260125_Chapter_1A_-_Medical_Scope_of_Work.docx

RFP# 260125 Attachment 1A - Medical

Medical/Telehealth, and Health Savings Account (HSA) & Health Reimbursement Account (HRA)

Introduction The City of Tucson is soliciting proposals for Medical/Telehealth, HSA & HRA Administration and services for employees and retirees for a July 1, 2026 effective date.

The City is looking to continue the current self-funding arrangement that went into effect July 1, 2019 (note that stop loss will be bid at a date closer to the effective date).

Contractors should match or improve upon current plan design features as close as possible, specifically noting any differences in the Deviations section of this Attachment.

The City requires Contractors to provide ALL services in this Attachment. Contractors must (1) own their own services or (2) with partners provide ALL services included in this Attachment. Offers with partners must be returned under one submission.

The City’s website: https://tucsonaz.gov/benefits contains current benefit plan information and contribution rates (employer and employee); eligibility can be found in the Insurance Handbook. Current benefit booklets can be found on the City’s Procurement website with the RFP documents.

The City reserves the right to carve out any service or program, change contribution strategies, funding, rate structure (e.g., blended/un-blended active/retiree, etc.), benefit designs or any aspect of their program in the future as they deem appropriate. Plan Designs for effective date 7/1/2026 may be changed from current.

Please note that the requirements listed in the Scope of Work in this RFP are minimum service levels the City expects to receive through this solicitation. Any offeror may introduce enhanced services as part of their comprehensive response to this solicitation given that the minimum service levels are met.

MINIMUM REQUIREMENTS

At minimum, Contractor shall meet the following:

Any offeror not meeting the minimum requirements will be rejected.

Background CIGNA Healthcare has been the exclusive provider of the City’s medical and pharmacy programs since July 1, 2007. The City’s contract was fully insured with Cigna until they moved to a minimum premium contract with Cigna on 7/1/16. The City changed their funding with Cigna to self-funding on July 1, 2019.

The City currently covers approximately 4,498 employees/retirees (3,887 active employees/Cobra beneficiaries and 611 retirees) under benefits relating to this chapter.

Underwriting Information Current Carrier: CIGNA since July 1, 2007. HSA/HRA administration, through CIGNA, moved from JPMorgan Chase to HSA Bank in September 2015.

Eligibility: Can be found in the Insurance Handbook on the City’s website: https://tucsonaz.gov/benefits

Current Funding & Additional Programs:

Self-funded. Currently, CIGNA provides a $410,000 general fund ($50,000 can rollover). The general fund is used for wellness initiatives, open enrollment costs, and communications. Cigna also provides a $50,000 Innovation Fund to be used for Pilot Programs. A Wellness Incentive Fund is also provided in the budgeted amount of $100 per subscriber per year for MotivateMe incentives as well as the Healthy Babies Incentives. Please note: members can earn up to $250 in wellness incentives and an additional $150 or $75 incentive for Healthy Babies enrollment (if applicable). The budgeted amount is an estimated average and has historically covered all incentives earned.

CIGNA also provides the City with an onsite Client Service Executive, an onsite Wellness Coordinator and two virtual Behavioral Health Counselors (one is paid by CIGNA and the other by the City (approx. $200,000 per provider).

CIGNA Also Provides the City with a “Your Call” Program which is a health program available to City of Tucson firefighters. Through the program, a firefighter has dedicated providers through El Rio which provide appropriate preventive physical and emotional screenings. There is a dedicated care coordinator at El Rio to assist these employees in scheduling their Your Call visit. Dedicated physicians evaluate firefighter health and order targeted screenings including metabolic, depression and anxiety, genetic, physical fitness, heart, lung, and various cancer screenings. CIGNA provides a fund of $20,000 for this program to be used for marketing and participation incentives. The City’s Fire Department has a budget of approximately $75,000 per year to pay for the claims that are run through this program.

Current Rate Contribution Strategy: details included on the City’s benefits site: https://tucsonaz.gov/benefits

Employer/Employee Contributions:

· Employee rates displayed on the City’s website are bi-weekly.

· Employer rate contributions vary based on employee salary bands.

Employer/Retiree Rates:

· Retiree rates displayed on the City’s website are monthly.

· Most retirees and their eligible dependents receive either a 75% City subsidy or a flat subsidy of $200.00 for retiree, $375.00 for retiree plus one dependent and $475.00 for retiree plus two or more dependents.

As the City has had numerous pricing plans for retirees through the years, the above employer subsidies reflect the most prevalent rates currently in effect. Some currently enrolled retirees retired under different incentive agreements, ranging from 0 – 100% subsidy. City subsidies depend on the date of retirement and the retirement system belonged to by the retiree.

