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OPERS Medicare Health Care Connector RFP

Request for Proposals

Medicare Health Care Connector

Date Issued: June 26, 2013

277 East Town Street

Columbus, Ohio 43215‐4642

1‐800‐222‐7377

Ohio Public Employees Retirement System


TABLE OF CONTENTS

A. Background

B. Overview

C. Scope of Engagement

D. RFP Process

E. Minimum Requirements

F. Proposal Content

1. Cover Letter

2. Understanding of Engagement

3. HIPAA Compliance

4. Vendor Organization

5. Vendor Personnel & Experience

6. Account Management & Support

7. Plan Selection Process

8. Plan Offerings

9. Health Reimbursement Account

10. Customer Service

11. Communications & Education

12. Commissions

13. Technology & Data

14. Work Plan & Implementation

15. Deliverables

16. References

17. Cost

18. Sample Contract

G. Selection Criteria

H. General Terms & Conditions for Submitting Proposals

I. Instructions for Submitting Proposals

J. Appendix A (Separate Excel File)

1. (A1) Plan Offerings

2. (A2) County Plan Indicator

3. (A3) Commission ‐ #1

4. (A4) Commission ‐ #2

5. (A5) Book of Business – Plan Type

6. (A6) Book of Business – Projected Growth

7. (A7) HRA Administrative Fees

K. Attachments

1. Attachment A—Required Contract Provisions

2. Attachment B—Business Associate Agreement

3. Attachment C —Definition of Eligible Dependent

IMPORTANT: No Vendor (or Vendor representatives, e.g. lobbyists) shall attempt to communicate with OPERS concerning this RFP in any manner or at any time other than during the open question/answer period (6/26/13 – 7/26/13) and the Vendor’s Conference held on 7/10/13. Communication with OPERS, other than as previously described, may result in immediate disqualification.


A. BACKGROUND

In 1935, the Ohio Public Employees Retirement System (OPERS) began a tradition of providing retirement benefits for

Ohio public employees. With approximately $80.3 billion in assets, OPERS provides retirement, disability, and survivor

benefit programs for public employees throughout the state who are not covered by another state or local retirement

system. Currently, OPERS serves more than 800,000 active/inactive members who are not yet retired and therefore, not

participating in the OPERS Retiree Health Care Program. At present, more than 229,000 Benefit Recipients and

Dependents participate in the OPERS Retiree Health Care Program of which 86,004 are Medicare A/B Benefit Recipients

and an additional 50,103 are Medicare A/B Dependents. Looking ahead to 2016, the OPERS Medicare population will

increase to ~98,000 Medicare A/B Benefit Recipients and ~54,000 Medicare A/B Dependents.

Since 2010, OPERS has offered Humana’s Medicare Advantage plan with a passive PPO and Express Scripts’ Part D plan

to eligible Medicare A/B Benefit Recipients and Dependents. Prior to 2010, Benefit Recipients and Dependents were

enrolled in various Medigap plans.

If a Vendor is interested in obtaining additional information about OPERS, including the most recent OPERS

Comprehensive Annual Financial Report, please refer to the OPERS website at www.opers.org.

B. OVERVIEW

In September 2012, the OPERS Board of Trustees (hereafter referred to as the “Board”) approved the OPERS Health Care

Preservation Plan (HCPP) 3.0. Faced with significant financial and demographic challenges that preclude OPERS from

being able to maintain its current level of retiree health care coverage, HCPP 3.0 entails substantial changes to the

current plan in order to preserve the health care program for the future. One of those changes is to no longer offer an

OPERS‐sponsored plan for Medicare‐eligible Benefit Recipients, but instead introduce a Medicare Health Care Connector

(hereafter referred to as “Connector”) that would allow Benefit Recipients greater flexibility in budgeting their health

care dollars and an opportunity to select a health care plan suited to their needs. OPERS’ definition of a Medicare Health

Care Connector is a model that will allow our Benefit Recipients to select among multiple individual Medicare plan

options (Medicare Supplement Plans, Medicare Advantage Plans, MAPD Plans, MA Special Needs Plans (SNP), and Part D

Drug Plans, etc.).

In order to support the Benefit Recipients’ ability to purchase an individual Medicare plan, OPERS will provide eligible

Medicare A/B‐enrolled Benefit Recipients with a monthly allowance credited to a Health Reimbursement Arrangement

(“HRA”). OPERS determines eligibility for the allowance amount. The eligible Benefit Recipients will have the HRA to use

to purchase a plan through the Connector (“Connector Participants”) and/or use in any permissible manner to reimburse

their or their eligible Dependents’ qualified medical expenses. OPERS anticipates that Benefit Recipients also will use

the Connector to assist their spouses in purchasing a plan. Not all Benefit Recipients will choose to purchase a plan

through the Connector; those individuals will remain HRA Participants, with access to their allowance to use as that

account permits.

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Administrative Fees – Monthly fees charged to Plan Sponsors or Medicare‐eligible Connector Participants for plan

selection support and ongoing Customer Service functions.

Benefit Advisor – Individual employed by the Connector. Individual will be responsible for facilitating and

completing, as applicable, the enrollment process with HRA Participants. In some Connector service models, the

Benefit Advisor also performs routine “post‐enrollment” Customer Service to Medicare‐eligible Connector

Participants. We are aware that organizations hire “seasonal/part‐time” Benefit Advisors to assist with high volume

periods such as the annual open enrollment period for individual Medicare plans. For this RFP, OPERS recognizes

that there are different Customer Service models. OPERS assumes that the Benefit Advisor may or may not provide

both carrier/plan selection support and “post‐enrollment” Customer Service support.

Benefit Recipient – Individual who is receiving an age and service retirement or disability benefit or a spouse or child

of a member or retiree receiving survivor benefits following a member or retiree’s death. With some exceptions,

Benefit Recipients are currently eligible for enrollment in OPERS health care coverage when the member earns at

least ten years of qualifying service credit. Not all Benefit Recipients are eligible to participate in coverage provided

by the system, and OPERS determines eligibility for coverage of the Benefit Recipient and Dependents.

Connector Participant – An HRA Participant and his or her Dependent who chooses to participate in the Connector

by purchasing and enrolling in a plan offered through the Connector.

Customer Service – Service the Connector will provide to OPERS’ Staff, Connector Participants, and HRA

Participants; including the following functions (but not limited to): inbound/outbound calls, education process (face‐

to‐face/telephonic), enrollment process (face‐to‐face/telephonic), appointment scheduling, answering questions,

claims resolution support, HRA support, etc.

Dependent – Has the same meaning as defined in Ohio Administrative Code section 145‐4‐09 (see Attachment C).

HRA Participant – An eligible Benefit Recipient, as determined by OPERS, who is enrolled in Medicare Part A and B,

and receives an allowance from OPERS in a HRA. HRA Participants are not required to become Connector

Participants.

Implementation Team (Connector) – Individuals employed by the Connector and subcontractor(s) (if applicable).

Responsible for implementing the Connector model for the Connector Participants and the HRA Participants. Team

will be available during Eastern Standard Time, 9:00 am – 5:00 pm, Monday – Friday. The Account Manager assigned

to the OPERS account must be a participant on the Implementation Team.

Insurance Carrier – An organization licensed to sell individual Medicare insurance plans; must be licensed in the

state that the plan is sold.

Medicare Health Care Connector – An organization that educates, supports and/or assists both Connector

Participants and HRA Participants in the consideration, selection and enrollment in individual Medicare plan(s), and

provides ongoing Customer Service. This organization also provides, internally or through a third party, HRA

administrative services.

Member Education Services – A group of OPERS’ Staff that facilitates educational sessions throughout Ohio.

Notional Account HRA Administrative Fees – Monthly fees charged to Plan Sponsors or Medicare‐eligible Benefit

Recipients to administer and/or manage HRAs.

Open HRA – An option in which Medicare‐enrolled (Part A and B) participants in OPERS’ sponsored health care

coverage who do not select an individual Medicare Plan (also, “HRA Participants”) through the Connector or their

third party subcontractor, but who will still be allowed to utilize the HRA program/processes administered by the

Connector selected by OPERS.

Origination Fees – First year fees pertaining to “start‐up” costs (communication and enrollment packets, etc.).

Plan Services – Services provided by the Connector and/or the third‐party HRA subcontractor (if applicable)

including the pre‐enrollment, enrollment, and post‐enrollment functions.


Portal – Provided by the Connector. Web site that Connector Participants and HRA Participants may use to educate

themselves on individual Medicare plan options suitable for their lifestyle and health care needs. Personal Health

Information may be present within the web site so Connector Participants and HRA Participants will need to login

with person‐specific credentials via an authentication process.

Retiree Health Care Program (OPERS) – Depending on an OPERS’ Benefit Recipient’s age and situation, there are

currently two options for health care coverage. Pre‐65 individuals are enrolled in a group plan provided by Medical

Mutual of Ohio. Post‐65 individuals and Medicare‐eligible, pre‐65 individuals are enrolled in a Medicare Advantage

plan provided by Humana.

Staff/Administration (OPERS) – Individuals employed by OPERS who will be responsible for the Connector

implementation, the continuous oversight of the Connector’s contractual obligations/performance

standards/guarantees, and the satisfaction of Connector Participants and HRA Participants.

Vendor – Connector organizations responding to the Request for Proposals.

C. SCOPE OF ENGAGEMENT The purpose of this Request for Proposals (“RFP”) is to seek proposals to provide the following Medicare Health Care

Connector services to Connector Participants and HRA Participants effective 2016.

Medical and Prescription Drug Plan Selection Support. Support the Connector will provide to Connector

Participants and HRA Participants during the decision‐making process when considering and selecting Medicare

plans; including discussions regarding the following (but not limited to): Connector Participant’s and HRA

Participant’s lifestyle and needs (residence, household income, budgetary restrictions, medical conditions,

prescriptions, provider relationships, etc.); cost considerations (premiums, deductibles, out‐of‐pocket

maximums, etc.) when selecting a plan; comparisons between their current health care coverage (provided by

OPERS as the plan sponsor) and available plan offerings on the individual Medicare marketplace.

Ongoing Customer Service. Service the Connector will provide to OPERS’ Staff, Connector Participants and HRA

Participants; including the following functions (but not limited to): inbound/outbound calls, education process

(face‐to‐face/telephonic), enrollment process (face‐to‐face/telephonic), appointment scheduling, answering

questions, claims resolution support, HRA support, etc.

Notional Account HRA Administrative Services. Service the Connector will provide to OPERS’ Staff, Connector

Participants and HRA Participants; including the following functions (but not limited to): education, customer

service, member self‐service functions (e.g. balance tracking, claim submissions), etc.

Operational Expectations

OPERS expects the selected Connector(s) to incorporate the following operational expectations into their business

strategic and operational planning.

Technology

o A secure VPN connection will be available for OPERS to push and pull electronic files and reports.

o The ability to receive, store, and report on five (5) 15 character alpha‐numeric identification numbers

will be available. The identifiers include: Individual’s SSN, Dependent’s SSN, alternative SSN, Account ID,

and Profile ID.

