2-Appendix B - Dental Questionnaire 7-10-25.docx

Questionnaire Instructions to Offerors:

***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***.

· Provide answers to the questionnaires in MS Word format.

· Provide an answer to each question even if the answer is “not applicable” or “unknown.”

· Answer the question as directly as possible.

· If the questions asks “How many…” provide a number.

· If the question asks “Do you…” indicate Yes or No first, followed by your additional narrative explanation.

· Lengthy responses may be truncated when displayed. Be concise in your response. Use bullet points as appropriate. Reconsider how to word any response that exceeds 250 words in length so that the response contains the most important points you want displayed. Responses longer than the 250 words will be truncated in review.

· Where you desire to provide additional information to assist the reader in more fully understanding a response, refer the reader of your RFP response to your appendix/attachments.

· Offeror will be held accountable for accuracy/validity of all answers.

· Remember, RFP responses will become part of the contract between the awarded Offeror and The City of Albuquerque.

· Any references to “Client” in the questionnaire refer the The City of Albuquerque. Other abbreviations include CITY for the City of Albuquerque.

MINIMUM CONTRACTUAL REQUIREMENTS

ALL OFFERORS

Indicate “Yes” or “No” as to your organization’s ability to meet the minimum requirements. Failure to complete this form and include it with your response may result in elimination from consideration.

A “Yes” response shall result in the provision being adopted in the final contract. No deviations will be accepted for “YES” answers in this section.

MINIMUM CONTRACTUAL REQUIREMENTS

1. Proposal, Interview, and Best and Final Responses Become Part of Contract: Do you agree that your written response to this RFP, written information provided as part of an interview and written responses provided during a Best and Final negotiation become part of the contract between your organization and The City of Albuquerque?

2. Agree that your proposal and pricing are not contingent on acceptance of other coverages or services outside the scope of this RFP.

3. Are each of the coverage lines included in your response free-standing and not contingent upon the CITY selecting the entire package of services being offered?

4. Effective Date of Offer: Proposal terms are guaranteed for at least 180 days from the proposal due date.

5. You agree that the Contract has a length of four (4) years.

6. Variance Provision: Any provisions relating to reevaluation of proposed rates due to variation in enrollment or other contingencies of the quote must be clearly noted in the financial section of the questionnaire.

7. Any changes in financial strength rating agencies (downgrades or upgrades) shall be disclosed to the City of Albuquerque within 30 days of the effective date of the award.

8. Proper Licensure: Do you agree to maintain proper licensure as required by any state law where it relates to the services that you will be performing for The City of Albuquerque?

9. Prior Notice of Major Operational Changes: Do you agree to provide no less than 30 day notice to the City of Albuquerque for any changes involving the sale, merger, data breaches, layoffs, participating provider facility terminations, consolidation or outsourcing of services to foreign countries that will impact The City of Albuquerque?

10. Subcontracting: Unless otherwise explained in this RFP, do you agree that you will disclose all subcontractor arrangements.

11. HIPAA Compliance: OFFEROR attests to meeting all applicable HIPAA EDI, Privacy, Security, and HITECH requirements and agrees to hold the City of Albuquerque harmless for breaches that are the result of OFFEROR actions.

12. The successful OFFEROR's proposal must contain provisions reserving these rights to City of Albuquerque:

No-Loss, No-Gain: Current participants in any of City of Albuquerque’s sponsored PPO dental will be provided coverage on a "no-loss, no-gain" basis.

13. Eligibility Rules and Uncertain Claimant Eligibility Situations: The OFFEROR agrees to the specified eligibility rules established by City of Albuquerque. The OFFEROR(s) must communicate directly with City of Albuquerque regarding any uncertain claimant eligibility situations before notifying the claimant of ineligibility.

14. No Member Communication Without Client Consent: The OFFEROR will not automatically enroll City of Albuquerque in any programs that involve any type of communication with members, without express written consent from City of Albuquerque.

15. Rights to Claims Data: Selling of the City of Albuquerque’s data to outside entities must be disclosed and approved in writing in advance by the City of Albuquerque.

16. Right to Audit: City of Albuquerque reserves the right to review and audit the PPO dental files and financial accounting data to assure that claims subject to each proposed coverage are evaluated in accordance with the plan provisions. Additionally, the OFFEROR agrees to allow for no less than one claim audit per year at no cost to City of Albuquerque using the auditor of City of Albuquerque’s choice (so long as the auditor is not a competitor or involved in any legal proceedings with the OFFEROR). The OFFEROR will cooperate with any outside auditor the City of Albuquerque selects to perform the audit. This provision shall survive the termination of the agreement between the parties for a period of two (2) years.