HRA/HSA Account Contributions:

· In addition to rate contributions, the City contributes $1,500 annually per primary subscriber and an additional $1,500 annually for dependents to an HSA account for those enrolled in the HDHP/HSA Plan.

· In addition to rate contributions, the City contributes $500 annually per primary subscriber and an additional $500 annually for dependents to an HRA account for those enrolled in the HDHP/HRA Plan.

· Retirees receive HRA account contributions but do not receive contributions to HSA accounts.

Requested Plan Design: Match or improve current Medical/Telehealth, HSA & HRA Administration benefits, services, and provisions.

Note: The City will be eliminating the current HRA plan effective 7/1/20227. For the 7/1/2026 plan year only currently enrolled participants will be able to continue the HRA. A Basic High-Deductible PPO plan will be in place as a replacement at some point in the future.

Non-Network Claims: Are paid at 110% of Medicare.

Commissions: All proposals should be submitted net of commissions.

Reason Bidding: Market evaluation.

Underwriting Data: An Excel workbook with pricing exhibits, claims experience, enrollment, and census data will be provided (See Request for Confidential Documents form in the RFP Specification document). The census includes Employees/Retirees who have waived coverage (note this is an FYI only – please do NOT include waivers in GEO Access results or in your enrollment caveat assumptions).

Scope of Work The City’s goal is to select the firm that will be the most effective and proactive partner. The minimum program services shall include:

General

1. Proposal, Interview, and Best and Final Responses Become Part of Contract: Contractor’s written response to this RFP, written information provided as part of an interview and written responses provided during a Best and Final negotiation become part of the contract between Contractor’s organization and the City of Tucson.

2. Contractor’s Proposal Terms: Are guaranteed for at least 180 days from the proposal due date.

3. Contract Length: The Contract has a length of one (1) year with the option to renew for six (6) additional one-year periods.

4. Fee/Rate Guarantee: Fees/rates are guaranteed for a minimum of three (3) years (July 1, 2026, through June 30, 2029).

5. Renewal Notification: The Contractor must provide any fee/rate changes in writing at least 180 days prior to the contract anniversary date (i.e., January 1 of the prior plan year for a July 1 effective date). Any requested increase must be provided in writing and must include the following with your renewal package:

a. Any contract language changes requested

b. Specific justification of fee/rate changes

c. Current enrollment by plan option, branch classification, and premium rate tier

d. Supporting underwriting fee/rate development including monthly paid claims and enrollment, utilization statistics, and projection analysis.

e. Additional options for consideration

f. All underwriting caveats

6. Flexibility: The City reserves the right to carve-out or change any service or program, contribution strategies, funding, rate structure (e.g., blended/un-blended active/retiree funding rates, etc.), benefit designs or any aspect of their program in the future as they deem appropriate.

7. Variance Provision: Contractor agrees that any provisions relating to reevaluation of proposed rates or re-rate during the contract due to variation in enrollment from the census provided or other contingencies of the quote or renewal will not be applicable unless total program enrollment variance is at least 20%.

8. Proper Licensure: Contractor agrees to maintain proper licensure as required by any state law and Department of Insurance regulations pertaining to this coverage where it relates to the services that Contractor will be performing for the City of Tucson.

9. Prior Notice of Major Operational Changes: Contractor agrees to provide no less than 30-day notice to the City of Tucson for any changes involving the sale, merger, data breaches, layoffs, participating provider facility terminations, consolidation or outsourcing of services to foreign workers that will impact/involve services provided to the City of Tucson.

10. Subcontracting: Unless otherwise explained in this RFP, Contractor agrees that they will disclose all subcontractor arrangements, and any additional fees associated with the subcontractor arrangements, that involve the services provided to the City of Tucson.

11. Subcontracting: Contractor agrees that all subcontract relationships are subject to the City’s consent prior to implementation.

12. Damages: Contractor accepts responsibility for all damages caused by their own negligence, gross negligence, willful misconduct, and/or breaches of the contract. The Contractor will not require the City to indemnify bidder for its own negligence.

13. HIPAA Compliance: Contractor attests to meeting all applicable HIPAA EDI, Privacy, Security, and HITECH requirements and agrees to hold the City of Tucson harmless for breaches that are the result of the Contractor’s actions. Further, Contractor agrees to perform all of the duties associated with breach notification, and assume financial responsibilities for the breach notice and notify plan participants if there is a breach and will pay for 24 months of identity theft repair and credit monitoring services for those plan participants impacted by the breach.

14. HIPAA Compliance: Contractor certifies that all services provided as part of this contract will be in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and HITECH and their subsequent amendments and changes. Violations shall be reported immediately to the City in writing. Contractor will notify the City of any and all actions taken as a result of any violation.

