2. Revised Attachment A - Administrative Requirements.pdf

RFP No.: DMS-24/25-312 Attachment A: Administrative Requirements Page 1 of 20

REVISED ATTACHMENT A: ADMINISTRATIVE REQUIREMENTS

The Contractor shall comply with and provide Services in accordance with the Administrative Requirements (which have been designated “AR” numbers) contained herein.

Should the Contractor become aware at any time that they are not in compliance with any AR, the Contractor will notify the Department’s Contract Manager immediately in writing. The Contractor is solely responsible for all costs associated with complying with and demonstrating to the Department compliance with these ARs.

I. IMPLEMENTATION

AR-1 The Contractor shall submit the Final Implementation Plan to the Department for approval no later than ten (10) Calendar Days from the Effective Date of the Contract. If the Final Implementation Plan is not determined by the Department to be sufficient, the Contractor will diligently work to revise and deliver a final Implementation Plan which is satisfactory to the Department. The Final Implementation Plan shall be based on the proposed plan submitted in response to question six (6) eight (8) of Attachment F: Technical Proposal.

The Final Implementation Plan shall fully detail all steps necessary to begin full performance of the Contract on January 1, 2026, 12:00 A.M., ET, specify expected dates of completion of all steps, and identify the person(s) responsible for each step. The Final Implementation Plan shall include, but is not limited to, the following implementation milestones:

(1) The development and execution of the Final Implementation Plan is subject to PG #1A and PG #1B of Attachment B: Performance Guarantees and Section 7.3 of the Contract for failure to meet the milestones identified therein.

(2) Establishing Department-approved website exclusively for State of Florida Participants by September 1, 2025.

(3) Establishing a functioning toll-free phone line(s) available to Participants by September 1, 2025.

(4) Creating Department-approved communications in advance of the Fall 2025 Open Enrollment period.

(5) Participating in Fall 2025 Open Enrollment benefit fairs and meetings coordinated by the Department or its designee.

(6) Scheduling weekly implementation status meetings with the Department’s Contract Manager. The Contractor shall record detailed meeting minutes and follow-up action items on behalf of all team members during implementation meetings.

(7) Conducting background checks in accordance with Section 4.2.4 of the Contract.

(8) Prior to Open Enrollment, the mailing of an announcement to all potential enrollees for the first year of the Contract.

(9) Testing eligibility files, reviewing key procedures and program process controls (i.e., approval, design, testing, acceptance, user involvement, segregation of duties and

Attachment A: Administrative Requirements Page 2 of 20 documentation) to the extent required by the Department. The Department must approve and accept the key elements listed prior to the Implementation Date of January 1, 2026.

(10) Designing and presenting to the Department for approval all communication materials to be used for Plan Participants prior to dissemination. Communication materials include, but are not limited to, Summary of Benefits, Evident of Coverage, brochures, paper Claims (reimbursement) forms, standard letters, system generated letters, templates, envelopes, posters and any other materials used to communicate with Plan Participants.

(11) Providing evidence of a disaster recovery plan sufficient to meet the requirements of this Contract. A disaster is defined as any unexpected event that disrupts normal business operations, threatens critical systems, or compromises data integrity. The disaster recovery plan information should include how often the systems backup and disaster recovery procedures are tested, when the last tests were and what the results were and should indicate how quickly the services can be replaced in the event of permanent disaster to both the hardware and software or during a natural disaster or other unplanned or planned event that may affect service. At a minimum, the Contractor shall maintain backup of State files/data and shall be fully operational within twenty-four (24) hours of a disaster. The disaster recovery plan shall include daily backup of Plan-related files/data, a contingency provision so that critical services are provided within twenty-four

(24) hours, and a fully operational provision so that all services are provided within forty-eight (48) hours of activating the disaster recovery plan at the same or better level of service as before the disaster recovery plan was activated. Any changes to the plan throughout the term of the Contract must be sent to and approved by the Department.

(12) Identification of an implementation team. Identifying roles for each member of the implementation team.

AR-2 The Contractor and all applicable Services shall be one hundred percent (100%) operational prior to the Implementation Date of January 1, 2026, 12:00 A.M., ET.

AR-3 Corrective Action Plan

The Contractor shall develop and submit a Corrective Action Plan (CAP) upon request by the Department within ten (10) Calendar Days of the request. The CAP must outline the steps necessary to address the identified issues and is subject to the Department’s approval.

(1) The Contractor must submit the CAP to the Department for review and approval.

(2) If the CAP is not approved, the Contractor must revise it based on the Department’s feedback and resubmit within five (5) Business Days for further approval.

(3) Upon approval, the Contractor must fully implement the CAP within ten (10) Calendar Days of approval.

II. ACCOUNT MANAGEMENT

AR-4 Account Manager

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The Contractor shall designate an Account Manager as the primary contact for the Department as identified in Section 11.6 of the Contract.

a. The Account Manager shall participate on the implementation team and coordinate, troubleshoot, advance, and track the State’s interests and requests throughout the organization.

b. If requested by the Department, the account manager shall be replaced with one that the Department approves.