HRA

o HRA Participants will receive notional HRA accounts with the OPERS’ Benefit Recipient as the primary

owner of the account. OPERS will not pre‐fund accounts. Reimbursements for claim payments will occur

on a cleared check basis.

o Unused HRA balances will carry forward for use in future years.


o HRA funding will be used for premium payments and the reimbursement of eligible medical out‐of‐

pocket expenses of the Benefit Recipient and his or her eligible Dependent.

o The HRA funding level will vary based on the OPERS’ Benefit Recipient’s age when he/she first enrolled

in OPERS health care and years of service at retirement.

o OPERS’ Benefit Recipients will receive their HRA allowance on a monthly basis.

o In addition to the educational support HRA Participants and Dependents will receive leading up to their

plan selection and enrollment, there also should be dedicated HRA education to ensure that HRA

Participants and their Dependents understand the concept of an HRA and how to utilize it correctly.

D. RFP PROCESS OPERS will utilize a five phase RFP process to select a Connector that will best meet OPERS’ needs and expectations.

Phase 1 – Minimum Requirements

Vendor proposals must meet the Minimum Requirements contained in section E. Vendor proposals that don’t

meet the Minimum Requirements will not be considered, reviewed, or evaluated. Upon receipt of the Vendor

proposals, OPERS will verify Vendor responses to the Minimum Requirements. Proposals meeting the Minimum

Requirements will advance to Phase 2.

Phase 2 – Verification of Key Contract Terms

For Phase 2, OPERS will request that advancing Vendors re‐confirm their agreement to the key contract terms

contained in Attachments A and B within the RFP. Vendors that re‐confirm their agreement to the terms will

advance to Phase 3.

Phase 3 – Proposals and Presentations

For Phase 3, OPERS will review advancing Vendors’ written proposals. Also during this phase, OPERS will

determine, in its sole discretion, whether any or all of the advancing Vendors will be asked to make oral

presentations. In that event, OPERS will develop and provide to such Vendors clarifications and questions to be

addressed in the oral presentations. OPERS will then evaluate the written proposals and presentations to

determine which Vendors, if any, will advance to Phase 4.

Phase 4 – Site Reviews

For Phase 4, OPERS will conduct comprehensive site reviews of the advancing Vendors’ infrastructure,

operations, IT systems, Customer Service, fulfillment functions, outreach/education process, and any other

critical operational components to support the OPERS’ population. OPERS will evaluate the site reviews.

Phase 5—Contract Negotiations

After evaluation of the site reviews, OPERS may determine a list of finalists and commence sequential

negotiations as described in section G.

A process flow chart that illustrates the OPERS Medicare Connector Selection process is included below.

OPERSS Medicare Heallth Care Connecttor RFP


E. MINIMUM REQUIREMENTS The items listed in this section of the RFP are mandatory proposal requirements (“Minimum Requirements”). A proposal must meet all of the Minimum

Requirements or it will not be considered, reviewed, or evaluated. For its proposal, a responding Vendor must complete the following chart, and include it with

the proposal immediately following the cover page.

Requirement Response Yes/No

Additional Clarification

1. Does your organization have experience enrolling a single group/organization with greater than or equal to 25,000 Medicare‐eligible individuals at one time within a single Medicare enrollment period, and/or have a contract in place to enroll a single group/organization with greater than or equal to 25,000 Medicare‐eligible individuals during the 2014 annual enrollment period?

If yes, provide contact information for the organization(s) with which you have had experience enrolling 25,000 individuals at one time within a single Medicare enrollment period or contact information for the organization(s) that you are contracted with

for the 2014 enrollment period.

Contact information should include: company, name, title, address, email address, and telephone number. We will use the contact information to verify "yes" responses to this question.

2. OPERS' strategy is to not mandate participation in the Connector. HRA Participants will receive a monthly allowance and utilize an Open HRA for reimbursement of their qualifying health care expenses. By January 1, 2016, will your organization support an Open HRA process so that HRA Participants who do not select an individual Medicare plan through the Connector may still utilize an HRA affiliated with your organization?


3. Is your organization able to provide a nationwide network of at least four (4) different Insurance Carriers licensed in the state of Ohio (e.g., Aetna, UnitedHealthcare, etc.)?

If yes, provide a summary report inclusive of the Insurance Carriers that are represented within your organization's service model and their respective individual Medicare plan offerings.

4. Does your organization offer the following individual Medicare plan offerings: MA only, MAPD, PDP only, MA Special Needs Plan, and Medigap Plans (A, C, F, G, and N)?

MA only

MAPD

PDP only

MA Special Needs Plan

Medigap Plan A

Medigap Plan C

Medigap Plan F

Medigap Plan G

Medigap Plan N

5. Does your organization agree to have the Account Manager who is assigned to the OPERS account included within the Implementation Team?

6. Does your organization agree to assign an Account Manager that operates on Eastern Standard Time, 9:00 am ‐ 5:00 pm, Monday ‐ Friday?

Vendors can be located in any time zone – this minimum

requirement identifies a vendor's willingness to operate on EST.

7. Does your organization agree to have the Implementation Team operate on Eastern Standard Time, 9:00 am ‐ 5:00 pm, Monday ‐ Friday?

Vendors can be located in any time zone – this minimum

requirement identifies a vendor's willingness to operate on EST.


8. Does your organization agree to provide a dedicated Implementation Manager and Account Manager (they can be the same person or separate) until March 30, 2017?

Dedicated is defined as assigned to OPERS without having responsibility for any additional clients.

Implementation Manager is defined as the lead associate

responsible for the successful implementation of the OPERS account.

Account Manager is defined as the day‐to‐day associate

responsible for the overall administration and management of the OPERS account.

9. Does your organization agree to have a designated IT Manager assigned to the OPERS account until March 30, 2017?

Designated is defined as being assigned to OPERS, but has the ability to support other clients. OPERS believes that the

designated IT Manager should treat the OPERS account as top priority.

10. Does your organization agree that enrollment and Customer Service (including HRA support) functions to support the OPERS account will not be outsourced for the duration of the contract?

OPERS believes that the annual/new‐eligible enrollment support and ongoing Customer Service (including HRA support) are core

business functions, and should not be outsourced to a subcontractor.

11. During the initial enrollment period(s) of this engagement (starting 30 days prior to the first open enrollment period), does your organization agree to provide, at minimum, the following schedule for HRA Participants who may have questions and/or would like to enroll in a Medicare plan? Monday ‐ Thursday: 8:00 am ‐ 8:00 pm EST Friday: 8:00 am ‐ 6:00 pm EST

Example: For an October 15th enrollment period start date, the schedule should start on September 15th.

Due to our size, OPERS has not decided on the number of "initial enrollment periods" that we may have. There could be multiple "initial enrollment periods" where these hours would be required

30 days prior to each "initial enrollment period."

In addition to the Customer Service hours listed in the minimum requirement statement, OPERS also would prefer Saturday hours

scheduled 8:00 am ‐ 2:00 pm EST.


12. Does your organization agree to provide in‐person support at Ohio‐based educational sessions where HRA Participants are learning about the Connector?

OPERS has not decided on the frequency and duration of the educational sessions; however, assume eight (8), two‐hour

sessions per month (may be virtual or in‐person) spanning the contract start date through the close of the initial enrollment

period(s).

Educational sessions (held throughout Ohio) are defined as forums in which Benefit Recipients, Dependents, family members,

etc. may learn about the following: the selected Connector, Medicare plan options, enrollment process, HRA process, etc. List is not inclusive of all the topics that may be covered within an

educational session.

13. Does your organization agree to provide face‐to‐face enrollment appointments (wherein an eligible HRA Participant can complete all components of the enrollment process) to HRA Participants in addition to telephonic enrollment?

14. Does your organization agree to allow OPERS Staff access to daily reporting that captures the following data elements? ‐ Quantity and percentage of Connector Participants who have selected a plan. ‐ Quantity and percentage of Connector Participants who have selected a plan broken out by insurer/carriers and plan types. ‐ Quantity and percentage of HRA Participants who have not selected a plan.

15. Does your organization agree to set up a secured email with OPERS by July 1, 2014?

Secured email is set up using Transport Level Security (TLS). This will allow for automatic encryption between OPERS and the

selected Vendor when emails are being sent and received. TLS may also be referred to as “Email over HTTPS” with the setup

being similar to setting up a secure website.


16. Does your organization agree to perform all direct and indirect functions to support the OPERS account within the United States of America?

17. Does your organization agree that the contract provisions contained in Attachment A shall be included in any contract with OPERS that may result from this RFP and such contract terms shall control in the event of any conflict?

Refer to Attachment A within the RFP.

18. Does your organization agree that it will (i) be a business associate of OPERS, (ii) maintain a HIPAA compliance program consistent with the requirements of the HIPAA privacy, security, and breach regulations, and (iii) execute the Business Associate Agreement found in Attachment B?

Refer to Attachment B within the RFP.


F. PROPOSAL CONTENT For ease of review, each requirement should be addressed in a separate section preceded by an index tab to identify the appropriate RFP section. The proposal should be formatted on consecutively numbered pages and include a table of contents. Although not required, OPERS prefers that submissions be two‐sided to reduce the volume of materials used to review the proposals. Please note that the completed Minimum Requirements chart must be included immediately following the cover page and before the Cover Letter.

1. COVER LETTER

1.1 The Vendor must include a cover letter, which will be considered an integral part of the proposal, in the form of a standard business letter, and must be signed by an individual who is authorized to contractually bind the Vendor. The cover letter must include:

1.1.1. A statement regarding the Vendor’s legal structure, Federal tax identification number, and principal place of business.

1.1.2. Vendor’s primary contact on this RFP, who has authority to answer questions, regarding the

proposal. Include the following: i. Organization Name ii. Contact’s Name iii. Contact’s Address iv. Contact’s Phone and Facsimile Numbers v. Contact’s Email Address vi. Additional Contacts (as appropriate)

1.1.3. A statement indicating that the Vendor’s proposal agrees to and meets all of the RFP

requirements.

1.1.4. A statement that the Vendor has not submitted its proposal with the assumption that there will be an opportunity to negotiate any aspect of the proposal.

1.1.5. A statement indicating that the Vendor acknowledges that all documents submitted in response to this RFP may be subject to disclosure under Ohio’s Public Records Act.

1.1.6. A statement that the Vendor acknowledges and agrees that the contract provisions contained in

Attachment A shall be included in any contract with OPERS that may result from this RFP, and such contract provisions shall control in the event of any conflict.

1.1.7. A statement that the Vendor acknowledges it will be a business associate to OPERS, and agrees to

execute OPERS’ Business Associate Agreement (Attachment B).

2. UNDERSTANDING OF ENGAGEMENT

2.1 Describe your organization’s understanding of the services requested in this RFP by OPERS.

2.2 Describe areas or processes not included in this RFP that your organization may examine in order to provide

more complete services.


2.3 Provide a narrative that supports why your organization believes that it is qualified to undertake the

proposed engagement.

3. HIPAA COMPLIANCE

3.1 Does your organization have a formal compliance program to comply with the HIPAA privacy, security and

breach regulations, as set forth in 45 CFR Parts 160 and 164?

3.2 Has your organization appointed a privacy officer?

3.3 Has your organization appointed a security officer?

3.4 Does your organization have written policies and procedures to comply with the privacy, security and breach

regulations?

3.5 Does your organization have a formal training program for your staff on the HIPAA privacy, security and

breach regulations?

3.6 Has your organization had any incidents which have been investigated as a potential breach of protected

health information? If so, please describe the incidents and the outcome of the investigation.

3.7 Has your organization had any complaints regarding protected health information? If so, please describe

generally the complaints and your response.