15. Contractor’s proposal contains provisions reserving these rights to CITY OF TUCSON: Any “actively-at-work” or non-confinement requirements will be waived on the effective date for all members or dependents participating in the plans immediately prior to the effective date of your contract with the City of Tucson.

16. Eligibility Rules and Uncertain Claimant Eligibility Situations: Contractor agrees to the specified eligibility rules established by City of Tucson. The Contractor must communicate directly with the City of Tucson regarding any uncertain claimant eligibility situations before notifying the claimant of ineligibility.

17. Eligibility Rules and Procedures for Retroactive Termination and Reconciliation: The Contractor agrees to the specified eligibility rules established by the City of Tucson. Upon receipt of a retroactive termination, the Contractor must review the applicable participant histories and initiate recovery efforts for any overpayments resulting from the late termination notice. The City generally will notify Contractor of terminations within 60 days after coverage termination date. However, the City reserves the right to terminate more than 60 days retroactively, under unusual circumstances.

18. Member Services: Contractor will record one hundred percent (100%) of member calls into a Customer Service Center and the recordings will be available to the City for inspection within 24 hours of recording and should be retained for a minimum of 12 months.

19. Termination Provisions: Contractor agrees the City of Tucson may terminate the contract at any time with or without cause, by giving 30 days written notice. The City may terminate any contract early if it deems such action necessary or appropriate to fulfil its duties to employees, retirees, and beneficiaries. Please refer to Termination clause in the Standard Terms and Conditions provided in the RFP.

20. Termination: Upon termination Contractor agrees to cooperate with the City in transitioning services and providing necessary reporting to a successor Contractor in a manner designed to mitigate disruption to participants and beneficiaries at no additional cost to the City.

21. Claims and Appeals Regulations: Contractor agrees that their systems, internal operations, correspondence, and services will be compliant with ERISA Claims and Appeals Regulations and the City of Tucson’s plan document.

22. Pended Claims: Contractor will make available, upon request, reports regarding the number and nature of claims pended, if their organization is processing the claims.

23. Maintenance, Ownership, and Transfer of Records:

a. The Contractor will be required to maintain all pertinent records (e.g., claims data (all fields indicated on the billing, eligibility information, member complaints, etc.) for seven years. This is in conjunction with prudent business practice and ERISA provisions; and

b. The Contractor will be charged with the safekeeping of plan experience information; and

c. In the event of contract termination, and related to contract termination, the Contractor will be required to cooperate with the City of Tucson, or their representative, in the prompt, accurate, and orderly transfer of the City of Tucson's plan experience, claims and utilization information to the City of Tucson or its designated succeeding health plan/carrier at no additional cost to the City and:

d. Contractor shall maintain a record of all complaints from all members and shall provide the same to the City of Tucson within ten (10) business days of the initial request. Such record shall include all correspondence relating to the disposition of the complaint.

e. In Compliance with Standard Terms and Conditions, Paragraph 33.

24. Assignment or Transfer of Rights: Contractor agrees that they will not assign or transfer the rights or obligations of the contract or any portion thereof, without the prior written approval of the City of Tucson.

25. Duties: Contractor acknowledges that their firm will perform all duties contracted for in accordance with the standard of care for a professional with expertise in all areas contracted for.

26. Applicable Law: This Contract shall be governed, and the City and Contractor shall have all remedies afforded to each, by the Tucson Procurement Code and the law of the State of Arizona. State law claims shall be brought only in Pima County Superior Court. Contractor agrees to comply with all applicable federal, state, and local laws, rules, regulations, and ordinances. Further, Contractor certifies compliance with all provisions, laws, acts, regulations, etc.

27. Contract: Contractor shall represent the complete contractual understanding of the parties and changes must be signed by both parties. The contract shall not incorporate policies or documents that are subject to unilateral change or are not agreed to in advance.

28. Contract: Contractor agrees that any service contract arising from this RFP will not include any limitations of liability or disclaimer of warranties.

29. Contract: Contractor shall provide with this proposal any additional documents or contracts the City will be required to sign. The documents provided must be updated with language based upon the specific requirements of this RFP. The documents should contain the following language: To the extent there is an inconsistency between the contract and the Request for Proposal (RFP) between the parties, the RFP responses will govern. Any documents not provided are subject to rejection after the contract is awarded.

30. Business Associate Agreement: Contractor shall agree to sign the City’s Business Associate Agreement as written and provided prior to award.

31. Plan Design and Plan Provisions: Contractor’s plan(s) must match or improve upon the current plan designs, provisions, exclusions, and limitations. Specific deviations, if any, are identified in the proposal responses and not just a general disclaimer indicating “some differences may exist” or “refer to my proposal.” The burden is on the Contractor to point out any and all differences. Differences not noted on the deviation form, shall not be accepted, even if not negotiated.

