122435 O5 - Attachment D - Performance Guarantees.xlsx
XLSX spreadsheet 24 KB Posted
- Attached to
- Administrative Support Services for the State of Nebraska Employee Health Care Medical Benefit Plans
- Solicitation number
- 122435 O5
- Issued by
- Lancaster County, Nebraska
About this file
This file is a Performance Guarantees (PGs) Attachment D document for the State of Nebraska's Administrative Support Services for Employee Health Care Medical Benefit Plans, associated with Solicitation Number 122435 O5. The document outlines detailed performance standards and potential financial penalties for a third-party administrator managing the state's self-insured medical plans. The contract will run from execution through June 30, 2029, with options for two additional one-year renewals, covering approximately 17,500 employees and 13,600 enrolled members. Performance guarantees span multiple service categories including implementation readiness, member services, claims processing, reporting, eligibility management, communications, satisfaction surveys, and clinical program engagement, with annual fees at risk ranging from 0.50% to 1.50% depending on the specific performance metric.
The performance guarantees establish rigorous standards across key operational domains, requiring 99% or higher accuracy in claims processing, 98% member satisfaction, rapid response times for inquiries, and specific benchmarks for member website availability, ID card distribution, and clinical program engagement. Financial penalties are structured to incentivize high-quality service delivery, with administrators required to self-report results and allow independent state auditing. The document emphasizes comprehensive performance measurement, including quarterly and annual assessments of service levels, with specific focus on areas such as HIPAA compliance, legislative updates, case management referrals, and clinical program effectiveness. Vendors must demonstrate the ability to manage complex administrative requirements while maintaining high standards of member service and operational efficiency.
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Text version
PGs
| Attachment D | ||
| Performance Guarantees | Bidder: | NAME |
| Solicitation Number: 122435 O5 |
| The State of Nebraska (the State) and the selected Administrator will enter into a performance agreement with the standards and guarantees/penalties outlined below at risk each year for the duration of the Contract based on actual performance. The following describes the minimum performance guarantees that the State will include in the contract with their selected Administrator. The Administrator will self-report results and the State will utilize their partners and internal staff to validate reported baseline and results for these outcomes. Administrator agrees to the State's right to independently audit and confirm all results. In the column titled "Confirm", indicate that you agree to meet the minimum criteria established by the State (Yes). Additional Performance Guarantees and/or fees at risk are encouraged. All measurements and standards are specific to the State's services, and not to be based on Administrator's performance for their book of business, or any other group that includes non-the State members. |
| What percent of total administration fees are you willing to put at risk?:___________________________________ (Answer Required) |
| Service/Task | Service Level Target | Measurement | Reporting & Assessment Intervals | Annual Fees at Risk | Confirm (Y/N) |
| Implementation and Go Live Dates | |||||
| Implementation Readiness - Contract Year 1 | 100% of Medical Administration services will take effect and be fully operational on the 'go live' date(s) as specified in the Contract. | Measured by Administrator's report of initial 'go-live' readiness, reported no later than 5 business days prior to the initial 'go-live' date; and the State's service experience during the month following the 'go-live' date. | One-time assessment, reported no later than one month after the initial 'go-live' date. | 1.00% | |
| Annual 'go live' Readiness - (for all subsequent Contract Years) | 100% of Medical Administration services will take effect and be fully operational on the 'go live' date(s) as specified in the Contract for each plan year. | Measured by Administrator's report of service readiness, reported no later than 5 business days prior to each annual plan-year effective date; for contract years 2 and 3; and the State's service experience during the month following each subsequent annual plan-year effective date. | Reported and assessed annually (ongoing) Note: this PG is not applicable to Year 1. | 1.00% | |
| Medical Prior Authorizations and Medical Pre-certifications | 100% of existing Medical Prior Authorizations and Medical Pre-certifications will be honored without disruption to the member. | Contractor confirms that any members will have existing Medical Prior Authorizations and Medical Pre-certifications honored and processed without disruption. All Prior Authorizations and Pre-certifications should processed within 2 business days of receipt. | Reported quarterly, assessed quarterly | 0.50% | |