4. VENDOR ORGANIZATION

4.1 Vendor’s domestic office locations, identifying which location will be assigned this engagement. Indicate the location(s) of the offices that will house the primary representatives providing the services necessary to support this engagement (including but not limited to: Customer Service, Account Management, etc.). Describe how your organization’s location will facilitate, and not adversely affect, the execution of this contract arrangement if your primary location is not located within Ohio.

4.2 Vendor’s organizational structure, including subsidiary and affiliated companies, and joint venture

relationships. 4.3 How many years has Vendor been in business as a Medicare Health Care Connector?

4.4 Has Vendor undergone any material change in its structure or ownership within the last 18 months? If yes,

describe.

4.5 Is any material change in ownership or structure currently under review or being contemplated? If yes, describe.

4.6 If available, provide a report, study, or assessment of your organization, prepared by an unbiased

independent third‐party source, concerning client satisfaction and measures of your organization’s strengths and weaknesses vis‐à‐vis your key competitors.


4.7 Provide your most recent financial statements including a statement of financial position, an annual income statement, and balance sheet.

4.8 Describe any material litigation to which your organization is currently a party. In addition, describe any

material litigation that your organization has been involved in over the last three (3) years.

4.9 Provide a list and describe litigation brought or threatened against your organization by existing or former clients over the past five (5) years.

4.10 Describe any relationships that your organization has with potential vendors to OPERS, including any potential fees or other remuneration your organization may receive for recommending their products or services. Within your response, you do not need to include information that will be provided in “Section 11: Commissions.”

5. VENDOR PERSONNEL & EXPERIENCE

5.1 For each individual that you propose to assign to this engagement, please provide a narrative with the following information: 5.1.1 Employee name and title. 5.1.2 Proposed position and area of responsibility on this engagement (manager, supervisor, officer, etc.) 5.1.3 The month and year that the employee began working for your organization. 5.1.4 Employee work history.

5.2 Vendor is requested to perform all services and may not subcontract without the written consent of OPERS.

For each of the Vendor’s potential subcontractors, provide a narrative with the following information: 5.2.1 The subcontractor’s (firm) name and address. 5.2.2 A brief description of the work said subcontractors might perform. 5.2.3 Subcontractor employee name and title. 5.2.4 Proposed position and area of responsibility on this engagement (manager, supervisor, officer, etc.) 5.2.5 The month and year that the subcontractor employee began working for the subcontractor

organization. 5.2.6 Subcontractor employee work history. 5.2.7 Description of how your organization will manage the subcontractor relationship and performance.

5.3 Describe your organization’s transition process to minimize the impact to OPERS in the event a primary

representative assigned to the OPERS account leaves your organization during the term of the engagement.

5.4 Provide a short overview of your organization, including a summary of the following items: 5.4.1 Date your organization began operations and overview of your organization’s products, lines of

business, and target markets. 5.4.2 Corporate ownership (current and any changes that have occurred in the past 18 months)

identifying any outside parties that have ownership interests in your organization. 5.4.3 Summary financial statements (income statement, balance sheet, statement of cash flows) for the

most recent two (2) completed fiscal years. If your organization is privately held and does not release financial statements, explain what information you will release on a confidential basis.

5.4.4 Describe significant changes/improvements that your organization has implemented to keep pace with market demand.

5.4.5 Describe any major system changes/upgrades your organization plans to make in the next 12‐24 months (include timeline).


6. ACCOUNT MANAGEMENT & SUPPORT

6.1 Describe how your organization structures your Account Management teams. Outline the service team you are proposing to serve OPERS, and provide a resume for each team member.

6.2 Proposals must include resumes of the primary representatives who would be assigned to our account. Resumes should indicate the office location, degrees, professional designations, experience, number of years with your organization, and any other applicable certifications.

6.3 Do you agree to allow OPERS to have input on the chosen Account Manager for the account? Describe your process when assigning an Account Team to a new client. How do you ensure that the identified Account Team will be able to best meet the needs of OPERS?

7. PLAN SELECTION PROCESS

This section focuses on how your organization will provide support during a HRA Participant’s decision‐making

process when selecting a Medicare plan. Please note the following points when answering the questions in this

section:

Indicate any differences that may be present when supporting HRA Participants who are/have:

o Selecting a Medicare plan for the first time (initial enrollment period) and for subsequent years.

o Selecting a Medicare plan for the first time (aging into Medicare).

o Disabilities and/or End Stage Renal Disease.

o Pre‐65 selecting a Medicare plan.

Indicate any difference that may apply for HRA Participants living outside the United States.

7.1 Describe your organization’s outreach strategy. Include the following information within your response:

7.1.1 What type of population data your organization will request from OPERS.

7.1.2 How your organization will utilize that population data.

7.1.3 Type of communication strategies and materials that will be used to educate HRA Participants

prior to the designated enrollment period.

7.1.4 Timeline outlining all outreach effort through the end of the enrollment period.

7.1.5 Description of any processes and/or technology (i.e., intelligent mail barcode) to track

information that is mailed to identified individuals.

7.2 Describe the process your organization will use to help HRA Participants select a plan. Include the following

information within your response:

7.2.1 How your organization will initiate contact with HRA Participants.

7.2.2 How your organization will acquire an understanding of a HRA Participant’s lifestyle and needs

(residence, household income, budgetary restrictions, medical conditions, prescriptions,

provider relationships, etc.).

7.2.3 How your organization will help HRA Participants evaluate all the cost considerations

(premiums, deductibles, out‐of‐pocket maximums, etc.) when selecting a plan.

7.2.4 How your organization will explain what HRA Participant‐specific information has already been

transferred to your organization (from OPERS) and how your organization will use that

information.

7.2.5 How your organization will educate HRA Participants on the available plan offerings and

corresponding implications of their selection decisions.


7.2.6 How your organization will educate HRA Participants on the concept of “guaranteed issues”

and “medical underwriting.”

7.2.7 How your organization will help HRA Participants compare their current health care coverage

(provided by OPERS as the plan sponsor) to available plan offerings on the individual Medicare

marketplace.

7.2.8 How your organization identifies and provides selection support to HRA Participants who may

qualify for a Special Needs Plan.

7.2.9 How your organization provides selection support to HRA Participants who are dually eligible

for Medicare and Medicaid or other federal or state programs that assist eligible individuals.

7.2.10 How your organization provides selection support to HRA Participants who are currently

enrolled in Tricare to avoid duplication of coverage.

7.2.11 How your organization provides selection support to HRA Participants residing in a nursing

home/assisted care facility.

7.2.12 How your organization provides selection support to HRA Participants who have legal

guardians.

7.2.13 How your organization provides selection support to HRA Participants who have a Power of

Attorney.

7.2.14 How your organization provides selection support to HRA Participants who don’t have a Power

of Attorney, but should have one because of their condition/level of capacity.

7.2.15 How your organization will ensure that all HRA Participants make a selection and/or confirm

that HRA Participants do not want to select a plan through your Connector. Be sure to include

the percentage of individuals that select a plan and percentage of people that don’t select a

plan based upon your organization’s prior experience.

7.3 Provide your organization’s standard script and/or outline of talking points that the Benefit Advisor team

utilizes when providing plan selection support.

7.4 Throughout the selection process, will HRA Participants be assigned a personalized Benefit Advisor? If yes: 7.4.1 Will they be given a direct telephone number and email? 7.4.2 What happens to HRA Participants who have been assigned a seasonal or part‐time Benefit

Advisor? 7.4.3 Describe your organization’s transition process to minimize the impact to a HRA Participant

and/or Connector Participant in the event a Benefit Advisor assigned to the OPERS account leaves your organization during the term of the engagement.

7.5 Describe how the tools and resources that Benefit Advisors utilize enhance the plan selection experience.

Include the following information within your response:

7.5.1 Indicate whether your organization’s Benefit Advisors use one standardized application or

different applications (based on Insurance Carrier) when enrolling a Connector Participant into

new plan.

7.5.2 Indicate whether voice signature and automated disclaimers are components of the telephonic

consultation.

7.5.3 Describe the tools that are available to Benefit Advisors to help HRA Participants find the plan

that best suits their lifestyle and needs.


7.5.4 Indicate whether your organization has the ability to load personal health information to

customize the available plan offering choices to an individual.

7.6 Describe how your organization will facilitate HRA Participant appointments. Include the following


7.6.1 Topics discussed during appointments.

7.6.2 Average number of appointments per Connector Participant.

7.6.3 Average length of each appointment.

7.6.4 How your organization facilitates appointments (telephone, online, in‐person)

7.7 Based upon previous client experience, indicate a percentage estimation of what method (telephone, in‐

person, etc.) HRA Participants typically utilize to select a plan.

7.8 Describe the appointment scheduling, reminder, and confirmation process. Who schedules the enrollment

appointments – your organization or the Connector Participant?

7.9 Describe how your Benefit Advisor team is compensated.

7.9.1 How does your organization ensure those Advisors remain objective and unbiased when

providing plan selection support?

7.9.2 What efforts does your organization take to ensure that all employees of your organization

remain unbiased, and will not steer OPERS’ HRA Participants to specific Insurance Carriers?

7.10 Is your organization’s Benefit Advisor team staffed with licensed/certified personnel? If so, describe the

various certifications those Advisors hold. Include the following information within your response

7.10.1 Percent of Benefit Advisors who are licensed as insurance agents to sell health care insurance

in the state of Ohio and appointed for all carriers for which they write coverage. Additionally,

include the same information for all other states in which the Benefit Advisors are so licensed,

and describe how your organization handles the Benefit Advisors’ appointments in these

States.

7.10.2 Are Benefit Advisors licensed by applicable state licensing boards for all carriers and products in

the states they are assigned to before taking enrollment appointments?

7.10.3 Are Benefit Advisors licensed to handle specific geographies, or do they handle all areas?

7.11 When considering the OPERS population of ~136,000 HRA Participants who may purchase a plan

through the Connector, estimate how many people will make the following plan selection choices (based

upon your organization’s book of business, previous experience, and industry knowledge):

INDIVIDUAL TYPE PERCENTAGE (must add up to 100%)

Connector Participants who select a Medigap plan and an additional Part D plan.

Connector Participants who select a Medigap plan and not an additional Part D plan.

Connector Participants who select a Medicare


Advantage with Part D plan.

Connector Participants who select a Medicare Advantage without Part D plan.

Connector Participants who only select a Part D plan.

Connector Participants who select a MA Special Needs Plan.

Other

TOTAL

7.12 Describe the five (5) most common issues that HRA Participants experience during the selection process.

Within your response, describe how each issue is typically addressed and resolved by your organization’s

Benefit Advisor and/or Customer Service staff.

7.13 Provide a process flow diagram (with supporting timeline) to document the experience HRA Participants

will have when considering and selecting a plan, as applicable, through your organization; include a separate

diagram (with supporting timeline) for face‐to‐face and telephonic experience.

7.14 Does your organization provide a decision‐centric Portal (i.e. website that authenticates the user via

login credentials) that allows for HRA Participants to educate themselves on the individual Medicare

market? If so, include the following information within your response:

7.14.1 List (with definitions) the tools and resources that a HRA Participant will be able to access.

7.14.2 Description of how HRA Participants may customize their search results by selecting different

attributes (premium cost, out‐of‐pocket cost, provider location, provider rating, etc.).

7.14.3 Overview of how OPERS staff will be able to run reports to check on plan selection progress,

etc.