32. Offshore Performance: Due to security and identity protection concerns, direct services under this contract shall be performed by Contractor within the borders of the United States. Any services that are described in the contract or scope of work that directly serve the City and may involve access to secure or sensitive data or personal client data or development or modification of software for the City shall be performed within the borders of the United States. Unless specifically stated otherwise in the contract, this definition does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the performance of the contract. This provision applies to work performed by Contractor and subcontractors at all tiers.

Data and Reporting

1. Contractor shall provide on a monthly basis in Excel, enrollee, and member counts and by contribution tier, plan option, and employee status (Active, Retiree, Cobra). Likewise, paid claims data by plan option and employee status no later than 15 days following the end of the month.

2. Contractor shall provide a quarterly lag report combined for Active and Retirees in Excel.

3. Contractor shall provide monthly utilization report by service class including in-network vs non-network usage, discounts achieved, savings from plan design features and utilization management in Excel.

4. Contractor shall provide to the City’s designated third-party data aggregator (McGriff) a complete claims file monthly at no additional cost to the City for data mining analysis and program effectiveness evaluation.

5. Contractor shall provide all required data in an electronic format file as requested and specified by the City of Tucson. Contractor shall not charge programming costs associated with data file generation or transfer. This data shall be made available using sFTP or other mutually agreeable secure transfer mechanism.

Administration

1. Contractor shall provide all required services to all eligible members including a toll-free number for member questions and claim inquiries.

2. Contractor agrees to provide performance guarantees, measured periodically as specified, and to financial penalties for failure to meet standards.

3. Contractor shall provide quality services, meeting or exceeding the City-approved industry standards as specified in the Proposed Performance Guarantees below. Contractor shall take immediate corrective action and provide a written plan, as requested by the City, should the City identify any issue related to poor quality or lack of responsiveness uncovered by way of observation or audit, either internally or externally, of Contractor’s required processes or procedures. This action plan shall clearly outline the corrective steps and timeframes for completion when services do not meet industry standards to include standards that are inappropriate, undesirable, and/or of poor quality, as identified by the City. Any additional resources required to support corrective actions shall be provided at no additional cost to the City. Corrective measures taken to ensure the City quality standards, reporting standards or performance standards will be provided at no additional cost to the City through fees or hidden charges.

4. Contractor shall provide resources to respond within five business days to all inquiries related to quality assurance, corrective actions, deficiencies, and/or inefficiencies in operations. In matters of extreme urgency and time-sensitive issues, contractor agrees to provide resolution within two business days of City notification.

5. Contractor shall provide draft ID card samples to the City for approval 30 days prior to each plan year and mail finalized approved ID cards 10 days before plan start date (15 days prior to effective date for new hire and life event changes). If electronic ID cards are required, please note this on the deviations page.

Implementation

1. Upon completion of the award, Contractor shall provide to the City communications and data support within a specified timeframe designated by the City for a successful transition to the new Contractor.

2. Contractor shall provide a team of individuals designated to implementing the provisions of this contract upon award.

3. Contractor’s implementation team shall meet with the City no less than weekly during the implementation of the process or more often if needed.

4. Contractor shall perform comprehensive system testing and quality assurance checks prior to the implementation date of July 1, 2026. Contractor shall report the results to the City no later than May 1, 2026.

5. Contractor shall have its customer call center and website available forty-five (45) days before open enrollment begins for members transitioning from the current contractor as well as for potential new members with questions about City of Tucson’s program and those who want to view information. Customer service representatives must be fully trained on City of Tucson benefits forty-five (45) days before open enrollment begins.

6. Contractor shall have City of Tucson’s specific toll-free telephone (pre-enrollment) number available to all plan members forty-five (45) days before open enrollment begins. Access to the number must remain available throughout the remainder of the plan year to assist newly eligible individuals with plan-related questions prior to enrollment.

7. Contractor shall provide accurate coverage details for all contracted plans prior to the effective date.

Open Enrollment, New Hire Orientations & Health Fairs

1. Contractor must comply with the following open enrollment procedures:

a. Contractor shall provide, at no additional cost to the City, the necessary staff for planning, transition, implementation, materials for annual open enrollment(s), and/or any special open enrollments that the City deems necessary to administer the plan.

b. Contractor shall begin services prior to the plan year effective date in order to prepare for the City’s open enrollment. The plan year for City of Tucson is July 1 through June 30, with open enrollment, generally scheduled for the month of May. The City of Tucson reserves the right to change these dates with a fourteen (14) day notice to Contractor.

c. Conduct an orderly transition for an implementation date of July 1 of each contract year for Active employees and Retirees.

d. Provide knowledgeable personnel (Client Service Executive) to attend annual onsite open enrollment meetings/days, in addition to two annual per year onsite health fairs and bi-weekly onsite new hire orientation (frequency and format to be determined by City, at no additional cost to the City). Locations of meetings may vary within the greater Tucson area. The number of open enrollment meetings will be determined based on the number of changes to the current program that will require plan education. Contractor will be responsible for designing and delivering brief presentations (subject to City approval prior to delivery) and answering questions.

