28-1.3 Questionnaire.pdf

Medical Questionnaire for Group Health Insurance (All Proposers) Provide the following information for the Suwannee County Board of County Commissioners

1. Provide a brief (one page or less) history of your organization including ownership structure and any other organization with which you are affiliated.

2. Provide the enrollment data (including all plans) requested below for your organization:

a. National Enrollment

b. Florida Enrollment

c. North Central Florida (Suwannee County) Enrollment

d. What percent of your Florida enrollment in 2025 and 2026 is from public sector clients?

What percentage is Fully-Insured vs. Self-Funded?

3. Provide references for three (3) similar size clients, by enrollment, for North Central Florida

(Columbia, Alachua, and Suwannee County) using the following format:

1/1/2023 1/1/2024 1/1/2025 1/1/2026 Commercial Enrollment Other Enrollment

Total Enrollment

1/1/2023 1/1/2024 1/1/2025 1/1/2026 Commercial Enrollment Other Enrollment

Total Enrollment

1/1/2023 1/1/2024 1/1/2025 1/1/2026 Commercial Enrollment Other Enrollment

Total Enrollment

Florida Enrollment Total Enrollment

2024 % of Public Sector

2025 % of Public Sector

2026% of Public Sector Fully Insured

Commercial Enrollment Medicare Enrollment Medicaid Enrollment Other Enrollment

Total Enrollment

Employer Name Number of Employees Date Services Commenced Date Services Ended (if applicable) Contact Person and Title

4. Provide NCQA, JCAHO, AAA and/or any other accreditation status that applies to the medical and/or

Behavioral Health plan(s) you are proposing. Provide a copy of your accreditation letter(s).

5. Detail any mergers/acquisitions involving your organization which have occurred in the last 12-month period, and any which are planned for the next 12 to 24 months.

6. Can your plan track and report on customer service activity?

7. Ad hoc reports shall be available upon request. Will there be an additional charge for these reports?

If yes, what is the cost?

8. Is your organization currently in compliance with Florida Office of Insurance Regulation profitability and reserve requirements? Yes ___ No ___ If no, have you been required to submit a Corrective Action Plan? If yes, attach a copy of the CAP.

Plan Administration

9. Describe, in detail, your out-of-area coverage for traveling members, both within and outside the

United States. Describe your capabilities for negotiating fees with out-of-area providers.

10. Does your plan cover members that utilize services offered through a walk-in facility such as those located in a retail environment? Yes ___ No ___ If yes, are there any limitations? If an employee is in an HMO plan and is outside of the service area and chooses to use a walk-in facility or urgent care instead of the emergency room, would this be covered as an in-network benefit? Yes ___ No___ Are there any limitations?

11. Confirm your organization can administer all proposed benefits as outlined in Attachment B1? Yes

___ No ___ Provide any deviations to covered services and limitations/exclusions in Attachment B.

Failure to disclose deviations that contribute to additional claims cost may result in the Awardee(s) being financially liable for the additional claims cost.

12. Provide a complete listing of EAP services included in your Proposal for both internal and external services.

Plan Network

13. Indicate your contract status for your top ten hospital providers (by number of admissions) as well as your top ten physician/physician group providers (by number of encounters) in Columbia and Alachua Counties. Indicate the current contract status and the contract’s expiration date.

Address Phone Number Email Address

Top Ten Hospitals (by number of admissions) Hospital Contract Status Contract Exp. Date Date of Last Contract Change 1.

14. Provide a link to your most up-to-date provider directory.

15. Are there any hospitals in the North Central Florida (Suwannee, Columbia & Alachua) area with which you are not contracted? Yes ___ No ___ If yes, list all hospitals.

16. Will your network allow participating dependents to select a PCP and access local providers if the dependent resides in another location and you have a network available in that location? Yes ___ No

17. Can each child select his/her own PCP? Yes___ No ___

18. Complete the following GeoAccess summary for BCC employees. Your study should include a summary report for each of the items listed below. Each summary should indicate the total number and percentage of employees with access by zip code and by county for all networks that you are proposing. Please include GeoAccess Reports:

a. Number and percentage of employees with two adult Primary Care Physicians (Family Practice, General Practice, Internists) within thirty miles of the employee’s zip code.

2.

3.

4.

5.

6.

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8.

9.

10.

Top Ten Physicians (by number of encounters) Hospital Contract Status Contract Exp. Date Date of Last Contract

Change 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

b. Number and percentage of employees with two Pediatricians within thirty miles of the employee’s zip code.

c. Number and percentage of employees with two OB/GYNs within thirty miles of the employee’s zip code.