7.14.4 Overview of how your organization will enhance the Portal’s design and functionality over the

next 1‐3 years.

7.14.5 Average portal utilization rates (count of unique visitors, average visit duration, average

number of page views, etc.) of other clients within your book of business.

7.14.6 Screen shots and/or samples of other Portals that your organization has developed for

past/current clients.

7.14.7 Login credentials for OPERS Staff to test your organization’s Portal experience.

7.15 Would your organization be willing to establish a walk‐in enrollment center located in the Columbus, Ohio metropolitan area (potentially in the OPERS building), in which Connector Participants and/or HRA Participants could receive education, schedule enrollment appointments, complete enrollments, etc.?

7.15.1 If so, describe your organization’s strategy to establish such a site. 7.15.2 OPERS prefers an option that all enrollment functions could be handled within a walk‐in

enrollment center located in the Columbus, Ohio metropolitan area (potentially in the OPERS building); however, if there are certain functions that would not be handled, indicate those within your response.

7.15.3 Indicate the pros/cons of establishing a walk‐in enrollment center within the OPERS building.


7.15.4 How would you propose providing face‐to‐face enrollment opportunities for Connector Participants and/or HRA Participants living outside the Columbus, Ohio metropolitan area?

8. PLAN OFFERINGS

8.1 Describe your organization’s overall strategy in structuring your insurance carrier/insurance plan roster

(number of carriers, number of plans, number of plan types, quality standards of plans selected, quality

standards of plans retained, premium stability, commission structure/amounts, etc.)?

8.2 Describe how your organization selects Insurance Carriers for inclusion within your roster. Within your

response, explain how you evaluate the items listed below – we’d like to understand your organization’s

due diligence process to ensure that the following items meet your internal performance

thresholds/targets (and how an item would meet your internal performance thresholds/targets).

8.2.1 Claims Adjudication (avg. time to adjudicate claims, payment accuracy, hours of operation,

etc.)

8.2.2 Customer Service Metrics (avg. speed to answer, one‐call resolution, etc.)

8.2.3 Financial Strength / Independent Financial Ratings

8.2.4 Market Share

8.2.5 Department of Insurance Ratings (carriers offering Medicare Supplemental plans)

8.2.6 Product Availability – Geography (carrier must offer plans in “x” counties, states)

8.2.7 Provider Network (adequacy of provider specialties, ancillary providers, hospitals, etc.)

8.2.8 Product Availability – Type of Offered Plans (choice of MA, MAPD, PDP, Medigap, MA SNP)

8.2.9 Real‐Time Reporting

8.2.10 Business‐to‐Business Technological Requirements – Electronic File Feeds

8.2.11 Business‐to‐Consumer Technological Requirements – Voice Signature

8.3 Describe how your organization selects individual Medicare plans for inclusion within your roster of plan

choices. Include specific information on how the items below are evaluated when adding a specific

individual Medicare plan (MA, MAPD, PDP, Medigap, and MA SNP) to your Connector. NOTE: If you have

different criteria for different individual Medicare plan types (MA, MAPD, PDP, Medigap, and MA SNP),

provide the relatable criteria for each applicable individual Medicare plan type.

8.3.1 Medicare Plan Quality Performance Ratings (STAR ratings for MA/MAPD)

8.3.2 Plan Availability

8.3.3 Plan Design (ancillary services such as Silver Sneakers, Dental Rider, Vision Rider, etc.)

8.3.4 Plan Maturity (minimum number of years the plan has been in existence)

8.3.5 Rate Stability (average increase or year‐to‐year rate increases for the plan over three‐year

period)

8.4 How many Insurance Carriers have left your roster since the inception of your organization’s retiree

Connector services? Describe the circumstances.

8.5 Indicate the percentage of auto‐payment arrangements for individual premium payments available from

Insurance Carriers within your roster. Indicate your organization’s target for how many Insurance Carriers

you’d like to have with auto‐payment arrangements, and describe the strategy to attain that target.


8.6 How do you manage Insurance Carrier relationships and performance?

8.7 How do you address situations where an Insurance Carrier drops a plan or product offering after Connector

Participants have already enrolled?

8.8 Complete the chart (Appendix A1: “Plan Offerings”) as specified to identify your organization’s current

number of plan offerings and the average monthly premium of each plan.

8.9 Complete the chart (Appendix A2: “County Plan Indicator”) as specified to indicate which Ohio counties your

organization has zero plan offerings within each Medicare plan category (MA, MAPD, PD only, MA SNPs, and

Medigap).

9. HEALTH REIMBURSEMENT ACCOUNT (HRA)

9.1 How does your organization provide HRA services – via an in‐house department affiliated with your

organization or via a third‐party subcontractor?

9.1.1 If a subcontractor will be utilized, provide a summary of any subcontracting relationships that

you have with other third‐party HRA Vendors. Include the following information:

9.1.1.1 Name and location of the organization

9.1.1.2 Duration of your relationship

9.1.1.3 Evaluation process to ensure that your organization’s third‐party subcontractor will

meet the Customer Service expectations of OPERS. If the relationship needs to be

terminated, describe how that would happen and the impact passed onto OPERS.

9.1.1.4 Description of how your organization’s Account Team will partner with the HRA

subcontractor’s Account Team to provide seamless support to OPERS.

9.1.1.5 Description of how your organization’s Customer Service team will partner with the

HRA subcontractor’s Customer Service team to provide seamless support to OPERS.

9.1.1.6 Description of how OPERS would work with the HRA subcontractor. Would OPERS work

directly with the HRA subcontractor or through the relationship with your organization

as the middle entity?

9.2 How many years of experience does your organization have in providing HRA services? How many lives are

using your HRA service as of May 31, 2013?

9.3 Describe the HRA staffing model your organization will use to handle the OPERS account. Include the

following information within your response:

9.3.1 HRA Staffing‐to‐HRA Participant ratios by title and role.

9.3.2 Employment status (number of individuals who are full‐time part‐time, seasonal, etc.).

9.3.3 Proportion of part‐time, full‐time, and seasonal employees?

9.3.4 Describe how the OPERS account will be supported by a dedicated Customer Service team.

9.4 Describe your organization’s customer service model for HRA administration.

9.5 State whether the customer service model is integrated or separate for HRA Plan Services, and describe the

rationale for using that model.


9.6 Describe your organization’s standards (performance goals) and respective result for the past rolling twelve

(12) months regarding HRA Customer Service accessibility and call/email volume. Include the following


9.6.1 Standard response time for calls and emails. What do you achieve?

9.6.2 Description of how after‐hour calls and emails are handled.

9.6.3 Is it possible that Connector Participants will hear a busy signal?

9.6.4 Percentage of abandoned calls.

9.7 Describe the following operational elements of your HRA Customer Service.

9.7.1 Methods in which a HRA Participant can access HRA Customer Service.

9.7.2 Indicate whether a dedicated and co‐branded toll‐free number can be provided.

9.7.3 Description of your organization's HRA telephonic call routing system. Describe the actual

experience a HRA Participant will have (i.e. voice menus, accessing a live person, etc.).

9.7.4 Description of your organization’s HRA process to monitor and manage call center activity.

9.7.5 Description of your organization’s HRA virtual call back system.

9.8 Describe how your organization will provide HRA Customer Service updates to OPERS. Include the following


9.8.1 Type of HRA reporting accessible by OPERS Staff (real‐time, daily, etc.).

9.8.2 Sample of HRA Customer Service reports.

9.8.3 Overview of how your HRA Customer Service report templates can be customized to fit our

needs.

9.9 Will HRA Participants be able to receive automatic reimbursements?

9.10 After HRA Participants are enrolled in a plan (through the Connector or through other means), describe how your HRA Customer Service team will perform the following functions and/or handle issues regarding:

9.10.1 HRA education and claims support 9.10.2 Claims and appeal support 9.10.3 Premium billing/reimbursement

9.11 Describe your organization’s HRA communication strategy for HRA Participants who will be utilizing an

HRA for the first time.

9.12 Describe how your organization will implement the HRA communications and engagement strategy for the OPERS population. Include the following in your response:

9.12.1 Timeline that includes initial point of contact (prior to enrollment period) through the start of a coverage year.

9.12.2 Description of all the HRA communication and educational methods (print, electronic, online, social media, etc.) that your organization utilizes.

9.12.3 Description of how your organization measures effectiveness for each method that has been indicated.

9.12.4 Description of all the HRA communication and educational materials (brochures, mailers, web site, flyers, etc.). Include a sample or screen shot of each piece of material that is indicated.

9.12.5 Description of how your organization measures effectiveness for each piece of material that has been indicated.


9.13 When developing new HRA communication materials, describe your organization’s process from concept to execution. Include the following in your response:

9.13.1 How the purpose is identified. 9.13.2 How the target audience is identified and considered. 9.13.3 How the content development process occurs. 9.13.4 How the material is tested for effectiveness prior to execution. 9.13.5 How the distribution method(s) is identified. 9.13.6 How the material is tested for effectiveness post execution.

9.14 Provide three (3) case studies that outline and illustrate the success that your organization has had with

a client in developing and executing a HRA communications and engagement strategy that resulted in positive, measurable results. Include the following within your response:

9.14.1 Outline of client demographics. 9.14.2 Overview of implementation process to migrate the population to a Connector. 9.14.3 Overview of communication and engagement strategies that were utilized. 9.14.4 Overview of how the communication and engagement strategy generated positive, measurable

results. Note: Be sure to define the result. 9.14.5 Description of any “lessons learned” your organization and your client identified for future

communication‐related initiatives. 9.14.6 Description of any strategies, tools, materials, etc. that seemed to work really well.

9.15 Describe how your organization will support OPERS in providing HRA educational opportunities to HRA

Participants – during the initial enrollment period, member age‐in period, and in subsequent years. Include the following in your response:

9.15.1 How many (and in what locations) educational sessions should be facilitated. 9.15.2 How an educational session should be facilitated. 9.15.3 What educational methods should be utilized. 9.15.4 How the educational sessions can be measured for effectiveness. 9.15.5 How your organization can augment the OPERS Member Education Services team. 9.15.6 What methods of education your organization would use for Benefit Recipients living outside

the state of Ohio. 9.15.7 Provide examples of the educational materials (print, electronic, video, etc.) that your

organization typically utilizes.

9.16 Provide a process flow chart (with supporting timeline) illustrating how the HRA process occurs. Include descriptions of the following components:

9.16.1 Claims and appeal process (submission, turn‐around times, auto‐reimbursement, appeals, etc.). 9.16.2 Self‐service functions (balance and claim tracking, etc.). 9.16.3 Provide a list (with screen shots) of all self‐service functions offered in your organization’s HRA

administrative process.

9.17 Describe in detail your organization’s substantiation procedures for HRA expenses. For this, include the

substantiation process, whether and how auto‐substantiation is addressed, as well as any follow‐up and

resolution regarding non‐qualifying expenses.

9.18 Describe the HRA reporting your organization provides regarding issued, cleared, and outstanding

payments.

9.19 Describe the process your organization utilizes to address outstanding warrants.


9.20 Describe your organization’s controls to ensure reporting accuracy to both OPERS and the Connector

Participant.

9.21 Describe your organization’s procedures and respective evaluation to ensure that overpayments (i.e. HRAs with negative balances) are not issued.

