sample rfp pool

7/29/2019 Sample Rfp Pool

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City of Somewhere

REQUEST FOR PROPOSAL

FOR MEDICAL, CONTINUATION OF COVERAGE, PHARMACY BENEFIT SERVICE,

PRE/POST 65 RETIREE, DENTAL, VISION, LIFE/LTD/STD AND EAP BENEFITS

Proposals must be received by:

Date


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TABLE OF CONTENTS

INTRODUCTION ........................................................................................................ 4

PRE-PROPOSAL MEETING............................................................................................................................4PROPOSAL FORMAT...................................................................................................................................4PROPOSAL QUALITYAND EVALUATION.............................................................................................................4PROPOSAL REVIEW....................................................................................................................................5

PROPOSAL INFORMATIONAND DUE DATE.........................................................................................................5SUBMITTAL REQUIREMENTS..........................................................................................................................5PROPOSAL DUE DATE................................................................................................................................5AWARDOF CONTRACT...............................................................................................................................5PROPOSAL TIMELINE .................................................................................................................................5

STATEMENT OF OVERALL REQUIREMENTS .................................................................. 7

OTHER FACTORSTO CONSIDER.....................................................................................................................9

SPECIFIC REQUIREMENTS ......................................................................................... 11

ID CARDS...........................................................................................................................................11BENEFIT PLANS......................................................................................................................................11BILLING PERFORMANCE ............................................................................................................................11

ELIGIBILITY PERFORMANCE ........................................................................................................................11PRIVACY REQUIREMENTS...........................................................................................................................11

QUESTIONNAIRE ..................................................................................................... 12

GENERAL INFORMATION............................................................................................................................12CLAIM AUDIT INFORMATION........................................................................................................................13EMPLOYER ACCOUNT MANAGEMENT/SERVICES.................................................................................................14CLAIM ADJUDICATION SERVICES..................................................................................................................14CLAIM ADMINISTRATOR BENEFIT INFORMATION.................................................................................................16BENEFIT CUSTOMER SERVICE.....................................................................................................................17

TECHNOLOGY........................................................................................................................................19UNDERWRITING .....................................................................................................................................19HIPAA COMPLIANCE..............................................................................................................................20

BUSINESS CONTINUITY.............................................................................................................................20REPORTING...........................................................................................................................................20

TRANSITION PLAN...................................................................................................................................20TERMINATION........................................................................................................................................20ELIGIBILITY INFORMATION...........................................................................................................................20CLAIM COST MANAGEMENT.......................................................................................................................21BENEFIT ID CARD .................................................................................................................................21MANAGED CARE NETWORK.......................................................................................................................22MEDICAL CARE MANAGEMENT....................................................................................................................24CONSUMER DRIVEN/CHOICE PLAN INFORMATION...............................................................................................25WELLNESS BENEFIT MANAGEMENT...............................................................................................................26PRESCRIPTION MANAGEMENT......................................................................................................................27CONTINUATIONOF COVERAGE.....................................................................................................................30

RETIREE BENEFITS..................................................................................................................................31VISION BENEFITS....................................................................................................................................32DENTAL BENEFITS..................................................................................................................................34LIFE/LTD/STD ....................................................................................................................................37LIFE/LTD/STD CLAIM PAYMENT SERVICES...................................................................................................39EMPLOYEE ASSISTANCE PROGRAM................................................................................................................41EAP REPORTING...................................................................................................................................43DEFINETHE FEE STRUCTURE ....................................................................................................................44

Page 2 of 48RFP for Medical, Continuation of Coverage, Pharmacy Benefit Service, Pre/Post 65 Retiree, Dental, Vision,

Life/LTD/STD and EAP BenefitsCopyright 2011. All rights reserved.

No part of this RFP may be used or reproduced in any manner whatsoever without express writtenpermission.


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RIGHT OF REJECTION ............................................................................................... 46

NON-COLLUSION AFFIDAVIT ..................................................................................... 47

STATEMENT OF COMPLIANCE ................................................................................... 48





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INTRODUCTIONThis document contains information which is considered Confidential to Employer. Thisdocument may not be copied or reproduced without prior written consent and may notbe disclosed to third parties. This information is to be kept in strictest confidence. TheEmployer provides employee benefits (medical, continuation of coverage, dental, vision,Life, LTD, STD and EAP). The Employer is a not-for-profit organization and is tax exempt.

Pre-Proposal MeetingProposal review personnel are available to meet with interested representatives of firmsdesiring to submit a proposal. During this conference, interested parties will have anopportunity to ask any questions they have about the services requested herein. Thismeeting may be set by appointment only. Meetings will be scheduled between Date andDate. Meetings will only be held in the Texas Municipal Center building located at 1821Rutherford Lane # 300, Austin, Texas.

Proposal FormatProposals submitted in response to these specifications should be submitted in theproposal format. The employer reserves the right to reject any or all proposals, waiveany technicality, issue a subsequent Request for Proposal, cancel the entire Request forProposal and remedy technical errors in the Request for Proposal.

The RFP does not commit the parties into a contract, nor does it obligate the employer topay any costs incurred in preparation, submission or presentation of proposals or inanticipation of a contract.

ReservationsThe employerreserves the right to request clarification of any segment of any proposal,request any additional information concerning any proposal, or negotiate any term withthe proposers. The employer also reserves the right to reject any or all proposals.

DisclaimerEvery effort has been made to ensure the accuracy of the information presented in this

request for proposal. Prospective contractors are requested to review this data and takewhatever steps they feel necessary to verify the information. While every precaution hasbeen taken to ensure the accuracy of the data and information provided herein, theEmployer cannot assume responsibility for any errors in its presentation, nor would theEmployer be held accountable for any service cost increase based upon the statisticaldata contained herein.

Proposal Quality and EvaluationProposals should respond to the specifications and describe clearly the services to beoffered. Employer will evaluate proposals. Vendors must specify all deviations from thesespecifications on the Statement of Compliance. It is understood that the proposal is incompliance except for any deviation(s) noted on the Statement of Compliance form.

