpart01.pdf

5.5.2.1: For consistency, incorporate all protected classes in the list of specific identities (see Section 5.4.7). “Culture” applies to diverse identities, and not solely confined to a race and ethnic framework.

5.5.2.2: The cultural competency training topics listed below this section is very limited and reinforces a paternalistic model of addressing diversity and inclusion.

“Health care attitudes, values, customs and beliefs that affect access to and benefit from health care services…” suggests deficits in the home culture of a Member, rather than leading with a strengths-based approach. While it may not have been intentional, this point-of-view is problematic because it puts the “blame” on people we serve, rather than taking a critical look at how organizations – and the people working there – must change to provide the best service and care for diverse communities.

This section must place “cultural self-awareness” as the centerpiece of any diversity and inclusiveness training. Training on implicit bias is a solid first step in acknowledging embedded prejudice in systems.
Somewhat clearSomewhat clear5.8.4: Community and the Social Determinants of Health

Throughout this section, acknowledge the importance of specifically naming diverse communities that are more adversely impacted by social determinants of health, such as communities of color, LGBTQ+ community, people with disabilities, among others. “Social determinants” of health requires a close scrutiny of socio-political factors that create health disparities in underserved communities.

5.9.3.7.4: Explain “culturally competent” in the context of Care Coordination

5.10.6.2.7: In this section, “cultural responsiveness” is used, while “cultural competency” is used in other sections. Recommendation to use “cultural competency” or “cultural proficiency” instead of “cultural responsiveness.”

Somewhat clearSomewhat clear5.5.2.6.7: “…that takes into consideration the special needs of Members with disabilities, Members who are visually impaired and Members who have limited reading proficiency.”

Please clarify: does the term “Members with disabilities” refer to Deaf and Hard-of-Hearing individuals? If so, “Members with disabilities” should be changed to “Deaf and Hard-of-Hearing Members.”

5.5.2.6.9: “The Contractor shall ensure that all written materials for Members have been tested by Member representatives.”

Please clarify requirement to “test” all written materials. This requirement could impact communications compliance deadlines. It must be reworded to properly acknowledge potential financial and human resource costs involved in soliciting Member feedback. Include acknowledgment of cost impacts.

5.7.1.3: “… across all ages, levels of ability, gender identities, and cultural identities.”
Edit this phrase to specifically include racial, ethnic and linguistic communities,