9.22 Describe your organization’s 2012 reimbursement/payment account performance success rates for: 9.22.1 Turnaround time 9.22.2 Financial accuracy 9.22.3 Processing accuracy 9.22.4 Payment accuracy 9.22.5 First call resolution

9.23 Provide sample reports of the following:

9.23.1 Member Detailed Balance (MTD, YTD, CTD Contributions, Claims, etc.) 9.23.2 Check Status (Outstanding checks issued, Void/Reissued checks, etc.) 9.23.3 Claims Lag Payment 9.23.4 Reconciliation

10. CUSTOMER SERVICE

This section focuses on the Customer Service function that your organization will provide to Connector Participants and HRA Participants including pre‐enrollment, enrollment, and post‐enrollment (“Plan Services”).

10.1 Describe your customer service model for Plan Services.

10.2 State whether the customer service model is integrated or separate for Plan Services, and describe the

rationale for using that model.

10.3 Describe the staffing model your organization will use to handle the OPERS account. Include the


10.3.1 Staffing‐to‐Connector Participant ratios by title and role. Specify any differences for the annual

vs. ongoing enrollment time periods).

10.3.2 Employment status (number of individuals who are full‐time, part‐time, seasonal, etc.).

10.3.3 Proportion of part‐time, full‐time, and seasonal Benefit Advisors?

10.3.4 Describe how the OPERS account will be supported by a dedicated Customer Service team.

10.4 Describe the various personnel who may interact with Connector Participants during their entire life

cycle (i.e. initial plan consideration, selection, and enrollment through death) and the personnel’s respective

roles. Include the additional information within your response:

10.4.1 Organizational chart – list the various titles, roles, and responsibilities of staff (e.g. appointment

scheduling, plan enrollment, application status, escalations, monitoring, etc.).

10.4.2 Escalation process to resolve an outstanding issue (this can include enrollment/selection‐

related or customer service‐related).

10.5 Describe your organization’s approach to providing training to your Customer Service team. Include the



10.5.1 Description of the initial position‐specific training that a Customer Service representative

receives when hired into your organization.

10.5.2 Description of Medicare and Medicaid training/education available that a Customer Service

representative receives.

10.5.3 Description of marketplace training (Medicare plan offerings, HRA regulations, etc.) that a

Customer Service representative receives.

10.5.4 Description of cultural training on how to interact with a diverse Medicare population

(including age‐in and disability populations).

10.6 List all the languages that your Customer Service representatives can speak.

10.7 Of the languages that you list in the previous question, describe your organization’s cultural training

program to educate the Customer Service team about the cultural norms of each ethnic group.

10.8 How does your organization provide plan selection support to persons with disabilities?

10.9 Describe your organization’s standards (performance goals) and respective result for the past rolling

twelve (12) months regarding Customer Service accessibility and call/email volume. Include the following


10.9.1 Standard response time for calls and emails. What do you achieve?

10.9.2 Description of how after‐hour calls and emails are handled.

10.9.3 Is it possible that Connector Participants will hear a busy signal?

10.9.4 Percentage of abandoned calls.

10.10 Describe the following operational elements of your Customer Service.

10.10.1 Methods in which a Connector Participant can access Customer Service.

10.10.2 Indicate whether a dedicated and co‐branded toll‐free number can be provided.

10.10.3 Description of your organization's telephonic call routing system. Describe the actual

experience a HRA Participant will have (i.e. voice menus, accessing a live person, etc.).

10.10.4 Description of your organization’s process to monitor and manage call center activity.

10.10.5 Description of your organization’s virtual call back system.

10.11 Describe how your organization will provide Customer Service updates to OPERS. Include the following


10.11.1 Sample of Customer Service reports.

10.11.2 Overview of how your Customer Service report templates can be customized to fit our needs.

10.12 After Connector Participants are enrolled in a plan, describe how your Customer Service team will perform the following functions and/or handle issues regarding:

10.12.1 HRA education and claims and appeal support 10.12.2 Claims resolution support 10.12.3 Premium billing/reimbursement 10.12.4 Plan availability/termination 10.12.5 Carrier availability/termination 10.12.6 Provider network changes


10.13 Describe your organization’s process when an individual other than the Connector Participant calls your

customer service center.

10.14 Describe the process to investigate and resolve (if applicable) a situation in which a Connector

Participant and your organization’s Customer Service representative don’t agree on information that was

shared or plan selection choice that had been made.

10.15 Describe the top five Customer Service‐related issues (and respective resolution) that your team handles. Within your response, describe how each issue is typically addressed and resolved by your organization’s Customer Service staff.

11. COMMUNICATIONS & EDUCATION

11.1 Describe your organization’s communication strategy for the OPERS’ population. Within your response, include how your organization’s strategy may change based on the following situations:

11.1.1 HRA Participants experiencing a Connector for the first time. 11.1.2 HRA Participants who have had experience with a Connector (i.e. they made an initial plan

selection when they became newly‐eligible for Medicare). 11.1.3 HRA Participants who have had experience with a Connector in previous years. 11.1.4 HRA Participants who are not familiar with an HRA.

11.2 Describe how your organization will implement the Connector communications and engagement

strategy for the OPERS population. Include the following in your response: 11.2.1 Timeline that includes initial point of contact (prior to enrollment period) through the start of a

coverage year. 11.2.2 Description of all the communication and educational methods (print, electronic, online, social

media, etc.) that your organization utilizes. 11.2.3 Description of how your organization measures effectiveness for each method that has been

described. 11.2.4 Description of all the communication and educational materials (brochures, mailers, web site,

flyers, etc.). Include a sample or screen shot of each piece of material that is described. 11.2.5 Description of how your organization measures effectiveness for each piece of material that

has been described.

11.3 When developing new communication materials, describe your organization’s process from concept to execution. Include the following in your response:

11.3.1 How the purpose is identified. 11.3.2 How the target audience is identified and considered. 11.3.3 How the content development process occurs. 11.3.4 How the material is tested for effectiveness prior to execution. 11.3.5 How the distribution method(s) is identified. 11.3.6 How the material is tested for effectiveness post execution.

11.4 Provide three (3) case studies that outline and illustrate the success that your organization has had with

a client in developing and executing a communications and engagement strategy that resulted in positive, measurable results. Include the following within your response:

11.4.1 Outline of client demographics. 11.4.2 Overview of implementation process to migrate the population to a Connector. 11.4.3 Overview of communication and engagement strategies that were utilized.


11.4.4 Overview of how the communication and engagement strategy generated positive, measurable results. Note: Be sure to define the result.

11.4.5 Description of any “lessons learned” your organization and your client identified for future communication‐related initiatives.

11.4.6 Description of any strategies, tools, materials, etc. that seemed to work really well.

11.5 Describe how your organization will support OPERS in providing educational opportunities to HRA Participants – during the initial enrollment period, member age‐in period, and in subsequent years. Include the following in your response:

11.5.1 How many (and in what locations) educational sessions should be facilitated. 11.5.2 How an educational session should be facilitated. 11.5.3 What educational methods should be utilized. 11.5.4 How the educational sessions can be measured for effectiveness. 11.5.5 How your organization can augment the OPERS Member Education Services team. 11.5.6 What methods of education your organization would use for Connector Participants living

outside the state of Ohio. 11.5.7 Provide examples of the educational materials (print, electronic, video, etc.) that your

organization typically utilizes.

12. COMMISSIONS

This section focuses on commission‐related information.

12.1 Complete the chart (Appendix A3: “Commission #1”) as specified.

12.2 Complete the chart (Appendix A4: “Commission #2”) as specified.

13. TECHNOLOGY & DATA 13.1 Describe your technology platform including any and all systems used to deliver your organization’s

solution, their ownership, and function.

13.2 Are the various functions (enrollment, licensure, and certification tracking, call monitoring, HRA

administration, claims processing, etc.) in one integrated system or separate systems? Describe how the

systems are integrated and for aspects that aren’t integrated, describe how data is stored and transmitted.

13.3 From a file exchange perspective, describe the biggest challenge in setting up a new client. How can

those challenge(s) be proactively identified/resolved?

13.4 Describe the data layout and fields needed for the data transmission processes included below.

13.4.1 Eligibility file

13.4.2 HRA set‐up and ongoing administration.

13.5 Describe how your organization manages the following data functions/processes:

13.5.1 Ensuring that HIPAA compliant formats are utilized.

13.5.2 Client customizations to file formats.

13.5.3 Eligibility error/reconciliation reporting.

13.5.4 HRA error/reconciliation reporting.


13.6 Describe the process of receiving file feeds from OPERS and the process of sending a file feed to OPERS.

13.7 What transfer methods does your organization support (FTP with PGP, SFTP, FTPS, HTTPS)? Which

method is preferred?

13.8 Describe the security setup to protect OPERS’ files once they have been transmitted to your site. Include

an overview of your organization’s policies, procedures, and systematic efforts to protect data security.

13.9 Describe the process for which OPERS will pass personal health information to your organization so that

your Customer Service team will be able to access it during an educational and/or enrollment call with a)

HRA Participants considering a plan, b) a Connector Participant enrolling during the first enrollment period,

and c) future Connector Participants and HRA Participants who will age into Medicare.

13.10 OPERS has an external website that provides members access to their online retirement

account. Describe if/how your organization’s Portal could connect to OPERS’ external website via a single

sign on/seamless website integration process. For example, if a Connector Participant or HRA Participant

logged into the OPERS external website, he/she could seamlessly connect to your organization’s Portal. Our

external website uses JAVA/.Net technologies.

13.11 Does your Portal support a base load capacity of five hundred (500) simultaneous connections? Describe

the proposed technical environment to support this, and the methodology for testing and quality assurance.

Include the specific load testing tools that your organization proposes to use.

13.12 Will your Portal adhere to the following expectations? Describe how your organization proposes to

ensure the following degree of availability and reliability.

13.12.1 Hours of operation 24 hours per day, 365 (or 366) days per year, minus pre‐disclosed periods of

planned maintenance.

13.12.2 During the published hours of operation, the portal must maintain a 99.99% (4‐nines) reliability

ratio.

13.13 How much has your organization invested on IT infrastructure upgrades in each of the last five (5) years?

14. WORK PLAN & IMPLEMENTATION

14.1 How many individuals have currently selected an individual Medicare plan through your Connector?

14.2 Complete the chart (Appendix A5: “BOB – Plan Type”) as specified to indicate how many individuals

have selected the different Medicare plan types.

14.3 Complete the chart (Appendix A6: “BOB – Projected Growth”) as specified to outline your current clients

and projected new clients.

14.4 Provide detailed recommendation(s) for how your organization would successfully implement the

OPERS’ population of ~136,000 HRA Participants. Include the following within your response:


14.4.1 Provide pros/cons of your recommendations from the following three perspectives: 1) Your

Organization; 2) OPERS Administration/Staff; and 3) HRA Participants.

14.4.2 Describe how your organization will strategically prepare for accommodating the size of the

OPERS population.

14.4.3 Describe any challenges that your organization foresees with an implementation the size of the

OPERS population, and how your organization will proactively plan to overcome them.

14.5 Given the size of the OPERS population, describe the pros and cons of your recommendations (from the

following three perspectives: 1) Your Organization; 2) OPERS Administration/Staff; and 3) HRA

Participants) of implementing a January 1 effective date vs. an off‐cycle effective date. Include your

recommendation (and respective justification) for a specific off‐cycle effective date.