| Plan Design Administration | |||||
| Medical Plan Design Administration | The Medical Plan will be administered according to plan design specifications including but not limited to copays, coinsurance, deductibles and Maximum Out of Pocket limits. | Measured by Administrator's report of Medical Plan Reporting to be delivered to the State to later than 30 business days after the end of the plan year. | Reported and assessed annually | 1.00% | |
| Member Services | |||||
| Average Speed of Answer (ASA) | 100% of all inbound the State-specific Member calls will be answered within 30 seconds for member calls selecting a live Member Service Representative (MSR). This excludes calls abandoned before answering. This standard will be measured monthly and summarized in quarterly reports. | Measures 100% of inbound calls selecting a live MSR; Excludes calls abandoned before answering. Measured by the total time for all calls to be answered, divided by the total number of calls. The response level must be maintained each month. | Reported monthly, assessed quarterly. | 0.50% | |
| Telephone Abandonment Rate | Average call abandonment rate will be less than 3%. This standard will be measured monthly and summarized in quarterly reports. | The number of calls abandoned compared to total number of calls accepted into the system. Measured by Administrator’s standard internal call reports for the State-specific calls produced by Administrator’s automated phone system for all member calls. The response level must be maintained each month. | Reported monthly, assessed quarterly. | 0.50% | |
| First Call Resolution | 95% of member calls will be resolved within 2 business days and 100% w/in 20 business days, with no repeat of the same call disposition in 30 days. This standard will be measured monthly and summarized in quarterly reports. | Number of total inquiries received, minus the total number of inquiries requiring follow-up. The response level must be maintained each month. | Reported quarterly, assessed annually | 0.50% | |
| Inquiry Timeliness | 100% of inquiries received from the State members that require follow-up will be resolved within 2 business days. This standard will be measured monthly and summarized in quarterly reports. | Number of inquiries resolved 2 business days with no repeat of the same call disposition within 30 days, compared to all inquiries received. | Measured monthly, reported quarterly, assessed annually | 0.50% | |
| ID Cards | 98% of ID cards will be mailed to the State's members within five (5) business days and 100% w/in 10 business days following receipt of valid enrollment documentation and processable eligibility tape or transmission during the Plan Year. | Measured as the percentage of ID cards mailed within 5/10 business days following receipt date of valid enrollment documentation and processable eligibility tape or transmission or 5/10 business days following date member requests additional or replacement ID cards. The response level must be maintained each month. | Reported quarterly, assessed annually | 0.50% | |
| Member Website Availability | Administrator's website will offer continuous online, real-time access, allowing downtime only for scheduled maintenance. Administrator website available and fully operational 99.99% of the time, except for scheduled maintenance. This standard will be measured monthly and summarized in quarterly reports. | Total 'live' operational and accessibility time, divided by the difference of total time less maintenance time. The response level must be maintained each month. | Reported quarterly, assessed annually | 0.50% | |
| Member Website Content | Administrator's website for the State's members will be maintained with current, up to date plan design and benefits information. Updates of changes approved by the State will be posted within 14 calendar days of approval. Updates include but are not limited to SPD(s), and other forms and materials associated with the benefit plan. | Administrator and the State staff will set standards and timeframes for measuring Administrator's ability to maintain website with up to date materials and information; Administrator will maintain an issues log, to track response and resolution timeliness. The response level must be maintained each month. | Reported quarterly, assessed annually | 0.50% | |
| Account Management/ Client Services | |||||
| Trend Review | At least quarterly, within 45 days after the close of a calendar quarter, Administrator will conduct a review, with the State, of the most recent statistical analysis by type of service and emerging trends data. | Administrator and the State staff will determine items to be addressed in Trend Review reporting, including but not limited to statistical analyses by type of service and emerging trends data. | Reported quarterly and assessed annually. | 0.50% | |
