260125_Chapter_1A_-_Attachment_Medical_Questionnaires_(MOA_and_QE)-RETURN_WITH_BID.xlsx
XLSX spreadsheet 55 KB Posted
- Solicitation number
- 260125
- Issued by
- Pima County, Tucson City, Arizona
About this file
This document is a comprehensive medical services Request for Proposal (RFP) issued by the City of Tucson for medical, telehealth, disease management, and health savings account (HSA/HRA) administration services. The RFP (#260125) seeks a third-party administrator to provide medical and behavioral health services for the city's employee and retiree population, with a contract start date of July 1st and an open enrollment period typically occurring in May. The solicitation includes detailed questionnaires covering network capabilities, physician networks, customer service, medical management, utilization review, disease management, telehealth services, and HSA/HRA administration.
The RFP requires respondents to demonstrate extensive capabilities, including maintaining a robust provider network in Arizona, offering comprehensive telehealth services, providing disease management programs, and administering HSA/HRA accounts. Proposing organizations must have at least five years of experience, a minimum of 10,000 full-service contractor-covered members, and specific qualifications such as having three Arizona clients with over 10,000 total members. The document emphasizes the city's requirements for high-quality, accessible healthcare services with strong customer support, detailed reporting capabilities, and compliance with regulatory standards like HIPAA.
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Questionnaire Instructions
| Questionnaire Instructions to Offerors: |
| ***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***. |
| Ø Provide answers to the questionnaires in MS Excel format (per instructions on the Excel files--Questionnaires. |
| Ø Provide an answer to each question even if the answer is “not applicable” or “unknown.” |
| Ø Answer the question as directly as possible. |
| Ø If the questions ask “How many…” provide a number. |
| Ø If the question asks “Do you…” indicate Yes or No first, followed by your additional narrative explanation. |
| Ø 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 200 words in length so that the response contains the most important points you want displayed. |
| Ø 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. |
| Ø RFP responses will become part of the contract between the winning Contractor and the City of Tucson. |
| Ø Any references to “Client” in the questionnaire refer to the City of Tucson. |
Answers to the questions must be provided in MS Excel format. Failure to complete the questionnaire and submit in MS Excel format without alterations will make it difficult to thoroughly understand your proposal.
&"-,Bold"&14RFP #260125 Attachment 1A - Medical
&"-,Bold"&10&F&"-,Regular" Page &P
MOA Questionnaire
| MINIMUM REQUIREMENTS | OFFEROR RESPONSE | |
| 1 | Please confirm you have been in business, performing the services being proposed herein, for a minimum of five (5) years. | |
| 2 | Confirm you have ten thousand (10,000) full-service Contractor covered members | |
| 3 | Confirm you have at least three (3) Arizona clients under contract with a minimum of ten thousand (10,000) total members per client | |
| 4 | Confirm you have at least three (3) Arizona clients under contract with a minimum of one thousand (1,000) retirees per client | |
| 5 | Confirm you have had no bankruptcy filings within the last five (5) years | |
| 6 | Acknowledge you are compliant with all City of Tucson and federal applicable regulations and currently not restricted or prohibited from conducting business in all states where City of Tucson’s members reside or access related goods and services | |
| 7 | Confirm you have no current senior officer, board member, or director with a felony conviction on record. |
Address how you will meet each of the requirements listed under Scope of Work. If you intend to provide services that differ from what is outlined in the Scope of Work, you must provide a detailed explanation of how your services will differ and why that method is an appropriate method for meeting the City’s needs in the Deviations and Exceptions section.
| NETWORK/HMO PLAN NETWORK | OFFEROR RESPONSE | ||
| 1 | What is the name of your network? | ||
| 2 | Is your health plan accredited? Please list accreditations. | ||
| 3 | Owned or Leased: | ||
| 3a | Is your Network/HMO Plan network wholly owned or leased? | ||
| 3b | If the latter, what is the name of the organization? | ||
| 4 | Is your proposed Network/HMO Plan equivalent to a gatekeeper arrangement or open access? | ||
| 5 | What types of providers are considered primary care? | ||
| 6 | Do primary care providers function as gatekeepers for referral to: | Yes | No |
| 6a | specialists | ||
| 6b | inpatient and outpatient hospital services | ||
| 7 | Can women self-refer to an OB/GYN for their annual well woman exam? | ||
| 8 | To what providers (or for what services) can participants self-refer? | ||
| 9 | Wrap Networks: | ||
| 9a | Do you use any wrap networks where the City has participants? | ||
| 9b | If yes, what is the name of the network(s)? | ||
| 10 | Describe any value based contract arrangements you have in place for the network you are proposing. | ||
| 10a | Describe the fees (including any provider incentives) associated with this program that would be charged to the City. | ||
| 10b | If the value based metrics are not met, are the fees refunded to the City? | ||
| 11 | Do any of your contracted hospital owned doctor practices or urgent care centers charge a “facility fee” when patients get care outside a hospital (e.g. Banner)? How do you assist patients in these situations in terms of cost transparency? | ||
| 12 | What is your primary reimbursement method for PCPs? | ||
| 12a | Discounted fee-for-service | ||
| 12b | Diagnostic related group | ||
| 12c | Capitation | ||
| 12d | Fee Schedule | ||
| 12e | Other – Specify | ||
| 13 | Provide details on how Outlier claims are handled. | ||
| 14 | Is your Network/HMO type network national in scope? If not: | ||
| 14a | What type of coverage is offered to plan participants who reside outside the service area? | ||
| 14b | Do you offer reciprocity arrangements for members who travel outside the service area and need emergency treatment? | ||
| 14c | Non-emergency treatment? | ||
| 15 | Is access to alternative medicine providers available? If so, please describe. | Yes | No |
| 15a | Homeopaths | ||
| 15b | Acupuncture | ||
| 15c | Massage Therapy | ||
| 15d | Naturopaths | ||
| 16 | Is the Arizona Mayo Clinic a contracted provider in your network? | ||
| 17 | Is the Arizona Mayo Hospital a contracted provider in your network? | ||