14.6 Given the size of the OPERS population, would you recommend that OPERS Connector Participants be

enrolled in separate groups/enrollment periods? If yes, please respond to the following questions:

14.6.1 How many groups would your organization recommend?

14.6.2 What criteria would your organization recommend to select/assign each OPERS Connector

Participant to the appropriate group/enrollment period?

14.6.3 When would you recommend each group begin/end their enrollment period?

14.6.4 Describe the pros and cons of enrolling OPERS Connector Participants in separate enrollment

periods from the following three perspectives: 1) Your Organization; 2) OPERS

Administration/Staff; and 3) OPERS Connector Participants.

14.7 Has your organization ever enrolled members from one Plan Sponsor in separate enrollment groups? If

yes, how many of your engagements met this scenario and what were your lessons learned from

this/these engagement(s)?

14.8 Based on your organization’s preferred enrollment strategy, provide a detailed implementation

schedule including specific activities, target dates, data requirements, and roles/responsibilities (your

organization vs. OPERS) with respective hourly estimates. Also include the following with your response:

14.8.1 Description of how your organization will consult with and make presentations to Staff during

engagement.

14.8.2 Description of the service management and quality control procedures to be utilized. These

should identify and describe any anticipated potential problems, your organization’s approach

to resolving these problems, and any special assistance that will be requested from OPERS.

15. DELIVERABLES

15.1 OPERS shall have full ownership, including copyright interests in all software, documentations and other

related work projects, as applicable.

15.2 The Vendor will ensure that the Vendor’s subcontractors shall be obligated to assign to OPERS their

ownership rights in any deliverables.


16. REFERENCES 16.1 Provide the names, addresses and telephone numbers of five (5) current clients. Include the name and

telephone number of a responsible official who may be contacted as a reference and summary description of the scope of work.

16.2 Provide at least two (2) references of former clients who terminated your services within the past two (2) years. Information about these clients should include: name and position, contact information (telephone, address and email address) of an individual within the client organization who is willing to provide a reference; date your organization began working with this client; date your organization terminated work with this client; and summary of the scope of services provided to this client.

17. COST

For the following questions in this section, assume that OPERS will be entering into a three‐year base

agreement, with an option for an additional three‐year renewal.

17.1 Confirm that there will be NO "Origination Fees" charged by your organization (the Connector) to OPERS

or its Connector Participants in the first year transition or the age‐in population throughout the original

three‐year agreement as well as the three‐year renewal term, if exercised by OPERS.

17.2 Confirm that there will be NO "Administrative Fees" charged by your organization (the Connector) to

OPERS or its Connector Participants in the first year transition or the age‐in population throughout the

original three‐year agreement as well as the three‐year renewal term, if exercised by OPERS.

17.3 How much is your organization willing to put at risk for performance penalties – during implementation

and for ongoing administration? In addition, what performance standards would your organization propose

for this engagement? OPERS reserves the right to accept, reject or negotiate the proposed amount and/or

standards if a contract may result from this RFP.

17.4 Complete the chart (Appendix A7: “HRA Admin Fees”) as specified to indicate the Per Member Per

Month HRA Fees (assume Retiree and the Spouse will utilize the same HRA).

17.5 State whether Vendor will negotiate its proposed fee if OPERS decides negotiation is appropriate as to

any aspect of the proposals, including the fee, with the finalist(s). In no case, however, will the negotiated

fee be higher than the fee submitted in the proposal.

18. SAMPLE CONTRACT

Provide a sample contract with your proposal for consideration if you are selected for this engagement, along

with a copy of your certificate of insurance. The contract should reflect the specific scope and deliverables of

this engagement and the hourly fees for any potential work outside the scope of this engagement and response

times. Notwithstanding the foregoing, any contract that may result from this RFP must include the contract

provisions included in Attachment A, which provisions shall control in the event of the any conflict.

G. SELECTION CRITERIA Proposals will be evaluated, and OPERS will make any final decision to award the contract. During the evaluation

process, the OPERS management may, at its discretion, request any or all Vendors to make oral presentations.


Such presentations will provide Vendors with an opportunity to answer questions regarding the Vendor’s

proposal. Not all Vendors may be asked to make such oral presentations. Proposals will be evaluated based on

the following criteria, (each criteria may be weighted, if desired):

1. Understanding of the engagement. 2. Soundness of the approach and quality of the work plan. 3. Vendor qualifications. 4. Individual qualifications of the assigned staff. 5. Proposed deliverables. 6. References 7. Cost.

After evaluation of the proposals, OPERS may determine a list of finalists and may commence sequential

negotiations on any aspects of the proposals OPERS deems appropriate beginning with the highest scoring

finalist. If OPERS does not reach agreement with the highest scoring finalist, or if in the opinion of OPERS,

negotiations reach an impasse, OPERS may decide not to award the contract or may begin negotiations with the

second highest scoring finalist. OPERS may choose to continue such negotiation schedule with subsequent

finalists on the same basis until a contract is negotiated, no other finalists remain, or OPERS decides not to

award the contract.

H. GENERAL TERMS & CONDITIONS FOR SUBMITTING PROPOSALS 1. Vendor acknowledges that OPERS is subject to the Ohio Public Records Act, and the documents submitted

pursuant to this RFP may be subject to a public records request. Accordingly, Vendor must identify any material or documents that are confidential and clearly mark those items or documents at the time of submittal. If a request for records is made that includes information Vendor has identified as confidential, OPERS will make reasonable efforts to contact Vendor in sufficient time to allow Vendor to take appropriate legal steps to protect the confidential information from disclosure. If as a result of the position taken by Vendor regarding the confidentiality of the information OPERS is assessed any damages or fees, Vendor shall indemnify OPERS for such damages or fees. If no documents or materials are identified and marked by Vendor as confidential, Vendor will be deemed to have consented to the release of the document or material, and to have waived any cause of action against OPERS resulting from the release of the documents or materials.

2. It is the sole responsibility of the Vendor to ensure that entire proposals are received at the time and place specified herein; any assumption as to the dependability and/or reliability of services such as UPS or the U.S. Postal Service, are made at the Vendor’s own risk. Regardless of cause, late proposals, in whole or in part, will not be accepted and will automatically be disqualified from further consideration. It shall be the Vendor’s sole risk to ensure delivery at the designated office by the designated time. Late proposals will not be opened and may be returned to the Vendor at the expense of the Vendor, or destroyed if so requested.

3. OPERS reserves the right, in its sole discretion, to reject any or all proposals submitted, and to waive as to any vendor or as to all vendors, any informality or irregularity in a proposal or proposals or any failure to conform to the instructions in this RFP.

4. OPERS reserves the right, in its sole discretion and without giving reasons or notice, at any time and in any

respect, to amend or cancel this RFP, to alter the procedures described in this RFP including but not limited to the procedures for evaluation, to change, alter or waive any and all criteria included in this RFP, to waive


or modify any requirements of this RFP or to add additional requirements, and to terminate discussions with any or all Vendors.

5. This RFP is not a contract, not meant to serve as a contract, and does not constitute a promise to enter into a contract.

6. All documents, proposals and other materials submitted in response to this RFP will become the property of OPERS and will not be returned to Vendor.

7. Vendor agrees to comply with all terms, conditions and requirements described in the RFP. Any failure by any responding Vendor to so comply shall be grounds for rejection of that Vendor’s proposal, as determined by OPERS in its sole discretion.

8. If a contract results from this RFP, neither the successful responding Vendor, nor anyone on its behalf (including its agents, affiliates, subcontractors and/or vendors), shall publish, distribute or otherwise disseminate any press release, advertising and/or publicity matter of any type or kind (collectively “advertising material”) having any reference to OPERS, this RFP or the resulting contract, unless and until such advertising material first shall have been submitted to and approved in writing by OPERS.

I. INSTRUCTIONS FOR SUBMITTING PROPOSALS OPERS’ organizational goal is to allow for a 15‐month implementation window prior to a 2016 effective date.

Our objective of an extended timeline allows for sufficient strategic and operational planning, communications,

education/outreach, testing, etc. to ensure that the transition for our Connector Participants is as seamless as

possible.

The procurement and selection schedule outlined below is subject to change.

DATE ACTIVITY/PHASE

JUNE – AUGUST Duration of Phase 1 – refer to Section D.

6/26/13 RFP Release Date

6/26/13 – 7/26/13 Question & Answer Period

Vendors may submit questions to [email protected] anytime between 6/26/13 and 7/26/13, 5:00 PM EST.

OPERS will post answers throughout the open Q&A period on the “Vendor Opportunities” page at www.opers.org. It will be the Vendors’ responsibility to check the website on a regular basis to retrieve updated information.

OPERS will post any remaining answers by 7/31/13.

7/10/13 Vendor Conference

Will be held at OPERS location from 12:30 – 3:00 PM EST.

8/5/13 Proposal Due Date

Proposals must be received by 2:00 PM EST.

AUGUST Duration of Phase 2 – refer to Section D.


SEPTEMBER Duration of Phase 3 – refer to Section D.

OCTOBER – DECEMBER Duration of Phase 4 – refer to Section D.

FEBRUARY – MARCH (2014) Negotiations

APRIL (2014) Target Date to Begin Engagement.

Provide six (6) hard copies and one (1) electronic copy (include one redacted copy for public record requests) of your organization’s proposal by August 5, 2013, 2:00 PM EST to:

Jay Yoho Manager of Support Services & Procurement Ohio Public Employees Retirement System 277 East Town Street Columbus, OH 43215‐4642

No Vendor (or Vendor representatives, e.g. lobbyists) shall attempt to communicate with OPERS concerning this RFP in any manner or at any time other than during the open question/answer period (6/26/13 – 7/26/13) and the Vendor’s Conference held on 7/10/13. Communication with OPERS, other than as previously described, may result in immediate disqualification.


ATTACHMENT A

CONTRACTOR’S REPRESENTATIONS, WARRANTIES AND COVENANTS: Contractor represents, warrants

and covenants that: (a) it has the authority to enter into the Agreement and perform the services

provided thereunder; (b) it shall comply with all applicable federal, state and local laws in providing

services under the agreement, including, but not limited to the reporting requirements contained in

Sections 101.90 et seq. (Joint Legislative Ethics Commission) of the Ohio Revised Code, and the laws

contained in Chapter 102 (Ohio Ethics Commission) of the Ohio Revised Code governing ethical

behavior, understands that the provisions apply to persons doing or seeking to do business with OPERS,

and agrees to act in accordance with the requirements of such provisions; and, (c) it has not paid and

will not pay, has not given and will not give, any remuneration or thing of value directly or indirectly to

OPERS or any of its members, officers, employees, or agents, or any third party in connection with its

engagement under the agreement or otherwise, including, but not limited to a finder’s fee, cash

solicitation fee, or a fee for consulting, lobbying or otherwise.

CONFIDENTIALITY AND PUBLIC RECORDS: Contractor shall not disclose to any other person or use any

information concerning OPERS’ members, or any other confidential information obtained in providing

services under the agreement, without the prior written consent of OPERS. Contractor acknowledges

that OPERS is subject to the Ohio Public Records Act. If a request for records is made that includes

information Contractor has identified as confidential, OPERS will make reasonable efforts to contact

Contractor in sufficient time to allow Contractor to take appropriate legal steps to protect the

confidential information from disclosure. If as a result of the position taken by Contractor regarding the

confidentiality of the information OPERS is assessed any damages or fees, Contractor shall indemnify

OPERS for such damages or fees.