Claims Administration

1. Contractor shall provide the City with a minimum of 12 months advance notice of any claim system conversion or change that may disrupt the current processes.

2. Contractor receiving claims missing information that prevents contractor payments shall pend claims for a period of not more than 60 days allowing time for additional information for processing.

3. Contractor agrees to send initial requests for information within 5 working days of claim receipt and second requests within 21 calendar days of initial request.

Account Management and Member Service

1. Account Manager – Contractor shall provide one (1), day-to-day contact for City of Tucson with the primary responsibilities of responding to all plan issues, coordinating with the Contractor’s various departments to resolve issues, and overseeing all aspects of project management including, but not limited to, initial implementation and any ongoing or new program facilitation. The Account Manager shall have a minimum of five (5) years’ experience with the Contractor’s organization or in a similar industry. If possible, the Account Manager shall also be a local resident of Arizona or have intensive familiarity with factors influencing care and services in the local market.

2. Contractor shall respond to account issues and member service issues within one to two business days at minimum with a plan to resolve the issue within a specified timeframe established to do so.

3. Contractor shall provide a designated customer service team at a minimum.

4. Contractor shall provide exceptional customer service support via phone, e-mail, and website for the City and their plan participants as documented by consistent reporting through performance guarantees and City specific customer satisfaction surveys.

5. Contractor shall provide a designated fully operational toll-free telephone line that is answered by a live person 24-hours per day, 365-day per year toll-free telephone access to live US-based customer service representatives.

6. Contractor shall provide a designated team of professionals who will be responsible to see that all contract requirements and service deliverables are met by the Contractor.

7. Contractor shall provide an account management team that is experienced in providing services for similar entities, trained in the City’s plan issues, is accessible to the City during normal business hours (8:00 a.m. to 5:00 p.m. AZ time) and with capacity and authority to respond to the City’s issues in a timely manner.

8. Contractor shall provide an escalation process to assist in matters that cannot be resolved at the customer service unit level.

9. Contractor shall provide documentation of a process for prompt issue resolution and maintain an issue log.

10. Contractor shall provide the City access to an electronic tracking and resolution log of all open and closed City issues, in the required format agreed upon during implementation.

11. Contractor shall attend in person or via video conference monthly, quarterly, and annual program review meetings, meetings with the HR department, Trust Board, Benefits Committee and periodic telephone calls, as requested by the City’s insurance benefits office at no additional cost to the City.

Appeals and Disputes

1. Contractor shall handle all levels of claims appeals.

2. Contractor shall adhere to appeals and dispute processes as developed and directed by the City and stipulated in the subscriber’s certificate/booklet section relating to the written appeals process, including meeting timeframes and reporting on all levels of appeals with responses and results. Also, processes shall be kept current and made available at any interval requested by the City.

3. Contractor shall maintain procedures for responding to appeals and disputes as well as reporting the responses and results to the City.

4. Contractor shall provide the City a clear path (representative phone number or email, etc.) for plan participants to register complaints.

Audit

1. Once each year, or within two (2) years following termination of this Agreement, the City’s third party Auditor(s) (“Auditor”), as reasonably approved by Contractor (which approval shall not be unreasonably withheld), may inspect and verify claim data, eligibility, billing records, pricing discounts and terms, claims adjudication systems, healthcare benefits, clinical programs, subcontracted administrative services directly related to the City’s Member utilization and services, performance guarantees, and operational processes relating to the services provided to the City pursuant to this Agreement to ensure Contractor’s compliance with the terms and conditions of this Agreement.

2. Contractor shall agree to allow the audit of the Contractor’s records and those of their respective subcontractors including, but not limited to: access to provider data/records; provider contracts; all types of provider fee schedules; customer service departments; claims departments; records to support network adequacy; appeals/grievances/disputes both from providers and/or members; quality assurance programs; systems data; reporting data; overpayments and underpayments; fraud hotline complaints; investigations and closing actions; shared cost savings, if the concept continues; eligibility records; fraud detection and preventative activities; performance guarantees; and reporting.

3. Contractor shall provide full disclosure of all their records and those of their subcontractors upon notice from the City and/or the City’s selected auditor, should an audit be requested by the City. Contractor shall cooperate with the auditors and waive any fees associated with obtaining access to the City’s data and/or records.