| 18 | Does your network contract with Mayo Hospital in locations outside Arizona? | ||
| 19 | Does your network contract with Mayo Clinics in locations outside Arizona? | ||
| 20 | If certain specialties (radiology, anesthesiology, etc.) or services (ambulance, etc.) are not represented in your network of providers, can you administer these claims at the in-network benefit level assuming network hospitals are used? | ||
| 21 | In the state of Arizona, can your network providers deliver services for the following specialized treatment conditions? | Yes | No |
| 21a | Care for major burns | ||
| 21b | Organ transplants | ||
| 21c | Bone marrow transplants | ||
| 21d | Specialized cancer treatments such as Proton Beam Radiation | ||
| 21e | Neonatal care | ||
| 21f | Fertility treatments | ||
| 22 | Indicate all “centers of excellence” under contract with your network in Arizona. | ||
| 23 | Can a physician limit the number of network patients accepted? | ||
| 24 | What is your average turnover ratio in the Tucson, AZ area for PCPs and specialists leaving the plan for the periods indicated? | 2024 | 2025 YTD |
| 24a | PCPs | ||
| 24b | Specialist | ||
| 25 | Can each member of the family choose a different PCP? | ||
| 26 | Size or Location: | ||
| 26a | Do you anticipate a significant change in the size or location of your network in the next year that would affect the City’s population? | ||
| 26b | If so, discuss the impact of your anticipated network changes for providers and hospitals. | ||
| 27 | Indicate any hospitals or major provider groups that have been terminated from your network in the past year in Arizona. | ||
| 28 | Indicate any major hospital contracts that are up for renewal in Arizona within the next 12 months. | ||
| 29 | If actual billed charges are less than the contracted arrangement (DRG or per diem), do your hospital contracts permit payment of the lesser amount? | ||
| 30 | Explain what happens when a member goes out-of-network for services. What are the situations in which benefits are payable? | ||
| 31 | What ratio of PCPs-to-participants do you maintain in the Tucson, AZ area? | ||
| 32 | What ratio of network specialists-to-participants do you maintain in the Tucson, AZ area? | ||
| 33 | Mental Health Providers: | ||
| 33a | List the types of mental health providers and facilities that are included in your network. | ||
| 33b | Are there any areas where the City has members and these providers are not available? | ||
| 34 | Direct Provider Contracting: | ||
| 34a | Are you able to administer direct provider contracting initiated by the City for certain community providers that may not be part of your network? | ||
| 34b | Is there an additional cost for this arrangement, and if so, what is the cost? | ||
| 35 | How many urgent care facilities do you have in your network that have after hours (nights and weekends) care within Pima County? | ||
| 36 | Indicate which walk-in clinics (Minute Clinic, etc.) are in your network? | ||
| 37 | How is continuity of care maintained if the City were to change to your organization? | ||
| 38 | Can you administer the plan so that network physicians are responsible for any pre-certification requirements and that the member will not be penalized if the provider does not follow the proper procedures? | ||
| 39 | Please describe any special provider programs or pilots you currently have in place to provide an alternative to the traditional delivery of primary care services to the City’s members to both lower cost and provide customized service. | ||
| 40 | List the Accountable Care Organizations in AZ with which you contract and the counties in which they operate. |
| NETWORK – HRA/HSA PPO PLAN NETWORK | OFFEROR RESPONSE | ||
| 1 | What is the name of your network? | ||
| 2 | Is your health plan accredited? Please list accreditations. | ||
| 3 | Owned or Leased: | ||
| 3a | Is your HRA/HSA PPO network wholly owned or leased? | ||
| 3b | If the latter, what is the name of the organization? | ||
| 4 | What types of providers are considered primary care? | ||
| 5 | Can women self-refer to an OB/GYN for their annual well woman exam? | ||
| 6 | To what providers (or for what services) can participants self-refer? | ||
| 7 | Wrap Networks: | ||
| 7a | Do you use any wrap networks where the City has participants? | ||
| 7b | If yes, what is the name of the network(s)? | ||
| 8 | Describe any value based contract arrangements you have in place for the network you are proposing. | ||
| 8a | Describe the fees associated with this program that would be charged to the City (including any provider incentives). | ||
| 8b | If the value based metrics are not met, are the fees refunded to the City? | ||
| 9 | Do any of your contracted hospital owned doctor practices or urgent care centers charge a “facility fee” when patients get care outside a hospital (e.g. Banner)? How do you assist patients in these situations in terms of cost transparency? | ||
| 10 | In the state of Arizona, can your network providers deliver services for the following specialized treatment conditions? | Yes | No |
| 10a | Care for major burns | ||
| 10b | Organ transplants | ||
| 10c | Bone marrow transplants | ||
| 10d | Specialized cancer treatments such as Proton Beam Radiation | ||
| 10e | Neonatal care | ||
| 10f | Fertility treatments | ||
| 11 | Is access to alternative medicine providers available? If so, please describe. | Yes | No |
| 11a | Homeopaths | ||
| 11b | Acupuncture | ||
| 11c | Massage Therapy | ||
| 11d | Naturopaths | ||
| 12 | Is the Arizona Mayo Clinic a contracted provider in your network? | ||
| 13 | Is the Arizona Mayo Hospital a contracted provider in your network? | ||
| 14 | Does your network contract with Mayo Hospital in locations outside Arizona? | ||
| 15 | Does your network contract with Mayo Clinics in locations outside Arizona? | ||
| 16 | If certain specialties (radiology, anesthesiology, etc.) or services (ambulance, etc.) are not represented in your network of providers, can you administer these claims at the in-network benefit level assuming network hospitals are used? | ||
| 17 | Indicate all “centers of excellence” under contract with your network in Arizona. | ||
| 18 | What is your average turnover ratio in the Tucson, AZ area for PCPs and specialists leaving the plan for the periods indicated? | 2024 | 2025 YTD |
| 18a | PCPs | ||
| 18b | Specialist | ||
| 19 | Size or Location: | ||
| 19a | Do you anticipate a significant change in the size or location of your network in the next year that would affect the City’s population? | ||
| 19b | If so, discuss the impact of your anticipated network changes for providers and hospitals. | ||
| 20 | Indicate any hospitals or major provider groups that have been terminated from your network in the past year in Arizona. | ||
| 21 | Indicate any major hospital contracts that are up for renewal in Arizona within the next 12 months. | ||
