The Kansas Department of Health and Environment, Division of Health Care Finance (KDHE-DHCF) may have a requirement for Medicaid Eligibility Compliance.

The following information is sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

BACKGROUND

KDHE-DHCF serves as the designated Medicaid single state agency, as defined by 45 CFR 205.100. The statutory mission of KDHE-DHCF is to develop and maintain a coordinated health policy agenda that combines effective purchasing and administration of health care with health promotion oriented public health strategies. The powers, duties, and functions of KDHE-DHCF are intended to be exercised to improve the health of the people of Kansas by increasing the quality, efficiency, and effectiveness of health services and public health programs. Medicaid is a joint federal and state assistance program that provides medical benefits for qualifying persons.

Medicaid operates under Title XIX of the Social Security Act, commonly known as the Medicaid Act, 42 U.S.C. §1396 et seq. Under the Medicaid Act, participating states receive financial assistance for administering a medical program in accordance with the requirements of a comprehensive federal scheme. The State of Kansas participates in the Medicaid program and is eligible for federal funding.

KDHE-DHCF operates the Children’s Health Insurance Program (CHIP). CHIP is a joint federal and state assistance program that provides medical benefits for qualifying persons. CHIP operates under Title XXI of the Social Security Act, 42 U.S.C. §1397 et seq.

KDHE-DHCF seeks to improve the Medicaid eligibility determination process by exploring technology-driven solutions that enhance efficiency, accuracy, compliance with federal and state regulations, and a better member experience.

GOALS

The goals of a Medicaid eligibility determination RFI include, but are not limited to the following objectives:

• Improved eligibility determination, screening, enrollment, credentialing, monitoring, and automated background checks for all providers.
• Gather information on managing centralized eligibility processing operations.
• Eligibility Determination & Processing across all Medicaid categories, including Family Medical, Presumptive Eligibility, Elderly and Disabled (E&D), and Long-Term Care (LTC).
• Comprehensive Administrative & Support Services including customer service and call center operations.
• Operational excellence in training programs and quality assurance processes
• Solutions for efficiently automating eligibility determination and other associated functions to improve processing speed and accuracy.
• Streamlined processing of mail room operations and document scanning services
• Measurable improvements in Efficiencies, Automation, and Cost Saving in the KDHE-DHCF Eligibility process.

The following information is sourced from the Request for Information (RFI) document and is subject to change upon the release of a formal solicitation.

Please respond to each of the questions listed below.

CALL CENTER

1. Describe how you are able to provide full Call Center capabilities.
2. Please describe how your Call Center handles multiple communication channels (i.e. voicemails, emails, SMS, Live Chat/Chatbot, and/or other forms of communication).
3. Describe your use of AI and other tools in your Call Center to promote efficiency and cost savings.
4. Describe your staffing forecasting include metrics for voicemails, emails, SMS, Live Chat/Chatbot, and/or other forms of communication.
5. What call routing options are available (i.e. IVR)? If using something similar to IVR, do you have the ability to change messaging quickly by local staff?
6. If the state requests different options in the IVR how quickly can that change be made? How quickly can wording changes be made in the IVR?
7. Do you use subcontractors for your IVR solution, or do you have an internal solution?
8. What are the best practices you are using to provide alternative language solutions in a Call Center?
9. How do you identify which languages are used in a state?
10. What is your process for providing access to call recordings, and how do you ensure secure retrieval and management of these recordings for compliance and quality assurance purposes?
11. What are the best practices you are using? How can these best practices maximize efficiency? How can efficiency metrics be balanced with customer satisfaction tools and surveys?
12. Can you offer features such as agent scripting, knowledge bases, or auto-suggestions to assist agents during calls?

ELIGIBILITY PROCESSING

1. Workload Distribution Tools
   • Please describe any experience dealing with data issues with a state eligibility system and how you addressed the data issues to ensure work was identified and completed timely
   • Explain your approach to distributing eligibility work to eligibility staff. What technology do you utilize?
   • Please explain what factors, if any, are considered when distributing work.
   • Does your workload distribution strategy allow you to pivot within the day, if needed? If yes, please explain how.
   • Please explain your approach to forecasting staff FTEs to maximize efficiencies and CMS compliance, as well as how/if it is used with workforce management and planning. In your response be sure to include all types of Medicaid all Medicaid categories (including but not limited to Family, PE, E&D, LTC) and all types of Medicaid processing work.
   • How do you leverage data analytics to improve decision making and process efficiency?
   • How is your workforce structured to support Medicaid eligibility tasks? Please explain the roles and teams involved.
   • Explain how you have balanced influxes in work, based on seasonal increases such as open enrollment, system outages, or unexpected environmental factors.
   • What is your experience managing remote and on-site staff? Do you have a typical percentage of onsite staff and what is it?
   • How do you handle turnover or absenteeism within your workforce, and what steps do you take to minimize disruption in service delivery?
2. Automation Efficiencies
   • Please explain any automation opportunities within the eligibility process that you believe are beneficial (based on personal knowledge, experience, or industry standards). Which of these are you using?
   • Please describe any overlays you have done of state systems to implement automation or improve processes
   • In your opinion, what items should be considered when exploring automation opportunities?
3. Reducing processing time
   • What strategies have you implemented, that proved beneficial in reducing eligibility processing times?
   • What are your average eligibility processing times?
   • What strategies are you using to achieve these or reduce eligibility processing times?
   • What strategies have you implemented to balance the need to produce quality eligibility outcomes, while increasing productivity?
   • What eligibility systems do you have experience working with?
4. End-to-end processing
   • Describe your experience with end-to-end processing including processing applications received by mail, fax, portal and on through determination.
   • Tell us your experience working with a state as an eligibility contractor, to timely process eligibility, where both are involved in completing an eligibility determination.
   • KDHE-DHCF currently accepts walk-in customers at two different locations. One location assists the elderly/disabled population. The other location assists families, and children. Explain your approach to assisting walk-in customers and providing the best level of customer support as possible, in a situation where a walk-in customer requiring subject matter expertise has visited the wrong site.
   • Give an example of how you have effectively worked with a client/state to successfully implement a process that required action by both state and contractor.
   • Provide an example from past contracts where you have adjusted to change in scope or additional responsibilities.
   • Please explain strategies you have implemented to successfully obtain needed verifications in a timely manner, from Medicaid applicants, to complete the eligibility determination.
   • How do you ensure transparency with your state partner in your administrative processes, especially regarding case handling, turnaround times, and quality?
   • Describe and provide data around any efficiencies your company has achieved in other states around operating both a Call Center and an eligibility team.
5. Registration
   • In past or current contracts, describe your responsibility for registering Medicaid applications or renewals.
   • Based on your knowledge and experience with eligibility processing, what best practices have you identified, if any, as it relates to eligibility registration?
   • What is your experience in the automation of the registration function for eligibility? Include, if available, cases that require multiple levels of screening?