AR-5 Account Management Team

The Contractor shall assign an Account Management Team which shall include an executive sponsor and an Account Manager. The Account Management Team shall meet the following requirements:

a. Devote the time and resources needed to successfully manage the State of Florida account including, but not limited to, being available for virtual, telephonic, email and on-site consultations.

b. Be thoroughly familiar with the Contractor’s functions and operations related directly or indirectly to the Department and the Plan including, but not limited to, customer service operations, claims and enrollment systems, and systems reporting capabilities.

c. Maintain a current Account Management Team organizational chart.

d. Promptly notify the Department of any changes to the Account Management Team, including provision of an updated organizational chart.

AR-6 Meetings / Conference Calls

a. Weekly Meetings: The Contractor shall hold weekly implementation status meetings with the Department’s Contract Manager. The Contractor shall record detailed meeting minutes and follow-up action items on behalf of all team members during implementation meetings.

Account Management Team meetings shall be conducted as follows:

b. Quarterly Meetings: The Contractor’s Account Management Team (excluding the executive sponsor) shall attend all Department scheduled quarterly performance review meetings in-person at the State offices in Tallahassee, Florida, via web conferencing, or via telephone conference call, as determined by the Department.

Quarterly reports are due within forty-five (45) Calendar Days following each quarter’s end and quarterly reviews to be scheduled within sixty (60) Calendar Days following each quarter’s end unless an extension is requested and granted by the Department. The meeting to review the fourth quarter of a calendar year is considered both a quarterly and year-end meeting. The fourth quarter meeting shall include review of both quarterly and annual calendar year reports and Deliverables.

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c. Agenda: At the Department’s request, Contractor may provide a draft agenda two Business Days in advance of a meeting, allowing changes to the agenda and a reasonable opportunity to prepare for the meeting. The Contractor and Department will discuss issues such as Performance Guarantees, quality assurance, operations, network status and access, benefit and program changes or enhancements, legislative matters, audits, cost trends, utilization patterns, program outcomes, customer service issues, future goals and planning and other issues reasonably related to the Contract. Contractor shall address performance and compare the Plan(s)’s experience to 1) national trends, 2) Contractor’s total book of business, and 3) other governmental clients.

d. Minutes: The Contractor’s Account Management Team shall submit draft meeting minutes to the Department within two (2) business days following each meeting.

The Department will review the draft, make any necessary revisions, and return it to the Contractor for finalization.

The Contractor shall provide the Department with the final approved meeting minutes within two (2) business days of receiving the Department’s revisions. The minutes shall include:

• A comprehensive summary of the meeting agenda and key discussion points.

• A detailed list of follow-up deliverables, including descriptions and any required actions.

• Assignment of responsibilities, clearly identifying the responsible party(ies) for each action item.

• Due dates for all follow-up tasks to ensure accountability and timely completion.

e. Other Meetings: Progress meetings, issue meetings and emergency meetings shall be held as needed. Either Party may call such a meeting, subject to reasonable notice. Any meeting held in person shall be at the State offices in Tallahassee, Florida. Contractor shall be available to attend any and all contract oversight meetings as may be required by the Department in compliance with section 287.057(26), Florida Statutes.

III. SUPPORT SERVICES

AR-7 Open Enrollment Benefit Fairs

The Contractor shall participate at all locations of the annual Open Enrollment Benefit Fairs that are sponsored by the Department or its designee. The number of fairs and locations may vary each year or may be held through webinars or other virtual options at the discretion of the Department. Contractor representatives attending the Benefit Fairs shall be adequately trained and knowledgeable about the MA-PD Insurance Plan. In past years, the Department held approximately twenty-four (24) in-person fairs statewide in the Fall; however, the Contractor should be prepared for either format as well as additional locations as required by the Department.

Contractor shall educate Participants and prospective Participants on Plan benefits, services, and other tips to ensure a positive participant experience. The Contractor shall be responsible for all

Attachment A: Administrative Requirements Page 5 of 20 costs associated with participating in benefit fairs including, but not limited to, travel and a proportionate share of facility fees. A notification regarding open enrollment should be sent to all potential Subscribers before the commencement of open enrollment for the initial year of the Contract.

The Contractor shall not discuss with Participants or prospective Participants or in any manner allude to coverage, products, or materials other than those explicitly related to the Plan without the permission of the Department.