17. Maintenance, Ownership, and Transfer of Records:

a) The OFFEROR will be required to maintain all pertinent records for seven years.

b) The OFFEROR will be charged with the safekeeping of plan experience information; and

c) In the event of contract termination, and related to contract termination, the OFFEROR will be required to cooperate with City of Albuquerque, or their representative, in the prompt, accurate, and orderly transfer of City of Albuquerque's plan experience, claims and utilization information to City of Albuquerque or its designated succeeding dental carrier at no added fee.

18. Renewal Notification: The OFFEROR must provide any rate changes in writing with full justification by January 1 of the Calendar year for a July 1 effective date in that Calendar Year. (For example, January 1, 2026 is the deadline for rate actions effective July 1, 2026). Additionally, the OFFEROR must provide the following with each renewal package:

a. Any contract language changes requested

b. Specific justification of rate/fee changes, including the Rate Development/Underwriting Worksheet.

c. Current enrollment by rate class

d. Additional options for consideration

e. All underwriting caveats

f. Any proposed plan design or benefit changes

19. Assignment or Transfer of Rights: Do you agree that you will not assign or transfer the rights or obligations of the contract or any portion thereof, without the prior written approval of City of Albuquerque?

20. Scope of Services: Are you able to provide the services outlined in the Scope of Services?

21. Commissions: The City contracts with McGriff, a Marsh McLennan Agency as the City’s benefits consultant. The City does not seek to add another consultant or general agent through this RFP.

a) Proposal submitted must be net of commissions. Confirm.

If you answered “No” to any of the questions above, please provide an explanation below:

If your response varies based on line of coverage, please clearly indicate

Month and Year of Rating

A.M. Best

Standard and Poor’s (S&P)

Fitch

Moody’s

Weiss

2. Organization background:

a. Organization’s name.

b. Corporate headquarters address.

c. City & State that will service the City’s account.

d. Does your firm have a local office?

e. Date your firm became operational.

f. Date your firm became operational for the services requested in this RFP.(Specify dental and/or vision separately.)

g. Ownership of your firm.

3. Is your company "affiliated" with another company? If so, describe the "affiliate relationship." "Affiliated" means owned by another company, owned by a common controlling shareholder or interest, or inter-tied by contract so as to be under the dominion or influence of another.

4. If your firm is not a corporation, please advise who each of the partners, proprietors or other owners are and whether they have interest in any dental services provider firms.

5. Is your firm involved in any current litigation against or from the Client? If yes, please describe.

6. Have you been involved in litigation within the last five years arising out of your performance in the administration of a Group Dental or Vision plan? Exclude routine matters involving participants that do not reflect on your performance under the contract with your Client. If the answer is yes, explain fully.

7. a. Has your organization acquired, been acquired by, or merged with another organization in the past 24 months?

b. Is your firm anticipating restructuring or reorganizing in the next two years? (Include any major staff relocations or office closings.)

c. What is your plan for continuance of principles in the event of a reorganization or restructuring?

8. Do you understand that you are prohibited from using the IIHI for any purpose other than as required by law and further agree to promptly destroy such data if you are NOT the successful bidder?

9. Do you agree to attend the Annual Open Enrollment meeting at the City’s desired location (up to 10 meetings over the course of 3 weeks) at no additional cost?

10. Implementation:

a. What is the minimum implementation lead-time needed to initiate the proposed services?

b. List any transition issues the City should consider.

c. List any specific administrative procedures or information your firm will need from the City in order to implement your services?

11. If your company is awarded this business, how soon after notification of the award would you be able to have a draft of the:

a. Master Policy?

b. Certificate booklet?

c. ID Cards

12. Complete the following information about the individual who will be assigned as the OVERALL ACCOUNT MANAGER for the City:

Name & Title:

City/State:

Length of Time in Current Position:

13. Complete the following information about the individual from your organization who will be assigned as the PRIMARY DAY TO DAY CONTACT for the City:

Name & Title:

City/State:

Length of Time in Current Position:

14. The master contract is to reflect the elimination of the actively-at-work restrictions or deferred effective date for employees and dependents eligible on the effective date of the contract. This provision however, does not remove the liability of the prior carrier for expenses incurred with respect to the extension of benefits provisions of their contract. Indicate your agreement to this stipulation.

15. Identify any services under any subsequent contract that may be awarded as part of this RFP that are currently or planned to be performed outside the borders of the United States.