SYSTEMS

1. What steps do you take to ensure that HIPAA and other privacy compliance requirements are being followed in the handling of sensitive Medicaid data, including any protected health information?
2. How does your company manage limited system resources across multiple contracts?
3. How would urgent or escalated situations be identified, communicated, and resolved?

TRAINING AND QUALITY

1. How do you see the relationship between training and quality working together as a best practice?
2. What should be the major focus of quality in the Eligibility space, Call Center space and Registration space?
3. What systems or tools do you currently use to track and record quality metrics, performance data, and training information across all areas (Eligibility, Call Center, and Registration)?
4. Please describe your Call Center’s quality assurance plan. What kind of coaching and feedback mechanisms are in place? How do you evaluate/score agent performance within the Call Center? What percentage of inbound calls are monitored for quality assurance?
5. How do you handle Staff (Eligibility, Call Center, and Registration) who consistently fail to meet quality assurance standards?
6. Do you offer real-time and post-call monitoring? How are these processes conducted?
7. How do you communicate the results of your quality assurance efforts to the client?
8. What actions do you take after identifying quality issues?
9. What are your key performance indicators for quality control measures?
10. What methodologies do you currently utilize to design, develop, and implement training materials (including curriculum, assessments, and objectives)?
11. Does your current methodology utilize a Learning Management System (LMS)? If yes, please describe your experience with developing and maintaining an LMS for training purposes. Do you have subject matter experts within your organization who are able to provide ongoing technical support? What duties are they currently responsible for?
12. Describe your experience with adult learning best practices.
13. Describe your experience with using a virtual classroom environment and providing technical support during online training sessions.
14. How do you conduct a thorough evaluation to identify any potential training gaps and develop targeted training programs?
15. How do you ensure that all training content remains current, up-to-date, and compliant with policies? Do you use a system to track training content?
16. Describe training curriculum(s) that you have developed for other clients.
17. How do you measure learning for Call Center and Eligibility?

SECURITY

1. User Security Policies
   • Password Management: What are the policies regarding password management, such as how frequently password resets are required?
   • Multi-Factor Authentication (MFA): Is MFA implemented at either the network or desktop level?
   • Training: Do you provide training on HIPAA and SSA regulations for staff?
   • Compliance Reporting: Can you produce reports that verify staff compliance with HIPAA?
   • Information Technology Security Training: Do you offer any training related to IT security for staff, such as phishing awareness, password protection, and recognition of social engineering tactics?
2. Network
   • User Connection Solutions: What solutions would you use to connect users to state systems (e.g., VPN, VDI, Next-Generation Firewalls, Data Loss Prevention)?
   • Network Access Security: What security controls and monitoring mechanisms are in place for network access?
   • Endpoint Detection and Response (EDR) and Extended Detection and Response (XDR): What technology do you utilize for EDR and XDR?
   • System Maintenance: Please describe your approach to system maintenance, including scheduled downtime, patch management, and data backup and recovery procedures.
3. General
   • Visitor Identity Validation: What protocols do you have for validating visitor identity and authorization to enter the premises? This may include identification checks, issuance of identification badges, recording the purpose of visits, and physical security policies for personnel, such as a “clean desk” policy.
   • Data Privacy and Protection Policies: What are your policies on data privacy and data protection?
   • Paper Document Management: What is your policy regarding the management of paper documents containing sensitive data?
   • Background Checks: Do you perform background checks on employees?
   • Personnel Screening Process: Please describe your personnel screening process.
4. Remote Access Policy
   • What is your policy regarding remote access when connecting with a client?
5. Compliance Maintenance
   • How do you ensure compliance with regulations and standards?
6. Physical Security Evaluation
   • How do you assess the security of your physical facilities?

ADDITIONAL INFORMATION

Please provide any relevant insights or recommendations your company may provide that KDHE-DHCF is not aware of. Along with response please provide current documentation which provides examples of your company’s:

1. Sample e-learning modules, presentations or manuals developed for training
2. Sample training schedules
3. Onboarding procedures for staffing
4. Quality Standard Operating Processes (SOPs)
5. Corrective Action Plan samples for trending issues
6. Sample Quality Reports
7. Call tree
8. IVR diagram