ADVERTISING AND PUBLICITY: Neither Contractor, nor anyone on Contractor’s behalf (including its

agents, affiliates, subcontractors and/or vendors), shall publish, distribute or otherwise disseminate any

press release, advertising and/or publicity matter of any type or kind (collectively “advertising material”)

having any reference to OPERS or the agreement, unless and until such advertising material first shall

have been submitted to and approved in writing by OPERS.

INDEMNIFICATION AND LEGAL ACTION: Contractor agrees to indemnify and hold harmless OPERS, its

members, officers, and employees for damages, costs, losses or any other claims directly arising from

the negligent or intentional acts of Contractor, its officers, employees or agents under the agreement.

Contractor shall reimburse OPERS for any judgments rendered against OPERS for Contractor's actions.

Contractor agrees to defend OPERS against any such claims or legal actions if called upon to do so.

OPERS shall not indemnify Contractor for damages, costs, losses or any other claims of any nature that

may arise under the agreement. To the extent that Contractor may be damaged or may be required to

assume a liability as a direct result of the actions taken or not taken by OPERS, the parties agree that

Contractor may sue or take legal action against OPERS to seek recovery of such damages.

GOVERNING LAW AND FORUM: Issues concerning OPERS’ existence and/or authority, or the Ohio

Public Records Act, shall be governed by, construed and enforced in accordance with, the laws of the

State of Ohio. Any litigation arising out of or related in any way to the agreement shall be brought only

in the state or federal courts sitting in Franklin County, Ohio, and Contractor irrevocably consents to


such venue and jurisdiction. OPERS shall not waive its right to trial by jury in any action, proceeding or

counterclaim (whether based on contract, tort or otherwise) arising out of or related in any way to the

agreement or the actions of either party in the negotiation, administration, performance or

enforcement thereunder, unless the Ohio Attorney General consents to such waiver.

RENEWALS: The parties agree that the agreement may be renewed by written mutual consent of the

parties, and further, that the agreement shall not renew automatically.


ATTACHMENT B

BUSINESS ASSOCIATE AGREEMENT

This Business Associate Agreement (“Agreement”) is entered into by and between The Ohio Public

Employees Retirement System (“OPERS”), an Ohio public retirement system created pursuant to Chapter 145 of

the Ohio Revised Code, located at 277 East Town Street, Columbus, Ohio 43215, and (“Business

Associate”), a _______corporation, located at ____. This Agreement is effective on ___ (“Effective Date”).

WHEREAS, OPERS is the sponsor of one or more health plans which are covered entities under the Privacy and

Security Regulations adopted by the United States Department of Health and Human Services (“HHS”) pursuant

to the Administrative Simplification Provisions of the Health Insurance Portability and Accountability Act of 1996

and subsequent amendments thereto (“HIPAA”); and

WHEREAS, OPERS has, on behalf of one or more of the health plans it sponsors, contracted with Business

Associate to perform certain services related to the administration of the health plans; and

WHEREAS, in the course of providing such services, Business Associate will create, receive and/or maintain

protected health information from or on behalf of one or more of the health plans; and

WHEREAS, the Privacy and Security Regulations require that covered entities enter into a written agreement

with all organizations which create, receive and/or maintain protected health information from or on behalf of

the covered entity;

NOW, THEREFORE, in consideration of the mutual promises and agreements made herein, OPERS, acting as

sponsor and on behalf of the Plan, and Business Associate hereby agree as follows:

I. Definitions. Capitalized terms used in this Agreement shall be defined as set forth below. To the extent not otherwise defined in this Agreement, terms shall have the same meaning as in HIPAA and in the Privacy and Security Regulations, as they may be periodically revised or amended by the U.S. Department of Health and Human Services, the U.S. Congress or other federal agency subsequent to the effective date of this Agreement.

Breach means the acquisition, access, use, or disclosure of Protected Health Information that is not a

permissible acquisition, access, use or disclosure under HIPAA and the Privacy and Security Regulations, and

which compromises the security or privacy of the Protected Health Information. "Compromises the security

or privacy of the Protected Health Information" means that the acquisition, access, use or disclosure poses a

significant risk of financial, reputational, or other harm to the Individual. Breach does not include the

following:

1. Any unintentional acquisition, access, or use of Protected Health Information by an employee, officer, or contractor working for Business Associate, if such acquisition, access, or use was made in good faith and within the scope of authority of such employee, officer, or contractor working for Business Associate, and does not result in further use or disclosure of the Protected Health Information in a manner not otherwise permitted under the HIPAA privacy rules.

2. Any inadvertent disclosure of Protected Health Information by an employee, officer, or contractor of Business Associate who is otherwise authorized to access Protected Health Information by Business Associate, when the inadvertent disclosure is to another similarly situated employee, officer or contractor of Business Associate, and the Protected Health Information received as a result of such disclosure is not further acquired, accessed, used or disclosed without authorization by any person.


3. A disclosure of protected health information where OPERS has a good faith belief that an unauthorized person to whom the disclosure was made would not reasonably have been able to retain such information.

Disclose or Disclosure means the release, transfer, provision of access to, or divulging in any other manner

of Protected Health Information outside of Business Associate’s operations, or to a person who is not an

employee or officer of Business Associate. Disclosure includes both intentional and inadvertent or accidental

disclosures.

Electronic Protected Health Information means Protected Health Information that is transmitted by

electronic media or maintained in electronic form.

HITECH Act means the provisions of the American Recovery and Reinvestment Act of 2009 that address the

privacy and security of personally identifiable health information.

Individual means a person whose Protected Health Information is created, accessed, used, held or

maintained by Business Associate on behalf of OPERS or the Plan.

Individual Right means the right of an Individual to access or amend their Protected Health Information, to

request an accounting of uses and disclosures of their Protected Health Information, to request restrictions

on the use and disclosure of their Protected Health Information, to request confidential communications,

and any similar right of an Individual with respect to Protected Health Information which arises out of HIPAA

or the Privacy and Security Regulations.

Limited Data Set means Protected Health Information from which the following identifiers of the individual,

or of relatives, employers, or household members of the individual, have been removed: (i) names; (ii)

postal address information, other than town or city, state, and zip code; (iii) telephone numbers; (iv) fax

numbers; (v) electronic mail addresses; (vi) social security numbers; (vii) medical record numbers; (viii)

health plan beneficiary numbers; (ix) account numbers; (x) certificate/license numbers; (xi) vehicle

identifiers and serial numbers, including license plate numbers; (xii) device identifiers and serial numbers;

(xiii) web Universal Resource Locators (URLs); (xiv) Internet Protocol (IP) address numbers; (xv) biometric

identifiers, including finger and voice prints; and (xvi) full face photographic images and any comparable

images.

A Limited Data Set may include the following identifiable information: (i) admission, discharge, and service

dates; (ii) date of birth and date of death; (iii) age (including age ninety (90) or over); and (iv) five‐digit zip

code.

Plan means the health plans sponsored by OPERS to provide health care coverage to certain retirees who

are entitled to benefits under Chapter 145 of the Ohio Revised Code and their eligible dependents.

Privacy and Security Regulations means the regulations promulgated by HHS pursuant to HIPAA to address

the privacy and security of Protected Health Information, which currently are codified at 45 C.F.R. 160 and

164, as now in effect or as amended, expanded or recodified from time to time subsequent to the Effective

Date of this Agreement. Privacy and Security Regulations also includes without limitation any regulations

adopted under the amendments to HIPAA enacted in the HITECH Act.


Protected Health Information means information that is received from, or created or received on behalf of the Plan, and is information i) about an Individual which relates to the past, present or future physical or mental health or condition of an Individual; the provision of health care to an Individual; or the past, present, or future payment for the provision of health care to an Individual, and ii) which either identifies the Individual or includes information which can reasonably be used to identify the Individual. Protected Health Information pertains to both living and deceased Individuals.

Security Incident means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system, as such definition may be amended from time to time by HIPAA or the Privacy and Security Regulations.

Security Requirements means 45 C.F.R. Sections 164.308, 164.310, 164.312, and 164.316, as now in effect or as subsequently amended. Security Requirements also includes any law or regulation promulgated after the Effective Date to address the requirements imposed on a covered entity or a business associate of a covered entity under HIPAA.

Underlying Agreement means the Medicare Health Care Connector Agreement between OPERS and

Business Associate effective___, as such may be renewed and amended from time to time.

Use means the sharing, employment, application, utilization, examination or analysis of Protected Health

Information by an employee or officer of Business Associate within Business Associate’s operations.

II. Restrictions on Use and Disclosure of PHI. Except as otherwise provided herein, Business Associate may Use or Disclose Protected Health Information only as necessary to perform Business Associate’s obligations under the Underlying Agreement, subject to the conditions and restrictions set forth below.

A. Business Associate may Disclose Protected Health Information to other organizations with whom OPERS or the Plan has executed a business associate agreement related to the Plan, and to Business Associate’s subcontractors and agents, but only as necessary to perform services under the Underlying Agreement. Prior to the Disclosure of Protected Health Information to a subcontractor or agent of Business Associate, the subcontractor or agent must agree in writing to be bound by the same restrictions that apply to the Business Associate under this Agreement.

B. Unless otherwise limited by this Agreement, Business Associate may Use Protected Health Information in its possession for the proper management and administration of Business Associate or to carry out its legal responsibilities.

C. Unless otherwise limited by this Agreement, Business Associate may Disclose Protected Health Information in its possession for the proper management and administration of Business Associate or to carry out its legal responsibilities only if such Disclosure is required by law or is addressed in this Agreement.

D. Business Associate shall, in all cases, limit any Use or Disclosure of Protected Health Information to the minimum amount of Protected Health Information necessary to perform the task or accomplish the purpose of the Use or Disclosure.

E. Business Associate may not Use or Disclose Protected Health Information in any manner that would constitute a violation of HIPAA, including without limitation the Privacy and Security Regulations, if Used or Disclosed by the Plan.


F. Business Associate may not de‐identify Protected Health Information created, received or maintained by Business Associate under this Agreement, except as requested by OPERS. Protected Health Information created, received or maintained by Business Associate under this Agreement which has been de‐identified at the request of OPERS may not be Used by Business Associate for any purpose not expressly approved by OPERS.

G. Except as expressly approved by OPERS, Business Associate may not aggregate Protected Health Information created, received or maintained by Business Associate under this Agreement, whether de‐identified or not, with any other Protected Health Information, including without limitation Protected Health Information of Business Associate’s other customers.

H. Business Associate agrees to not Use or further Disclose Protected Health Information other than as authorized by this Agreement, as requested by OPERS or as required by law.

I. Business Associate shall implement and use reasonable and appropriate administrative, technical and physical safeguards which will protect the confidentiality, integrity, and availability, and prevent uses or disclosures of Protected Health Information, other than as provided for by this Agreement.

J. If Business Associate becomes aware of any Use or Disclosure of Protected Health Information not permitted under this Agreement, it shall report such Use or Disclosure to OPERS within one (1) business day of gaining such knowledge. Business Associate shall also use its best efforts to mitigate the effect of such unauthorized Use or Disclosure, and shall implement or modify practices or take other reasonable action to prevent further unauthorized Uses or Disclosures.

III. Other Obligations of Business Associate.

A. Business Associate acknowledges that Business Associate is directly subject to certain provisions of the HITECH Act and the Privacy and Security Regulations, and Business Associate certifies that Business Associate has implemented policies and procedures and taken such other action as is necessary to comply with those provisions of the HITECH Act and the Privacy and Security Regulations which are directly applicable to Business Associate.