| 22 | If actual billed charges are less than the contracted arrangement (DRG or per diem), do your hospital contracts permit payment of the lesser amount? | ||
| 23 | Explain what happens when a member goes out-of-network for services. What are the situations in which benefits are payable? | ||
| 24 | What is your primary reimbursement method for PCPs? | ||
| 24a | Discounted fee-for-service | ||
| 24b | Diagnostic related group | ||
| 24c | Capitation | ||
| 24d | Fee Schedule | ||
| 24e | Other – Specify | ||
| 25 | Provide details on how Outlier claims are handled. | ||
| 26 | Is your HRA/HSA PPO network national in scope? If not: | ||
| 26a | What type of coverage is offered to plan participants that reside outside the service area? | ||
| 26b | Do you offer reciprocity arrangements for members who travel outside the service area and need emergency treatment? | ||
| 26c | Non-emergency treatment? | ||
| 27 | What ratio of PCPs-to-participants do you maintain in the Tucson, AZ area? | ||
| 28 | What ratio of network specialists-to-participants do you maintain in the Tucson, AZ area? | ||
| 29 | How many urgent care facilities do you have in your network that have after hours (nights and weekends) care within Pima County? | ||
| 30 | Indicate which walk-in clinics (Minute Clinic) are in your network? | ||
| 31 | Mental Health Providers: | ||
| 31a | List the types of mental health providers and facilities that are included in your network. | ||
| 31b | Are there any areas where the City has members and these providers are not available? | ||
| 32 | Mexico: | ||
| 32a | Describe what type of coverage would be available to members that go out of the country for routine care (i.e. to Mexico)? | ||
| 32b | Do you currently have an extended network that crosses into Mexico or a Mexico partner? | ||
| 32c | If you can partner, will your claim system recognize the Mexico network providers as in-network? | ||
| 32d | Will your system apply the plans deductible and out-of-pockets (OOP) limits to these providers (not managed under a separate deductible/OOP? | ||
| 32e | Is there any additional cost for this type of arrangement? | ||
| 32f | Do you have any plans to add or partner with any Mexico networks in the future? | ||
| 33 | Direct Provider Contracting: | ||
| 33a | Are you able to administer direct provider contracting initiated by the City for certain community providers that may not be part of your HRA/HSA PPO network? | ||
| 33b | Is there an additional cost for this arrangement, and if so, what is the cost? | ||
| 34 | How is continuity of care maintained if the City were to change to your organization? | ||
| 35 | Can you administer the plan so that network providers are responsible for any pre-certification requirements and that the member will not be penalized if the physician does not follow the proper procedures? | ||
| 36 | Please describe any special provider programs or pilots you currently have in place to provide an alternative to the traditional delivery of primary care services to our members to both lower cost and provide customized service. | ||
| 37 | List the Accountable Care Organizations in AZ with which you contract and the counties in which they operate. |
| METHOD OF APPROACH - GENERAL INFORMATION | OFFEROR RESPONSE | ||
| 1 | Organization: Please complete the following background information about your organization: | ||
| 1a | Organization’s name | ||
| 1b | Address of your corporate headquarters | ||
| 1c | Address of the location that will service the City of Tucson’s account | ||
| 1d | Date your firm became operational | ||
| 1e | Ownership of your firm | ||
| 1f | 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 other service provider firms related to any services requested under this RFP. | ||
| 1g | Is your organization "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. | ||
| 1h | Has your organization acquired, been acquired by, or merged with another organization in the past 24 months? | ||
| 1i | Is your organization anticipating restructuring or reorganizing in the next two years? (Include any major staff relocations or office closings.) | ||
| 1j | In order to meet ALL of the services in this Attachment are you including any subcontractors or partners in the delivery of ANY services to the City? If so, please list ALL subcontractors and partners including a list of services they will provide, their location and any fees that will be associated with their services. | ||
| 1k | Offshore: 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. | ||
| 2 | Commissions: Does your proposal include any direct, indirect compensation, fees, commissions, incentive awards, rebates, payments, fees or remuneration of any sort, however characterized, as a result of or arising from the City account? Confirm you agree that if they cannot be netted out of the rates or fees they will be paid to the City’s Consultant. Also, confirm no commissions are submitted through a third-party broker. | ||
| 3 | Litigation: | ||
| 3a | Is your organization involved in any current litigation against or from the City? If yes, please describe. | ||
| 3b | Have you been involved in litigation within the last five years arising out of your performance in the administration of a program similar to what your organization is proposing for the City of Tucson? Exclude routine matters involving participants that do not reflect on your organization’s performance under the contract with your client. If the answer is yes, explain fully. | ||
| 4 | Laws: | ||
| 4a | Explain how you stay current with changes in federal and state laws pertaining to the services you are proposing. | ||
| 4b | Confirm you agree to supply, upon request by the City, verification of compliance with any regulation stipulated herein or pursuant to any state or federal law. | ||
| 5 | Audits: | ||
| 5a | Confirm you agree to provide full disclosure of your records and those of your subcontractors upon notice from the City and/or the City’s selected auditor, should an audit be requested by the City. | ||
| 5b | Confirm you agree to cooperate with the auditors and waive any fees associated with obtaining access to the City’s data and/or records. | ||
| 5c | On average, what percentage of all claims are audited by your internal team and how often are they audited? | ||
| 5d | Confirm you will provide a fund of $45,000 during each year of the contract for an annual claims audit to be paid to the City’s selected auditor. | ||
| 6 | Administration: | ||
| 6a | Confirm the online system accessible to the City allows them to assign different levels of access internally. | ||
| 6b | Can you pay retrospective COB Medicare Secondary Payer claims as needed? | ||
| 6c | Confirm you will match the City’s COB guidelines and the process for determining primary and secondary responsibility. | ||