16. Do you agree to provide the City a clear path (representative phone number or email, etc.) for employees to register complaints?

17. All sample forms and communication materials should be provided for approval to the City in advance of distribution (ID cards, claim forms, enrollment forms, booklets, brochures, flyers, mailers, etc.). Do you agree to this requirement?

CUSTOMER SERVICE OPERATIONS

DENTAL

OFFEROR RESPONSE

1. Will there be a designated team of customer service representatives for the City?

2. Will you provide a toll-free customer service number for claim and benefit inquiries?

3. Are questions regarding provider billing, benefits, or member grievances covered by the same phone number? If not, please explain.

4. What hours and days are live customer service representatives available (indicate using NM time)?

5. Are your customer service representatives located in the continental US?

6. What alternative services do you provide? (i.e., Assistance for the hearing impaired, 24-hour toll-free automated benefits and eligibility, bilingual option, customer service accessible via the internet, etc.).

7. Please provide the following statistics for 2023 and 2024:

Average speed to answer: ___% within 30 seconds

Busy rate: ___ seconds

Abandonment Rate : ___%

8. Will the City have online access to address additions, terminations, and status changes?

9. Are plan participants able to access a web portal for:

a. Status of claims

b. Benefit brochure

c. ID cards

d. Cost estimator of common services

e. Cost of services by a specific provider

f. Network Provider Quality

g. Deductible/benefit maximum accumulator

10. Can the City and their designated Consultant access eligibility and reporting through a secure website?

11. What kind of reports can the City and/or their designated Consultant retrieve online?

12. What other kinds of information can the City obtain through your website?

13. Please provide a temporary login/password so the Client can evaluate your tools. (If Available)

14. What methods does your organization use to measure customer satisfaction?

15. Provide a copy of your most recent customer satisfaction survey statistics.

16. How do your providers recognize a patient as a participant in your program – voucher, ID card, electronic connection to your eligibility database, etc.? Please explain.

1. Do you contract with individual dentists, dental group facilities, or both?

2. Do you wholly own and operate the network you are proposing for the City?

3. Indicate the marketing name of the network you are proposing.

4. Provide the number of network providers that terminated in the City’s service area during the past 12 months:

a. By your organization

b. By the provider

5. What changes do you anticipate to your network over the next two years?

6. Please provide Geo Access reports using the following access standards:

For the census provided, provide a GeoAccess report to determine the following ( 6,900 employees must be used in each determination):

Reports should reflect city, state, zip code, and number of unique dental providers by zip, number of employees with desired access (as defined below) for each category AND locations (Zip Code and County) where access standards are not met including the number of employees without desired access.

a. General Dentists:

Access criteria: 2 providers within 10 miles of home zip code

b. Specialists (excluding orthodontists):

Access criteria: 2 providers within 10 miles of home zip code

c. Orthodontists:

Access criteria: 2 providers within 15 miles of home zip code

7. How does your organization measure the quality of care provided by the providers in your network?

8. How many complaints per 1,000 visits do you receive on your network providers?

9. Do any network providers include night or weekend hours?

10. Do network providers pay a membership fee to your organization?

1. Are you able to match the requested PPO Dental plan (Current & Alternates)

2. a. Does your proposed plan include any exclusions or limitations that are more restrictive than the current plan?

1. Does your proposed plan include any services that are paid in a different benefit class than the existing plan design?

1. Does your proposal include any pre-existing condition limitations?

1. If yes to ‘a’, ‘b’, or ‘c’ above, identify any differences in the Deviations Exhibit A. Do not merely refer the reader to your proposal but specifically detail in the exhibit.

3. Describe any exclusions or limitations on your orthodontia benefits.

4. Describe how treatment in progress (at initial takeover) will be covered.

5. How will orthodontic claims be adjudicated?

6. What portion of claim expenses will be honored?

7. Describe how treatment in progress will be covered if your plan is terminated during an episode of treatment.

8. What services (i.e., root canal, crowns, etc.) are covered and for what amounts?

9. Describe any missing tooth limits your plan may have for new participants.

10. Describe how you would handle a late entrant.

11. Are implants covered under the dental plan?

12. How does your plan handle a resin composite filling on teeth that traditionally would be treated with an amalgam?

13. If benefits under the City’s plan are exhausted or not covered, can members take advantage of your negotiated pricing? If not, please explain.

14. How will your plan pay benefits for students who reside outside of the state?

15. Describe how your pretreatment review system operates and the current turnaround time.

16. What additional benefits do you offer to pregnant women?

17. Does your plan allow nitrous oxide analgesia? If so, please indicate any additional costs.

18. What types of sedatives do you cover and what are the coverage limitations?

19. Do you cover temporary fillings?

20. Up to what age do you cover fluoride treatments and how often?

21. Up to what age do you cover sealants and how often?

DENTAL PPO CLAIM

ADMINISTRATION SERVICES

OFFEROR RESPONSE

1. From what location would this policyholder’s claims be processed?

1. What is your company’s claims processing turn-around time for dental claims not involving coordination of benefits?

1. Does your claim system have any protections against fraud by:

1. Providers

1. Members

1. Employees

1. Does your claim system have any protections against unbundling and/or upgrading claims? If so, describe in detail.

1. a. What cost containment/management programs are available to City of Albuquerque (i.e., precertification, utilization review, etc.)?

b. Are these programs included in your quoted premium or are they an additional cost? If an additional cost, list the cost for each individual program.

1. a. How are network claims processed?

b. Are any authorization forms necessary or ID cards required?

c. Do members pay up-front and submit claims for reimbursement or are members responsible for only plan copays, deductibles and coinsurance?

1. How are non-network claims processed?

1. How do you determine Usual, Customary, and Reasonable (UCR) for non-network dental benefits (e.g., own data, percentile of HIAA data, relative value scale, Fair Health)?

1. Does your plan use maximum allowable cost for limiting non-network allowances?

1. What UCR level have you used for non-network claims?

1. Explain how maximum allowable charges are determined geographically:

1. a. By the location of the employer, or the provider of dental services? Other? Please explain.

1. How are specific areas delineated (e.g., 5 digit zip, 3 digit zip, county)?

1. How often is data updated?

1. What steps are taken if the maximum allowable charge is un-coded?

1. How are the client and plan participants supported in their resistance to charges in excess of the maximum allowable charge?

1. How can a claimant find out what the maximum allowable charge is for a particular procedure in advance of having the procedure performed?

1. With respect to dental surgery, do you ever reimburse assistant surgeons?

1. What is the basis for such a determination

1. How is the allowance for the assistant surgeon, if any, calculated?

1. When you are COB secondary payor, do you use your UCR profiles or those of the primary carrier to determine your level of reimbursement?

1. What experience period will be used for the first renewal (e.g., first 6 months)? What period will be used in subsequent renewals?

1. How much would the group have to change in size before the credibility percentages above would vary by more than 10 percent?

1. What credibility do you anticipate assigning to the Client’s experience at:

First Renewal?

Subsequent?

1. How will projected incurred claims be estimated?

1. a. Do you agree to use client specific lag to determine paid to incurred adjustments for renewal calculations?

b. If no, describe how you adjust paid claims to incurred claims? What standard reserve factor would you use?

1. Is retention calculated as a percentage of claims, a percentage of premium, or a per capita basis?

1. What were your historic 2023 and 2024 DPPO trends and anticipated 2025 trends for your proposed plan in the greater Albuquerque metropolitan area?

a. 2023

b. 2024

c. Anticipated 2025

FINANCIAL

1. Please list all provisions relating to reevaluation of proposed rates due to variation in enrollment or other contingencies of the quote.

1. When is premium due and when is it considered delinquent?

2. How do you handle reconciliation of billing and enrollment issues?

3. How often would you audit the City of Albuquerque for eligibility discrepancies?

4. The City of Albuquerque would prefer at a minimum current month plus 60 days for retroactive terminations. What is your timeframe allowed for retroactive terminations? Is this negotiable?

REPORTING

1. Based on the attached required structure, do you agree to provide the following reports as identified in the table below? Please indicate if your report is available online to City of Albuquerque (and/or their consulting firm). Please include sample reports.

REPORTING – ALL OFFERORS

(Y or N) Online Access (Y or N) Excel (Y or N)

Dental

Enrollment (subscriber/member) by coverage tier and active/cobra.

Premiums paid

Claims paid by Status (active/cobra) and in-network vs out of network

Utilization report

Lag report

Ad Hoc Reporting Capabilities

Ability for the City to generate Ad Hoc Reports

DEVIATIONS

Offeror Name:

Signature:

Date:

Deviations

Part 1 – Instructions to Offerors: 1.5.5

Part 1 – Instructions to Offerors: 1.5.9, 1.5.10

Part 1 – Instructions to Offerors: 1.23.1

Part 1 – Instructions to Offerors: 1.23.2

Part 1 – Instructions to Offerors: 1.23.3.1

Part 1 – Instructions to Offerors: 1.23.4, 1.23.5