1. Q: Do Hospital Service Associations fall under the definition of a Health Plan Corporation in the Adult CHIP RFP?
   A.   A Health Plan Corporation is a corporation engaged in either the business of maintaining and operating a non-profit hospital plan (defined in 40 Pa.C.S. §6103) or a non-profit professional health service plan (defined in 40 Pa.C.S. §6301), or both.  A “Hospital Service Association” falls under the definition of a Health Plan Corporation if it meets this statutory definition.
2. Q. Can you provide more clarity as to the definition of a prescription drug discount program?
   A. A prescription drug program provides a discounted price on prescription drugs.  Typically, such a discount is a percentage off of the retail price charged by a pharmacy.
3. Q. The RFP did not state the minimum number of inpatient hospitalization days that are required to be offered.  Can the PID clarify the requirement? Also, when an inpatient stay did occur, would medical assistance spend down affect and, if so, how many days?
   A. An unlimited number of medically necessary inpatient days may be provided under the program.  If an enrollee in the program requires inpatient hospitalization, the contractor will not refer the matter for a determination of eligibility for Medicaid (using the “spend down”methodology).
4. Q. Is there a potential opportunity for the state to contract with a single ambulance company to provide medical transportation for the state’s  new uninsured adults program?
   A. No
5. Q. May we assume that the CHAPS/CAPS System will be fully operational on or before February 1, 2002?
   A. Yes
6. Q. As with the CHIP Program today, contractors cover all eligible inpatient admissions and do not apply a spend down process.  Will this process be the same for the Adult Basic Program?
   A. Yes
7. Q. The RFP places a large emphasis on managed care techniques delivered in an HMO product, i.e. PCP designation, qualify measurements, etc. The legislative intent seems to clearly indicate a desire for basic coverage, not including many benefits ordinarily associated with the HMO benefit model. How will you reconcile the RFP with the legislative intent?
   A. The meaning of the question is unclear.  Consequently, the Department’s answer is based on its own understanding of the question. Under the provisions of the Act, the Department is required to select contractors that use cost management methods.  The RFP was developed to implement that statutory requirement. However, the Department’s ability to award contracts under the RFP is not limited to only health maintenance organizations.
8. Q. Both hospital and non-hospital rehab therapy should be included in the rates and covered benefits, however, physical,  occupational, and speech therapies are specifically excluded.  What types of rehabilitative therapies are intended to be covered?
   A. Rehabilitation therapies (physical, occupational and speech) are included subcategories Hospital & Non-Hospital only when “Medically Necessary”.  Purpose of Exclusion: To exclude those out-patient therapies which will not result in any further improvement and, therefore, become “Not Medically Necessary”.
9. Q. How do you anticipate contractors being able to cover diabetes supplies and injections if we do not cover prescription drugs/durable medical equipment?
   A. The RFP specifies that service coverage includes diabetic supplies and injections.  Prescription drugs and durable medical equipment are limited to this disease. The offeror should describe how they will provide these medical services.
10. Q. Is there a limit on inpatient days?
    A. No
11. Q. May we place a limit on inpatient days?
    A. No
12. Q. Gateway Health Plan is a 156,000 member, NCQA accredited (Excellent level) Medicaid HMO, certified in 31 counties throughout Pennsylvania. We are very interested in responding to the above RPF since we are in a position to meet or exceed the RFP’s requirements.  Gateway is owned 50% by Highmark Blue Cross/Blue Shield, headquartered in Pittsburgh, and 50% by Mercy Health Plan, headquartered in Philadelphia.  Highmark BC/BS wants to respond separately to the RFP, as do we.  Under the rules of engagement, is that permissible?  Gateway Health Plan has its own license and NAIC code and government structure which is represented 50% by Highmark and 50% by Mercy Health Plan. Thank you for clarifying whether we both can respond.
    A. Any insurer, as that term is defined in the RFP, is permitted to submit a proposal in response to the  Department’s RFP. If Gateway Health Plan meets the definition of  “Insurer” as contained in the RFP, a proposal may be submitted.  Gateway Health Plan must make that determination.
13. Q. Please clarify what type of benefits would be included in the miscellaneous.
    A. Miscellaneous Categories must be used only when the contractor renders a service which does not fall under any of the services listed on the RCS Form.  For example, the Miscellaneous category under Hospital Services (Item 7 on the RCS Form) may be used to list Ancillary charges, Operating and Recovery Room, Observation and Treatment Room charges, etc.  Under Physicians Services (Item 15 on the RCS Form) may be used to list Allergy Testing, Allergy Immunotherapy, Physical Exams, etc. The Miscellaneous Category (Item 24 on the RCS Form) may be used to list any other covered service which the contractor does not know where else to put. The contractor does not have to use any of these listed Miscellaneous categories.  These are there just to provide some flexibility when the cost is very small. Please note that the services included under the Miscellaneous categories must be listed at the bottom of the RCS Form as instructed. 
14. Q. What is the time we should note on the cover of the RFP for the opening time?  Should it be one minute after 11:00 A.M. on 9/14/01?
    A. The covering letter which accompanies the RFP requires that “all proposals must be submitted by Friday, September 14, 2001 on or before 11:00 A.M. to the Pennsylvania Insurance Department…”. Further, Part II-1 of the RFP requires that proposals must be received by the designated date and time in order to be considered for evaluation. There is no requirement that an offeror make any reference in their proposal to the opening of proposals.