| 6d | Please detail what COB provisions you can administer. | ||
| 6e | Do you agree to submit data required to CMS and pay any penalties if not submitted timely to comply with the Medicare Secondary Payer requirements (Mandatory Insurer Reporting Obligation Section 111)? | ||
| 6f | Do you agree to provide reporting to the City for Part III of IRS form 1095-C in Excel or CSV file format at no additional charge to the City? | ||
| 6g | Subrogation: | ||
| 6gi | Describe your process to identify and adjudicate potential subrogation claims (i.e., accident, etc.). | ||
| 6gii | Confirm you agree to cap the cost of subrogation services to no more than 15% of any recovery. | ||
| 6h | Out-of-Network Claims | ||
| 6hi | Is this service done in house or do you need to work with a third party to re-price? | ||
| 6hii | Is there an additional charge for this service, and if so, what would the cost be? | ||
| 6i | City is requesting a flat PEPM fee for Contractor to negotiate all out of network claims. Are you able to provide this in your quote? If not, detail the fees you are proposing as well as per claim cap and PEPM caps. | ||
| 6j | Do you have a fraud and abuse detection program that monitors claims for billing irregularities by a provider (such as regular overcharging, unbundling of procedures, up-coding or billing for inappropriate care for stated diagnosis, etc.)? Is there any additional cost for this service? | ||
| 6k | Describe your company’s timeline and deadlines for open enrollment (systems updates due to plan changes or file formats, new divisions, manual workarounds, dates for last pre-OE updates, OE file updates, etc.). | ||
| 6l | Would the City have the ability to customize the EOB (either add or remove data elements)? If so, is there any additional cost for this feature? | ||
| 7 | HIPAA: | ||
| 7a | Confirm that if you receive individually identifiable health information (IIHI) from the City in order to perform underwriting, pricing, or other activities relating to the renewal or replacement of a contract, that you will protect such IIHI as required by HIPAA Privacy regulations. | ||
| 7b | Are all your systems and staff HIPAA compliant? | ||
| 7c | Have you had a HIPAA violation in the past? If yes, please describe. | ||
| 7d | Are you aware of any complaints that have been filed against your organization regarding HIPAA EDI, Privacy or Security with a government oversight agency? | ||
| 7e | Do you collect the minimum necessary data needed to administer your program in compliance with HIPAA Privacy? | ||
| 7f | How do you remain current on the latest HIPAA developments / changes? | ||
| 7g | Do you plan to sell, lease or transfer the City’s protected health information (PHI) to a third party in the course of administering this contract or after the contract has terminated? | ||
| 7h | Please describe the liability insurance (including the amount) that your organization currently holds. | ||
| 7i | Confirm you agree to provide City insurance staff with access to secure email for resolving any eligibility or other related issues. | ||
| 7j | Confirm you agree to communicate through HIPAA-compliant electronic sites to exchange data between yourself and any other required contractor as requested by the City at no additional cost. | ||
| 8 | Implementation: | ||
| 8a | Confirm you agree to begin implementation immediately upon award or at the direction of the City, and participate as specified in this RFP in the open enrollment for coverage that will begin July 1, 202 Open Enrollment generally the month of May. | ||
| 8b | Provide an implementation plan outlining tasks necessary to install the program, the timetable and the parties responsible. | ||
| 8c | Describe your capacity to produce communication materials and ID cards. Do you produce these materials or are these services subcontracted? Confirm ALL services are provided and performed in the United States. | ||
| 8d | What is the minimum amount of implementation lead-time you need in order to initiate the proposed services for the City of Tucson? | ||
| 8e | List any transition issues the City of Tucson should consider with respect to moving services from an existing Contractor to your organization. | ||
| 8f | Are there any specific administrative procedures or information that your firm will need from the City of Tucson in order to implement your services? If yes, please describe. | ||
| 8g | If ID cards are standard for your proposed plan, how quickly are they produced and delivered? | ||
| 8h | Please identify the key personnel who will be assigned to this account for ongoing administration, including biographical information, location, and role of each individual. | ||
| 9 | Scope of Work: | ||
| 9a | Do you agree to provide each and every item listed in the Scope of Work? | ||
| 9b | If not, have you listed all deviations or exceptions on the Deviations exhibit? | ||
| 9c | Outline Fund Allowances you are providing as well as onsite or virtual representatives dedicated to the City of Tucson members. | ||
| 10 | Future: | ||
| 10a | What features or enhancements to the program or services you are proposing are on your roadmap for the next 12 months? | ||
| 11 | Appeals and Disputes: | ||
| 11a | Please detail your procedures for responding to appeals and disputes as well as reporting the responses and results to the City. | ||
| 11b | Please confirm you will manage all levels of claims appeals and disputes including Level 3 external appeals in the capacity of a fiduciary to the plan. Is there any additional cost for this service? | ||
| 12 | Fiduciary: Would you be willing to be a named claims fiduciary under the City’s plans? Would you be willing to meet fiduciary standards as found in ERISA, even though the City’s programs are not governed by ERISA? | ||
| 13 | Eligibility and Billing: | ||
| 13a | Confirm you agree that the City determines eligibility for coverage. | ||
| 13b | Confirm you agree that you determine eligibility with respect to plan coverage and the appropriate amount of benefits. | ||
| 13c | Agree to maintain full coverage for over-65 retirees who lack sufficient quarters to qualify for Medicare Part A without paying Part A premium. | ||
| 13d | Agree to continue Spouse Only, Child(ren) Only or Spouse and Child(ren) coverage until 65 or 26, respectively, for spouses and children of retirees who age out or pass away. | ||
| 13e | Agree to cover disability retirees under age 65 who qualify for Medicare. Medicare pays primary, and the successful Offeror would pay secondary. | ||
| 13f | Confirm you agree to determine and maintain eligibility for all dependents age 26+ who are disabled. This includes mailing, accepting and evaluating disability determination applications for dependent children who are approaching age 26 and annual recertification thereafter, as needed. Please describe your application and determination process. | ||
| 13g | Are you able to administer an end-date for dependents to age 26 (end of the month) and ensure it remains in place even when new eligibility files are received that may continue to show the dependent? If not, could you generate a monthly report for the City showing dependents that are ageing off the plan? | ||
| 13h | Describe how you handle newborn coverage in the first 60 days and steps you take to help members enroll a newborn dependent for coverage. ID cards may not be issued to dependents until the City’s Benefits Office has approved the enrollment, and enrollment information feeds to the insurance carrier via the City’s online enrollment system. If ID cards are issued on a temporary basis, explain how you communicate to participants that coverage will end at 60 days if the enrollment process is not successfully completed with the City’s Benefits Office. | ||
| 13i | Confirm you agree that the City may change enrollment system providers at any time and that there shall be no charge to the City if the City changes enrollment system providers, regardless of new reporting interfaces. | ||
| 13j | Confirm you agree to load eligibility files weekly and within 2 working days of receipt. | ||
| 13k | Confirm you agree to notify the City of discrepancies and errors within the eligibility file within 2 working days of receipt of each eligibility file. | ||
| 13l | Confirm you agree to accept the City's self-bill (no true up of any eligibility discrepancies other than those based on eligibility file transfer). | ||
| 13m | Grace Period: Confirm you agree to accept payment of fees and premiums 60 days in arrears. For example, July’s premium would be due August 29. | ||
| 13n | Do you agree to provide, at no additional cost to the City, collection of coordination of benefits (COB) information and audit of COB dependents and maintain up-to-date COB information at a minimum of per year? | ||
| 13o | Do you agree to establish appropriate FTP site(s) to exchange eligibility data at no additional cost and at the frequency established by the City? | ||
| 13p | Are eligibility updates shared online and in real time with ancillary providers? | ||
| 14 | Account Management: | ||
| 14a | Do you agree to provide to the City an electronic tracking and resolution log of all open and closed City issues? | ||
| 14b | Do you agree to notify the City within 1 business day of receipt of any public information written request regarding any information that relates to the City’s benefit plans and to review all responses with the City and obtain approval prior to the release or response of any inquiry? | ||
| 14c | Do you agree to respond to the City’s HR team’s questions within 1 business day of request (even if the answer is “I am working on it”)? | ||
| 15 | Onsite Visits: | ||
| 15a | Do you agree to provide knowledgeable personnel to attend scheduled informational, orientation and open enrollment meetings? Locations of meetings may vary. The number of meetings will be determined based on the number of changes to the current program that will require plan education. Contractor will be responsible for brief presentations and answering questions. Open Enrollment generally occurs the month of May. | ||
| 15b | What capabilities do you have to support the City’s employee and retiree enrollment and orientation meeting needs using video conference or other electronic means (e.g. videos, etc.)? | ||
| 15c | Do you agree to attend in person (or via video conference) monthly, quarterly and annual on-site program reviews, with periodic telephone calls, upon request from the City’s insurance benefits office? | ||
| 15d | Do you agree to be available for onsite meetings with City of Tucson staff at a minimum of one meeting per quarter? | ||
| 15e | Do you agree to participate in any future open enrollments or special enrollments as specified in this RFP and as directed by the City at no additional cost to the City? | ||
| 16 | Customer/Member Service: | ||
| 16a | Describe your company’s expectations for quality of customer service. | ||
| 16b | Describe your customer service capabilities. | ||
| 16c | Confirm you will provide at a minimum a designated customer service team of representatives for the City and describe that team. | ||
| 16d | How are after hours calls handled? | ||
| 16e | Do members have access to the claims/ customer service group via: | Yes / No | Hours Available if Applicable (AZ Time) |
| 16ei | Phone |
| 16eii | |
| 16eiii | Face-to-face onsite |
| 16eiv | Face-to-face Phoenix |
| 16ev | Face-to-face open enrollment |
| 16f | Would the City be provided with a dedicated member services 800 number? |
| 16g | Where is the customer service staff located that will service the City of Tucson account? |
| 16h | What is the ratio of member services representatives to 1,000 members? |
| 16i | Describe the relationship between your claims processing and member services staff. Are these responsibilities consolidated under one unit, or are they functionally separate? |
| 16j | Describe your phone management system's ability to track, monitor and manage incoming calls. How are calls distributed to staff? |
| 16k | Do you agree to respond to account issues and member service issues within one to two business days maximum with a plan to resolve the issue within a specified timeframe established to do so? |
| 16l | Do you agree to provide documentation of a process for prompt issue resolution and maintain an issue log? |
| 16m | Do your customer service representatives have outbound call capabilities and authority? |
| 16n | Do you take proactive action to facilitate claims issues between providers and members? Describe. |
| 16o | Do you provide members with limited English proficiency, Spanish-speaking, and those who are deaf or hearing impaired with access to communication services that enable them to utilize the phone lines? |
| 16p | Please detail your escalation process to assist in matters that cannot be resolved at the customer service unit level. |
| 17 | Data: (Respond with no more than 500 words in total) |
| 17a | Describe your organization’s approach to authorizing systems access and City information access both for your employees and for participants of the program. |
| 17b | Who owns the critical data (i.e., client information, network data, etc.) within your organization and how is it secured? |
| 17c | What quality control measures do you have in place to ensure it remains secured? |
| 17d | Are these processes audited? If yes, how often? |
| 18 | Historical Results: Please provide the following statistics for calendar years 2024 and 2025 YTD: |
| 18a | Average speed to answer: ___% within 30 seconds |
| 18b | Busy rate: ___ seconds |
| 18c | Abandonment Rate : ___% |
| 18d | Resolution of an issue on the first call |
| 19 | Communications: |
| 19a | What type of communication support do you provide to your clients (scheduling, posters, educational material/videos, etc.)? |
| 19b | Please provide sample communication materials you have produced for your clients. |
| 19c | Are customized communications available at no additional cost to the City? |
| 19d | If your organization is awarded the City’s business, how soon after notification of the award would you be able to have a draft of the plan booklet ready for the City to review? |
| 19e | Does your organization have the capability to provide communication pieces in Spanish and other languages? Please specify which languages you can accommodate. |
| 19f | Identify the services and any communication allowances you will provide to help the City introduce the new program to its employees. |
| 19g | Describe all services currently available to members on your website. |
| 19h | Confirm you will supply both written and electronic member communication materials (flyers, plan summaries, etc.) at no additional cost to the City. |
| 20 | Website and/or Mobile Applications: |
| 20a | Indicate if you have a mobile application or mobile optimized website. |
| 20b | What features does the mobile application include or is it limited compared to the regular member website? |
| 20c | What information (if any) can be customized by the City at no additional charge? |
| 20d | Indicate whether and how you maintain consistency between your mobile application and website. |
| 20e | Please provide a demo of your member website and/or mobile application(s) that would be used by the City and their participants. |
| 21 | Consumer and Modeling Tools: |
| 21a | Do you have an online modeling tool for employees to use during open enrollment that would help predict their costs for the plan options offered by the City? Please provide a temporary login and password for us to review a demo of your system. |
| 21b | If you have a pre-enrollment online modeling tool, does it include contributions that employees make towards their medical coverage as a variable in the model? |
| METHOD OF APPROACH - NURSELINE | OFFEROR RESPONSE | |
| 1 | What accreditation does your nurse line program hold? | |
| 2 | What are the hours of operation for your nurse line program? | |
| 3 | Does your nurse line include provider referral services? | |
| 4 | Does your call center have bilingual assistance? | |
| 5 | What type of reporting do you provide for your nurse line program? Provide a sample. How often will you provide reporting? | |
| 6 | What are the qualifications of the call center staff? | CHECK ALL THAT APPLY |
| 6a | Registered Nurses (RNs) | |
| 6b | RNs with advance degrees/certifications | |
| 6c | RNs specializing in the conditions they manage | |
| 6d | RNs specializing in groups of conditions | |
| 6e | Other health professionals | |
| 6f | Non-professionals | |
| 6g | Other – Specify |
| METHOD OF APPROACH - TELEHEALTH | OFFEROR RESPONSE | |
| 1 | Capabilities & Services: | |
| 1a | Provide an overview of your telehealth capabilities. Include the methods through which consultations are currently available (telephonic, video, from mobile device, text, etc.) and types of visits supported (physical, behavioral health, etc.). | |
| 1b | Is your service available 24 hours, 7 days a week, 365 days a year? If not, please specify. | |
| 1c | What is the total number of telephonic/video consultations provided in the last two calendar years by your organization? | |
| 1d | List all operating systems that are supported by your platform. | |
| 1e | Which platforms do you provide patient mobile apps? Can the patient connect without an app? | |
| 1f | Which platforms do you provide provider mobile apps? Can the provider connect without an app? | |
| 1g | Are your services available in all 50 states? List all limitations (including states in which you do not provide video consultations and why, states in which there are limits on prescriptions, states in which your services are unavailable, etc. Please identify whether this is a legal/state law limitation or an internal administrative limitation. | |
| 1h | List all content that can be shared during a phone or video conference call and any limitations. | |
| 1i | What conditions can you treat? Please be specific. | |
| 1j | What conditions are you unable to treat? Please be specific. | |
| 1k | Do you offer virtual care for mental and behavioral health? | |
| 1l | Strep Throat: are you able to diagnose, treat and prescribe if needed? | |
| 1m | What are the top 10 most frequent diagnoses, by percent of encounters? | |
| 1n | What are the top 10 prescriptions that your physicians write, by percent of encounters? | |
| 1o | How do you handle emergencies? | |
| 1p | What type of communication support do you provide to your clients (scheduling, mailings, videos, etc.)? Please include samples of your standard communication pieces with your RFP response. | |
| 1q | Do you provide operational support? If so, list the types of services provided. | |
| 1r | Is customer service for patients/technical support part of the offering? If yes, do you have any Spanish speaking staff (physicians and call center)? | |
| 1s | Describe both online and offline capabilities. | |
| 2 | Physician Network: | |
| 2a | What are the minimum qualifications of your participating physicians? What credentialing requirements do they have? Are they employees of your firm or independent contractors? | |
| 2b | Will you use only U.S. based physicians and employees to service this account? | |
| 2c | Do you monitor time-sensitive licenses and maintain re-credentialing? | |
| 2d | How do you maintain the adequacy of your physician network? If you were awarded this contract will you need to add to existing staff? | |
| 2e | Describe the contracting process with your providers. | |
| 2f | Describe your quality assurance program. How do you assure that physicians practice evidence-based medicine? How do you monitor the quality of each consultation? | |
| 2g | What proportion of the time do your physicians prescribe a medication? Describe the process of how a patient obtains their prescription. | |
| 2h | How do your physicians coordinate with patient’s regular physicians? | |
| 2i | How do physicians refer to other specialties? Can that process be customized? | |
| 2j | How does the patient’s primary care physician access patient records after Telehealth sessions (i.e. for follow-up care and referrals)? | |
| 2k | How do referrals to specialists work? Are you able to use a client specified network for referrals to specialists? Please disclose if you have any commission arrangements with any specific networks for referrals. | |