19. Are all hospital-based physicians (e.g., emergency, pathology, anesthesia and radiology) affiliated with network hospitals contracted? Yes ___ No___ If no, list any hospital physician group(s) not contracted. Please include the hospital affiliation.

20. Does the network you are proposing allow for direct access to network specialists or is it a

“gatekeeper” network?

21. If the network proposed is not a “gatekeeper”, can your administrative system record a designated

PCP for each member to be used for reporting, tracking purposes and quality initiatives?

22. Describe, in detail your out of area coverage for dependents attending school out of area. Include your procedures for emergency care, as well as follow-up visits.

23. Is your HMO network national or local? If an employee or retiree is located outside of North Florida and you have a national HMO network, can they elect to remain in the HMO plans? Yes___ No ___

24. What provisions are made for transition of care if a provider is terminated by your plan? If the provider terminates the contract? Will ongoing services be treated as in-network? Describe the member notification process.

25. If covered services are not available within the contracted network, how will members obtain necessary services?

Network Pricing

26. What is your overall network pricing as compared to prevailing Medicare reimbursement for hospitals? For physicians?

27. Using paid claims information on your Group book of business, please provide the following information for Columbia, Suwannee, and Alachua County, Florida for each network you are

County Number of

Eligible Employees

Percent of employees with 2

PCPs within 30 miles

Percent of employees with 2 pediatricians within 30 miles

Percent of employees with 2

OB/GYNs within 30 miles

HMO PPO/POS HMO PPO/POS HMO PPO/POS HMO PPO/POS

Suwannee Columbia Alachua proposing. Please limit this to the selected counties. This should not include your Medicare book of business. Please use claims incurred 1/1/24 through 12/31/24 and paid through 3/31/25.

• Exclude pending, denied, duplicate, Medicare-primary, and other secondary claims.

• Exclude prescription drug (retail and mail-order), dental, and vision hardware claims.

• Exclude individual denied services within a valid claim. For example, if one service provided during an office visit is not covered, exclude that service.

28. Provide hospital cost data for Suwannee, Columbia and Alachua Counties.

Provider Relations

29. Does your organization provide information directly to the plan participant to make provider selections that are cost effective for the plan? If so, please explain.

30. Does your organization work with the plan providers who deliver the most efficient and effective care? If so, please explain.

31. Does your organization offer incentives to network providers to encourage minimally invasive procedure techniques over open surgery? If so, please explain.

PPO Network Category a) Total $ Billed b) Total $ Allowed* Discount** Hospital Inpatient Hospital Outpatient Emergency Room Physicians – MDs and DOs

HMO Network Category a) Total $ Billed b) Total $ Allowed* Discount** Hospital Inpatient Hospital Outpatient Emergency Room Physicians – MDs and DOs

2023 2024 2025

HMO PPO HMO PPO HMO PPO

Average cost per admission Average cost per day Average discount level Average length of stay Days per 1000 Admissions per 1000

32. Describe how your organization will communicate with providers regarding BCC’s schedule of benefits, changes to the schedule of benefits and general administrative policies and procedures specific to BCC’s Medical Plan?

33. Describe how your organization will ensure that providers in your network refer to network facilities and other network providers?

Eligibility and Claims Administration

34. Will BCC have a dedicated team for eligibility, claims and customer service?

35. Do you plan on major changes or upgrades to your administrative system or the platform you are proposing for BCC in the next 24 months? If yes, please explain.

36. Will you provide BCC with an eligibility contact person for eligibility file issues and questions?

37. What eligibility responsibilities does your organization expect BCC to perform?

38. Describe your explanation of benefits (EOB) process for HMO/EPO, Consumer Driven and PPO and if these are available hard copy and/or online. Is there any flexibility? What is included on the EOB statements?

39. Will you process run-out claims after plan termination? If yes, for how long and at what cost?

Medical Management

40. Describe the employee’s responsibility for compliance with Utilization Management programs, in-network, out-of-network, and out-of-area.

41. Are your utilization review service/requirements different in any way for in-network, out-of-network, or out-of-area participants?

42. Are network providers at risk for not following your Medical Management Program? Please explain.

43. Describe your pre-certification process for inpatient admissions.

44. Describe how inpatient utilization is managed. Specifically address after hours, emergency, in and out-of-network.

45. Is inpatient census reviewed on a daily basis? If no, how often?

46. How do you communicate with patients and family members regarding length of stay and discharge planning?

47. How are members identified for enrollment in Case Management? Check all that apply.

Disease Management/Wellness

48. Complete the chart below for each service your organization provides (check all that apply). Provide examples of your resources:

49. Do members in Case Management have a consistent Nurse Manager presiding over each case?

50. How are members discharged from Case Management?

51. Describe how providers are made aware of Case Management.

52. How can you assist BCC with targeted comprehensive initiatives to improve the health of BCC population? Can you report on the effectiveness of implemented initiatives, including clinical feedback to providers and follow-up activities when indicated?