15. Q: Will there be any waivers for the 90 day period that applicants must wait before being eligible for adult basic coverage?  For instance, CHIP children that turn 19?
    A: The definition of  “Eligible Adult” prescribed in Act 77 requires that an applicant not be covered by a health insurance plan, a self-insurance plan, or a self-funded plan during the three months immediately preceding the determination of eligibility for the adult basic insurance coverage program. Three exceptions are also specified in the Act:
l).  The person is eligible to receive unemployment compensation benefits.
2). The person was covered by one of the above plans, but is now unemployed.
3). The person is the spouse of a person who meets either of the first two exceptions and is also applying for coverage.

Please refer to Chapter 7 of the draft Procedures Manual appended to the RFP.

Neither CHIP nor Medicaid is a health insurance plan, a self-insurance plan or a self-funded plan.  Therefore, a child or adult who has been enrolled in CHIP or Medicaid, but is no longer eligible, is not subject to the waiting period requirement and may be immediately enrolled in the adult program – assuming that all other conditions of eligibility are met.

16. Q: Can you please describe what is meant by transportation services on page 48 of the RFP?  Is this referring to ambulance services for emergencies?  Or is this referring to transportation to PCP offices such as Access vans, etc?
    A: The reference relates to ambulance transport for emergency services.
17. Q: Excluding this category of services except in emergencies eliminates the ability to transport members home from an inpatient stay or to a facility for ongoing outpatient services or skilled nursing. Is this a reimbursable expense when members are being transported from a facility to another or home?
    A: Ambulance service from a covered inpatient stay to a covered SNF stay or to covered home health care is covered, as would transport between inpatient institutions.  Transport home is not covered unless the patient is going to be receiving covered home health care. To be covered, any transport must be medically necessary.`
18. Q: Is there additional information on how we can provide coverage for immunosuppressives when prescription drug coverage is excluded?  Can we require that members purchase these and then receive reimbursement after submitting a claim form? These drugs are quire expensive.
    A: The offeror should describe in its proposal the method of payment it will use in providing this service.
19. Q: Are home infusion and hospice care considered part of Home Health Care and would therefore be covered in lieu of a medically necessary hospital stay?
    A: Hospice is not covered.  Medically necessary infusion is a covered service in an inpatient setting; home infusion is covered if the patient is in a home setting in lieu of a hospital or SNF.
20. Q: Do providers have the option to make the co-payment for the gyn exam part of the specialist  office visit so that it matches network HMO rules?
    A: No.  Co-payments may not be charged for annual gyn examinations. See Footnote (*) to co-payment chart found on page 20 of the RFP.
21. Q: Should rehab therapies be rated under inpatient and outpatient?  If so, what are the services to be provided if PT, OT, and ST are excluded?
    A: Inpatient admissions for rehabilitative services must be put on Line 20 – Rehabilitative Therapy, Hospital, of the RCS form in Appendix B.
22. Q: Will the CHAPS System ever process claims? Is this part of the future plan?
    A: The technical design of the CHAPS System does not include the payment of claims. There are no plans to change the technical design of the system.
23. Q: Will it be possible, at some future date, to “reset” some adult renewal months according to a fair algorithm so that we do not have enormous volumes of renewals processing in February, March, and April since this will be when the bulk of adults begin their coverage?
    A: After contracts are executed, the Department will give strong consideration to the concern raised in this question in the development of final implementation instructions for contractors and the Procedures Manual.
24. Q: In an effort to provide “family friendly” service to families with children in CHIP and adult parents/guardians on Adult Basic Coverage, will it be possible to provide one common renewal month for both programs so the families don’t have to send their renewal docs in twice, separately?
    A: After contracts are executed, the Department will give strong consideration to the concern raised in this question.
25. Q: In the event of a waiting list, when another adult in a household applies and is eligible, shall we place that adult on the waiting list?
    A: Section 1303 (D) of Act 77 (relating to Potential Waiting Lists) requires that the Department “maintain a waiting list of eligible adults who have applied for Adult Basic Coverage insurance but who are not enrolled due to insufficient appropriations”. Further, an eligible adult on the waiting list may choose to purchase the benefit package. As directed by the Act, the Department will develop and maintain a centralized system for managing and administering a waiting list. Contractors will receive written instruction from the Department regarding the procedures developed for this purpose.
26. Q: The glossary of the Procedures Manual (Appendix F) defines creditable coverage. Additionally, Section 7.1 of the manual states that a person is not eligible if he or she has creditable health insurance coverage or has had creditable health insurance coverage during the three months immediately preceding the determination of eligibility.  Is a limited benefits health insurance plan included in the scope of the definition of creditable coverage?
    A: A limited benefits health insurance plan (i.e. a plan which covers only a specific service such as dental or prescription drugs) is not considered to be creditable insurance coverage.  Please refer to the “Glossary and Acronyms” Section of the Draft Procedures Manual for a definition of Creditable Insurance.
27. Q: We were unable to find a precise definition of the line items on the RCS (Appendix B).  For example, on which line would outpatient (hospital surgeries go)?
    A: Outpatient hospital surgeries should be put on Line 4 (Special Procedure Unit) or on Line 5 (Hospital Outpatient), depending on how the offeror codes these benefits.