4. Contractor shall maintain a record of all complaints from all members for seven years and make requested information available within ten (10) business days of the initial request. Such record shall include all correspondence relating to the disposition of the complaint.

5. Contractor shall 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.

Eligibility

1. Contractor agrees that the City shall be the final authority in deciding eligibility of participants.

2. Contractor agrees to receive eligibility and enrollment information via a weekly electronic feed from the City’s online enrollment system (currently Workday), at no additional cost to the City. The City reserves the right to change enrollment system providers at any time. Should a different enrollment system provider be used, there shall be no charge from the Contractor to the City to change providers including any changes to data files or feeds, etc.

3. Contractor shall establish appropriate FTP site(s) to exchange eligibility data at no additional cost to the City.

4. Contractor must agree to load eligibility file weekly within 2 working days of receipt and notify City of discrepancies and errors within the eligibility file within 2 working days of receipt of each eligibility file.

5. Contractor shall absorb any/all programming costs associated with data file transfers (weekly eligibility feed) in current data file compliant format (see attached Medical File Layout).

6. Contractor shall send eligibility files to the City’s pharmacy benefit manager and any other vendors at the frequency the City deems necessary at no additional cost to the City.

7. Contractor agrees to accept the City's self-bill (no true up of any eligibility discrepancies other than those based on eligibility file transfer).

8. Contractor agrees to accept payment 60 days in arrears. For example, July’s premium would be considered late after August 29.

9. Contractor shall 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 minimum per year. The Contractor shall verify COB status based on the guidelines and frequency as stipulated by the City during implementation and for the full term(s) of this contract.

10. Contractor shall provide City benefits/finance/management with access to secure email at no additional cost to the City for resolving any eligibility issues, transmit secure data and have secure discussions.

11. Contractor shall agree to communicate through HIPAA-compliant electronic sites to exchange data between themselves and any other required contractors as requested by the City at no additional cost.

12. Contractor shall provide unlimited, online eligibility updating entry capabilities for a minimum of six (6) City of Tucson approved users.

13. Contractor agree to maintain full coverage for over-65 retirees (and their eligible dependents, including surviving dependents) who lack sufficient quarters to qualify for Medicare Part A without paying Part A premium.

14. Contractor agrees to continue eligibility for Spouse and/or Child(ren) until 65 or 26, respectively, for spouses and children of retirees who age out or pass away.

15. Contractor agrees to cover disability retirees under age 65 who qualify for Medicare. Contractor will manage coordination of benefits with Medicare, with Medicare paying primary, and the successful Contractor paying secondary.

Plan Member Communication Materials

1. Contractor shall submit all copies of member materials, web portal member communications communication distributed in any fashion to 50 or more plan members.

2. Contractor shall ensure that members with limited English proficiency, Spanish-speaking, and those that are deaf or hearing impaired have access to communication services that enable them to utilize the phone lines.

3. Contractor shall supply both written and electronic member communication materials (flyers, plan summaries, etc.) at no additional cost to the City. Documents will be requested in English and Spanish (when available)

4. Contractor shall prepare and provide plan document(s), summary of benefits coverage, summary plan descriptions (SPDs) and all other communications including educational videos to describe the City’s plan benefits and provisions at no additional cost to the City.

5. Contractor shall provide a website and/or mobile application(s) for use by employees, retirees, and eligible dependents to obtain information on the City’s benefit plans, services offered and their individual account information at no additional cost to the City.

6. Contractor shall provide web-based consumer tools for all plans including, but not limited to, online provider directories (as appropriate), summary of benefit coverages and/or plan benefit descriptions, provider cost comparison tools, as well as access to claim status (Explanations of Benefits) at no additional cost to the City.

Public Information Requests or Other Communications

1. Contractor shall 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. Contractor shall review all responses with the City and obtain approval prior to the release or response of any inquiry.

2. No member communication without the City’s consent: The Contractor will not automatically enroll the City of Tucson in any programs that involve any type of communication with members, without express written consent from the City of Tucson.

Commissions, Overrides and Bonuses

1. Contractor agrees commissions shall not to be included in the fees/rates submitted, (i.e., all fees/rates are to be quoted net of commission.). Any proposal that includes payment of commissions to a third party may be deemed non-responsive.

2. Contractor agrees that if commissions are included in their filed rates and cannot be removed from the rates provided, the level of commissions included in the proposed rates must be disclosed. Contractor agrees to disclose all direct and 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. If commissions cannot be removed dollar for dollar from Contractor’s rates commissions will be payable to the City’s consulting firm.

Medical and Behavioral Health Third Party Administrator (TPA) and Network

1. Contractor shall own all contracts with medical and behavioral health providers and take responsibility for all subcontracted networks/providers proposed by the Contractor within this RFP.

2. Contractor shall update the online provider directory every 96 hours for any changes reported by a provider.

3. Contractor shall agree to accept and review provider nominations on behalf of the City or its plan members.

4. Contractor shall maintain for the duration of the contract a network of providers in the City’s geographic locations no less than that proposed in this RFP.

5. Contractor shall adopt and disseminate practice guidelines that consider the needs of enrolled members and are:

a. Based on AMA guidelines or a consensus of medical professionals in the particular field;

b. Developed and/or adopted in consultation with contracting medical care professionals;

c. Reviewed and updated periodically within timeframes determined appropriate by the Contractor and approved by the City; and

d. Applied consistently to all members covered under the program.

6. Contractor shall provide monitoring and evaluation of all types of provider performance and remove providers that do not meet the performance and quality standards required by Contractor to be part of the network.

7. Contractor shall provide to the network of providers both toll-free telephone support and field service support.

8. Contractor shall resolve provider issues that relate to the City’s members in a timely fashion.

9. Contractor shall assist members in disputes between provider contract and claims administration. This includes customer service representatives reaching out to providers to work toward resolution. This assistance must be proactive to assist the City’s members toward reaching resolution; the assistance may not be simply passive where members have to figure out how to resolve issues on their own.

10. Contractor shall provide medical and behavioral health claims administration, eligibility services including but not limited to tracking and determination of disability for adult children approaching and over age 26 and provide notification and verification to the City (this process must be initiated by the TPA).

11. Contractor agrees 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. Load an end date for dependents to age 26 (end of the month) and ensure it remains in place when new eligibility files are received (does not overwrite the end date as long as the dependent remains on the plan).

12. Contractor shall pay non-network claims at 110% of Medicare.

13. Contractor agrees to negotiate, on behalf the City, on all out of network claims. Preference is to pay Contractor a fixed PEPM for ALL non-network negotiations or to include a reasonable percent of savings with a max per claim dollar cap and max PEPM to be reconciled quarterly.

14. Contractor shall administer a fraud and abuse detection program.

15. Contractor shall provide subrogation services.

16. Contractor shall provide reporting to the City or its designated vendor for Part III of IRS form 1095-C in Excel or CSV file format at no additional charge.

17. Contractor shall provide an easy to read explanation of benefits resulting from claims transactions to plan participants (EOB).

18. Contractor shall provide both mobile app and web-based pricing transparency tools.

19. Contractor shall provide employee access to Claims Administration Portal to view claim status, EOB’s, etc.

20. Contractor shall provide bilingual communication/educational materials.

21. Contractor shall produce plan document, SBC’s, summary plan description;

22. Contractor shall produce and mail ID cards (standard stock) to employee and retiree mailing addresses.

23. Contractor shall provide a designated account management/service team and a designated call and claim unit with toll free telephone access.

24. Contractor shall respond to the City questions/needs within 1 business day of request (even if the answer is “I am working on it”).

25. Contractor shall 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).

26. Contractor shall pay retrospective COB Medicare Secondary Payer claims as needed.

27. Contractor shall manage all levels of claims appeal including Level 3 external appeals.

28. Contractor shall match the City’s COB guidelines and process for determining primary and secondary responsibility as follows: The Secondary Plan may reduce benefits so that the total benefits paid by all Plans are not more than 100% of the total of all Allowable Expenses. 100% of the total allowable expenses are considered and claims are coordinated so that a covered person may receive a maximum of 100% payment.

29. Contractor shall provide a 24-hour nurse line.

30. Contractor shall provide decision support and plan comparison for members (online and by phone) including having pre-Enrollment specialists available by phone to assist members in understanding their plans and making enrollment decisions, a site available to City employees and retirees that helps them make an enrollment decision by comparing their total medical costs across the plans offered including assumed utilization based on their history or expected medical needs, and includes their contributions to see a total cost picture and tools that provide the ability to look up providers that are in the different networks as part of the decision making process.

31. Contractor shall provide an online portal for plan participants to track medical history, estimate medical costs, compare providers for quality and price, print/request personalized ID cards, search for network providers;

32. Contractor shall provide an option of a more tightly managed plan option to match the City’s Network Plan with either a gatekeeper PCP or open access.

33. Contractor shall provide broad medical network access including coverage outside of AZ and Centers of Excellence with minimal disruption to City of Tucson plan participants.

34. Contractor shall provide flexibility in administration & network design (for example the ability to partner with a Mexico domiciled PPO network, the ability for the City to directly contract with certain community providers that may not be in the existing PPO network or the ability to contract with an onsite or near-site clinic).

