The Delaware Department of Health and Social Services (DHSS) is rebidding the Medicaid managed care organization (MCO) contracts for its Diamond State Health Plan (DSHP) and DSHP Plus. DSHP provides acute physical and behavioral health services, as well as pharmacy, for traditional Medicaid beneficiaries. DSHP Plus provides acute physical and behavioral services for people who need long-term services and supports (LTSS), including those dually eligible for Medicare and Medicaid, those receiving home- and community-based services (HCBS), and nursing facility residents. The state intends to select two or three MCOs. The request for proposals (RFP HSS-22-008) was released on December 15, 2021, and proposals are due by February 22, 2022.
For adults all traditional and specialty mental health services are included in the MCO capitation rate, unless an individual qualifies for Promoting Optimal Mental Health for Individuals through Supports and Empowerment (PROMISE) services. PROMISE services are for individuals with behavioral health needs and functional limitations. The services include an array of HCBS that are provided on a fee-for-service (FFS) basis. For children, the MCO capitation rate includes 30 outpatient visits. If that limit is exceeded behavioral health services are provided FFS by the state, along with all behavioral health inpatient services. The MCOs cover treatment for opioid use disorders, including office-based opioid treatment and opioid treatment programs.
The incumbents are AmeriHealth Caritas Delaware and Highmark BCBS Delaware Highmark Health Options; their contracts expire December 31, 2022. Awards announcements are anticipated by May 3, 2022. The new contracts are slated to go live on January 1, 2023.
The RFP includes provisions to achieve the following goals:
- Member focus: The MCOs will help improve the quality of care and heath outcomes for members by providing whole person, person-centered care; engaging with communities; identifying and addressing health related-social need, and advancing health equity.
- Accountability: The MCOs will be accountable for program costs, performance, and creativity.
- Innovation: The MCOs will lead by example and drive innovation across the state’s health care system.
- Alignment with other state initiatives: The MCOs will collaborate with efforts to align Medicaid initiatives with other DHSS programs and state health care initiatives.
The proposals will be evaluated based on seven criteria, as follows:
- 10 points for qualifications and experience
- 35 points for delivery and coordination of services
- 10 points for community engagement, health equity, and health related social needs (HRSN)
- 10 points for the provider organization network and provider services
- 15 points for value-based purchasing strategies
- 10 points for administration and operations
- 10 points for case scenarios
The value-based purchasing strategies (VBPS) should address one or more of the following domains: primary care, maternal and child health, behavioral health , HRSN, health equity, and LTSS. The contractors’ value-based purchasing strategies must reach minimum payment threshold levels in each year of the contract, and a smaller percentage must take place through VBPS that have downside risk to the provider organization, such as bundled or episode payments, risk/capitation rates/total cost of care.
For calendar year 2023, at least 60% of all medical/service expenditures for all populations must be through VBPS. In addition, at least 45% of all expenditures must be through a VBPS with downside risk to the provider organizations. For calendar year 2024, at least 70% of all medical/service expenditures for all populations must be through the VBPS listed in the RFP, and at least 50% must be from a combination of VBPS with downside risk to the provider organizations. For calendar year 2025, and subsequent years the minimum level remains the same as for calendar year 2024.
Delaware’s mandatory Medicaid managed care program, comprised of DSHP and DSHP Plus, is authorized under a Medicaid 1115 waiver. About 86% of the 264,440 Delaware Medicaid beneficiaries are enrolled in one of the two Diamond State plans. The two programs serve different populations:
- DSHP was implemented in 1996; it serves traditional Medicaid beneficiaries. Beneficiaries needing long-term services and supports are excluded, as are those dually eligible for Medicare. DSHP provides acute physical and behavioral health care services.
- DSHP Plus was implemented in 2012; it serves people dually eligible for Medicare and Medicaid, people receiving home- and community-based services (HCBS), and nursing facility residents. The MCOs are also responsible for covering HCBS and custodial nursing facility services.
For more information about the RFP, contact: Kathleen Dougherty, Division of Medicaid and Medical Assistance, Delaware Department of Health and Social Services, 1901 North DuPont Highway, Lewis Building, New Castle, Delaware 19720; Email: Kathleen.Dougherty@state.de.us; Website: https://www.dhss.delaware.gov/dhss/dmma/
For more information about the state’s current Medicaid contracts, contact: Jill Fredel, Communications Director, Delaware Department of Health and Social Services, 1901 North DuPont Highway, Main Building, New Castle, Delaware 19720; 302-255-9047; Email: firstname.lastname@example.org; Website: https://dhss.delaware.gov/