| Acknowledgement of inquiries/complaints from State staff | Administrator to acknowledge all inquiries and/or complaints from the State staff, whether made via phone or email, within 1 business day. Additionally, Administrator will initiate a resolution plan, and when requested, create a corrective action plan, within 2 business days of initial notification. | Administrator will maintain an issue log to track response and resolution timeliness. At a minimum, the log will capture each inquiry or complaint, action taken, long term solution if inquiry or complaint reveals an underlying issue with current process(es) and duration of inquiry or complaint from initial reach out to final resolution. Log will be presented to the State staff at each quarterly meeting. | Reported quarterly, assessed annually | 0.50% | |
| Contracting Cooperation | Contractor will adopt contract language changes recommended by the State 100% of the time. | Confirmation of adoption of language changes recommended by the State within 15 business days. | One-time assessment, reported no later than one month after the contract is finalized. | 0.50% | |
| Quarterly Meetings | For each topic being presented or discussed, Administrator will identify a subject matter expert (SME) to participate in the meeting. Applies to all topics where at least 10 calendar days advance notice is provided. |
| Administrator will attend onsite Quarterly meetings as described in the RFP Questionnaire and in this Performance Guarantee. | Reported quarterly and assessed annually | 0.50% |
| Claims Processing | ||
| Claims Accuracy - Financial | 99% or greater of audited claim dollars finalized accurately; (vs. amount should have paid). Financial errors shall not include errors made in reasonable reliance upon the information provided by the State, participants or providers of services in connection with a claim. Processing errors shall not include errors made in reasonable reliance upon the information provided by the State, participants or providers of services in connection with a claim. | Claims financial accuracy is measured by dividing the total dollar amount of all correctly paid claims by the total dollar amount that should have been paid for all claims in the sample. Financial errors shall include, but are not limited to |
1. Incorrect application of deductibles and co-payments.
2. Payment for non-covered services under the Plans.
3. Overpayment of covered services under the Plans.
4. Failure to apply or incorrect application of any coordination of benefits provisions of the Plans.
5. Duplicate payments.
| 6. Incorrect application of limits. | Reported quarterly, assessed annually | 1.00% | |
| Claims Processing Accuracy | 97% of audited claims finalized accurately. | Claims processing accuracy is measured by dividing the total number of claims processed correctly by the total number of claims paid during the measuring period. This will result in the percentage of claims paid accurately. Errors shall include: |
1. Claim paid for the incorrect amount.
2. Claim rejected when it should have paid.
3. Claim paid when it should have rejected.
| 4. Claim did not process in accordance with contract benefits as of the date the claim processed. | Reported quarterly, assessed annually | 1.00% | |||
| Claims (Clean) Timeliness | 95% claims processed within 10 business days and 100% w/in 20 business days | Measured as the percentage of clean claims processed within 10 business of the Administrator's 'received' date, to the date the claim is adjudicated with a status of pay or deny. Claims timeliness is not indicative of the actual date of payment. No adjustments are included. | Reported quarterly, assessed annually | 0.75% | |
| Reporting | |||||
| Create and generate accurate and detailed reports as described in the RFP | Administrator will provide the minimum reporting requirements as detailed in the RFP Questionnaire. | Measured by the State's date of receipt. Reports will be delivered on the report cadence outlined in the RFP Questionnaire. | Measured by the specified report receivable timeframe and assessed annually | 1.00% | |
| Create and generate Standard Utilization and Cost reports | Administrator will provide Standard Management Reports including utilization and claim payment reports no later than 30 calendar days following the end of reporting period (i.e., quarterly, monthly, annually) unless discussed and mutually agreed upon. | ||||
| Measured by the State's date of receipt. Report shall be submitted no later than 30 calendar days following the end of specified reporting period (i.e., quarterly, monthly, annually) unless discussed and mutually agreed upon. | Measured by the specified report receivable timeframe and assessed annually | 0.50% | |||
| Eligibility | |||||
| Eligibility Loads | Update enrollment eligibility and dependent data within one (1) business day of receipt of valid electronic file transfer. | Loaded accurately, in use, and notification transmitted to the State within 24 hours of receipt. | Reported quarterly, assessed annually | 1.00% | |
| Eligibility Reconciliations | By the first business day of each month, Administrator will provide the State a HIPAA compliant reconciliation full file. |
This format is utilized to balance participation from the State records to the records of the Administrator on a monthly basis.