28. Q: Does the enrollment form include routine consent for health care operations in accordance with NCQA requirements?
    A: A review of the draft application document appended to the RFP (Appendix G) reveals that such a statement has not been included.  However, it will be included in a final iteration of the prototype application document.
29. Q: How many days advance notice will contractors receive in the event of a change in standards?  By what method?
    A: It is not possible to provide a specific response to this question.  The amount of advanced notice and means of notification a contractor will receive regarding a change in a performance standard will, to some extent, depend upon the nature of the matter at issue. The Department intends to work in partnership with contractors to meet the objectives of the program and will involve contractors in discussion as new standards come under development.
30. Q: Will a contractor be permitted to invoice a member on a prepaid quarterly basis or must the invoices be sent monthly?  Can we offer the option for members to pay in advance for a month, quarter, semi-annually if they desire?
    A: Act 77 requires that each enrolled person pay a monthly fee of $30.00  However, a contractor may offer the enrollee other payment options such as bi-monthly, quarterly, or annually. If a contractor intends to offer such options, they should be described in the proposal. It is also permissible for a contractor to offer a variety of payment methods, such as but not limited to, check, money order, and credit card. The variety of payment methods the contractor intends to offer should also be described in the proposal.  We emphasize that the choice of the enrollee must be honored with regard to payment periodicity and method.
31. Q: Should all services with a diagnosis of infertility be excluded under this program?
    A: Yes.
32. Q: On page 41 of the RFP it states the “Contractors shall provide a Member Handbook to each new enrollee…” As a CHIP contractor, we currently provide one Member Handbook per family/household.  Would this same practice be acceptable for the ABC Program?
    A: Yes.
33. Q: Does this benefit include oral drugs?  Does this benefit only include the test strips, glucometers, lancets, and syringes and not the actual medications (since drugs are not covered)?  How can we include these if durable medical equipment is excluded?
    A: The RFP, in Section IV-4.A., excluded prescription drugs as a benefit except for immunosuppressives prescribed in connection with covered transplants. The RFP in Section IV-4.A. specifically  provides that diabetic supplies and injectibles are included benefits. Therefore, oral medications are not covered benefits in this context.
34. Q: Will the QME reporting process that is used on CHIP business be implemented for this program? Will the reporting requirements change following the review by NCQA? Will the cost of performing a CAHPS survey be reimbursed to Adult Basic Coverage contractors separately?
    A: The QME evaluation will not be specific to the adult program because of the newness of the program. We will only require that contractors submit their company-wide HEDIS and CAHPS reviews. Once the program has been in place long enough to accumulate enough enrollees to generate an adequate sampling, we will re-consider the feasibility of doing a review specific to the adult program.  That will be determined after we have had a chance to analyze the results of NCQA’s study.  Since we are not requiring a CAHPS survey specific to the adult program, no reimbursements will be forthcoming.
35. Q: In Section I-13, it states that the proposal must remain valid for the greater of 120 days or through the effective date of the contract resulting from the RFP. Does the Department expect an offeror’s proposal to remain valid even if the effective date of the contract is later than February 1, 2002? If so, can the rates be subject to adjustment?
    A: Section 13 requires that the offeror’s proposal must remain valid for the greater of 120 days or through the effective date of the contract. The cost section is a component of a proposal. Therefore, even if the contract were to become effective after February l, 2001, all components of the proposal must remain valid as proposed.
36. Q: Capital Blue Cross and Pennsylvania Blue Shield currently market a limited benefits coverage product to low income subscribers. This product features limited hospital days, limited doctor visit, a pre-existing conditions clause, and provider discounts. With the possible exception of provider discounts, the proposed uninsured adult product’s benefit design does not include these features.  For this reason, it is likely that the uninsured adult product will be more than 50% more expensive than the existing low-income product.  Is the Department aware of this?
    A: The Department is aware of commercially available insurance products for adults of low income.  However, the RFP, in response to Act 77 reflects the provision of the Act and those provisions are not necessarily co-extensive with the benefits provided in the commercially available insurance products.  As a result, the Department acknowledges that there may be differences between the costs of the adult program and the commercially available products.
37. Q: The RFP requires bidders with a discount drug program to provide this to ABC “enrollees” at no cost.  Can the bidder include the administrative fee of the discount program into the rate development for the ABC Program? (When using a PBM, there is an administrative cost charged by the PBM to the carrier.  Dispensing fees are part of the prescription cost charged to the member by the pharmacy with the cost of the drugs).
    A: No.
38. Q: The RFP makes reference to “Final Settlement Sheets” (page 29) and a “risk protection arrangement” (page 57) but we were unable to find reference to a proposed rating/financial arrangement. Does this mean, for example, that a Cost Plus with individual stop loss arrangement is acceptable to the Department?  Also, where on the RCS (Appendix B) should the contractor include a rate for the “risk protection arrangement”?