AR-8 Plan Material

The Contractor shall provide all CMS approved marketing, promotional, educational, or any other materials, or written communication related to the Plan, to the Department for review and written approval at least 30 Calendar Days prior to its use and dissemination. The Department shall be provided the opportunity to customize all such communications. The final materials used by the Contractor must not differ in form or utility from those approved by the Department. The Contractor shall be responsible for the development of Plan benefit information including, but not limited to,

1) open enrollment brochures and promotional pieces and 2) other Plan-related printed materials (e.g., Summary of Benefits, Evidence of Coverage, Annual Notice of Change, and benefit brochures). The Contractor shall also meet the following requirements:

a. Be responsible for writing, printing, and distributing (electronically or by mail as required) Plan materials and any additional educational materials as needed.

b. Upon Department request, provide Participants printed materials in a language other than English and in a medium widely accepted for the hearing and/or visually impaired.

c. Provide all printed material in electronic format with final versions submitted to the Department in PDF file format.

d. Provide Plan materials in formats widely accepted for participants with hearing or visual impairments within 30 Calendar Days of Department’s request.

f. As applicable or as required by state or federal laws or regulations, Contractor(s) shall pay for the expenses for printing and mailing the Summary of Benefits, Evidence of Coverage, Annual Notice of Change, and any associated forms.

g. Contractor(s) shall assist the Department (i.e., review, clarify, edit, and confirm accuracy) as requested in developing Department communications on the Plan including but not limited to the Summary of Benefits and the Department's benefit website: www.mybenefits.myflorida.com.

e. After initial enrollment, Participants shall receive communication materials welcoming Participant to the Plan.

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AR-9 Membership Materials

Contractor(s) must mail enrollment materials to new Enrollees within four (4) Business Days of receiving the enrollment data file or notice from the Department, its designated agent, or as required by state or federal regulations. The mailing must include:

• A flyer, letter, or other communication providing instructions on where to access the Summary of Benefits, Evidence of Coverage, Annual Notice of Change, how to select a Primary Care Provider (PCP), and other relevant Plan and enrollment details.

• The Member Identification Card (ID).

Additional Membership Mailing Details:

• The mailing may include a customized greeting and form letter tailored to new Enrollees.

• Letters may summarize key information from the Summary of Benefits and highlight critical details, such as how to obtain referrals to specialists or access urgent or after-hours care.

Regulatory Compliance:

• If CMS regulations or any federal or state laws mandate the physical mailing of the Summary of Benefits, Evidence of Coverage, Annual Notice of Change or other required materials on an annual or other specified basis, those regulations will take precedence over State requirements. However, Contractor will provide the State with those requirements in detail and confirm compliance with those CMS requirements no less than annually or as otherwise specified.

AR-10 ID Cards

Contractor(s) shall issue ID cards to new Enrollees in compliance with CMS requirements for format, design, and distribution.

• ID cards must adhere to all State standards and include the necessary medical benefits information.

• While the Enrollee’s Social Security number shall be maintained in the Contractor(s)’s information system as the number of records, it must not be displayed on the ID card.

Contractor(s) must ensure ID card issuance aligns with regulatory requirements, industry best practices, and security protocols to protect Member information.

AR-11 Formulary Changes

a. Regulatory Compliance – Contractor shall comply with all CMS requirements regarding formulary changes, ensuring timely and accurate notifications to impacted Members and their prescribing providers.

Advance Notice Requirements – Contractor must provide written notification to affected Members and prescribing providers at least 60 Calendar Days before any formulary change that:

• Removes a drug from the formulary.

• Alters the drug’s cost-sharing or tier placement.

• Adds new prior authorization, step therapy, or quantity limits.

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Notification Content – The written notice must include:

• The name of the affected drug and the nature of the change.

• The reason for the change (e.g., formulary review, safety concerns, market withdrawal).

• Alternative covered drugs in the same therapeutic category and expected cost-sharing details.

• Instructions on how Members may request an exception or appeal the change.

b. Emergency Formulary Adjustments – If a drug is removed due to an FDA recall or manufacturer withdrawal, Contractor must provide immediate notification to impacted Members, providers, and the Department, ensuring Members have continued access to appropriate alternatives.

Reporting & Documentation – Contractor shall submit a report to the Department detailing:

• All formulary changes made during the reporting period.

• The number of impacted Members.

• Copies of Member and provider notifications.

• Any related coverage determination or exception requests received.

AR-12 Public Records Requests and Subpoenas

The Contractor shall, upon request, provide the Department with any necessary data, documents, etc., to enable the Department to timely (as defined by the Department) respond to Public Record Requests and subpoenas.

The Contractor may receive public records inquiries or subpoenas relating to the Plan. The Contractor shall notify the Department immediately in writing of such inquiries. Any response or material responding to such an inquiry shall be submitted to the Department for approval prior to dissemination by the Contractor.

AR-13 Responding to Requests

The Contractor shall, upon request of the Department or its attorneys, make available all necessary resources to assist the Department in responding to any aspect of Services delivered under the Contract including, but not limited to, Departmental inquiries or those received by the Department from Participants, providers, or any other persons or entities. Such requests shall 1) be given a priority status, 2) be subject to a method of tracking, 3) result in the delivery of all requested information, documentation, etc., and 4) be overseen by a lead staff person specific to the subject matter area. When the Department is required to provide immediate responses to inquiries, the Contractor shall immediately assist the Department in preparing its reply including providing data and documentation within the timeframes prescribed by the Department at that time.