All records, member files, and miscellaneous data necessary to perform theservices requested in this Request for Proposal (RFP) are and will remain theproperty of the Employer. These records contain confidential information andare not to be disclosed to any other party.

Each vendor must sign the Non-Collusion Affidavit enclosed or the proposal will not beconsidered. In addition, the vendor must submit the required disclosure notices pursuant





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to Texas HB 914. Since multiple political subdivisions are participating in the RFP,multiple disclosure notices may be required.

All proposals received from interested parties will receive a fair evaluation. While price isa paramount consideration, the Board will consider all applicable factors in determiningwhich is the best proposal and to accept the most beneficial proposal. The Boardreserves the right to reject any or all proposals, issue a subsequent Request for Proposal,cancel the entire Request for Proposal and remedy technical errors in the Request for

Proposal process.

Proposal ReviewUpon receipt of the proposals, Employer will review the proposals and select potentialcontractors with which to schedule interviews. After the Employer has reviewed theproposals and clarified questions about the proposals during discussions with thepotential contractors, the Employer may schedule visits to offices of potential contractorsto observe the performance of services as requested herein.

Proposal Information and Due DateIn the event that it becomes necessary to revise any part of this Request for Proposal(RFP) or that additional information is required to enable adequate interpretation of this

document, an attempt will be made to notify all known prospective vendors. However, itwill be the responsibility of each vendor, prior to submitting a proposal, to ascertain, ifthey have received all issued addenda.

All questions must be received no later than Date. Employer will respond to all questionsvia email and will provide all interested vendors a weekly questions and answersproposal update.

Submittal RequirementsRFPs will not be considered unless the RFP is fully completed. Pencil submittals will berejected. Alterations and illegible submissions may not be considered.

Proposal Due DateProposals are due by time p.m. CST Friday, Date. Three (3) copies of all proposals shouldbe submitted to the following:Employer:Attention:Address:

In addition to the hard copies, an electronic copy of the proposal will be required. Pleasesubmit the electronic copy to the following email address:

Award of ContractA contract will be awarded only after Employer has determined that a potentialcontractor can provide the quality of service desired. Employer hopes to select a

contractor for the services requested herein by Date.

Proposal TimelineFor your reference the enclosed timetable as a proposal review timeline guide.

April 1-20, 20XX Pre-Proposal Meetings with Vendors

April 20, 20XX Vendor Questions due to Employer

April 27, 20XX Proposal Due Date





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May 15, 20XX Proposal Committee Review

May 15, 20XX Award of Contract

May 16, 20XX Conference Calls with Vendors

October 1, 20XX Initial Effective Date and Thereafter for AppropriatePlan Years





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STATEMENT OF OVERALL REQUIREMENTS

The proposal shall be signed by a person authorized to legally bind the vendor with theunderstanding the proposal submitted shall remain firm for acceptance for a period ofsixty (60) days from the date and time of the proposal opening, and shall be valid for theperiod 10/01/11-09/30/12; 10/01/12-09/30/13 and 10/01/13-09/30/14.Vendor mustbe authorized to do business in the State of Texas.

All proposals shall be quoted net of any commissions. Commissions shall not be paid bythe Political Subdivision. If any commission fee or other reimbursement arrangementsare paid to any individual or company, they must be disclosed in the proposal as to whois paid and commission amount.

Political Subdivisions are exempt from premium taxes and, therefore, premium taxesshould not be included in any proposal.

In the event that it becomes necessary to revise any part of this RFP or that additionalinformation is required to enable adequate interpretation of this document, an attempt willbe made to notify all known prospective vendors; however, it will be the responsibility ofeach vendor, prior to submitting a proposal, to ascertain they have received all RFP

Addendums.This RFP does not commit the Employer to enter into a contract, nor does it obligate themto pay any costs incurred in preparation, submission or presentation of proposals or inanticipation of a contract.

Services are to include annual education/enrollment meetings with all employees. Defineeducation for new enrollments. At completion of enrollment the Employer is to receive amaster payroll deduction list that includes age, benefit amount and premium foremployee and dependent, if applicable.

Include the following documents in the proposal Schedule of Benefits being proposed Benefit Book/Plan Document being proposed Sample Identification Card for Medical, Rx, Dental, Vision Network Coverage Consumer Driven/Consumer Choice Plan Options with/without Debit Card Access A list of benefits that have calendar/lifetime limitations A list of benefits that are excluded from coverage A list of benefits that are paid at 100% with no copay or deductible penalty Sample Wellness Benefit communication materials Sample of the Wellness Benefit Incentive Program Sample Onsite Enrollment/Education Materials A sample of your Online Enrollment Procedures and/or paper procedure Fee schedule for all services included in your proposal

Business Continuity Plan and Test Results of Business Continuity Plan Network Coverage Area Pharmacy Benefit Management Services Pre and Post Sixty-Five Retiree Benefit Options Life, AD&D, LTD and STD Benefits Supplemental Benefit Options: Critical Care, Cancer, Accident, EAP and/or other

options





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Underwriting Procedures and Rate Distribution Schedules. Renewal rates must bereceived at least 60 days prior to renewal date

HIPAA Title I, Title II compliance and tracking of Security Breach information





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Other Factors to Consider1. General Benefit Plan Characteristics2. Effective Use of Technology

A. Daily Electronic Data Interchange within 24 business hoursperformance guarantee

B. Within 24 business hours the eligibility information will be availablefor benefit access

C. Daily file upload for employee eligibility and terminationsD. Interface with supplemental benefit vendors

3. Define the Account Management Team including the experience of assignedteam members and service levels provided

4. Ease of contracting process as well as the transparency of the contract,including vendors willingness to disclose all revenues from supplementalbenefits.