    A: With respect to the RFP making reference to “Final Settlement Sheets” on page 29, it is the expectation that the offeror will provide clear documentation of “how incurred claims are calculated”. Regarding the reference to a “risk protection arrangement”, the RFP in Part IV.-7.A.l  provides guidance by stating that the risk protection arrangement submitted by the applicant at a minimum, must include reinsurance that covers “eighty percent (80%) of inpatient costs by (1) member during one (1) year in excess of $150,000”. The key point to be made here is that if reinsurance is offered by the contractor that does not have the minimum levels of protection delineated in the RFP, the arrangement will be considered an “alternative risk protection arrangement”.   The Department will evaluate the arrangement to determine if the alternative proposal provides at a minimum, the same level of protection as the standards established in the RFP.  The contractor should provide clear documentation that explains how the alternative risk plan, whether it be in the form of an official cost with individual “stop loss arrangement” or in any other form, and meets the standard of the RFP. If applicable, the costs of any “risk protection arrangement” may be included in the “Risk and Contingency” entry below line #24 on the RCS Form.
39. Q: Quite often, members present at doctor offices with symptoms or “medical conditions” that later turn out to be mental in nature.  In situations where members are being treated for medical conditions with an underlying health component, can we provide reimbursement for the initial diagnosis and treatment up to the point where it clearly becomes a mental health case?
    A: The contractor is required to pay for medical services, but not for mental health diagnosis and treatment. Payments for non-mental health services are required; payments for mental health services are not permitted once the mental health condition is identified.  The offeror is also reminded that mental health benefits may be added as an additional or optional benefit as indicated in the RFP at no additional cost to the Department.
40. Q: How are we to reimburse when members are hospitalized primarily for a medical condition but require a psych consult? Would this be a non-covered service?
    A: Mental health diagnosis and treatment are not covered benefits.  Therefore, the contractors are required to pay for medical services only.
41. Q: Section IV-4.A. (page 37) states “If changes to the Benefit Package or eligibility criteria occur, the Department will conduct an actuarial analysis to determine if there is a need for a rate change and appropriate contract amendments will be executed.” To what extent will the contractor have input into the rate determination process? What recourse does the contractor have if it is dissatisfied with the final rate determination?
    A: If any such changes occur, the Department will request that the contractors submit rating proposals based on each contractor’s loss experience.  Each contractor may be required to demonstrate that its proposal is actuarially sound. The Department will evaluate each proposal accordingly. Should a contractor disagree with any final rate determination, the contractor may refer to Paragraph 19, Contract Controversies, of the Standard Contract Terms and Conditions found in Appendix C.
42. Q: Section IV-7.C.4 (page 59) states, regarding rate adjustments for the third year (agreement) year: “If no agreement is reached by the start of the third contract year, rates applicable to the previous year continue to apply until any new rates are finalized.”  What recourse does the contract have if it is dissatisfied with the final rate determination?  Also, should “third contract year” read “third year of the contract” in two places in this section?
    A: Should a contractor disagree with any final rate determination, the contractor may refer to Paragraph 19, Contract Controversies, Standard Contract Terms and Conditions found in Appendix C. The “third contract year” is the third year of the contract.
43. Q: What is the statewide funding level for this program?
    A: $77,738,000.
44. Q: We will submit a rate developed of sound actuarial principles. To what extent, if any, will our rate submission be altered because a lower rate is submitted by a competitor?
    A: The Department reviews each proposal independently and recognizes individual differences in the rating process and loss experience in different counties.  However, when there is a significant difference in the rates of two or more offerors for the same county or counties, the Department will ask for an explanation from the offerors and review all proposals and documentation for actuarial soundness.
45. Q: Will the quarterly and annual reports submitted to the DOH under Act 68 (e.g. external quality reviews) be sufficient to comply with the general requirements or will separate reports need to be generated specific to this program?
    A: The annual and quarterly reports the DOH require are company-wide commercial reports.  The reporting requirements we list in the RFP will be specific to the adult program. As much as possible, we will try to use DOH forms and formats, similar to the ones used in CHIP, for quarterly and annual reports.  The external review required by DOH is the accreditation review by NCQA (which is required once every three years for established MCOs) and may potentially be used for the adult program purposes.  DOH may change their approved list of external review organizations (EQROs). If this becomes the case, we may adjust our requirements accordingly.  Copies of their commercial, company-wide HEDIS and CAHPS reviews will be a requirement for the adult program on a yearly basis.
46. Q: Which guidelines should we follow for preventive care and measurement of compliance related to the recommendations?
    A: The RFP states that offerors can make the decision to use either the U.S. Preventive Health Services Task Force, the American Academy of Family Physicians or any equivalent medical guidelines (or they can use all guidelines if they want to). The RFP requires that offerors tell us which guidelines they intend to use.
47. Q: Under the section “Quality Management and Improvement and Utilization Management Program Requirements (QMI/UM)”, the requirement for the readiness review is for a QMI/UM information system that uses a relational database with SQL and OLAP.  This same requirement was in CHIP.  We do not meet this exact requirement structure (but do have the necessary date).  Is the current system, that is CHIP compliant, acceptable for ABC?
    A: Yes.
48. Q: What will be the basis for adjusting rates for Year 3 of the program?
    A: The actual experience of the adult program and industry trends would be the basis to determine whether any adjustments in the rates would be necessary.
49. Q: Could you please list the types of family members you envision being counted in family size and income when you mention “other family member?”  Would this include the following scenario… husband and wife apply with wife’s sister who lives with them and the husband’s mother who is 62 years old?