AR-14 Responding to Requests for Legislative Initiatives

The Contractor shall make available all necessary resources to assist the Department in responding to bill analysis, legislative inquiries, and requests related to any aspect of Services delivered under the Contract. The Contractor shall respond in the timeframe set by the

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Department, which shall be determined at the time of inquiry depending on the scope and complexity of the request.

AR-15 Returned Mail

The Contractor shall hold returned mail for thirty (30) Calendar Days, during which time the Contractor shall search for an updated address within each subsequent enrollment file received from People First and, if located, re-send the communication. After thirty (30) Calendar days, if no updated address information is provided via the subsequent enrollment file, the Contractor shall store copies on its document imaging system and destroy the returned mail.

AR-16 Grievance Procedures

The Contractor shall develop and maintain formal and informal grievance procedures designed to fairly and expeditiously resolve problems related to the Plan. The procedures shall be made available to the Department during Implementation. The Contractor shall maintain a record of all grievances from Participants and shall provide a summary of grievances to the Department via Quarterly Reports, or more frequently upon request.

The Contractor’s system must indicate type or topic of the written correspondence and corresponding dates that individual mailings are provided to specific Participants.

AR-17 Care Management & Utilization Management

Contractor shall establish and maintain comprehensive policies and procedures for care management and utilization review to ensure efficient, high-quality, and cost-effective healthcare services under the Plan(s). These processes must include:

a. Pre-certification for medical procedures and treatments.

b. Prior authorization for medications, diagnostic tests, and specialized services.

c. Concurrent review and discharge planning for inpatient admissions to facilitate timely, coordinated care.

d. Retrospective clinical review to assess appropriateness of past care decisions.

e. Implementation of proactive care management programs, including chronic disease management, case management, and Member engagement initiatives.

f. Development of future care management programs as needed to enhance service delivery and cost containment.

g. Utilization of an automated system for medical benefits management, capable of generating utilization statistics, trend analyses, and care management interventions.

h. Implementation of an automated platform for identification, tracking, and management of care management activities, ensuring compliance with regulatory and contractual obligations.

Contractor must ensure that all care and utilization management activities are conducted in alignment with state and federal regulations, industry best practices, and Member-focused care standards.

IV. CUSTOMER SERVICE

AR-18 Customer Service Unit

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The Contractor shall maintain a Customer Service Unit to perform all aspects of customer service to assist Participants, prospective Participants, etc., regarding all aspects of the Plan. Calls to this unit must be promptly accepted and answered by a live customer service representative or an Interactive Voice Response Unit (IVRU) during business hours (8:00 AM to 5:00 PM ET, Monday through Friday, excluding State holidays as outlined in Section 110.117, F.S.).

Additionally, the IVRU must be available 24/7 to ensure continuous access to support. The Customer Service Unit shall have the capability to adequately provide service and issue resolution, as well as sufficient numbers of qualified personnel trained in the administration of the Plan to meet or exceed related Performance Guarantees.

a. The Contractor shall ensure a sufficient number of toll-free phone lines are available at the required times to specifically address Participant inquiries. It is the responsibility of the Contractor to determine the appropriate number of lines required to effectively serve all Participants and prospective Participants.

b. The Contractor shall ensure the calls to the toll-free phone lines are answered within thirty (30) seconds or less.

c. The call abandonment rate for the dedicated toll-free customer service phone lines, where the caller disconnects before reaching a live customer service representative, shall not exceed three percent (3%) of total calls.

d. Toll-free phone lines downtime must be reported to the Contract Manager including the expected timeframe and a detailed reason for the downtime.

e. The Contractor shall furnish to the Department within 24 hours of the request a recorded call to the Customer Service Unit.

f. The Customer Service Unit shall have the ability to monitor and gauge call center statistics encompassing metrics like average speed to answer, abandonment rate, average length of call, average hold time, Interactive Voice Response (IVR) self-service interactions, and reasons for calls and generate reports including such metrics.

g. The Contractor shall ensure that at least 95% of all calls received by the Customer Service Unit result in accurate information being provided to the Participant. Calls requiring additional research are excluded from this measurement. The Contractor shall perform quarterly audits using a statistically valid sample and submit the audit results to the Department.

h. The Customer Service Unit shall have the ability to adequately provide service and issue resolution, as well as sufficient numbers of qualified personnel trained in the administration of the Plan to meet or exceed related Performance Guarantees.

i. The Contractor shall resolve at least 90% of all caller inquiries during the initial call, excluding appeals, billing corrections, and complex escalations. A quarterly audit must be conducted using a statistically valid sample to assess compliance. Results of this audit must be submitted to the Department along with corrective actions for any deficiencies.