5. Service StatisticsA. Claim Adjudication Process

a. Claim Turnaround Timeb. Claim Procedural Accuracyc. Claim Financial Accuracy

d. Subrogation Servicese. Claim Audit Procedures

System Audits Internal Audits External Audits Specialty Clinical Audits

B. Customer Servicea. Abandonment Rateb. Talk Timec. Response Accuracyd. Manned Hourse. 1.800 number accessf. Bi-Lingual Support

C. Security Audita. Administrativeb. Physical

6. Medical Management/Clinical ProgramsA. NotificationB. Concurrent ReviewC. Discharge PlanningD. Intensive Care ManagementE. Professional Health CoachingF. Population Health Engagement Management

a. Disease States Managedb. Stratificationc. Supportive Covered Individual Intervention Techniquesd. Participation Managemente. Behavior Change Tracking for Population Health Engagement

7. Pricing on a Voluntary, Contributory and/or Mandatory Basis





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8. Web Based ServicesA. Web wellness portalB. Provider Access to Covered Individual Eligibility and Benefits

a. Web ITb. Phone/Fax IT

9. Performance Guarantees10. Management Reporting

A. On-line claim information and eligibility reportsB. Ability for month end reporting to be delivered electronicallyC. On-Line Debit Card InformationD. On-Line Network InformationE. On-Line EnrollmentF. On-Line Supply Request

11. Implementation Timeline12. Privacy and Security Policies and Procedures13. Notification regarding Breech of Protected Health Information





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SPECIFIC REQUIREMENTS

ID CardsThe selected vendor must agree to both:

Allow the opportunity for the political subdivisions claim administrator to print an IDcard with all benefit information (Medical, Dental, Vision, PBM, EAP) or maintain a

separate card through their vendor of choice. Both options must be available peremployer.

Print custom ID cards for the participating political subdivisions. ID card printed by thevendor must conform to state and federal laws regarding the prohibition on the use ofunique identification numbers on ID cards and other printed materials. Enclose asample ID card.

Benefit PlansThe selected vendor must agree to provide benefit information before the plan year peremployer choice of paper or electronic. Employee confirmation of receipt of benefitinformation is required from the Employer. Enclose sample Benefit Books andSchedule of Benefits.

Billing PerformanceBilling must be from the first of the month to the end of the month. An electronic billmust be available to the group. The bill will identify the eligible individuals per eachbenefit. If a standard file layout for such a transmission is available, please include this inthe proposal.

Eligibility PerformanceIt is anticipated that the eligibility information will be transmitted electronically. It ispreferred to have real-time updates to the eligibility data once a file is received andloaded into the vendors system. At most, the turnaround time of data transmission andimplementation will be required within twenty-four hours of transmittal. Eligibility

acceptance and any error reports must be transmitted back to the source of the file, orother identified party.

It is preferred to have a unique ID number for each covered member. In addition to theassigned UID, the selected vendor must be able to store the SSN of each participant andto provide a crosswalk between the UID and the SSN so that members records can beretrieved using their SSN.

Privacy RequirementsThe selected vendor must agree to comply by all applicable privacy laws, including theexpansion of HIPAA Title I and II, active maintenance of Business Associate agreementswith all participating vendors. No claims or other information regarding covered

individuals will be permitted to be disclosed to any third party, such as pharmaceuticalmanufactures for marketing purposes.

If the selected vendor processes credit/debit card payments, the vendor must complywith all application laws regarding the privacy and security of the credit card or otherfinancial data that will be processed by or reside in your systems, website or other mediaof the vendor. Any unauthorized disclosure of credit/debit card information must bereported to the member as required by law.





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QUESTIONNAIRE

General Information1. Name of Company:

A. Address:B. Phone Numbers including toll free:C. Web Site/email Address:

D. Fax Number:E. Contact Person:

2. Who owns the company?

3. Provide a brief ten-year history of your companys business philosophy,growth and benefit services.

4. Brief ten-year history regarding the average medical and prescription rateincrease in Texas.

5. If applicable, describe the organizational relationship between yourorganization and the parent company. Is your company independentlyowned or affiliated as either a subsidiary or division of some otherorganization?

6. Is your company currently involved in any discussions that would change theownership or basic structure of the organization? If so, please provide details. Isthere any purchase, sale, change in ownership or other change anticipated in thenext three (3) years that may prevent your firm from being able to honor theproposed three (3) year engagement?

7. How long have the proposed medical benefits been available in the State ofTexas?

8. Is your company outsourcing any of the services included in this proposal?

9. When did your company begin administering the benefits included in theproposal?

10. Is your company licensed to do business in the State of Texas?

11. Provide a brief biography of the senior official responsible for the overallservice of the account and for the day-to-day operations.

12. What are the standard hours of customer service?

13. Enclose a copy of your E&O Insurance Certificate.

14. Enclose a copy of your General Liability Certificate.

15. Enclose a copy of your most recent Financial Statement.

16. Enclose a copy of your most recent claim audit.Page 12 of 48

RFP for Medical, Continuation of Coverage, Pharmacy Benefit Service, Pre/Post 65 Retiree, Dental, Vision,Life/LTD/STD and EAP Benefits

Copyright 2011. All rights reserved.No part of this RFP may be used or reproduced in any manner whatsoever without express written

permission.


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17. Enclose a copy of your most recent security audit.

18. Enclose a copy of your Business Continuity Plan.

19. Enclose a copy of the most recent test results of your Business ContinuityPlan.

20. How many complaints are on file against your company with the TexasDepartment of Insurance in Texas for calendar year 2010?

21. Is your company currently involved in any litigation as a defendant over anybenefits?

22. Please identify if any association endorses your benefits or services.

23. Provide three Texas political subdivisions that you provide employeebenefits for.

Name of Company Location # of

Employees

24. Please provide three Texas political subdivisions that have terminatedbusiness with your company.

Name of Company Location # of Employees

25. Are there any other services that you or your agency would be willing toprovide that are not shown in these specifications?

Claim Audit Information1. Describe your system claim audit function.

2. Describe you internal claim audit procedures.

3. Describe your internal customer service audit procedures.

4. Describe your internal billing and eligibility audit procedures.

5. Describe your internal Network Repricing audit procedures.

6. Include the most recent external financial audit for your company.

7. Include the most recent external claim audit for your company.





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8. Include the most recent SAS 70 audit for your company.

9. Include the most recent external security audit for your company.

10. Include the most recent 12 months internal claim audit results for your company.A. Turnaround TimeB. Financial Accuracy

C. Procedural Accuracy

11. Include the most recent 12 months internal customer service audit results for yourcompany.A. Abandonment RateB. Talk TimeC. Quality of CallD. Seconds to Answer

12. Does your customer serviceA. Include e-mail customer service?B. If yes, what is the most recent turnaround time for e-mail customer service?

13. Include most recent 12 months of Billing and Eligibility audit results for yourcompany.

Employer Account Management/Services1. Provide a copy of an on-site employee education presentation regarding medical,

prescription, dental, vision, life/LTD/STD, early retiree and >65 retiree benefits.

2. Identify the service team of personnel, tenure with the company and functionalarea responsibilities that would be designated to this account.

Name

FunctionalArea of

Expertise Title

Tenurewith

Company

Services

provide toEmployer

and/ormembership

Frequencyof

Contact

3. If your company is chosen as the administrator, will you be able to provideenrollment materials within three weeks of notification for each plan year?

4. Does your company provide onsite claim look up and education meetings foremployees and their dependents?

Claim Adjudication Services1. How many claim analysts will be assigned to this account?





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2. What is the minimum amount of experience your company requires to process andrelease claims for payment with little to no supervision of upper management?

3. What is the minimum acceptable processing and financial accuracy that isacceptable to you for all claims adjusters?

4. Does your company auto-adjudicate any medical claims? (If yes, what percentageis currently being electronically paid?)

5. What is your standard turnaround time?

6. What percentage of your business is currently being processed within standard?

7. What will your company do to increase the percentage paid within goal time?

8. Does your claim system check for duplicate charges? What is the criterion used forthe duplicate checks?

9. Does the claim system check for bundling/unbundling claims? What criteria areused?

10. Describe the process for appeal of a contested claim.

11. Describe your procedure(s) for Co-ordination of Benefits when your plan(s) areconsidered as the secondary carrier.

12. Does your company provide a monthly paid claim summary?

13. What system is used for claim adjudication?

14. Is there an upgrade or plan to change claim adjudication systems in the nexttwelve months?

15. What percentage of claims paid 90 days?

16. Enclose a sample copy of an Explanation of Benefits.

17. Will the Explanation of Benefits be available in other languages besides English?

18. Define the Percent of Turnover in your Claims Department.

19. Describe you claim adjudication process.

20. Where will claims be paid?

21. How do you track pended, suspended and held claims?

22. How do you monitor benefit accumulator information?





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23. How do you comply with the prompt pay guidelines?

24. Do you require a claim form to be completed by the employee, doctor, and/orhospital? If so enclose a copy of the claim form.

25. Does your company outsource the claim adjudication function? If so, pleasedefine.

Claim Administrator Benefit Information1. Describe the educational meeting provided to the employee population.

2. Define the frequency of the educational meeting information and if multiplemeetings may be held due to the shifts employees work.

3. Define coverage for vaccines/immunizations and age/gender criteria?

4. How does your company comply with State mandates?

5. How does your company comply with the Patient Protection Accountable Care Act

(PPACA) Healthcare Reform mandates? Define your PPACA compliance or yourgrandfather clause implementation.

6. What benefits are paid at 100% of the network price?

7. What benefits have calendar, dollar, visit and lifetime limitations?

8. Describe the pre-existing limitation benefit.

9. How do you recognize creditable coverage?

10. What is the Other Insurance Procedure?

11. What is the Right of Recovery Procedure?

12. Define your Coordination of Benefit Procedure.

13. How do you integrate/coordinate with Medicare for disabled individuals?

14. How do you integrate/coordinate with Medicare for End Stage Renal individuals?

15. How to you interface with Medicare in regards to the Medicare Secondary Payerregulations? Do you interface Medical only or Medical and Prescription?

16. Provide a list of excluded/calendar or lifetime limited benefits.

17. What services are included under your Wellness Benefit Program?

18. Define your procedure for second opinions.

19. Does you plan implement a no loss/no gain procedure during the transition?





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20. Describe your procedure for handling appeals, denied claims and/or disputedclaims.

21. Define your procedure for covered individuals request for the external appealprocess.

22. Will you honor deductibles that have been satisfied for the current calendar yearand what evidence would employees need to furnish?

23. How do you cover sick baby services at time of birth?

24. How do you cover well baby services at time of birth?

25. Do you implement a mandated waiting period?

26. Describe your morbid obesity benefit.

27. Include a copy of the pertinent schedule of benefits.

28. Describe the management of unproven/experimental benefits.

29. Define the actively-at-work provision.

30. Define the no loss/no gain provision.

31. Do the medical benefits require voluntary, contributory and/or mandatory subsidy.

32. Are the benefits provided at a voluntary, contributory, mandatory employeroption?

Benefit Customer Service1. Does your company provide a 1-800 customer service line at no additional charge?

2. Identify the multi-lingual services your customer service department can provideto the employee/dependent population.

3. What are the hours of operation for your customer service department?

4. Do you have a tracking system to log-in customer service calls and content ofcustomer service calls?

5. Do you record any calls? If so, what percentage?

6. Identify the specific services and information an employee, dependent andprovider could expect during a customer service call:A. NotificationB. EligibilityC. Benefit InformationD. Claim Status





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E. Network InformationF. Out of Pocket Expenses

7. What is the ratio of customer service representative to 1,000 members?

8. Is the same number used for customer service, billing and eligibility, medicalmanagement, network information, patient advocacy and complaints?

9. Does your company have a service for handling calls after standard businesshours? Please define.

10. Will there be a dedicated customer service unit?

11. Does your company outsource Customer Service? If so, please define.A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email Address

F. Fax NumberG. Contact PersonH. Ownership of Vendor

I. Is this company currently involved in any discussions that would change theownership or basic structure of the organization? If so, please providedetails. Is there any purchase, sale, change in ownership or other changeanticipated in the next three (3) years that may prevent your firm from beingable to honor the proposed three (3) year engagement?

J. How long has the service been licensed in the State of Texas?K. When did your company begin administering the benefits included in

the proposal?L. Is your company licensed to do business in the State of Texas?

M. Provide a brief biography of the senior official responsible for theoverall service of the account and for the day-to-day operations.

N. What are the standard hours of service?O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.S. Enclose a copy of the test for the Business Continuity Plan.

T. Is the company currently involved in any litigation as a defendantover any benefits?

U. Provide three Texas political subdivisions that they provide employeebenefits for.






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V. Provide three Texas political subdivisions that have terminatedbusiness with the company.


W. Are there any other services that you or your agency would be willingto provide that are not shown in these specifications?

Technology1. Does your company provide an on-line enrollment service? Please describe and

identify if there is an additional fee for this service.

2. Does your company provide access to a web wellness portal? Please describe andidentify if there is an additional fee for this service.

3. Is your company compliant with 835 and 837 claim administrative functions?

4. Does your company provide for on-line eligibility look up?

5. Is your company compliant with the timelines in regards to the HIPAA transitionfrom 4010 to 5010 guidelines?

6. Does your company provide Phone/IT eligibility fax correspondence?

7. Does your company provide e-mail customer service? If so, what is the guaranteeof turnaround time on e-mail customer service correspondence?

8. Does our company pay providers electronically?

9. Does the website have access to provider grade point system?

10. How does the eligibility information get transferred to any outsourced vendors?

11. What is the security guarantee of the transition of protected health information tooutsourced vendors

Underwriting1. What is the percent for operating expenses in your company?

2. Define your underwriting formula for manual rate development?

3. Define your underwriting guidelines regarding medical and prescription trends.

4. Define your companys utilization of the manual rating procedure, claim utilizationand predictive modeling information.

5. Are the rates your company is quoting guaranteed for twelve months?





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6. Do the health rates include IBNR (Incurred but not reported) reserves?

7. Do the health rates include IBNR and the Lag Report reserves?

HIPAA Compliance1. Define the Plans Compliance with HIPAA Title I

2. Define the Plans Compliance with HIPAA Title II

3. How are employers notified of a HIPAA breach?

Business Continuity1. Enclose your Companys Business Continuity Plan.

2. Enclose copies of the tests you have conducted or will conduct on your BusinessContinuity Plan.

3. Enclose the last audit conducted regarding the functionality of your Business con-tinuity Plan.

Reporting1. Enclose samples of monthly, quarterly and annual reporting information

Transition Plan1. Please include the transition/implementation plan with functions and dates that

will be required.

2. Do you provide an implementation team?

3. What minimum amount of notice time would be required for your Company to

meet the employers Plan Year effective date?

Termination1. Does this proposal include run-out services? If so, is there an additional cost?

2. Upon termination will you provide claim information and high dollar (>$10,000)utilization information, diagnosis and prognosis for the proposal process?

Eligibility Information1. Are eligibility/billing reporting available on-line to Human Resource Staff?

2. Does your eligibility system have the ability to run reports per civil servants andcivilians?

3. Define eligibility guidelines for:A. Active EmployeesB. DependentsC. Dependent Children





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D. Dependent SpouseE. GrandchildrenF. Early RetireesG. RetireesH. Survivors

4. Describe your ability to bill employer, the employee, or split bill the employer and

the employee.

5. Describe your ability to bill the employer, the employee, or split bill the employerand employee for Continuation of Coverage, Pre/Post Sixty-Five Retirees.

6. Does your company provide on-site enrollment assistance? If so, please define.

7. Does your company outsource the Eligibility Management function? If so, pleasedefine.

Claim Cost Management1. Does your company provide access to tiered, provider network, fee negotiation

and/or patient advocacy services?A. Premium:B. Preferred:C. Out of Network:D. Secondary Network:E. Professional Negotiations:F. Patient Advocacy:

2. How do you establish usual and customary or reasonable and customaryinformation?

3. When are usual and customary or reasonable and customary informationimplemented.

4. Does this proposal include run-out services? If so, is there an additional cost?

5. Does you proposal deduct an employees previous covered and paid medicalexpenses from you maximum calendar and lifetime benefits?

6. Define your overpayment collection services and frequency of reporting to theemployer regarding collection efforts. Once, overpayment funds are collected, howare they applied?

7. Does your company outsource claim cost management? If so, please define.

Benefit ID Card1. What is the average turnaround time for supplying ID cards?

2. Are the cards mailed to the employer or the covered individual?





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3. Do the ID cards include medical and prescription information or do you providetwo separate cards?

4. Are Benefit Books and ID cards customized for the Employer?

5. Identify cost (if applicable) for annual ID cards and replacement ID cards.

Managed Care Network1. Where is your primary place of business?

2. Is your network accredited by NCQA and/or URAC or neither?

3. How many member lives do you service in the Dallas market?

4. Is your network National?

5. If your network is not national, do you have a network wrap for access tohealthcare outside the State of Texas?

6. Will you add providers per the employers request? If so, describe the process.

7. Who reprices the network claims? Describe the workflow process for claimadjudication once the claim is received electronically or by mail.

8. Are there any network centers of excellence? Describe by provider specialtycategory.

9. What type of contract do you have with the providers?A. DRGB. Per DiemC. Case RateD. Percentage of DiscountE. RBRVSF. CPT code specificG. Other

10. Provide a Provider Network geo access report.

11. By Geo access, identify the number of primary care physicians, specialists andhospitals per zip code.

12. What is the network stability over the last three years?

13. What is your average discount in the Texas Market place by county, region and/orzip code?

14. How is the employer notified of provider network changes?

15. Enclose the most recent paper provider directory.





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16. Describe the network credential process and average timeline for a provider to gothrough the contracting and credentialing process.

17. What is the average discount received in the Dallas Market?

18. Does your company outsource the Network services? If so, please define andrespond to the following information:

A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of Vendor

I. Is this company currently involved in any discussions that would change theownership or basic structure of the organization? If so, please providedetails. Is there any purchase, sale, change in ownership or other changeanticipated in the next three (3) years that may prevent your firm from being

able to honor the proposed three (3) year engagement?J. How long has the service been licensed in the State of Texas?K. When did your company begin administering the benefits included in

the proposal?L. Is the company licensed to do business in the State of Texas?M. Provide a brief biography of the senior official responsible for the

overall service of the account and for the day-to-day operations.N. What are the standard hours of service?O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.

S. Enclose a copy of the test for the Business Continuity Plan.T. Is the company currently involved in any litigation as a defendant

over any benefits?U. Provide three Texas political subdivisions that they provide employee

benefits for.


V. Provide three Texas political subdivisions that have terminated

business with the company.Name of Company Location # of Employees





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W. Are there any other services that you or your agency would be willing toprovide that are not shown in these specifications?

Medical Care Management1. Define your standard benefits that required pre-certification/notification.

2. Define the penalty for no pre-certification/notification information.

3. Define your Intensive Care Management Program.

4. Define your Professional Health Coach Services.

5. Define your Population Health Engagement Services and how the populationhealth engagements are measured, monitored and reported to the employer.

6. Define your nurse lines and hours of service.

7. Identify your NCQA/HEDIS scores state and national.

8. Do you employee a MD medical advisor/consultant? If so, defined the role.

9. How do you handle complicated Specialty Medical Reviews?

10. Do you outsource your Medical Management Services? If yes, please describe howthe services are integrated into the claim system.

11. Define your multi-lingual Medical Management Services?

12. If an External Vendor provides the Medical Care Management Services, pleasecomplete the following:

A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of Vendor

I. Is this company currently involved in any discussions that would change theownership or basic structure of the organization? If so, please providedetails. Is there any purchase, sale, change in ownership or other changeanticipated in the next three (3) years that may prevent your firm from being

able to honor the proposed three (3) year engagement?J. How long has the service been licensed in the State of Texas?K. When did your company begin administering the medical

management services included in the proposal?L. Is the company licensed to do business in the State of Texas?M. Provide a brief biography of the senior official responsible for the

overall service of the account and for the day-to-day operations.N. What are the standard hours of service?





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O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.S. Enclose a copy of the test for the Business Continuity Plan.


U. Provide three Texas political subdivisions that they provide employeebenefits for.Name of Company Location # of Employees

V. Provide three Texas political subdivisions that have terminated businesswith the company.Name of Company Location # of Employees


Consumer Driven/Choice Plan Information1. Define and include a sample of your standard Section 125 Plan with associated

costs. Please indicate whether this is paper or debit card accessed.

2. Define and include a sample Health Savings Account Plan with associated costs.Please indicate whether this plan is paper or debit card accessed.

3. Define and include a sample Health Reimbursement Account Plan with associatedcosts. Please indicate whether this plan is paper or debit card accessed.

4. Define and include a sample Retiree Reimbursement Account Plan with associatedcosts. Please indicate whether this plan is paper or debit card accessed.

5. In the definition of each plan please include information pertaining to:A. Annual Enrollment ProceduresB. New Hire ProceduresC. Qualifying Event ProceduresD. Tracking and Reporting Utilization Transaction, fund balancesE. Is information regarding account activity available on-line?

F. Document the pre/post tax procedures for each plan.G. Document compliance with the Internal Revenue Code.H. Define if monthly, quarterly, annually reports are submitted to participants

pertaining to account activity and fund balances.I. Identify correspondence due to ineligible purchases.

J. Identify required documentation for purchases using a consumer drivenplan.





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6. Does your company outsource the Consumer Driven Plan ManagementFunction? If so, please define.A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?

E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of Company



the proposal?

L. Is your company licensed to do business in the State of Texas?M. Provide a brief biography of the senior official responsible for the

overall service of the account and for the day-to-day operations.N. What are the standard hours of service?O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.S. Enclose a copy of the test for the Business Continuity Plan.


U. Provide three Texas political subdivisions that they provide employee

benefits for.Name of Company Location # of Employees




Wellness Benefit Management1. Define your Wellness Program and Services.





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2. Identify the plan and employee/dependent out of pockets cost in accessing theWellness Benefit Program.

3. Do you provide access to discounts for wellness services that are not coveredunder the benefit plan (ie Gym membership, Alternative Medicine Services, etc.)?

4. Does your Wellness Program include an incentive package for Population Health

Engagement?

Prescription Management1. Is the Pharmacy Benefit Manager (PBM) outsourced to an external vendor? If yes,

answer the following questions:A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax Number

G. Contact PersonH. Ownership of the companyI. Is this company currently involved in any discussions that would change the

ownership or basic structure of the organization? If so, please providedetails. Is there any purchase, sale, change in ownership or other changeanticipated in the next three (3) years that may prevent your firm from beingable to honor the proposed three (3) year engagement?


the proposal?L. Is your company licensed to do business in the State of Texas?M. Provide a brief biography of the senior official responsible for the











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2. Identify the PBM network options. Please note if the PBM offers a value tierednetwork option.

3. Enclose current Texas Network.

4. Identify if the PBM includes a value tiered option.

5. Identify the AWP Discount Per plan, network options and type of prescription.

6. Define access to Over the Counter, formulary, generic, brand, and biotechprescriptions.

7. Provide a schedule of benefits identifying eligible and ineligible prescriptions.

8. Define the source the retail and mail order AWP is derived.

9. Define the MAC List Repricing Component.

10. Define your prior-authorization procedures and what prescriptions require prior-authorization.

11. Define the procedure and the prescriptions accessed through a step-therapyprogram.

12. How is the formulary developed and managed?

13. Define the administrative, dispensing fee costs.

14. Define the rebate refund process.

15. How is the biotech/specialty list of prescriptions developed and managed?

16. How will the mail order prescriptions be transitioned to the new vendor tominimize disruption?

17. Define the education process for employees to be educated on more cost effectiveprescriptions.

18. Identify the Prescription Benefit Managers customer service hours?

19. Is the Pharmacy Benefit Manager National?

20. Enclose sample reports that would be distributed:A. Top Prescription Utilization Report





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B. Top Dollar Prescription ReportC. Retail Utilization

a. Generic Utilizationb. Formulary Utilizationc. Multi-Source Utilizationd. Brand Utilizatione. Biotech Utilization

D. Mail Servicea. Generic Utilizationb. Formulary Utilizationc. Multi-Source Utilizationd. Brand Utilizatione. Biotech Utilization

21. Identify the PBMs Substitution Stats for the most recent 12 month.

22. Does the plan limit extended release prescriptions?

23. Enclose a retail and mail service schedule of prescription benefits.

24. Does the plan offer retail maintenance purchase options?

25. Define your recommendations on managing Therapeutic class categories.

Category Top DrugsCost ManagementRecommendations

Cholesterol Lowering Lipitor, Crestor, Vytorin

Anti-ulcer Nexium, Prevacid

Antidepressant Lexapro, Cymbalta, Effexor

Antihypertensive Avapro, CozaarAntidabetic Actos

Anti-asthmatic Advair Diskus, Singulair

Analgesic anti-inflammatory

Celebrex, Enbrel, Humira,Orencia

Misc. EndocrineMetabolic

Fosamax, Boniva, Actonel,Forteo

Anticonvulsant Topamex, Lamictal, Lyrica

Analgesic, Opiod Vicodin, Oxycontin






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Continuation of Coverage1. Is Continuation of Coverage Services outsourced to an external vendor? If yes,

please answer the following questions:A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?

E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of the company



the proposal?









2. Define their Continuation of Coverage (COBRA) Procedures.

3. Enclose a COBRA Plan Document.





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4. Enclose your companys procedures for the Continuation of Coverage premiumSubsidy American Recovery and Reinvestment Act of 2009 administration.

Retiree Benefits1. Define the benefit services offered to the Pre-65 Retiree population?

2. Enclose your companys Medicare Supplemental Plan Options and fee structure.

3. Enclose your companys Medicare Advantage Plan Options and fee structure.

4. Does your company outsource the retiree benefits? If so, please define and answerthe following questions.

A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax Number

G. Contact PersonH. Ownership of the company




overall service of the account and for the day-to-day operations.N. What are the standard hours of customer service?O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.S. Enclose a copy of the test for the Business Continuity Plan.










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Vision Benefits1. Does your company outsource vision benefits to an external company? If yes,

please answer the following questions:A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax Number















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2. Enclose a schedule of benefits for your Vision Plan.


4. Does your vision plan access a network of providers? If so, enclose a directory.

5. Enclose a copy of the Vision Exclusion and/or limitations to Benefits.

6. Do you offer an indemnity vision benefit plan? If so, please enclose a sample.

7. Enclose information regarding vision plan utilization.

8. Is there a materials guarantee for frames? Lenses? Contact Lenses? If so, what arethe limits for each?

9. Describe the network provider credential process.

10. Does the plan cover for lasik services?

11. Does the benefit cover for lens options such as tint, UV coding and lens protectionservices.

12. What would be the transition plan for current covered individuals who are

accessing current Vision Services?

13. What employee education meetings does your company provide for theemployer and is there additional cost for employee education meetings?

14. Describe and attach samples of your vision utilization reporting.

15. Is there a materials guarantee for frames? Lenses? Contact lenses? If so,what are the time limits for each?

16. Discuss preparations and guidelines your organization has implementregarding HIPAAs regulations for Protected Health Information.

17. Will all participants receive an ID card? If no, how do providers confirmeligibility for members?

18. Are ID cards sent in bulk to the Employer for distribution, or are they sent tothe members homes? Is there an additional charge for mailing them to themembers home?





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19. Is a separate vision card required or can the Employer include informationon the medical card?

20. If selected, please confirm that you will provide a Summary Plan Descriptionand benefit plan document?

21. Define and price any Optional Services/Benefit Riders that are available.

22. Describe underwriting guidelines for applicants subject to vision costreview.

23. Is there a waiting period and if so, will it be waived for initial enrollment?

24. Is the policy a group or individual product?

25. Is the policy portable and guaranteed renewable for life as long aspremiums are paid when due?

26. What are the termination provisions of policy?

27. Do the policy benefits reduce at any age?

28. Does the premium stay consistent regardless of employment or healthcondition?

29. Have there been any premium rate increases? If yes, how many times andwhen?

30. Does the policy pay in addition to any existing major medical or vision planthat the employee and/or their dependents may currently have in force at

the time the services are received?

31. Does the Policy offer more than one level of benefit? If yes, show benefitlevels.

32. Does policy provide for Experimental Treatment? If yes, how much?

33. Does the policy provide benefits for refractive surgery? If yes, what are thelimitations?

Dental Benefits

1. Does your company outsource the Dental benefits, if yes please answer thefollowing questions?A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax Number





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J. How long has the service been licensed in the State of Texas?K. When did your company begin administering the benefits included inthe proposal?









2. Enclose a schedule of benefits for the Dental Plan


4. Does you dental plan access a network of providers? If so, enclose a directory.

5. Enclose a copy of the Dental Exclusion and/or limitation to Benefits.

6. Define elements of dental utilization management that are implemented withinyour dental program. Enclose information regarding dental plan utilization.