| Measured by Administrator's ability to provide, by the first business day of each month, consistent and accurate reporting. | Reported monthly, assessed annually | 0.50% | |
| Communications | |||
| Approval of Communications | |||
| Correspondence and information (whether written, electronic, telephonic, or in any other medium or form) developed by the Administrator and intended for Members, (e.g., open enrollment materials, network changes) must be reviewed and approved by the State prior to dissemination. | Administrator will submit correspondence and information to the State, in a timely manner, for review and approval prior to dissemination. | Reported quarterly, as applicable, and assessed annually | 0.75% |
| SPDs, Benefit Booklets and Summary of Benefits and Coverage (SBCs) |
Draft SPDs, Benefit Booklets and SBCs will be prepared by Administrator and provided to the State in a manner that highlights all changes from the State's then-existing documentation/materials. This includes updates to the State’s current SPD, Benefit Booklets and SBCs with redlines to be presented to the State for review and approval.
| The Administrator must submit draft SPDs, Benefit Booklets, and SBCs in the format specified by the State and in a timely manner, as specified in this PG, for approval prior to dissemination. | Administrator will submit SPDs, Benefit Booklets, and SBCs no later than April 1 of each year for the State's review. Administrator will finalize all SPDs, Benefit Booklets, and SBCs by May 1 each year so the State has sufficient time to process and print prior to Open Enrollment. | Reported quarterly, as applicable, and assessed annually | 0.50% |
| Satisfaction Surveys | |||
| Annual Account Management Survey | Satisfaction rate will be a minimum of 98%. | Administrator will work with the State to develop a mutually agreed upon Account Management Survey, for evaluation of the Account Management Team. Administrator will be responsible for development of a corrective action plan, to be provided to the State no later than 10 business days after survey completion to address satisfaction rates below 98%. |
| Survey results will be provided to the Administrator's Account Management Team. Results may be a topic at quarterly meetings where Administrator and the State can collaborate on appropriate actions, as necessary, based upon the feedback received. | Reported and assessed annually | 1.50% | |
| Member Satisfaction Survey | Satisfaction rate will be a minimum of 98%. Administrator will be responsible for development of a corrective action plan to address satisfaction rates below 98%. This plan to be provided to the State no later than 10 business days after survey completion. | Administrator to conduct an annual member satisfaction survey, developed by the State and the Administrator. The satisfaction survey must be administered at least annually. |
| Survey results will be provided to the Administrator's Account Management Team. Results may be a topic at quarterly meetings where Administrator and the State can collaborate on appropriate actions, as necessary, based upon the feedback received. | Reported and assessed annually | 1.50% | |||
| Compliance | |||||
| HIPAA Assessments and Breaches | Administrator will provide documentation to the State that HIPAA assessments have been performed with all results and action items fully disclosed. In addition, Administrator will notify the State immediately (within 24 hours) should a HIPAA breach occur, relevant to the State and its members. Full documentation will be made available to the State concerning all details relating to the breach. Full details must be provided on an ongoing timely basis until full resolution is reached. | Measured by Administrator's report of HIPAA Assessments and report of HIPAA breaches relevant to the State and its members. | Reported and assessed annually, as applicable | 1.00% | |
| Legislative Updates | Administrator to provide timely, legislative updates to the State. | Administrator will notify the State of any potential legislative update applicable to the administration, design, and/or cost of the State's plan(s). | Tracked and assessed annually | 0.50% | |
| Timeliness of Response to Legislative Bills and Fiscal Notes | 100% of Legislative Bills and Fiscal Notes introduced will be responded to timely, as requested by the State, and in no less than 24-hours of initial receipt. | Administrator will provide written responses regarding the potential impact of all Legislative Bills and Fiscal Notes introduced by the State and in the timing outlined in this PG. | Reported and assessed quarterly | 1.50% | |
| Health Management | |||||
| Referrals to Case Management | 90% of referrals to case management, complex case management and disease management programs (if applicable) will be outreached to within 5 business days of identification. Requires that the Administrator has valid phone number and address. Note: Administrator should contact the State for assistance in obtaining valid phone numbers and addresses. | ||||
| The Administrator will track each referral and timeliness for each outreach and present to the State quarterly. The standard must be maintained each quarter. | Measured quarterly, assessed annually | 0.50% | |||
| Screening for Case Management | 90% of members exceeding a $50,000 paid threshold (medical only) in a rolling 12 month period and members who have reached their Maximum Out of Pocket (MOOP) will be screened for case management and complex case management within 21 business days of identification. This includes outbound telephone calls for assessment. |
Standards and timeframes for data coordination with the State's vendor partners will be established and mutually agreed upon.