Quality Assurance

53. Provide specific examples as to how your objective measurement and information sharing process has improved clinical and financial outcomes in North Central Florida over the past two years.

54. What clinical studies were conducted in the past two years?

55. What interventions were put into place to improve outcomes as a result of the clinical studies?

DELIVERY MODE OUTSOURCED

VENDOR

Wellness Services Direct Mail Online Telephonic Onsite Seminars/One-on-One Counseling

Name of Vendor

Health Risk Assessment Biometric Screenings Diabetic Counseling Health Coaching Health Education & Awareness Campaigns

Self Directed Programs Resource Facilitator Health Partnerships Physician Follow Up Reports

Admission Notifications Pre-Certifications Other

Wellness Please indicate the ability of your organization to provide all of the following services and their associated fees on a PEPM basis (if any). Provide examples of your resources:

56. Describe all onsite Disease Management/Lifestyle Management/Wellness programs available to

BCC. Are they incentive based? Provide samples/evidence (i.e., brochures, posters, etc.).

57. Describe your capabilities to manage rewards and incentives. Provide examples of incentives and budget.

58. Describe your strategy to drive participation and maintain participant engagement.

59. Complete the chart below and provide documentation and evidence for the Lifestyle Management

Programs you provide (check all that apply). Provide evidence for gender specific education and awareness (i.e., breast care for women, cardiovascular disease for women, prostate for men).

Delivery Mode Outsourced Vendor

Wellness Services Direct Mail Online Telephonic Onsite

Seminars/ One-on-One Counseling Name of Vendor

Cost Cost Cost Cost Cost

Health Risk Assessment Y N Y N Y N Y N Y N

Biometric Screenings

Diabetic Counseling

Musculoskeletal Coaching

Maternity

Behavioral Health Counseling

Asthma Coaching

Obesity and Weight Loss

Hypertension

60. What additional Lifestyle Management Programs are planned for the next two (2) years?

61. How are network providers made aware of the availability of your Lifestyle Management Program?

62. Describe your capabilities to manage or offer the following (check all that apply):

Lifestyle Management Programs – Delivery Mode

Mailings Self Directed Programs

Telephonic Coaching

Onsite Seminars, Lunch & Learns

One-on-One Counseling Other

Heart Disease Diabetes & Diabetic Counseling

Cholesterol Hypertension Asthma Nutrition Fitness & Exercise Women’s Health Men’s Health Musculoskeletal/ Back Pain

Smoking Cessation Weight Management

Stress Management

Other

SERVICES OUTSOURCED VENDOR

Offer Manage Coordinate Community Partnership

Name of Vendor

Service Not Offered

Lunch and Learns

Fitness Center Discounts

Weight Loss Competitions

Stress Management (Yoga, Tai Chi, etc.)

63. What criteria is used to identify and select members for participation in each Lifestyle Management

Programs?

64. Are members identified for Lifestyle Management automatically enrolled (requiring them to opt-out if they choose not to participate) or do members identified for Lifestyle Management have to enroll to participate?

65. What is your organization’s criteria to discharge/disenroll a member?

66. Provide patient attrition rate (patient disenrolls) in 2025 and 2026 for each Lifestyle Management

Program offered.

67. All members in the Lifestyle Management Program should have a specific nurse manager regardless of whether they are suffering from one or more than one chronic condition. If there are exceptions, explain each.

68. How does your organization measure clinical impact of each Lifestyle Management Program?

Customer Service

57. Does your plan have a 24-hour toll free number for member services and provider services? Yes ___ No ___ If no, what are the days and hours of operation?

58. Describe the services and features members have access to on your website?

59. How many cards will be distributed per family?

60. Is there a charge for replacement cards? Yes ___ No ___ If yes, what is the charge?

61. What is your normal turnaround time for production and mailing of ID cards?

62. Describe your 24-hour nurse line. Do you report on usage? Yes ___ No ___tation

63. Describe your implementation process if you are the Awardee(s), including significant deliverables, project manager and timelines for an implementation date of October 1, 2026.

SERVICES OUTSOURCED VENDOR

Offer Manage Coordinate Community Partnership

Name of Vendor

Service Not Offered

Walking Programs

Other: