11-Exhibit 1. Fort Bend ISD Stop Loss RFP Workbook RFP 26-023KB.xlsx
XLSX spreadsheet 799 KB Posted
- Attached to
- Stop Loss Insurance
- Solicitation number
- RFP 26-023KB
- Issued by
- Fort Bend County, Texas
About this file
This document is a Request for Proposal (RFP) issued by Fort Bend Independent School District (Fort Bend ISD) for stop loss insurance services. The RFP seeks proposals for stop loss reinsurance coverage effective January 1st, 2026, with a contract duration of one year through December 31st, 2026. The district is requesting stop loss insurance with individual specific deductible options of $450,000, $500,000, and $550,000, covering medical and prescription drug expenses. Vendors are required to provide comprehensive proposals including an executive summary, standard proposal, and complete all sections of the provided workbook template.
The current stop loss insurance vendor is UHC, and the district currently has three UHC plans. Medical administration will remain with UHC, and pharmacy administration will continue with CVS. Vendors are instructed to propose fees and premiums net of broker/agent commissions, and the district will not accept multiple proposals from the same vendor. Key pricing considerations include a 50% rate cap, no new lasers at renewal, and 12 months of run-out coverage. The district expects vendors to provide monthly reports, comply with HIPAA regulations, and be prepared to integrate pharmacy benefit data if the district chooses to carve out that service. Proposals must include detailed information about the vendor's company, stop loss administration approach, and ability to meet the district's specific insurance requirements.
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Cover
Fort Bend ISD
| Request for Proposal |
| for |
| Stop Loss # 26-023KB |
Disclaimer: Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please contact Fort Bend ISD Procurement.
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&"Arial,Regular"&7 © 2018 ARTHUR J. GALLAGHER & CO. &"Arial,Regular"&7AJG.COM
General Information General Information
| Please consider the following information for your proposal. | ||
| 1. | EFFECTIVE DATE: | January 1st, 2026 |
2. CONTRACT DURATION: 1/1/2026-12/31/2026
3. CURRENT VENDOR: UHC
4 The client has 3 current UHC Plans. Please refer to the 2025 SBCs for further information. The client will consider these 3 models for weighted average scoring. Proposals will be scored on these 3 models.
5 Medical adminsitration is with UHC and Pharmacy adminsitration is with CVS and will remain in place for 2026. Assume that current 2025 benefit coverage will remain intact for purposes of developing your cost, network, utilization management, modeling strategies.
6 Vendors are to propose all fees and premiums net of broker/agent commissions; the client is not requesting services of an agent/broker.
7 All reporting files and other supporting documentation can be found attached to the bid posting.
8 All workbook pages must be completed and returned with your proposal.
9 The client will not accept competing multiple proposals from the same vendor, so manage your internal proposal process to assure that one (1) proposal is presented.
10 PLEASE provide an Executive Summary, as well as your standard Proposal with this submission. PLEASE note, you MUST provide your responses in our standard template in order to be considered for this RFP.
| Disclaimer: |
| Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please reach out to Fort Bend ISD procurement. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Scope of Work Scope of Work
| Please consider the following information / requirements for your proposal. | ||
| A. | Stop Loss Reinsurance Coverage | |
| Please quote the following specifications: | ||
| ISL Deductibles: | $450,000, $500,000, $550,000 | |
| Contract Period: | 01/01/2026 - 12/31/2026 | |
| Include ASL | No | |
| Medical and Rx Coverage | Both |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Proposal Specifications
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| All vendors must complete this section. | ||
| Proposal Specifications | ||
| # | Specification | Agree / Disagree |
| 1 | The effective date of coverage January 1st, 2026 is acknowledged and accepted. | |
| 2 | All fees / premiums are quoted NET of commissions; no commissions or fees are to be paid to any entity. | |
| 3 | Preliminary renewal rates must be submitted six months prior to the effective date. | |
| 4 | You completed all sections of the workbook in their entirety, in the format requested. | |
| 5 | Vendor agrees to provide all communication materials in electronic (pdf) format. | |
| 6 | Vendor agrees to provide all standard reports to the client and its professional advisor. | |
| 7 | Do you agree to provide the consultant with monthly reports for the data warehouse at no additional charge? | |
| 8 | Claims experience must be provided at least monthly, including each renewal. | |
| 9 | You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security Regulations and will use HIPAA 834 (ASC X12N 834) for the file transmission layout. | |
| 10 | You have reviewed and accept the Plan’s eligibility provisions. | |
| 11 | Your contract must require no more than a 90-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off anniversary. | |
| 12 | Vendor has specifically listed all deviations from the RFP and coverage requirements. NOTE: Deviations MUST be listed; vendors cannot simply make “general” references to the proposal. | |
| 13 | If the client wishes to carve-out the pharmacy benefit, TPA agrees to take weekly feeds from the pharmacy vendor and will mine/integrate the data into the medical management program. | |
| 14 | Vendor agrees to provide a dedicated reporting contact for the client and its consultant. This person would be responsible for running ad hoc reports for the client and/or its consultant’s discretion, at no additional cost to the client. | |
| 15 | You must permit the employer to have access to all files on request (e.g., a claims audit). | |
| 16 | Benefits should be payable based on the plan documents of the coverages being quoted and the Stop Loss contract should not supersede those plan documents of the quoted coverages. | |
| 17 | Stop Loss Contract basis: 24/12 | |
| 18 | Stop Loss ISL options: $450,000, $500,000, $550,000 | |
| 19 | Include an overall composite rate covering all available medical plans. | |
| 20 | Spec Advance Funding option. If there is a cost associated with it, please break it out in your proposal. | |
| 21 | Include Plan Mirroring option. If there is a cost associated with it, please break it out in your proposal. | |
| 22 | Vendor must waive any “actively-at-work provisions | |
| 23 | Vendor must waive any late entrant penalties | |
| 24 | Run-in should not be limited | |
| 25 | Please include 12 months of run-out coverage in your rates | |
| 26 | Vendor must agree to no new lasers at renewal. | |
| 27 | Spec Advance Funding option. If there is a cost associated with it, please break it out in your proposal. | |
| 28 | As part of your proposal response, please compare the employer’s current plan document, which has been included, to your proposed stop loss policy and identify any areas where there are gaps in coverage or include in your proposal a statement that you will mirror the employer’s plan document. | |
| 29 | Vendor must agree to release the stop loss renewal proposal within 120 days of expiration | |
| 30 | The client intends to include your RFP responses as part of the overall Contract. Please acknowledge you understand and agree to this expectation. | |
| 31 | Quote must include 50% rate cap |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Deviations Tab
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| If you have any Deviations to the Proposal Specifications, OR need to add additional commentary on any item of the Questionnaire, please include this here | ||
| Proposal Specifications | ||
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
SL Pricing $450K Opt. 1
| Stop Loss Pricing Spreadsheet | ||||||||||||||||
| Please record all answers on this excel spreadsheet | ||||||||||||||||
| Company Legal Business Name: _________________________________________________________________ | ||||||||||||||||
| Plan Provisions | Current | Option 1 | Option 2 | Option 3 | Option 4 | Option 5 | Option 6 | |||||||||
| 1/1/25 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | ||||||||||
| PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | |||
| Network: | UHC | |||||||||||||||
| # EE | ||||||||||||||||
| Coverages included for Specific | Aggregate | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | ||
| Individual Stop Loss Level | $450,000 | $450,000 | $450,000 | $450,000 | $450,000 | $450,000 | $450,000 | |||||||||
| Individual Policy Year Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Individual Lifetime Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Maximum Annual Aggregate Refund | NA | |||||||||||||||
| Claim Accumulation Basis | Per Member | |||||||||||||||
| Reimbursement Percentage | 100% | |||||||||||||||
| Contract Basis | PAID | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | |||||||||
| Agree to waive any "actively at work" provisions | Yes | |||||||||||||||
| Agree to mirror employer's plan document | Yes | |||||||||||||||
| Terminal Liability Option | No | |||||||||||||||
| Dollar Limit on Run-in Claims - Speciific | Aggregate | NA | NA | ||||||||||||||
| Retirees Included | No | |||||||||||||||
| INDIVIDUAL STOP LOSS PREMIUM | ||||||||||||||||
| Single | 7596 | $40.17 | $3,661,576 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Spouse | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Children | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Family | 1947 | $40.17 | $938,532 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Composite | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| TOTAL ANNUAL STOP LOSS PREMIUM | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | ||
| TOTAL COMBINED ESTIMATED MAX LIABLITY | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Fixed $ Change over Current | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | ||||
| Fixed % Change over Current | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | ||||||||||
| Lasers | ||||||||||||||||
| Text is limited to 25 characters | 1. | None | None | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | |
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| Proposal Contingencies | ||||||||||||||||
| Text is limited to 60 characters | 1. | |||||||||||||||
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| 5. |
| No | ||
| Yes - 3 months | ||
| Yes - 6 months | ||
| Per Member | Yes | |
| Per Family | No |
SL Pricing $500K Opt. 2
| Stop Loss Pricing Spreadsheet | ||||||||||||||||
| Please record all answers on this excel spreadsheet | ||||||||||||||||
| Company Legal Business Name: _________________________________________________________________ | ||||||||||||||||
| Plan Provisions | Current | Option 1 | Option 2 | Option 3 | Option 4 | Option 5 | Option 6 | |||||||||
| 1/1/25 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | ||||||||||
| PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | |||
| Network: | UHC | |||||||||||||||
| # EE | ||||||||||||||||
| Coverages included for Specific | Aggregate | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | ||
| Individual Stop Loss Level | $450,000 | $500,000 | $500,000 | $500,000 | $500,000 | $500,000 | $500,000 | |||||||||
| Individual Policy Year Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Individual Lifetime Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Maximum Annual Aggregate Refund | NA | |||||||||||||||
| Claim Accumulation Basis | Per Member | |||||||||||||||
| Reimbursement Percentage | 100% | |||||||||||||||
| Contract Basis | PAID | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | |||||||||
| Agree to waive any "actively at work" provisions | Yes | |||||||||||||||
| Agree to mirror employer's plan document | Yes | |||||||||||||||
| Terminal Liability Option | No | |||||||||||||||
| Dollar Limit on Run-in Claims - Speciific | Aggregate | NA | NA | ||||||||||||||
| Retirees Included | No | |||||||||||||||
| INDIVIDUAL STOP LOSS PREMIUM | ||||||||||||||||
| Single | 7596 | $40.17 | $3,661,576 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Spouse | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Children | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Family | 1947 | $40.17 | $938,532 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Composite | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| TOTAL ANNUAL STOP LOSS PREMIUM | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | ||
| TOTAL COMBINED ESTIMATED MAX LIABLITY | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Fixed $ Change over Current | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | ||||
| Fixed % Change over Current | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | ||||||||||
| Lasers | ||||||||||||||||
| Text is limited to 25 characters | 1. | None | None | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | |
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| Proposal Contingencies | ||||||||||||||||
| Text is limited to 60 characters | 1. | |||||||||||||||
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| 5. |
| No | ||
| Yes - 3 months | ||
| Yes - 6 months | ||
| Per Member | Yes | |
| Per Family | No |
SL Pricing $550K Opt. 3
| Stop Loss Pricing Spreadsheet | ||||||||||||||||
| Please record all answers on this excel spreadsheet | ||||||||||||||||
| Company Legal Business Name: _________________________________________________________________ | ||||||||||||||||
| Plan Provisions | Current | Option 1 | Option 2 | Option 3 | Option 4 | Option 5 | Option 6 | |||||||||
| 1/1/25 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | 1/1/26 | ||||||||||
| PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | |||
| Network: | UHC | |||||||||||||||
| # EE | ||||||||||||||||
| Coverages included for Specific | Aggregate | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | ||
| Individual Stop Loss Level | $450,000 | $550,000 | $550,000 | $550,000 | $550,000 | $550,000 | $550,000 | |||||||||
| Individual Policy Year Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Individual Lifetime Stop Loss Payment Limit | Unlimited | |||||||||||||||
| Maximum Annual Aggregate Refund | NA | |||||||||||||||
| Claim Accumulation Basis | Per Member | |||||||||||||||
| Reimbursement Percentage | 100% | |||||||||||||||
| Contract Basis | PAID | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | 24/12 | |||||||||
| Agree to waive any "actively at work" provisions | Yes | |||||||||||||||
| Agree to mirror employer's plan document | Yes | |||||||||||||||
| Terminal Liability Option | No | |||||||||||||||
| Dollar Limit on Run-in Claims - Speciific | Aggregate | NA | NA | ||||||||||||||
| Retirees Included | No | |||||||||||||||
| INDIVIDUAL STOP LOSS PREMIUM | ||||||||||||||||
| Single | 7596 | $40.17 | $3,661,576 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Spouse | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Children | $0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||||
| Family | 1947 | $40.17 | $938,532 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Composite | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| TOTAL ANNUAL STOP LOSS PREMIUM | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | ||
| TOTAL COMBINED ESTIMATED MAX LIABLITY | 9543 | $40.17 | $4,600,108 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Fixed $ Change over Current | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | -$40.17 | -$4,600,108 | ||||
| Fixed % Change over Current | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | -100.00% | ||||||||||
| Lasers | ||||||||||||||||
| Text is limited to 25 characters | 1. | None | None | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | |
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| Proposal Contingencies | ||||||||||||||||
| Text is limited to 60 characters | 1. | |||||||||||||||
| 2. | ||||||||||||||||
| 3. | ||||||||||||||||
| 4. | ||||||||||||||||
| 5. |
| No | ||
| Yes - 3 months | ||
| Yes - 6 months | ||
| Per Member | Yes | |
| Per Family | No |
Questionnaire
| Stop Loss Administration Questionnaire |
| Company Legal Business Name: __________________________________________________________________ |
| Affirmation / discussion must be given on each of the following topics. | ||
| Section I - General Company Information | ||
| # | Question | Vendor Response |
| 1. | Please confirm your organization will be ready to begin services on January 1st, 2026. | |
| 2. | Indicate what year the company was founded. | |
| 3. | Describe the ownership structure. | |
| 4. | What is the total number of employer clients that you have for the services you are proposing? What is the average size of your client as well as the largest? | |
| 5. | What is the legal name of your organization as it should appear on the Agreement? | |
| 6. | What is the name of your parent organization if you have one? | |
| 7. | Please provide the main address, phone number, fax number, email address, web address for your company as well as your internal identification code for this RFP. | |
| 8. | Provide the contact information of the individual authorized to answer questions related to this RFP, including their name, title, physical address, direct office phone number, fax number, cell phone number and email address. | |
| 9. | To the extent applicable, are you now and will you remain duly licensed and in full compliance with all federal and state statutory administrative requirements? | |
| 10. | Do you agree to do what is necessary to execute an agreement within 30 days of award of service(s)? | |
| 11. | How many public school districts or other public institutions do you provide similar services for? What is the largest public school district you currently service? | |
| 12. | Provide three references for three current accounts comparable in size to the client (prefer public sector account, school district and/or Texas based references). Provide two former accounts lost in the past year also in comparable size to the client. Include reference contact name, office phone number and email address. Include the length of relationship, number of employees of the reference and services provided to the reference. | |
| 13. | Where will the account team be located? | |
| 14. | If you plan on using any third-party organizations please provide a detailed list of who will participate in the execution of the services you will provide as a part of your proposal response (name, nature of relationship, length of affiliation). | |
| 15. | Please provide the number of employees in your organization. | |
| 16. | Please provide the ratings of your company (A.M. Best, Moody's, Standard & Poor's). | |
| 17. | Have you recently been acquired or been involved with any mergers/acquisitions? If yes, please describe. | |
| 18. | Will you need to hire additional customer service personnel if awarded this business? | |
| 19. | Provide a detailed implementation plan, including action items and due dates. Include support for implementation and open enrollment | |
| 20. | Will you agree to comply with the proposed medical plan Performance Guarantees (as outlined in this RFP)? If you are unable to comply with the proposed guarantees, provide your alternate proposal. |
| Section II - Stop Loss | ||
| # | Question | Vendor Response |
| 1 | What type/list data files are required from the client's health plan administrators on a routine monthly and claim filing basis. Will there be any fees for integrating with files? | |
| 2 | Discuss your renewal philosophy. Be specific as it relates to known ongoing large claims, high deductibles, lasering, rating up, exclusion, etc. | |
| 3 | To your knowledge, has a renewal ever been denied solely due to claim experience? | |
| 4 | Is this a 100% direct policy, a captive model, or is an MGU responsible for any claim risk? | |
| 5 | Define an eligible "paid" claim. Will you adhere to the terms and conditions established by Aetna for member eligibility, benefit adjudication, and provider contractuals? What is your role in determining an eligible claim? | |
| 6 | Define an eligible "pended" claim. How are year end incurred claims covered retroactively back to the contractual policy period; upon claim resolution, include timeframe limitations if any. | |
| 7 | How are the answers to Questions 5 and 6 impacted by policy termination? | |
| 8 | Please provide the definition of experimental procedures and note how this provision is interpreted for a claim approved for payment under the medical plan. | |
| 9 | Does the proposal include any fiduciary protection in case of provider contractual or procedural reimbursement disputes/denials? | |
| 10 | Do you offer Advanced Funding or Accelerated Funding options? If so, what is the cost to the base premium rate? | |
| 11 | Do any capitated claim costs apply to claim accumulators | |
| 12 | What fees will be considered as part of claims (example, shared savings fees)? | |
| 13 | Do you cover Gene Therapy? If so, how is it included? Please explain coverage details, pricing, etc. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Stop Loss RFI
| Gallagher Benefit Services | 2019 notes | 2019 notes | 2019 notes |
| Request for Information | |||
| Specific Stop Loss Insurance |
Questions RESPONSES
| Stop Loss Provider Name | ||
| Date Completed | 2018 Johns notes | |
| Responses Effective Through | sample answer: 12/31/2021 or 1/1/2022 |
Questions RESPONSES Category Previous Question
| 1 | Explain your ownership structure in detail. | Please explain: | organizational structure | RFI 1 | ||
| 2 | How long has your organization been in business for stop loss insurance? | Year established | organizational structure | RFI 2 | ||
| Additional Information: | ||||||
| 3 | Has your company done business under other names? If yes, please provide historical background information. Identify any interests your organization may have with associated vendors (claims administrators, brokerage firms, managed care firms, etc.). | Yes No | organizational structure | RFI 3 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 4 | Have you ever been suspended from writing this line of coverage? | Yes No | organizational structure | RFI 4 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 5 | Is your organization licensed to do business in all 50 states and U.S. territories? If no, identify the states/territories in which you are not currently licensed. | Yes No | organizational structure | RFI 5 | ||
| If no, please explain: | ||||||
| Additional Information: | ||||||
| 6 | What percentage of the risk does your company assume? If less than 100%, please identify additional reinsurer(s) and the respective percentage of assumed liability. | % | organizational structure | RFI 8 | ||
| If less than 100%, please explain: | ||||||
| Additional Information: | ||||||
| 7 | Do you allow your paper to be used by MGUs? If yes then please identify those MGU(s). | Yes No | organizational structure | RFI 8 | ||
| If yes, then list the MGU(s) | ||||||
| Additional Information: | ||||||
| 8 | Do you have a relationship with another carrier that would prohibit your ability to quote a particular case? | Yes No | organizational structure | RFI 8 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 9 | Who has final claim decision-making authority with respect to specific claims? | Details: | organizational structure | RFI 9 | ||
| 10 | How many stop loss clients do you currently have in your block of business and what is the annualized premium? | # of Clients | organizational structure | RFI 6 | ||
| Annualized premium | ||||||
| 11 | How many stop loss clients do you currently have with Gallagher and what is the annualized premium? | # of Clients | organizational structure | New | ||
| Annualized premium | ||||||
| 12 | BUCA Block of Business: What percentage of your block of business is with BUCA's? | Aetna | marginally important | organizational structure | ||
| BCBS | Key Question 7 (split into 2 questions) | |||||
| Cigna | ||||||
| UHC | ||||||
| 13 | Do you have ineligibles industries or other ineligible categories? | Yes No | less important | organizational structure | RFI 12 | |
| a. Captives | Eligible Ineligible | RFI 12 | ||||
| b. Casinos | Eligible Ineligible | RFI 12 | ||||
| c. Employee Leasing / PEOs | Eligible Ineligible | RFI 12 | ||||
| d. Hospitals | Eligible Ineligible | RFI 12 | ||||
| e. Indian Tribes | Eligible Ineligible | RFI 12 | ||||
| f. METS / MEWAs | Eligible Ineligible | RFI 12 | ||||
| g. Mining | Eligible Ineligible | RFI 12 | ||||
| h. Other ineligible industries or categories | Please list: | RFI 12 | ||||
| 14 | Do you have a minimum specific deductible amount? | Yes No | RFI 12 | |||
| If yes, add minimum amount: | ||||||
| 15 | Do you have a minimum group size? | Yes No | RFI 12 | |||
| If yes, add minimum # of EEs: | ||||||
| 16 | Do you offer a pharmacy only policy? | Specific: Yes No | less important | organizational structure | New | |
| Additional Information: | less important | organizational structure | ||||
| 17 | Claims covered period: Do you agree to offer a Paid claims covered period? If yes, under what criteria? | Yes No | less important | organizational structure | ||
| If no, please explain: | less important | organizational structure | Key Question 1 | |||
| Additional Information: | less important | organizational structure | ||||
| Define a paid contract. | Details: | New | ||||
| 18 | Formal Disclosure: Will you agree to no client signature required at new business or renewal? | Yes No | less important | organizational structure | ||
| If no, please explain: | less important | organizational structure | RFI 10/Key Question 5 | |||
| Additional Information: | less important | organizational structure | ||||
| 19 | In most cases, we require that your organization work directly with Gallagher Benefit Services rather than our client’s claims administrator (TPAs, BCBS plans, carriers, etc.) on such things as: | Agree Disagree | less important | organizational structure | RFI 11 | |
| 10 | Ø Renewals | If disagree, please explain: | less important | organizational structure | ||
| Ø Specific contract concerns | ||||||
| Ø Plan Document/SPD adoption / approval | Additional Information: | less important | organizational structure | |||
| Ø Plan amendments | ||||||
| 20 | Does your stop loss policy contain an Actively at Work provision? | Yes No | ||||
| If yes, please explain: | RFI 14/Key Question 8 | |||||
| Additional Information: | terms | |||||
| 21 | Waive Active at Work: On new business and renewals, do you agree to waive actively at work for covered employees and dependents per the employer's plan document other than any lasers put in place on new business? | Agree Disagree | less important | organizational structure | ||
| If disagree, please explain: | RFI 13/Key Question 10 | |||||
| Additional Information: | ||||||
| 22 | If a client acquires a new company during the contract year, do you agree to waive the actively at work, dependent non-confinement and pre-existing condition limitation provisions for the newly acquired employees, their dependents, spouses, domestic partners, FMLA, retirees (if applicable), and COBRA beneficiaries? | Agree Disagree | RFI 18 | |||
| If disagree, please explain: | ||||||
| Additional Information: | terms | |||||
| 23 | Firm Rate Guarantee: Will you commit to a rate guarantee at least 3 months prior to effective date and for public sector more than 3 months? | Yes No | ||||
| If no, please explain: | RFI 14/Key Question 8 | |||||
| Additional Information: | terms | |||||
| How many months of claims are needed to produce an illustrative quote and a firm quote? | Details: | New | ||||
| 24 | Laser Policy: Do you agree to offer a no new lasers at renewal option? If yes, at what cost and under what terms? | Yes No | RFI 15/Key Question 2 | |||
| If yes, please explain: | ||||||
| Additional Information: | terms | |||||
| 25 | Rate Cap Guarantee at Renewal: Will you offer a rate cap at renewal? If yes, please provide details including any additional cost. | Yes No | ||||
| If yes, please explain: | Key Question 3 | |||||
| Additional Information: | ||||||
| What various rate caps are offered? 35%, 40% etc. | Details: | New | ||||
| 26 | What fees will be considered as part of claims (example, shared savings fees, negotiated savings, and state surcharges) | Details: | RFI 16 | |||
| 27 | Will you allow “non-covered” alternative care, if approved by your case managers or negotiated as part of an out of network cost negotiation? | Yes No | terms | RFI 17 | ||
| If no, please explain: | ||||||
| Additional Information: | terms | |||||
| 28 | Do you offer advance funding or quick pay options for stop loss claims? If yes, please provide details including any additional cost. | Yes No Specific | ||||
| If yes, please explain: | ||||||
| Additional Information: | terms | |||||
| 29 | Dividend Eligible: Do you offer the potential for a client dividend? If yes, please explain and note any additional costs? (Include any renewal requirements) | Yes No | ||||
| If yes, please explain: | changed wording slightly. | terms | Key Question 4 | |||
| Additional Information: | ||||||
| 30 | Changes in Rates and Terms: Do you agree to no change in rates or terms unless the nature of the risk is impacted by 15% or more from changes in enrollment, benefits, networks, and/or claim administrators? | Agree Disagree | ||||
| If disagree, please explain: | Key Question 6 | |||||
| Additional Information: | terms | |||||
| 31 | Specific Coverage Maximums: All GBS clients must have unlimited specific coverage maximums. Do you agree to this? | Agree Disagree | ||||
| If disagree, please explain: | terms | Key Question 9 | ||||
| Additional Information: | terms | |||||
| 32 | When do you require notification of a specific claim? | % of Specific Deductible or | ||||
| Amount of Claim, or | RFI 20 | |||||
| Or other, please explain: | ||||||
| Additional Information: | Less important | terms | ||||
| How often do you require specific claim reporting information? | Details: | RFI 21 | ||||
| What is the timing for filing of an specific claim? | Details: | RFI 21 | ||||
| How is the claim filing period extended due to COVID-19 ("Outbreak Period" or other extensions) | Details: | RFI 21 | ||||
| Define specific deductible claim accumulation definition vis-à-vis individual v family? | Details: | RFI 21 | ||||
| 33 | Will you guarantee you are responsible for getting claims data directly from the payor? | Yes No | organizational structure | RFI 8 | ||
| If no, then please explain. | ||||||
| Additional Information: | ||||||
| 34 | BUCA Reconciliation: Will you commit to reconcile issues with BUCA's? | Yes No | ||||
| If no, please explain: | Key Question 7 (split into 2 questions) | |||||
| Additional Information: | less important | terms | ||||
| 35 | Who are your preferred TPA's? Will you commit to reconcile issues with them? | Preferred TPA's | ||||
| Yes No | ||||||
| If no, please explain: | less important/all typically have this | terms | New | |||
| Additional Information: | ||||||
| 36 | Do you offer any special contract provisions or features (please include potential cost)? | Details: | New | |||
| 37 | If you cover hospitals then what is your domestic reimbursement percentage? | Details: | New | |||
| 38 | Does your organization offer “preferred provider network” pricing based upon the client’s network(s)? | Details: | New | |||
| If yes, provide a listing of the preferred provider networks your organization has rated; identify the status level for each and the associated percentage of savings discount. | ||||||
| Details: | New | |||||
| 39 | Are there any networks ineligible? | Details: | New | |||
| 40 | How are you effectively managing large claims? | Details: | New | |||
| 41 | How many business days, on average, does it take to underwrite stop loss for a group? Does the amount of time change during peak season? | Details: | New | |||
| 42 | Will you offer 2, 3, 4 and 5 tier quote options when requested? | Details: | New | |||
| less important/all typically have this | terms | |||||
| HEALTHCARE REFORM RELATED | RESPONSES | |||||
| 43 | External Review Appeals | Please explain: | ||||
| Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop-loss policy) and denied by the claim administrator is subject to appeal. A claim properly incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. | Less important | procedure | RFI 22 |
| How does your organization address claims that were denied in one coverage period and paid in another coverage period? | ||
| less important | procedure |
| I understand and hereby certify that all information provided in this RFI is true and correct. | ||||
| Questionnaire Completed By | ||||
| (typed signature is acceptable) | marginally important/usually don't have issues | procedure | ||
| Title | ||||
| Stop Loss Provider Name | ||||
| Date | ||||
| Email Address | ||||
| Phone Number | ||||
| procedure |
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File details come from the government source that posted it. Updated .