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7. What percentage of total dental claims is routed for dental clinical review?

8. Identify the three most common procedures or combination of procedures that arequestioned by dental clinical reviewers.

9. Do you offer an indemnity dental plan? If so, please enclose a sample.

10. Describe the network provider credential process.

11. Explain benefit access and include sample descriptions of how the process willwork for orthodontics, endontics, surgical periodontics and cowns/prosthodontics.

12. What percentage of claims are professional reviewed?

13. List the three most common procedures or combination of procedures that arequestioned by clinical staff and/or possibly provider abused.

14. Describe in detail Vendors communication program as it related but not limited tothe following:

A. EnrollmentB. Identification card distribution process;C. Plan document;D. Newsletters;E. Preventive/incentive type programs;

15. State how plan members are notified when a provider is no longer a part of theplan.

16. Provide a sample contract between Vendor and a network provider (physician andnon physician). State whether the terms and conditions are standard to allproviders participating in Vendors network.

17. State how Vendors primary and specialty providers are reimbursed (i.e.negotiated fee schedule, capitation, etc.).

18. Does Vendor require its providers to agree to an exclusive contract prohibitingthem from participating in other managed care plans?

19. Do the dental rates include IBNR (Incurred but not reported) reserves?

20. If no, what are your companys procedures for developing IBNR (Incurred but notreported) reserves for the renewal?

21. Under what conditions can the contract between Vendor and a provider beterminated?

22. Describe the process involved in the recruitment, credentialing and qualityassurance standards for providers?





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23. Describe fully your use of R&C. What percentile is commonly used? Will the Cityhave the option to set the R&C percentile? Is application of R&C automatic in yoursystem, or are claims pended for manual review? How often is the R&C updated?Is it geographically based?

Life/LTD/STD1. Does your company outsource this service? If so, please define and answer the

following questions.A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of the company

I. Is this company currently involved in any discussions that would change theownership or basic structure of the organization? If so, please providedetails. Is there any purchase, sale, change in ownership or other change

anticipated in the next three (3) years that may prevent your firm from beingable to honor the proposed three (3) year engagement?













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2. Is coverage provided for all currently insured employees who are actively-at-work?

3. Is the actively-at-work requirement waived for currently insured employees who arenot covered by the existing carriers Extension of Benefits provision?

4. Is coverage provided for all current classes of employees in accordance with theexisting provisions at each participating school corporation?

5. What is the length of the rate guarantee?

6. What is the Guarantee Issue limit for basic life coverage?

7. Are current insured employees subject to a Guarantee Issue limits?

8. What is the volume of basic life insurance assumed in your rating?

9. What is the volume of basic AD&D coverage assumed in your rating?

10. Please indicate if Paid Premium and Paid Claim reports for each line of coverage willbe provided at the time of future renewal offers?

11. Does your plan have age reductions?

12. Does your plan include an accelerated death benefit option?

13. Will you agree that no employees will lose coverage as a result of changinginsurance carrier?

14. Confirm that your plan includes waiver of premium for disabled?

15. What is the Waiver of Premium Elimination Period? Are other options available?

16. Is Waiver of Premium based on Own Occ or Any Occ? Are there options available?

17. At what age does Waiver of Premium terminate?

18. Will Life Waiver of Premium claims automatically be filed if you also write theSTD/LTD?

19. When do ported contracts terminate?

20. When do conversion contracts terminate?

21. Do your rates include the cost of printing booklets and certificates?

22. Is enrollment material available in Spanish?





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23. Will enrollment material be pre-populated with employee information anddeductions?

24. Is portability available at retirement?

25. How will rates and renewals be determined-based on actual claims experience,manual rates, or a blend?

26. What is your target loss ratio?

27. Are interest credits paid to the beneficiary from date of death? If so, state rate.

28. Besides pending life claims, does your Company require the establishment of anyadditional reserves? If so, explain the amount and formula.

29. Enclose a sample of the claim form(s) that will be used by members.

30. Will your Company accept the Employers enrollment card(s) for all transferredbusiness and new business? See samples attached

31. Please explain how your Company will take over our existing group.

32. Provide a brief explanation on the steps necessary to convert a life benefit. Is a LifeConversion Application, sample Life Conversion Policy, and current rates attached?

33. Is the Employers self-billing procedure acceptable?

34. If your Company cannot guarantee a rate for more than one (1) year, can they agreeto a formula for the 2nd and 3rd year rates? If yes, what is the formula?

35. If there are any commissions included in the proposal, please state the amount.

Life/LTD/STD Claim Payment Services1. What is the claims turnaround time for the last twelve months?

2. What is the quality of claim payment for the last twelve months?

3. Enclose a sample of the claim form(s) that will be used by membersattached?

4. Where will claims be paid?

5. What is normal claim processing time?

6. Describe documentation needed for payment of a claim?

7. Describe your procedure for claim declination.

8. Describe your procedures for handling appeals of denied or disputed claims.





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9. Will you or your agency complete claim forms over the telephone?

10. Are the plans available at voluntary, contributory and/or mandatoryemployer subsidy options?





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Employee Assistance Program1. Does your company outsource the benefit? If so, please describe and

answer the following questions.A. Name of Vendor:B. Address:C. Phone Numbers including toll free:D. Is there additional charge for toll free access?

E. Web Site/email AddressF. Fax NumberG. Contact PersonH. Ownership of the company?



the proposal?


overall service of the account and for the day-to-day operations.N. What are the standard hours of customer service?O. Enclose a copy of the E&O Insurance Certificate.P. Enclose a copy of the General Liability Certificate.Q. Enclose a copy of the most recent Financial Statement.R. Enclose a copy of the Business Continuity Plan.S. Enclose a copy of the test for the Business Continuity Plan.






W. Are there any other services that you or your agency would be willingto provide that are not shown in the

sample rfp pool

Documents