35. Contractor shall provide financial and statistical reporting with online access for City staff and their designated consultant.

36. Contractor shall provide an annual consultative analytics review and attendance by the medical director if the City requests.

37. Vendor Provided Funds: CIGNA’s provided funds and onsite representatives are outlined on page 2 of this RFP. The City desires to maintain at a minimum a general fund credit of $300,000 to be used at the City’s discretion. Vendors may provide additional funds/credits, however, the City seeks to keep Administrative fees down.

38. Currently the City has an onsite service representative (Client Service Executive) employed by Cigna. The City is interested in Contractor providing services that will include ALL services currently provided by the Service Executive, however, they are open to alternative approaches to providing an onsite person. Offeror shall describe how they will meet or exceed the requested services including the following:

a. Currently the Client Service Executive is working 40 hours per week. Duties include providing client support in the areas of benefit education, open enrollment and health and wellness initiatives. The Advisor coordinates with the account manager to ensure needs are met and potential problems are averted. The hours vary based on the City’s needs and may regularly include evening, early morning, and weekend hours at departmental locations. As a result, the specific days and hours of work may fluctuate. Current administrative activities include the following:

i. Optimize employee and retiree understanding of benefits by designing, planning and conducting meetings and presentations, preparing written and graphic communications, and responding timely to requests. Education program currently includes new hire orientation, open enrollment seminars, office hours, brown bags, larger scale presentations throughout the City at various onsite locations, coordination of EAP programming, and online webinars, live meetings and resources. While all components of education program are subject to the City’s approval, the Contractor is responsible for designing programs and building engagement and attendance.

ii. Build and execute open enrollment strategy in partnership with City staff

iii. Work with Well-Being Coordinator and/or the City’s Wellness Contractor and wellness team to implement well-being program and enrollment strategy. The Well-Being Coordinator is responsible for building and executing the program and driving department buy-in and employee engagement. The Client Service Executive may assist at times during health fairs, etc. But they wouldn’t be responsible for developing program and enrollment strategies.

iv. Maintains knowledge and expertise in City health products (medical/dental/pharmacy/EAP), programs, services and enrollment activity, effectively articulating and demonstrating program capabilities and tools

v. Acts as a liaison between plan participants/client and internal service agents to resolve issues including but not limited to customer service issues, administrative functions, eligibility and billing questions, installation matters, settlement production matters to appropriate service organization representatives (Employer Account Services, Customer Service Claim and Call Centers, etc.)

vi. Assist with implementation of new systems, program offerings, processes and procedures; evaluate and document processes and procedures, and make recommendations regarding opportunities to improve standards and efficiencies

vii. Construct and conduct benefits-related employee surveys; analyze and report on responses

viii. Order and maintain a supply of appropriate collateral, benefit summaries and giveaways

ix. Update job knowledge by participating in educational opportunities and reading professional publications

x. Handle difficult situations with diplomacy, good judgment and professionalism; exercise global and cultural awareness

xi. Maintain confidentiality throughout all communications and data interactions

xii. Preparing and executing a marketing strategy

xiii. Proactively drive buy-in and engagement; the Service Executive educates on health programs offered by the plan, but is not responsible for driving “buy-in”

xiv. Own any customer issue that is brought to the table for resolution by client. Manage resolutions in a timely manner and provide status to all appropriate parties when resolved, including a summary of root cause, countermeasures, and next steps.

xv. Deliver lunch and learn sessions on programs and services offered and/or meet with Employee Services team periodically to train and answer questions related to trending issues and/or provide updates to the team on Cigna processes/products.

xvi. Assist in arranging case manager (or other appropriate resource) for customers with complicated medical conditions or technical/non-clinical needs

xvii. Research, analyze, and track customer call/claim inquiries from employees. Communicate outcome and next steps directly to employees with cc to employee’s HR when appropriate.

xviii. Handle transactional tasks (customer/provider outreach calls, create out-of-pocket ledgers, etc).

xix. Pull claim reports and analyze data and trends.

xx. Compile monthly service reporting based on client needs/requests.

xxi. Other duties as assigned.

Telehealth

1. Contractor shall provide services for medical and behavioral/mental health care at a minimum.

2. Contractor shall provide 24-hour access to board-certified, licensed doctors; as well as licensed counselors and psychiatrists.

3. Provide 24-hour per day, 365-day per year – even on weekends and holidays;

4. Contractor shall provide efficient, quality care.

5. Contractor shall provide best in class patient wait times.

6. Contractor shall provide a HIPAA compliant telehealth platform that is intuitive and user friendly for non-technical users and utilizes the latest telecommunications technology.

7. Contractor shall provide…