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AR-19 Written Inquiries

The Contractor is responsible for acknowledging and resolving written inquiries related to the Plan—including communications received by mail, email, and fax from Participants—within twenty-one (21) calendar days. The Contractor shall monitor its performance in meeting this requirement and report compliance results to the Department on a quarterly basis. Reports must include the total number of inquiries received, timeliness of responses, and any trends or issues identified.

AR-20 Plan Website

The Contractor shall provide and maintain a Plan-specific Participant website, with access twenty-four (24) hours a day, seven (7) days a week, for general Plan information. The design and content of the Plan website must be approved in advance by the Department. This website shall include links to the Department website, the Contractor (non-Participant) website, and other sites as appropriate to make a variety of information related to the Plan available to Participants. Such web- based access shall include, at a minimum, the ability to access forms and brochures.

Members and non-members must be able to access information regarding the Plan.

Unscheduled website downtime shall be reported to the Contract Manager immediately, including the expected timeframe for the patch or repair and a detailed reason for the downtime. Any period of downtime where the website is not functional that exceeds twenty-four (24) hours from start to finish will be subject to the associated financial consequence in Attachment D, Performance Guarantees.

AR-21 Participant Satisfaction Surveys

The Department’s primary interest is ensuring that Participants have a positive and satisfactory experience with the Plan. To support this, Contractor(s) shall conduct an annual Participant Satisfaction Survey to gauge overall Member satisfaction, service quality, and perceived effectiveness of the program.

Survey Methodology & Standards, The survey must:

a. Follow established industry best practices (e.g., CAHPS or CMS Star Ratings methodology).

b. b. Include measurable indicators such as responsiveness of customer service, provider access, claims processing, and satisfaction with prescription drug benefits.

c. c. Be designed to yield actionable insights that support ongoing service improvement.

Department Oversight & Independent Evaluation

a. The Department reserves the right to conduct its own Member satisfaction survey or commission an independent third party to administer it.

b. The Department may select the survey instrument and methodology to ensure objective evaluation and comparability across Contractors.

Performance Evaluation & Corrective Action

a. Survey results will be used to evaluate contract performance and identify areas for improvement.

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b. If results indicate unsatisfactory performance, Contractor(s) must develop and implement a Corrective Action Plan (CAP), subject to Department approval.

c. The CAP must include specific improvement measures, timelines, and accountability mechanisms to address deficiencies.

d. Actions taken in response to previous survey findings.

AR-22 Appeal Services

Respondent(s) shall administer Member appeals in full compliance with the appeals process established by the Centers for Medicare & Medicaid Services (CMS), ensuring adherence to all applicable federal regulations, timelines, and procedural requirements.

a. Respondent(s) shall provide clear instructions and timely assistance to Members navigating the appeals process.

b. Appeals must be tracked, and Members must receive status updates in accordance with CMS guidelines.

c. Respondent(s) shall maintain detailed records of all appeals, including outcomes and resolution timelines.

d. The Department reserves the right to audit and review appeal processing data as part of contract compliance.

V. Data and Interface

AR-23 Protection of Protected Health Information (PHI)

In accordance with Attachment F L (PRIVACY, SECURITY, AND CONFIDENTIALITY BUSINESS ASSOCIATE AGREEMENT), Contractor shall implement and maintain a comprehensive data protection framework that ensures the confidentiality, integrity, and availability of Protected Health Information (PHI) in compliance with HIPAA Privacy, Security, and Breach Notification Rules, as well as all other applicable federal and state regulations.

AR-24 Breach Notification & Incident Response

Contractor shall comply with the Breach Notification and Incident Response requirements set forth in Attachment F L (PRIVACY, SECURITY, AND CONFIDENTIALITY BUSINESS

ASSOCIATE AGREEMENT).

AR-25 Eligibility Determination & Enrollment Compliance

The Department or its designated agent is solely responsible for determining the eligibility of Enrollees and their Eligible Dependents for health insurance benefits under the MA-PD plan.

Contractor shall enroll all eligible individuals as determined by the Department and provide health insurance benefits in accordance with contract terms.

If an Enrollee or Eligible Dependent is deemed ineligible for the MA-PD plan, the Contractor must:

a. Notify the Department of the ineligibility determination within two (2) Business Days of receiving the enrollment file.

b. Ensure that no coverage is activated for ineligible individuals to prevent billing or claims processing errors.

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Contractor(s) must verify the accuracy of enrollment files upon receipt and promptly report any discrepancies to the Department.

Contractor(s) shall implement secure data exchange protocols to ensure compliance with HIPAA and CMS enrollment processing standards.

AR-26 Notification of Compliance Changes

Contractor(s) must notify the Department within 24 hours if they or their provider network experience loss or suspension of accreditation, service area approval, licenses, or liability insurance or regulatory changes that impact plan operations or Member access.

Notifications must be submitted electronically to the Department’s designated contact and include the reason for the change and potential impact and planned corrective actions and timeline for resolution.