| The Administrator will track each screening and timeliness and present details to the State quarterly. | Measured quarterly, assessed annually | 0.50% | |
| Timely Post Discharge Counseling | The nurse team will make the first attempt to | ||
| contact 95% of qualified discharged members within 3 to 5 business days of discharge notification. | Numerator: Those in the denominator receiving a minimum of 1 outreach call attempt within 5 business days of discharge notification. |
| Denominator: Members qualified for a transitional case management (post discharge) call. | Measured quarterly, assessed annually | 0.50% | |||
| PMPM Savings: Clinical Program | Meet or exceed mutually agreed upon targeted savings for the State's Clinical Programs. | Administrator to provide suggested ROI targets and methodology. The measurement should apply to the entire population (i.e., employees and dependents). Overall measurement shall include an annual savings reporting on the ROI. | Measured quarterly, assessed annually | 0.50% | |
| Net Promoter Score (NPS) | See measurement. | Guarantees to maintain at least at 60 NPS Score. | Measured quarterly, assessed annually | 0.50% | |
| Clinical Program Engagement | Unique eligible adult members that have used any of the following services in person, digital, or via telephonic or virtual means (“engagement”): visit with a medical assistant, nurse, health coach (RD, CDE, RN) or provider (physician, advanced practitioner, physical therapist, behavioral health specialist. |
Maintain at least 35% engagement over the course of the contract. Numerator: Unique eligible adult members with engagement during the applicable 18-month period.
| Denominator: Unique eligible adult members with at least 6 months eligibility during the applicable 18-month period and eligible at the end of such period. | Measured quarterly, assessed annually | 0.50% | |||
| Disease Management | |||||
| Reduction in A1c | See measurement. | Identified diabetic members with diabetes will achieve a ≥1.0% reduction in A1c | Measured quarterly, assessed annually | 1.00% | |
| Blood Pressure Control | See measurement. | Identified hypertensive members will maintain BP <140/90 | Measured quarterly, assessed annually | 1.00% | |
| Medication Adherence | See measurement. | Achieve ≥80% medication adherence rate for targeted condition groups. | Measured quarterly, assessed annually | 1.00% | |
| Breast Cancer Screening (Mammogram) | 5% percentage points year over year Improvement. | Measurement identifies women 50 through 74 years of age during the reporting period who had a mammogram to screen for breast cancer within the past 24 months, with a 3 month grace period | Measured quarterly, assessed annually | 0.50% | |
| Colorectal Cancer Screening | 5% percentage points year over year Improvement. | Measurement identifies patients 45 through 75 years of age who received a colorectal cancer screening – look-back period varies with test type | Measured quarterly, assessed annually | 0.50% | |
| Utilization Management | |||||
| Timeliness of Prior Authorization Decisions | 100% of Prior Authorizations decisions made within the timeframes below. |
Urgent: ≤ 24 hours
| Non-urgent: ≤ 72 hours | Number of PA decisions made within the timeframes outlined in this PG, compared to PA decisions made. | Reported quarterly, assessed annually | 1.00% | ||
| Appeals Timeliness | |||||
| 98% of appeals resolved within regulatory timeframes. | Number of appeals resolved within the regulatory timeframes, compared to all appeals resolved. | Reported quarterly, assessed annually | 1.00% | ||
| Network Management | |||||
| Provider Turnover | 100% of Provider Turnover reported to the State staff and members within 30 days of termination. | Administrator will monitor turnover rates and provide notice to the State staff and members of all Provider Turnover within 30 days of termination. | Reported quarterly, assessed annually | 0.50% |
| PG Conditions |
| 1) Any penalties shall be paid to the State via ACH payment. Penalties are not to be credited to invoices or used to offset ASO fees. |
| 2) For performance guarantee measures where interface between the Administrator and the State and/or the State’s vendor(s) is required, the applicable |
| penalties shall apply to the Administrator if, and only if, the error(s) or lack of timeliness is caused by the Administrator. Penalties shall not apply to the |
| Administrator due to errors caused by the State and/or one or more of the State’s vendors. |
| 3) Performance Guarantees will be based upon the Administrator's self-reported results. Please note the State may ask for validation of reported PGs. |
&D Medical Performance Guarantees &P
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