| 2l | Do you provide an administrative portal for staff and assistants to schedule appointments and upload physician information (e.g., nurses, care managers)? Describe. | |
| 2m | Is you network NCQA certified? Is so, please include a copy of the NCQA certification. | |
| 2n | Is your organization URAC accredited in Telehealth? | |
| 2o | What is the minimum level of malpractice insurance your participating physicians are required to have? | |
| 3 | Member Experience: | |
| 3a | When a patient places a phone call, who answers the phone? Please describe their qualifications. | |
| 3b | What percentage of calls are taken by RNs, LPNs, PAs, board eligible physicians, and board-certified physicians? | |
| 3c | Describe the qualifications of the providers/extenders that complete the patient consultation. | |
| 3d | Provide a profile for the typical provider/extender providing consultations for your service. | |
| 3e | What information do you request from the patient during an initial phone call? How long does this intake process typically take? | |
| 3f | What is the average wait time to talk to a provider? Do you guarantee a timeframe? | |
| 3g | How do patients access your services? | |
| 3h | Describe the patient’s audio and video capabilities when using your software during a video conference call. Include any minimum hardware requirements, if applicable. | |
| 3i | In the event the video call is dropped, how does the patient reconnect to the provider? | |
| 3j | What happens if a patient has poor connectivity or loses internet connection during a visit or while waiting for the provider? | |
| 3k | Describe the contextual aids and other user help resources offered to patients throughout your platform. | |
| 3l | Can a patient schedule an exact appointment time with the provider? How do they do this? | |
| 3m | Can a patient choose a provider based on the provider’s profile, or are patients randomly assigned to providers? | |
| 3n | For a follow-up consultation, can the patient reach the same physician? | |
| 3o | Describe how you collect patient copayments. Do you accept debit/credit cards? | |
| 3p | What percentage of calls are monitored? Will you be willing to allow an independent audit of those calls? | |
| 4 | Integration: | |
| 4a | Describe your IT platform and systems. Are Electronic Medical Records and/or Personal Health Records (PHR) included? | |
| 4b | The City is currently in the RFP process for Medical/TPA services. Please indicate which Medical providers/networks you have the capability to work with. | |
| 4c | How do you handle eligibility? | |
| 4d | Please describe how claims are integrated. Describe the process for submitting claims to the health plan. | |
| 4e | How often will you send files including the cost of visits paid for by plan members to the City’s Medical Plan/TPA for inclusion in the plan participant’s benefits accumulators (e.g. high deductible health plan)? |
| METHOD OF APPROACH – MEDICAL MANAGEMENT: UTILIZATION REVIEW / CASE MANAGEMENT | OFFEROR RESPONSE | |
| 1 | Indicate if the following components are part of your utilization management program. | |
| 1a | Precertification | |
| 1b | Concurrent Review | |
| 1c | Case Management | |
| 2 | Are your UM services currently URAC accredited? | |
| 3 | How do you find cases to case manage? | |
| 4 | What types of cases do you identify for case management? | |
| 5 | During case management, do you direct the patient and/or their health care providers to use in-network services? | |
| 6 | Indicate the average number of hours per case your staff spends case managing. | |
| 7 | Outline the appeal process a patient, physician or provider would need to follow in the resolution of a complaint / disagreement, including key timeframes. | |
| 8 | What is the penalty for failure to pre-certify timely? Who bears responsibility for the penalty – participant or provider? |
| METHOD OF APPROACH – MEDICAL MANAGEMENT: | ||
| DISEASE MANAGEMENT | OFFEROR RESPONSE | |
| 1 | Please include a list of diseases that are included in your disease management programs. | |
| 2 | What claims data do you utilize to identify potential candidates for the disease management program? | |
| 2a | Medical only | |
| 2b | Prescription drugs only | |
| 2c | Medical & prescription drugs | |
| 2d | Other – Specify | |
| 3 | Do your proposed fees represent an “opt-in” or an “opt-out” (preferred) program? | |
| 4 | Which of the following describes the customer service relationship the participants will have access to while enrolled in the program? | |
| 4a | One nurse care manager | |
| 4b | Team approach | |
| 4c | Other – Specify | |
| 5 | Are reminders sent on a routine schedule to members and/or participants to motivate appropriate health actions (e.g., obtain certain tests, schedule follow-up exams, etc.)? | |
| 6 | What accreditations does your disease management program hold? | |
| 7 | Are you able to provide an Oncology support program to help the patient and their family through the screening, treatment, care and post-care of cancer? | |
| 8 | Are you able to provide case managers to assist with coordinating all necessary facets of care for participants with choric or acute conditions? | |
| 9 | Which conditions qualify a participant for a case manager to assist participants with their choric or acute conditions? | |
| 10 | Are you able to provide a Health Coach for Chronic Conditions to help members determine when to see a doctor, prepare a list of questions to ask the doctor, what they need to do to be adherent to doctors’ orders, identify barriers impacting their health, set goals and develop good habits, prepare for hospital stays and after care, and make informed decisions about treatment options? | |
| 11 | Will you provide a guarantee to reduce the health risk of the City’s population? What metrics are used? What form of advocacy is used? Is this guarantee available to all medical plans? | |
| 12 | Please provide details on your Diabetes Management Program offered through a digital tool. | |
| 12a | How does the program work and what is the member experience? | |
| 12b | .Do you work with Omada Health (the current digital tool)? | |
| 12c | If not Omada Health, who do you work with for your diabetes management digital services? | |
| 12d | Please describe the process of transitioning participants currently working with Omada Health to your service. | |
| 13 | Confirm you will provide an annual consultative analytics review. | |
| 14 | Confirm you can provide a program similar to the Your Call program for firefighters outlined on page 2 of this RFP. Provide details of the program you can provide. |
| METHOD OF APPROACH – | ||||
| HSA/HRA ADMINISTRATION | OFFEROR RESPONSE | |||
| HSA | HRA | |||
| 1 | Describe your proposed program in detail. List the services your firm offers for HSA/HRA administration. | |||
| 2 | Describe your approach to educating employees about the program and your plan for ongoing communications. Include samples | |||
| 3 | Please explain how you promote services to eligible dependents of employees. | |||
| 4 | Describe your company’s expectations for quality of customer service. In addition, describe your customer service in these areas: | |||
| 4a | Hours of operation | |||
| 4b | Methods of contact | |||
| 4c | Average response time for all customer service portals | |||
| 5 | Describe your organization’s approach to authorizing systems access and City information access both for your employees and for participants of the program. | |||
| 6 | How do you propose to alert the City’s key management and human resource staff regarding problem areas or trends identified from your HSA/HRA services? | |||
| 7 | Discuss any transition issues with respect to moving HSA/HRA services from the existing Contractor to your organization. | |||
| 8 | How do you accommodate calls to your HSA/HRA customer service center from people who do not speak English or are hearing impaired? | |||
| 9 | Indicate if you have a mobile application or mobile optimized website. What features does it include, or is it limited? Provide information regarding how to access your mobile application. Indicate whether and how you maintain consistency between your mobile application and website. | |||
| 10 | Customer Identification Process (CIP) Process: | |||
| 10a | Do you automatically open an HSA account for anyone who enrolls in the HDHP plan or is there some election process required? | N/A | ||
| 10b | If an account is closed due to failure to pass CIP how can an account for that participant be opened? | N/A | ||
| 10c | Please include details on how you would communicate the status of opening accounts to the City and to their plan participants. | N/A | ||
| 10d | What steps do you take to ensure the process goes smoothly? | N/A | ||
| 10e | Do you offer a liaison to assist employees through the application process? | N/A | ||
| 10f | Does the employer need to facilitate? | N/A | ||
| 10g | What reporting do you provide and how do you provide it? | N/A | ||
| 11 | Do you have a process in place to monitor the amount of contributions made into each individuals account? | |||
| 12 | What happens to funds remitted when an account is in CIP or if an account isn’t opened/doesn’t exist? | |||
| 13 | Do you have a process in place for accepting catch-up contributions for individuals between ages 55 to 65? | N/A | ||
| 14 | Are individual contributions accepted through the payroll process only (e.g., through a 125 plan) or are direct contributions by an individual outside of the payroll process also permitted? | |||
| 15 | Do you have timing rules for when contributions to an HSA/HRA must be made? | |||
| 16 | Do you have timing rules for claims submission and distribution of funds? | |||
| 17 | Do you have claim substantiation requirements? If yes, describe the requirements. | |||
| 18 | What is the balance level required for the member to start investing in funds. | |||
| 19 | Describe the investment options available and which company manages the investments. | |||
| 20 | Are you able to provide an HSA that is indexed to the stock market (or other market)? | N/A | ||
| 21 | Describe how the transition of existing investments from the current contractor to your organization would work. | N/A | ||
| 22 | Fees: | |||
| 22a | List any fees that may be charged to the City and the reason for each fee. | |||
| 22b | List any fees that may be charged to the participant and the reason for each fee. | |||
| 22c | What fees are charged with respect to individuals who terminate employment with the City, but retain their HSA with you: | |||
| 23 | Are your accounts FDIC insured? | |||
| 24 | What safeguards are in place to combat HSA/HRA fraud? | |||
| 25 | What resources does your company make available to accountholders that experience fraudulent activity? | |||
| 26 | Do you produce any year-end accounting of the HSA transactions for each HSA participant? | N/A | ||
| 27 | Will employees have a single sign-on through the medical TPA or will they need to access a separate portal? | |||
| 28 | Can claims automatically be sent from the medical TPA to the HSA/HRA system? Do plan participants elect this feature individually or is this a global employer decision? | |||
| 29 | Can claims from the City’s prescription benefit manager be sent automatically to the HSA/HRA system? Is there any extra charge to setup the feed? | |||
| 30 | How soon from the time a claim is submitted, is the reimbursement made to a participant? | |||
| 31 | Do you mail the reimbursement to the participant or do you use a direct deposit system? | |||
| 32 | What is the claim substantiation process for debit/credit card transactions? | |||
| 33 | Can plan participants be given a checkbook from which to write checks on their account? | |||
| 34 | How long after receipt of an HSA account deposit are funds available to the participant? | N/A | ||
| 35 | Is there a minimum HSA or HRA participation requirement? What happens if this minimum is not achieved? | |||
| 36 | Grievances: | |||
| 36a | How are they resolved? | |||
| 36b | Describe the appeals process for denied or rejected claims. Include how excluded services are handled. |
| COST (FINANCIAL) | OFFEROR RESPONSE | |
| 1 | Do your fees include the production of SPDs, a plan document, SBCs, employee booklets and ID cards (standard stock)? | |
| 2 | Capitation: Network/HMO Plan | |
| 2a | Do you capitate any network providers? If so, which types of providers or services are capitated? | |
| 2b | What is the first year proposed PMPM cost for each service capitated? | |
| 2c | Do you retain any portion of the capitation to be charged for network maintenance or other associated expenses? | |
| 2d | What is the amount of capitation retained by your organization? | |
| 2e | Would you be willing to offer any guarantees or inflation escalators? | |
| 3 | Capitation: HRA/HSA PPO Plan | |
| 3a | a.Do you capitate any network providers? If so, which types of providers or services are capitated? | |
| 3b | b.What is the first year proposed PMPM cost for each service capitated? | |
| 3c | c. Do you retain any portion of the capitation to be charged for network maintenance or other associated expenses? | |
| 3d | d.What is the amount of capitation retained by your organization? | |
| 3e | e. Would you be willing to offer any guarantees or inflation escalators? | |
| 4 | Banking: | |
| 4a | a.Can the City use its own bank account, or do you require a specific bank/account? | |
| 4b | b.Do you require an imprest amount or minimum balance be maintained? Specify. | |
| 4c | How frequently do you make draws on the account? |
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