Contractor(s) must submit a formal remediation plan within five (5) Business Days and cooperate with any Department compliance reviews.

AR-27 The Contractor shall be fully capable of accepting and implementing enrollment and other data files via a secure file transfer protocol (SFTP) on or before October 1, 2025.

AR-28 The Contractor shall not use, or otherwise disseminate, sell, copy, or make available to any person or entity data obtained through or relating to any aspect of the performance of the Services, without prior written authorization of the Department. This requirement shall survive the termination of the Contract.

AR-29 Enrollment File Transfer from the Department

The Contractor shall maintain an information system capable of electronically receiving and updating Participant eligibility information (e.g., eligibility, name, address, coverage code). The Contractor shall accurately convert and load the Department’s eligibility files.

The Contractor shall also:

a. Maintain enrollment records for all Participants based on the Department’s eligibility files submitted to the Contractor.

b. Maintenance Maintain enrollment records shall be in compliance with the required Gramm- Leach-Bliley Act standards.

c. Not overwrite, update, or in any way change the enrollment information without express direction from the Department. The Department’s enrollment file shall be the official system of records.

d. Accept from the Department the enrollment files in a format and frequency as required by the Department. The current enrollment file format and delivery schedule is in Attachment D: Enrollment File Layout and Schedule, of the Contract.

e. Accept routine enrollment files and an annual Open Enrollment file (generally provided at the end of November following Open Enrollment). The Open Enrollment file shall not be loaded into production by the Contractor.

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f. Process the enrollment files as required in PG-23A and PG-23B of Attachment B:

Performance Guarantees.

AR-30 Submission of Paid Claims File

Contractor(s) must securely submit a complete Claims data file to the Department and/or its designated third party in the specified format and timeframe.

a. Financial Details: Total charged amount, allowed amount, discounts, deductibles, copayments, and Plan payment.

b. Provider Information: Name, location, National Provider Identifier (NPI), and Tax Identification Number (TIN).

c. Claim Details: All fields from CMS 1500 (837-P) and UB-05 (837-I) forms, including patient demographics, diagnosis codes, procedure codes, and modifiers.

d. Claim Status: Includes all paid, denied, and adjusted Claims for the reporting period.

The Department may use Claims data for audits and oversight. Failure to submit accurate, complete, and timely data is a material breach of the Contract and may result in penalties or corrective actions.

AR-31 Records Retention

Respondent(s) shall retain all records for the duration specified in the Contract or for a longer period if required by applicable state and federal laws or regulations.

VI. REPORTS AND DELIVERABLES

AR-32 Ad Hoc Reports

The Contractor shall provide, at no additional cost, ad hoc reports in formats required by the Department. The Contractor shall provide the Department with priority positioning for delivery of ad hoc report requests made by the Department or its designee regarding Plan-specific financial and statistical data, Participant Services, and utilization and claims reports. The Contractor shall acknowledge report requests within one (1) Business Day and shall provide, as part of its acknowledgment, an expected timeline for completion and delivery.

AR-33 Reports Format

Reports shall be provided in a format subject to customization and approval of the Department that provides utilization and claims reporting by Plan and by subgroup. The subgroups at a minimum are Active (includes all active employees including OPS/Variable hour employees), Vested Legislators, retirees, spouses, and dependent children. Reports shall contain all such data/details as required by the Department. Reports shall be delivered electronically to the Department and/or its designee, and in hard copy by request. Reports that contain proprietary, trade secret and/or confidential information shall also be delivered in a redacted format at the same time as the non-redacted format.

a. Complete and detailed backup/supporting documentation must be provided with submission of each report. Backup/supporting documentation must identify the source of the material.

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AR-34 Weekly Reports

Reports shall be submitted to the Department or Department's designee within two (2) Business Days of receipt of the Enrollment File

a. Reject Records Report

b. Duplicate Records Report

c. Address Errors Report

d. System Generated Subscriber Drop Report

AR-35 Monthly Reports

Reports shall be submitted to the Department or Department's designee within fifteen (15) Calendar Days of the end of the reporting month.

a. Background Checks/Persons with Disqualifying Offenses The Contractor shall provide a list of new employees, confirmation of background checks, and anyone with disqualifying offenses.

b. Paid Claims File to Department or HIMIS vendor The Contractor shall provide a paid claims file to the Department or the HIMIS vendor.

c. Paid Claims Summary Report The Contractor shall provide a summary by month of enrollment, premium collected, claims paid in the month, claims incurred in the month and incurred loss ratio. The report shall provide subtotals for the reporting period(s) and the Plan Year.

d. Part C and Part D Medicare Membership report (MMR) Within fifteen (15) Calendar Days of receipt from CMS.

e. Enrollee Invoice The Contractor shall provide a billing statement to the Department that includes the billing period, and a detailed breakdown of charges related to MA-PD plan participation, such as lives covered for the period, retroactive charges and retroactive credits.