B. Business associate agrees to comply with the provisions of the HITECH Act and the Privacy and Security Regulations that are applicable to the Plan.

C. Business Associate agrees that the Protected Health Information of the Plan will be subject to the security requirements of and Business Associate shall comply with sections 164.308, 164.310, 164.312, and 164.316 of Title 45, Code of Federal Regulations.

D. Business Associate shall cooperate with OPERS in the administration of Individual Rights, and shall provide OPERS promptly upon request with the information in the possession of Business Associate or a subcontractor or agent of Business Associate which OPERS deems necessary for OPERS to respond to a request from an individual to exercise one or more Individual Rights. Upon the instruction of OPERS, Business Associate will amend any Protected Health Information in the possession of Business Associate or a subcontractor or agent of Business Associate, and will implement restrictions on the Use and Disclosure of Protected Health Information in the possession of Business Associate or a subcontractor or agent of Business Associate, and will employ procedures to assure confidential communications of Protected Health Information in the possession of Business Associate or a subcontractor or agent of Business Associate as directed by OPERS. Business Associate will notify, and will require its subcontractors and agents to notify OPERS promptly, but in no event later than five (5) days after receipt of a request from an Individual to exercise one or more


Individual Rights. All requests from an Individual to exercise an Individual Right will be processed and handled by OPERS.

E. Business Associate shall maintain a record of all Disclosures of Protected Health Information made for a purpose other than treatment of the Individual, payment for treatment of the Individual, or the health care operations of the Plan, or pursuant to the written authorization of the Individual.

F. Business Associate shall Disclose Protected Health Information to a third party upon the request and pursuant to the instructions of OPERS.

G. Business Associate shall make its internal practices, books and records relating to uses and disclosures of Protected Health Information available to OPERS, to the Secretary of the U.S. Department of Health and Human Services or designee, or to any other official or agency with enforcement authority under HIPAA, for purposes of determining the Plan’s and Business Associate’s compliance with HIPAA.

H. Beginning on and after the effective date of the requirements of HIPAA adopted under the HITECH Act and applicable to business associates or the adoption of regulations by HHS to implement such requirements, Business Associate shall comply with such requirements or regulations, and if necessary shall execute an amendment to this Agreement as required under HIPAA.

I. Upon the termination of the Underlying Agreement, Business Associate shall return or destroy all Protected Health Information and will retain no copies of such information. If such return or destruction of Protected Health Information is not feasible, as approved by OPERS, Business Associate agrees that the provisions of this Agreement are extended beyond termination of the Underlying Agreement to the Protected Health Information still in the possession of Business Associate or a subcontractor and agent of Business Associate, and Business Associate shall limit all further uses and disclosures to those purposes that make the return or destruction of the Protected Health Information infeasible.

J. Business Associate has implemented administrative, physical and technical safeguards that will reasonably and appropriately protect the confidentiality, integrity, and availability of Electronic Protected Health Information, as required under HIPAA.

K. Business Associate shall, within one (1) day of discovery, report to OPERS any Security Incident relating to Electronic Protected Health Information of which it becomes aware.

L. Business Associate shall require all employees, officers and contractors working for Business Associate to report immediately to Business Associate, no later than 24 hours after discovery, any occurrence, event or fact that could reasonably be considered an indication that a Breach of an Individual’s Protected Health Information has occurred. Upon receipt of a report, Business Associate shall immediately i) notify OPERS of the occurrence, event or fact, including the date and time of the discovery and as much information regarding the suspected Breach as is available; and ii) undertake an investigation of whether a Breach did occur, and apprise OPERS of the results of the investigation on an ongoing basis. Notification shall be provided by Business Associate to OPERS Privacy Officer/Legal Department, 277 E. Town Street, Columbus, OH 43215. Business Associate shall, and shall require its employees, officers and contractors to, cooperate fully with OPERS in providing any additional information requested by OPERS in connection with the breach. If OPERS determines that a breach has occurred, Business Associate shall take all action which is reasonably requested by OPERS to mitigate the Breach and to prevent further Breaches.


M. Business Associate acknowledges and agrees that the Protected Health Information of the Plan will be subject to and Business Associate shall comply with the Security Requirements. Business Associate certifies that Business Associate has adopted written policies and procedures consistent with the Security Requirements, and taken such other action as appropriate to comply with the Security Requirements.

N. Business Associate shall not sell or directly or indirectly receive remuneration in exchange for any Protected Health Information. Protected Health Information of an Individual will not be used or disclosed for marketing purposes, regardless of whether remuneration is received, unless a valid written authorization from each affected Individual has been obtained.

O. In providing services under this Agreement, Business Associate shall limit its use and disclosure of Protected Health Information to the Limited Data Set, if practicable, or if needed by the Business Associate, to the minimum amount of Protected Health Information necessary to perform the service. Upon issuance of guidance by the Secretary on what constitutes the minimum amount of Protected Health Information necessary, Business Associate shall limit the amount of Protected Health Information used or disclosed by Business Associate in accordance with such guidance.

IV. Termination and Survival.

A. This Agreement may not be terminated so long as the Underlying Agreement remains in effect. To the extent the Underlying Agreement is terminated for any reason whatsoever, and Protected Health Information remains in the possession of Business Associate or an agent or subcontractor of Business Associate, this Agreement shall continue in full force and effect until all Protected Health Information the possession of Business Associate or an agent or subcontractor of Business Associate has been returned to OPERS or destroyed.

B. Notwithstanding any other provision of the Agreement, OPERS may immediately terminate the Underlying Agreement, if Business Associate has materially violated its responsibilities regarding Protected Health Information under this Agreement and has failed to provide satisfactory assurances to OPERS within ten (10) days of notice of such material violation that the violation has been cured and steps taken to prevent its recurrence. The responsibilities of Business Associate under this Agreement shall survive termination of the Underlying Agreement indefinitely, until all Protected Health Information in the possession of Business Associate or an agent or subcontractor of Business Associate has been destroyed or returned to OPERS.

V. Indemnification. Business Associate shall indemnify to the fullest extent possible OPERS; its Board

members, employees and agents; and the Plan, for any loss, liability, damage, settlement, cost, expenses or

other obligation, including without limitation reasonable attorney fees and defense costs, incurred by OPERS; a

Board member, employee or agent of OPERS; or the Plan, as a direct result of Business Associate’s breach of any

obligation under this Agreement, or Business Associate’s negligence in performing its obligations under this

Agreement. This provision shall not inhibit OPERS' ability to seek relief from Business Associate for any claim of

negligence caused in whole or part by Business Associate or any other action at law or in equity.

VI. General Provisions.

A. The parties acknowledge that Business Associate is an independent contractor providing

services to OPERS, and no provision of this Agreement is intended to create or shall be

construed to create any employment relationship, partnership, joint venture, or agency

relationship between OPERS and Business Associate.


B. Business Associate may not assign this Agreement, or any of the obligations of Business

Associate hereunder without the written approval of OPERS.

C. Except as provided expressly in this Agreement, all notices required under this Agreement shall

be in writing and, unless hand delivered, sent by certified mail or other method whereby receipt

is evidenced in writing, addressed as follows:

If to OPERS:


Attention: Marianne Steger, Director—Health Care, or Successor


Columbus, Ohio 43215

With copies to:


Attention: Brian Pack, Assistant Director—Health Care, or Successor




Attention: Julie Becker, General Counsel or Successor



If to Business Associate:

With a copy to:


D. This Agreement may be amended only in writing signed by a duly authorized representative of

each party.

E. The waiver by either party of any breach of this Agreement shall not constitute a waiver of any

subsequent breach of any term or condition hereof.

F. If any provision of this Agreement shall be declared invalid, illegal, or unenforceable by a court

of competent jurisdiction, the remaining provisions hereof shall not in any way be affected or

impaired thereby.

G. This Agreement shall be governed by, and construed in accordance with, the laws of the State of

Ohio without regard to its choice of law rules, and by HIPAA. All actions regarding this

Agreement shall be filed and venued in a court of competent subject matter jurisdiction in

Franklin County, Ohio. The parties hereby consent to the jurisdiction and venue of such courts

and waive any right to assert forum non conveniens.

H. This Agreement shall be binding upon and inure to the benefit of the parties hereto and their

respective successors and assigns. This Agreement and the Underlying Agreement contain the

entire Agreement of the parties hereto, and supersede all prior agreements, representations

and understandings, whether written or oral, between the parties relating to the specific subject

matter stated herein.

I. This Agreement may be executed in one or more counterparts, each of which shall be deemed

an original.

J. Each party warrants that it has full power and authority to enter into and perform this

Agreement, and the person signing this Agreement on behalf of each party certifies that such

person has been properly authorized and empowered to enter into this Agreement on behalf of

such party.

K. If this Agreement, or any part hereof, is found not to be in compliance with any pertinent

federal or state statute or regulation, then the parties shall renegotiate the Agreement for the

sole purpose of correcting the non‐compliance. If this Agreement, or any part hereof, is found

not to be in compliance with HIPAA or the regulations promulgated thereunder, OPERS may

amend the Agreement to bring it into compliance with HIPAA and the regulation promulgated

thereunder by notice to Business Associate without Business Associate’s signature; provided,

however, that if HIPAA or the regulations promulgated thereunder requires Business Associate’s

signature on such amendment, Business Associate agrees to promptly sign the amendment to

bring the agreement into compliance with HIPAA and the regulations promulgated thereunder.

L. In the event that a change in HIPAA or the Privacy and Security Regulations causes a provision of this Agreement to become invalid or requires additional safeguards for the protection of Protected Health Information, Business Associate agrees to execute such amendments or additional agreements as may be required, in good faith and within thirty (30) days of such event, in order to comply with such change.


M. This Agreement shall be construed liberally and in a manner consistent with the intent and purpose of HIPAA and the Privacy and Security Regulations, and any ambiguity shall be resolved in a manner consistent with HIPAA and the Privacy and Security Regulations.

N. The headings of the various sections of this Agreement are inserted for convenience only and do not, expressly or by implication, limit, define, or extend the specific terms of the sections so designated.

OHIO PUBLIC EMPLOYEES

RETIREMENT SYSTEM

Signature: _________________________ Signature: ________________________

Name: _________________________ Name: ________________________

Title: _________________________ Title: ________________________

Date: _________________________ Date: ________________________


Attachment C

145‐4‐09 Definition of “eligible dependent” for health care coverage

For coverage commencing on or after January 1, 2011, “eligible dependent” means any of the following:

(A) The spouse of a primary benefit recipient. The spouse shall be an individual of the opposite gender who establishes a marriage by a valid marriage certificate recognized by Ohio law.

(B) The biological or legally adopted child of a primary benefit who is under the age of twenty‐six or is permanently and totally disabled prior to age twenty‐two. For purposes of this paragraph “permanently and totally disabled” means the individual is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than twelve months.

(C) The grandchild of a primary benefit recipient for whom the benefit recipient has been ordered pursuant to section 3109.19 of the Revised Code to provide for the health care coverage.

Promulgated Under: 111.15

Statutory Authority: 145.09, 145.58

Rule Amplifies: 145.38, 145.46, 145.58

Rule Review Date: 9/26/08, 9/29/13

Effective Date History: 1/1/05, 10/27/06, 1/1/09, 1/1/11

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