    A: This question is not relevant to the completion of a response to the RFP. However, the questioner is referred to Chapter 4 Family Composition of the draft Procedures Manual (Appendix F of the RFP) for guidance on this issue.  Subsections 4.2, 4.3 and 4.4 specify family members who must be included in the applicant group, family members who may be included, and family members who must not be included.  It should also be noted that, subsequent to the execution of a contract and during the readiness period, the Department intends to provide training for contractor’s staff regarding eligibility requirements and use of the centralized data system.
50. Q: Must we use the family members that apply on a single application as the household unit for renewal and billing purposes?  For instance, would we have to send a renewal/bill for coverage to each member of the household in a situation where the applicant is a male age 25 and his wife is age 23 and his mother age 62 lives with them? Or would we have to send ONE renewal to that family unit?
    A: This question is not relevant to the completion of a response to the RFP. Offerors are advised that this issue will be more fully addressed in implementation instructions or in the final Procedures Manual issued by the Department to contractors subsequent to execution of the contract. However, it would be reasonable that contractors might choose to send one renewal notice to the household if the renewal date for all household members is the same.
51. Q: In Section II-3, number 8, there is a reference to a prescription drug discount plan.  Our understanding of a prescription drug discount plan, as set forth in the RFP, is a card offered to members for a minimal fee that entitles the member to receive discounts at certain pharmacies for some or all of the member’s prescriptions.  A prescription drug discount plan does not mean a prescription drug insurance plan whereby a member receives a card and is then entitled to receive coverage for prescription drugs after satisfying any applicable deductibles, co-payments or co-insurance. Since prescription drugs are excluded under Section IV-4.A, we assume our interpretation is correct. Could you pleas confirm this?
    A: The understanding of the questioner with regard to the Prescription Drug Discount Plan is correct. Prescription drugs are not a covered service under the program. However, if the offeror has a drug discount plan currently available in Pennsylvania, that plan must be made available to enrollees of the Adult Basic Coverage Insurance Program.  The offeror must provide a description of the plan and how it is administered in the response to the RFP.
52. Q: In Section IV-4.A, it states that inpatient hospitalization must be covered, but neither a minimum nor a maximum is specified.  In response to Question 3 posted on the Department’s website, the Department states “an unlimited number of medically necessary inpatient days may be provided under the program”  (emphasis added).  This response suggests that an offeror may choose to impose a maximum on the number of inpatient days.  However, in response to Question 11, the Department states that offerors may not place a limit on the number of inpatient days. These two responses appear to conflict.  May an offeror set a maximum on the number of inpatient days?  If the answer is “yes”, may an offeror impose a maximum on any other benefits?
    A: No limit may be placed on the number of inpatient days.  If the offeror intends to impose limits for services other than inpatient hospital care, such limits must be described in the response to the RFP.
53. Q: In Section IV-4.A., it states that chiropractic care is excluded.  Was this exclusion intended to exclude any services provided and billed by a chiropractor or was it intended to exclude manipulation therapy services only?
    A: Services provided by or at the direction of chiropractors are not covered.
54. Q: Should we count live-in boyfriends/girlfriends of applicants if they contribute to household income? Should we only count related persons?
    A: This question is not relevant to preparation of a response to the RFP. However, the questioner is referred to Chapter 4 Family Composition of the draft Procedures Manual and to Chapter 5 Household Income for guidance on this issue.
55. Q: In Section ll.1 of Appendix F it states: “In order for renewal to occur, eligibility for continued coverage must be reviewed.” In Section 12.1 it states that a person is no longer eligible for coverage if he does not meet the eligibility criteria at the time of renewal. We interpret the Adult Basic Coverage to be a governmental group product for HIPPA portability purposes therefore, the enrollee does not have a guaranteed renewability right and the contractor may terminate coverage at the time of renewal if eligibility criteria are not met. Please confirm our interpretation.
    A: The interpretation is correct.
56. Q: Is a cousin, nephew, or aunt a family member if they live with the applying person?
    A: This question is not relevant to the preparation of a response to the RFP. However, the questioner is referred to Chapter 4 Family Composition of the draft Procedures Manual.
57. Q: If an enrollee requests immediate disenrollment, may the contractor honor the enrollee’s request?
    A: This question is not relevant to the preparation of a response to the RFP. However, the question is referred to Section 12.2 of the draft Procedures Manual relating to voluntary disenrollment.
58. Q: If the contractor determines that a period of overlapping coverage exists, may the contractor apply coordination of benefit rules?
    A: One of the conditions of eligibility for the program is that the person not be covered by a health insurance plan, a self-insurance plan or a self-funded plan.  Therefore, enrollment in the program should not occur if the person has such coverage.  If eligibility is properly determined by the contractor, no period of overlapping coverage should exist.
59. Q: Under CHIP if an enrollee becomes ineligible for CHIP coverage March 31st because, for example, they have been enrolled in another health insurance plan but we do not receive the information until April 7th, we would not terminate coverage on CHIP until May 31st in order to provide the 30 day notice. Would this same scenario apply to the Adult Basic Coverage?  If the answer to this question is yes, is it realized that a person enrolled in the Adult Basic Coverage Program essentially receives an additional month of coverage when they are not eligible for the program and there is someone that is eligible sitting on a waiting list and possibly paying full premium for an additional month?
    A: This question is not relevant to the preparation of a response to the RFP. However, the Department will take the practical aspects of the circumstance suggested in the question into consideration when developing requirements relative to a waiting list for the program.