AR-36 Quarterly Reports

Reports shall be submitted to the Department or Department's designee within forty-five (45) Calendar Days of end of the reporting quarter.

a. Performance Guarantee Report: The Contractor shall provide the Performance Guarantee Summary Report (PG Report) as developed and provided by the Department (or as developed by the Contractor if one cannot be provided by the Department). The PG Report shall include the following details:

• Grievances Summary. The Contractor shall provide a summary of grievances for

Participants to the Department.

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• Written Inquiries Response Report. The Contractor shall provide an audit report detailing the quantity of written inquiries received, a summary of inquiry subjects, and the number of inquiries resolved within the required timeframe of PG-13.

• Notice of Approved Coverage Summary. The Contractor shall provide a summary outlining the count of Participants approved for coverage and the percentage of Participants to whom notifications were distributed within five (5) Business Days.

• Call Abandonment Rate Summary. The Contractor shall provide a summary of the percentage of calls received and how many calls were abandoned in the queue where the caller disconnects before reaching a live customer service representative.

• Claims Timeliness Summary. The Contractor shall provide a summary of the total number of claims processed and the total number of claims processed within twenty (20) Calendar Days.

• Claims Payment Accuracy Summary. The Contractor shall provide a summary detailing the total number of accurately paid claims and the total number of claims sampled.

• Average Speed to Answer Summary. The Contractor shall provide a summary of the percentage of calls received by the Customer Service Unit phone line, the average response time of all calls, and the percentage of calls answered in thirty

(30) seconds or less.

• Enrollment File Upload Summary. The Contractor shall provide a summary detailing the total number of enrollment files uploaded and the number of enrollment files loaded within two (2) Business Days of receipt.

• ID Cards. The Contractor shall provide a summary detailing the number of cards mailed to Participants and the number of days the cards were issued within.

b. Formulary Changes Contractor shall submit a quarterly report to the Department detailing all formulary changes made during the reporting period, when the changes were reported to the Department, and the number of impacted Members.

c. Key Metric Cost Contractor shall provide a report showing spending, average cost per member, average cost per employee, and savings.

d. Utilization Report Contractor shall provide a utilization report showing paid claims by service and provider type.

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e. Trend Analysis Report Contractor shall provide a report identify patterns, improvements, or areas of concern related to how the plan is being used and how well it is working.

f. Network Provider Add / Delete Report Contractor shall provide a summary report that includes the number of provider adds/deletes including geographic information and net impact to the network.

g. Clinical Program Report Contractor shall provide a report detailing overview of the performance, outcomes, and effectiveness of clinical programs offered within the plan.

AR-37 Annual Reports

Reports shall be submitted to the Department or Department's designee within forty-five (45) Calendar Days of the end of the reporting year or as otherwise specified within this Attachment.

a. Renewal Report By May 1, 2028, and annually thereafter if the Contract is renewed pursuant to section 3.1.2 of the Contract, the Contractor shall submit to the Department a rate renewal report prepared and signed by an actuary with a Fellow of the Society of Actuaries (FSA) designation, subject to the Department’s approval, to validate premiums for the renewal term. The report shall include at least the following information:

i. Projection of incurred claim costs, a description of the methodology used to project incurred claims costs and justification of the use of any data not specific to the State of Florida.

ii. Detailed description of the methodology used to estimate claims trend.

iii. Disclosure of the targeted loss ratio used in the renewal calculation; and

iv. Disclosure of supporting data used in calculations, including enrollment, large claim analysis, trend analysis, demographic analysis, etc.

b. Participant Member Satisfaction Survey Report The Contractor shall annually survey a statistically valid sample of Participants using Plan Services to verify satisfaction levels relating to the Contractor’s customer service unit and other related services and to gauge satisfaction with the Plan. The Contractor will provide a copy of the survey instrument and results to the Department. The survey instrument and results reporting format shall be prescribed or otherwise approved in advance by the Department.

Approval of the survey entails both the methodology used for the survey and the calculation method to determine satisfaction as a percentage. This survey must incorporate an overall satisfaction question formulated by the Department. This data should be reported in the fourth quarter of the Plan Year.

c. Performance Bond Within thirty (30) Calendar Days of executing the Contract, and by December 31 of each Plan Year thereafter, the Contractor shall provide the Department with verification that a sufficient bond is valid and will remain in force for the calendar year as prescribed in Section 8.2 of the Contract.

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d. Insurance Certificates Within thirty (30) Calendar Days of executing the Contract, and by December 31 of each Plan Year thereafter, the Contractor shall provide the Department with verification that insurance policies are valid and will remain in force for the calendar year as prescribed in Section 8.1 of the Contract.

e. Part C and Part D Model Output Report (MOR) Within forty-five (45) Calendar Days of receipt from CMS.

f. Annual Plan Report Contractor shall submit to the Department plan experience documentation including, at a minimum, the overall loss ratio and the loss ratios. This report is due within 60 Calendar Days of the end of the Plan Year, January 1 through December 31.

g. The Contractor shall prepare and, at the discretion of the Department submit in its own capacity or as the designated agent of the Department, any and all federal or state governmental reports required by and in accordance with governing law that relate to the Contractor’s performance of the Contract. Such reports shall be prepared at no cost to the Department. This requirement shall survive termination of the Contract for reports related to work performed by the Contractor during the term of the Contract as renewed or extended.

