Opinion ID: 871688
Heading Depth: 2
Heading Rank: 1

Heading: The QExA Request for Proposals

Text: On October 10, 2007, the Department of Human Services (DHS) issued Request for Proposals (RFP) No. RFP-MQD-2008-006 QUEST Expanded Access (QExA) Managed Care Plans to Cover Eligible Individuals Who Are Aged, Blind, or Disabled. The RFP provided, in part: This [RFP] solicits participation by qualified and properly licensed health plans to provide required service coordination, outreach, improved access, and enhanced quality healthcare services through a managed care system for the State's Medicaid aged, blind or disabled (ABD) members who are currently not covered through a managed care system across the continuum of care. The services shall be provided in a managed care environment with reimbursement to qualifying health plans based on fully capitated rates for each island. (Emphasis added). The RFP defined managed care as [a] comprehensive approach to the provision of healthcare that combines clinical services and administrative procedures within an integrated, coordinated system to provide timely access to primary care and other necessary services in a cost-effective manner. The RFP further provided that QExA is a managed care program and, as such, all acute, pharmacy and long-term care services to members shall be provided in a managed care system. Regarding licensure, the RFP provided that: The health plan shall be properly licensed as a health plan in the State of Hawaii (See [Hawai`i Revised Statutes (HRS) chapters 431, and 432, and 432D]). The health plan need not be licensed as a federally qualified HMO, but shall meet the requirements of Section 1903(m) of the Social Security Act [(42 U.S.C. § 1396(m))] and the requirements specified by the DHS. (Emphasis added). The RFP's definition of Health Maintenance Organization (HMO) referred to its definition of Managed Care Organization, which stated: An entity that has, or is seeking to qualify for, a comprehensive risk contract under the final rule of the [federal Balanced Budget Act of 1997] and that is: (1) a federally qualified HMO that meets the requirements under Section 1310(d) of the Public Health Service Act; (2) any public or private entity that meets the advance directives requirements and meets the following conditions: (a) makes the service it provides to its Medicaid members as accessible (in terms of timeliness, amount, duration, and scope) as those services that are available to other Medicaid enrollees within the area served by the entity and (b) meets the solvency standards of 42 CFR Section 438.116 and HRS § 432D-8 [sic]. The RFP also defined the term Participating as [w]hen referring to a provider, a healthcare provider who is employed by or who has entered into a contract with the health plan to provide covered services to members. When referring to a facility, a facility which is owned and operated by, or which has entered into a contract with the health plan for the provision of covered services to members. The RFP required that successful bidders develop and maintain a provider network that is sufficient to ensure that all medically necessary covered services are accessible and available to plan members. To that end, the RFP set forth the minimum size of the plan's provider network, including the number of primary care physicians, specialists and hospitals required on each island. Under the QExA RFP, if the health plan is unable to provide medically necessary covered services to a member within its network or on the island of residence, then the health plan must provide the services out-of-network or transport the member to another island to access the services. No party disputes that the QExA RFP contemplated the provision of a closed panel plan, meaning that care must be obtained from the contracted network of providers if it is available within the network.