60. Q: In the event a person is terminated and requests an eligibility review when a waiting list has occurred, how do you handle staying the termination. Once you terminate that person, you would enroll the first person on the waiting list.  How do you stay the termination if the person chooses to pay their premium as stated in the Eligibility Review Process?  You would no longer have a spot for that person in the program.  The person has 30 days from the date on the notice to request a review. How is this going to be handled when a waiting list occurs?
    A: This question is not relevant to the preparation of a response to the RFP. As indicated in a previous response, the Department will develop and maintain a centralized system for managing and administering a waiting list.  Contractors will receive written instruction from the Department regarding the procedures developed for this purpose.
61. Q: The technical portion must be properly identified inside and out with the RFP number, opening date, time, and location. What is the proper opening time for the identification on the proposal?
    A: The proper opening time for identification on the proposal is after 11:00 a.m. on September 14, 2001.
62. Q: If an eligible adult on the waiting list fails to pay the premium cost or an enrolled adult fails to pay the $30 monthly premium, the plan is required to give the enrollee 30 days notice in advance of the effective date of the proposed disenrollment.  Given the prompt pay requirement in Act 68, this could leave the plan with a significant liability in claims already paid to providers for services rendered during this notice period.  Deducting these claims post-payment will cause significant provider concerns, especially since they rendered service dependent upon verification of enrollment by the plan.  Can the plan require payment of the monthly premium by the end of the second month preceding the covered period except for new enrollees (payment for September due July 31)?
    A: The question is not relevant to the preparation of a response to the RFP. However, the Department will take the issues raised in the question into consideration in developing the final version of the Procedures Manual.
63. Q: Will the offeror’s single rate proposal cover all of the counties that the plan is licensed in even if they do not have a  “commercial” membership?  Will DOI phase-in implementation by geographic region?
    A: The questions posed relate to two distinct issues. The first relates to the filing of a rate or rates for the counties for which the offeror is authorized to provide health care coverage.  The offeror may submit a single rate for all counties or may submit multiple rates. In either instance, the rate or rates must be actuarially sound. With regard to the second issue, the Department intends to make the program available to eligible persons statewide commencing with the date of implementation.  There will be no phase-in by geographic region.
64. Q: Did the Department intend to leave Inpatient Hospital as unlimited benefit? The CHIP Program has an annual limit of 90 days – there is no limit noted in this proposal except at contract termination.
    A: Yes. Act 77 imposes no limitation on the number of medically necessary inpatient hospital days that may be received by an enrollee.
65. Q: Can we assume that treatment for obesity will be excluded  (based on medical necessity)?
    A: Yes. However, the offeror may choose to offer this as an additional or optional benefit to enrollees as specified in the RFP at no additional cost to the Department.
66. Q: Can we assume that we will not cover corrective eye wear necessary secondary to cataract surgery?
    A: Yes. However, the offeror may choose to offer this as an additional or optional benefit to enrollees as specified in the RFP at no additional cost the Department.
67. Q: Can we assume that we will not cover dental care secondary to an accidental injury?  We normally cover this under the HMO plan if the services were the direct result of an accident occurring on or after the member’s effective date of coverage?
    A: Yes. However, the offeror may choose to offer this as an additional or optional benefit to enrollees as specified in the RFP at no additional cost to the Department.
68. Q: There have been “crowd out” concerns with other subsidized programs.  Is there a similar concern here?  Or is it permissible to work with small business employers and large part-time workforce employers to determine if they will collect the premium due from their employees through a payroll deduction. Is it permissible for an employer to pay the premium on behalf of their non-covered part-time employees?
    A: As with any public program, general concern exists that this program not replace already existing coverage available to potentially eligible adults.  The objective is to reduce the number of uninsured adults in the Commonwealth.  As a protection against “crowd out”, the legislature included in Act 77 a requirement that an eligible adult not have had health care insurance for three months preceding the determination of eligibility.  The questioner has posed some very intriguing questions with regard to outreach and the relationship with the employer community. More specific instruction on these matters will be included in implementation instruction or in the Procedures Manual subsequent to the execution of contracts.
69. Q: Coverage of Home Health Care or DME is permissible if intended to prevent a more expensive hospitalization.  Is it permissible to include pharmaceuticals in the same light, if it is determined on a case by case basis, that such coverage will prevent a more expensive hospitalization?  We can imagine numerous scenarios where a particular drug would be beyond the financial reach of a member but not taking it would result in severe complications and prolonged hospitalizations.
    A: No.  The RFP, in Section IV-A, excluded prescription drugs as a benefit with the exception of immunosuppressives.
70. Q: The RFP references bidders who may want to include areas outside their service area.  Is the converse permissible?  May an offeror propose to serve a geographic area that is smaller than their service area?
    A: No.  Please see Section IV-2 of the RFP (page 34) which specifies that “Offerors will be required to provide health care services in all counties in which the entity is offering commercial coverage”. The Department would clarify that, for entities that do not provide “commercial coverage”, but rather are providing coverage only in another public program (e.g. CHIP or Medicaid), the entity is required to provide service in all counties where such is provided.
71. Q: Will the Commonwealth provide estimates of the number of eligibles by county or service area? Will the Commonwealth provide any demographic information on eligibles, e.g. age, sex, disability?
    A: No.  This information is not available by county or service area.
72. Q: Is it possible to obtain an electronic copy (i.e., Excel) of the RCS Form?
    A: Yes. An Excel version of the RCS Form will be made available on the website.
73. Q: If a Plan’s provider contracts are specific to product line and therefore do not specifically cover the ABC Program, should all currently contracted providers be submitted with the RFP response even though providers will be given the option to contractually accept or not accept ABC once the plan is determined to be a successful bidder?
    A: Please refer to Part IV 5.D. Provider Networks of the RFP. The RFP requires that the offerors submit certain information regarding their provider networks so that the Department can evaluate the adequacy and availability of each provider’s network. Contractors will be required to notify the Department of changes to their networks if such changes occur.
74. Q: Given the likelihood of adverse selection in this voluntary enrollment program, is the Commonwealth willing to consider aggregate cost risk corridors or other aggregate cost risk limiting methods for contractors?
    A: The risk and contingency component up to 2% of the total rate is included to cover adverse selection and other adverse experience.
75. Q: Will the Commonwealth provide estimates or recommend data sources for such estimates of the projected cost to provide services to enrollees?
    A: The contractors must use their own commercial experience or other comparable loss experience to develop estimates of the projected costs.  The assumptions and adjustments made to the data must be explained in detail in the Actuarial Memorandum as discussed on page 28 of the RFP.
76. Q: What is the targeted effective date of the program?  When will outreach activities be initiated and what is the planned effective date of the first group of enrollees?
    A: The Department is planning for enrollment to begin during January 2002 with the first month of coverage to be February 2002. The Department will be initiating statewide advertisement of the program at an appropriate time in advance of implementation. Subsequent to execution of contracts, all contractors will be advised of the media strategy and other related matters.
77. Q: How many people are anticipated to be able to enroll before a waiting list is created? Is there an estimate of eligibles or potential enrollees by county?
    A: The number of persons to be enrolled in the program will depend upon the total funds available (appropriated at $77,778,000 Million for state fiscal year 2001-2002) and the per member per month rates negotiated with each contractor for their respective areas of service.  The Department will be putting mechanisms in place to monitor monthly spending and projected spending against available funding balances. Contractors will be provided with advance notice if and when it becomes necessary to cease enrollment and to place prospective enrollees on a waiting list. Further, more detailed, instruction in regard to this issue will be issued subsequent to the execution of contracts. There is no estimate of eligibles or potential enrollees by county.
78. Q: Please give examples of optional benefits that the Insurance Department expects will be offered.
    A: The Department has no expectations regarding optional benefits that might be offered by an offeror.  As directed in the RFP, the offeror should describe any additional benefit it intends to offer, either at no cost to the program or at an additional premium charge to the enrollee.
79. Q: If an individual health plan places limits on Adult Basic enrollment after the program is operational, how and when should the Insurance Department be notified?
    A: Section III-3 found on page 32 of the RFP (relating to Enrollment Limits) requires that “offerors should specify any enrollment limits to their proposal and the basis for any such limits”. Offerors are cautioned that proposals that propose no enrollment limits will be given preference over those that do. The imposition of limits by a contractor subsequent to the execution of a contract is not contemplated nor permissible unless specifically deemed necessary by the Department as a result of funding limitations for the program or for other good cause as determined by the Department.
80. Q: Can you clarify the last sentence of the definition that states, “Additionally, it included situations such as when a person’s discharge from a hospital will be delayed until services are approved or a person’s ability to avoid hospitalization depends upon prompt approval of services.” Thank you.
    A: The language in the definition requires no further clarification.  However, we offer the following examples to assist the questions:  “If an individual is hospitalized for observation or testing, but approvals for additional services to stabilize their condition have not been obtained from the insurer within the standard time frame for an urgent medical condition (approximately 24 hours), the person’s condition could potentially worsen necessitating a longer stay in the hospital than is necessary or a delay in being discharged from the hospital.  This might also apply in a situation where urgent medical care is warranted, but approvals for services are delayed and the members’s condition deteriorates to the point of needing hospitalization.”
81. Q: Do you mean spinal manipulations when using the term chiropractic care? We are not permitted to exclude chiropractors specifically?
    A: No.  Services provided by or at the direction of a chiropractor are excluded.
82. Q: If the provider information does not contain longitude and latitude information, are zip codes acceptable?
    A: Yes.
83. Q: Are inpatient admissions for rehab services considered to be part of the general category of inpatient hospital?  These types of admissions are typically done at a rehab hospital facility or in a specially designed unit within an acute care hospital.
    A: Yes.
84. Q: Will we be required to perform an external independent and separate HEDIS report for the Adult  Basic Coverage Program? Will this program be reviewed by NCQA?
    A: As stated in response to a previous question, contractors will only be required to submit their company-wide HEDIS and CAHPS reviews. Additionally, guidance will be forthcoming after the adult program has been operational and further analysis is completed.
85. Q: There are many cases when a PCP or specialist will see a patient for a condition (ex. headache) and after testing, assigns a diagnosis of depression or anxiety.  Are these services covered? Does the exclusion refer specifically to psychotherapy and other related services done by a mental health professional or does it refer to all services with a mental health diagnosis code?
    A: As answered in a previous question, the contractor should continue to provide payment for medical services, but not for mental health diagnosis and treatment. The offeror may add mental health benefits as an additional or optional benefit as indicated in the RFP at no additional cost to the Department.
86. Q: Can we define the covered number of visits/days on home health care and skilled nursing facilities?
    A: There is no day limit on home health care and skilled nursing facilities provided that the service is in lieu of inpatient hospital care.
87. Q: Is it permissible to put day limits on this benefit such as 60 days per condition per type of therapy?
    A: Yes. Offerors should describe the limits that are being proposed in their response to the RFP.
88. Q: Under benefit exclusions, “speech, physical, and occupational therapy” are excluded. The rate development section includes a line for “rehabilitation therapy.” Can you clarify what this benefit is in light of the exclusions?
    A: Speech, physical, and occupational therapy are included provided that such treatment is medically necessary.
89. Q: Under the section “Performance Management and Reporting Requirements”, we note that the reports are the same as in the CHIP RFP.  Since the CHIP RFP, the Commonwealth has undertaken a survey with NCQA to revamp reporting. Will these reporting requirements be consistent for all 3 years of the contract or will the Commonwealth change them based upon the CHIP NCQA survey results?
    A: Reports will be revised in accordance to any findings made by NCQA and which the Department deems appropriate.  In addition, the RFP notes that the Department can revise or require new reports, whether as a result of NCQA or not, as it deems appropriate.
90. Q: Under the section “Acceptance of Rate Payments, Using the CHAPS Database”, it states that the Commonwealth will authorize payments no later than the 15th day of the month.  We are a prepaid HMO and normally require premium payments prior to the first of the month, due to paying capitation on the first day of the month. Can we build an additional trend in the rate to compensate for additional cash flow?  The requirement states “authorize” payments.  When can we expect payment to be made?
    A: No.  An additional trend may not be built into the proposed rate.  The Commonwealth will pay for services in the same manner as it does for all other vendors.
91. Q: Under the Adult CHIP Program will the offerors be required to cover the newborn babies for the first 30 days?
    A: Yes. The baby must be covered for the first 30 days.  However, after that the baby may be covered under CHIP.
92. Q: If rate negotiations for the third year are completed subsequent to the beginning of a renewal year will the rates be retroactive to the beginning of the renewal year?
    A: No.
93. Q: In Section IV-4.A, it states that inpatient hospitalization must be covered, but neither a minimum nor a maximum is specified.  In response to Question 3 posted on the Department’s website, the Department states “an unlimited number of medically necessary inpatient days MAY be provided under the program” (emphasis added).  This response suggests that an offeror may choose to impose a maximum on the number of inpatient days.  However, in response to Question 11, the Department states that offerors may not place a limit on the number of inpatient days. These two responses appear to conflict.  May an offeror set a maximum on the number of inpatient days?  If the answer is “yes”, may an offeror impose a maximum on any other benefits?
    A: It is recognized that the answer to Question 3 may have inadvertently caused confusion.  There are no limits on the number of inpatient days.
94. Q: Can we assume that all abortions are not covered under this contract?  Is there a difference between elective and non-elective abortions in this contract?
    A: Abortion is not a covered benefit unless it is allowed under Pennsylvania law.
95. Q: For purposes of this contract, can we assume that the treatment for TMJ is a dental or medical condition?  Are there any benefits available for the treatment of TMJ such as when it’s secondary to arthritis?
    A: Treatment for TMJ is not covered.
96. Q: The RFP states “Reconstructive Surgery, includes surgery and prosthesis after medically necessary mastectomy.”  Is this the only reconstructive surgery that is covered?
    A: This is clarifying that reconstructive surgery is covered only when it is medically necessary following a covered surgical procedure.  Surgery that is primarily cosmetic in nature is not covered.
97. Q: Are we to exclude orthotic and prosthetic devices such as crutches?  For example, following a leg casting, which would be covered? Do we cover orthotic and prosthetic devices when related to care associated with diabetes due to Act 98 provisions?
    A: Prosthetics are covered only if medically necessary subsequent to the delivery of a covered benefit. Durable medical equipment is listed as an excluded service in Section IV-4.  The offeror may choose to offer this as an additional benefit or optional benefit to enrollees as specified in the RFP at no additional cost to the Department.
98. Q: Under the section “Risk Protection of High Cost Cases”, it requires reinsurance at a minimum of 80% of inpatient costs above $150,000.  This same requirement was in the CHIP RFP.  We carry reinsurance of 70% of all costs above $250,000.  This was acceptable for CHIP. Is it acceptable for ABC?
    A: The RFP, in Part IV-7.A.l, requires that the risk protection arrangement submitted by the applicant must, at a minimum, include reinsurance that covers “eighty percent (80%) of inpatient costs by (1) member during one (1) year in excess of $150,000.”   If reinsurance is offered by the contractor and does not have the minimum levels of protection delineated in the RFP, the arrangement will be considered an “alternative risk protection arrangement.” The offeror should provide clear documentation that explains the alternative risk protection arrangement, whether it be in the form of an official cost with individual “stop loss arrangement” or in any other form, and meets the standard of the RFP.  The Department will then evaluate the arrangement to determine if the alternative proposal provides, at a minimum, the same level of protection as the standards established in the RFP.

Final update August 31, 2001.
No more questions and answers will be posted.