VII. PERFORMANCE GUARANTEES AND FINANCIAL CONSEQUENCES

The parties acknowledge that Department’s actual damages likely to result from Contractor’s failure to satisfy a Performance Guarantee is difficult to estimate as of the Effective Date and do not intend for the Financial Consequences to serve as punishment. Further, the parties do not intend to create a Performance Guarantee for every material obligation under the Contract.

Accordingly, failure by the Contractor to satisfy an Administrative Requirement (or other requirement of the Contract) that does not have a corresponding Performance Guarantee may nevertheless constitute an Event of Default, as more particularly described in Section 9.1 of the Contract.

AR-38 The Department may require the Contractor to propose and implement a reasonable corrective action plan to address and correct the root cause of any missed Performance Guarantee. The corrective action plan must include a proposed implementation timeline and shall be subject to the Department’s approval.

AR-39 Contractor will advise the Department in writing as soon as possible of any circumstance or occurrence which could excuse or affect Contractor’s ability to achieve any of the Performance Guarantees. In all such cases, Contractor will cause to make all reasonable efforts to achieve the Performance Guarantees.

IX. CLAIMS PROCESSING

AR-40 The Contractor shall establish and perform all aspects of claims processing, adjudication, and payment in accordance with the Plan design.

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AR-41 Accounting System

The Contractor shall maintain an accounting system and employ accounting procedures and practices conforming to generally accepted accounting principles and standards. The Contractor’s accounting records and procedures shall be open to inspection by the Department, or its authorized representatives, at any time during the Contract period and for so long thereafter as the Contractor is required to maintain records. and such inspections shall be subject to reasonable confidentiality protocol requirements agreed to by the parties and as permitted by applicable law.

All charges, fees, costs, expenses, etc., and supporting documentation applicable to the Contract shall be readily ascertainable from such records. Supporting documentation for all charges, fees, expenses, etc., shall be readily ascertainable from such records.

AR-42 Claims Processing Timeliness

The Contractor shall process 100% of all submitted claims within thirty (30) Calendar Days of receipt. Claims not requiring additional documentation or clarification shall be considered complete and processable upon submission.

Claims that exceed this timeframe shall be considered late unless the Department has granted prior written exception.

The Contractor shall submit quarterly reports showing claim volumes and processing timeliness.

AR-43 Continuation of Services

The Respondent shall continue to perform the following services for up to sixteen (16) months following the Contract’s termination effective date, to ensure continuity and maintain the required level of service as outlined in this RFP:

a. Mailroom operations

b. Appeals processing

c. System and technical support

d. Claims entry, adjudication, and adjustments

e. Coordination of benefits

f. Customer service and call center support

g. Medical reviews, as needed

h. Issuance of payments/checks and Explanation of Benefits (EOB) statements

i. Required reporting

X. AUDITS

AR-44 The Contractor shall give the Department full access rights to perform audits, or have audits performed by a third party (selected by the Department), as determined necessary or required by the Department to ensure and validate that premiums are being expended timely, efficiently and within compliance of all governing laws and the Contract (such audits being collectively referred to herein as “AR-44 Audits” or “Audits”). Other audit rights of the Department

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(i.e., non-AR 44 Audits) are provided for in the Contract and are not subject to the terms of this Attachment A (Administrative Requirements).

AR-45 The Contractor shall make a designated, internal audit representative available to the Department or its designee throughout the entire audit process. This representative will facilitate communication and cooperation between the Contractor and the Department.

AR-46 Upon identification of any discrepancies during an Audit, the Contractor is responsible for promptly researching and analyzing the identified discrepancies.

The results of this research and analysis, along with explanations for the discrepancies, must be reported to the Department in writing within ten (10) Business Days of identification.

AR-47 The Contractor shall review draft Audit reports and provide written replies to the Department within ten (10) Business Days of receipt. Contractor’s reply will be included in final audit report.

AR-48 The Contractor shall provide one non-redacted reply to the Audit and one redacted reply to the Audit in the event confidential or proprietary information is contained within the report. Only confidential or proprietary information may be redacted.

AR-49 The Contractor shall provide a corrective action plan to address all Audit findings in the manner and timeframe designated by the Department. All Audit findings are to be completely remediated (system corrections, financial impact analyses and reimbursement, where applicable) within sixty (60) Calendar Days of the issuance of the Audit report.

AR-50 The Contractor shall reimburse impacted Participants for any financial findings identified during the internal Audit within twenty (20) Business Days of notification from the Department as to the final amount due.

AR-51 The Contractor…