9-FORM C - Manor ISD - Medical RFP Workbook.xlsx
XLSX spreadsheet 2 MB Posted
- Attached to
- Manor ISD - 2026 Medical RFP
- Solicitation number
- 26-008RFP
- Issued by
- Travis County, Texas
About this file
This is a Request for Proposal (RFP) workbook issued by Manor Independent School District in Texas for self-funded medical and prescription drug plans, fully insured medical and prescription drug plans, and stop loss products. The District is soliciting proposals for Administrative Services Only (ASO) Medical, Fully Insured (FI) Medical, Stop Loss, and Pharmacy Benefit Management (PBM) services. The RFP was released February 9, 2026, with questions due by February 23, 2026 at 2:00 PM CST, an addendum release scheduled for March 2, 2026, and proposals due March 11, 2026 at 12:00 PM CST. The effective date for coverage is September 1, 2026. The ASO contract will have a three-year term with two optional renewal periods, while the FI Medical contract is for one year. Current enrollment is approximately 1,038 composite members across three existing Blue Cross Blue Shield of Texas plans: HMO $3,000, HDHP PPO $3,400, and PPO $1,400.
Vendors must provide a $12.50 per capita per month (PCPM) commission and $100,000 annual targeted allowances, with annual payment structure to be confirmed. Current annual premium costs total approximately $7.92 million. The incumbent carrier is BCBS Texas, which currently holds the medical contract. Eligible employees are full-time employees and variable employees working 30 hours or more per week under the Affordable Care Act, with retirees excluded from coverage. The plan is non-grandfathered under PPACA. Proposals will be scored based on plan design and rates (40 percent), quality of goods and services (30 percent), administration (15 percent), reputation (7.5 percent), and proposal specifications adherence (7.5 percent). Vendors must complete all workbook pages, submit an executive summary with the standard proposal template, provide Network Disruption Reports and Claims Repricing Exercises, and agree to guarantee administrative fees for a minimum of three years with optional two-year renewals. Stop Loss coverage is required with individual specific loss deductible options of $200,000, $225,000, and $250,000, contract basis of 12/12 or 12/15, a 125 percent corridor, and inclusion of Aggregate Stop Loss with pharmacy included in the aggregate.
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Cover
Manor ISD
| Request for Proposal # 26-008 |
| for |
| ASO Medical, FI Medical, Stop Loss, and PBM (carved in only) |
| Release Date: February 9th, 2026 |
| Questions Due: February 23rd, 2026 @ 2:00 PM CST |
| Addendum Release: March 2nd, 2026 |
| Proposal Due Date: March 11th, 2026 @ 12:00PM CST |
Disclaimer: Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please submit through Bonfire.
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&"Arial,Regular"&7 © 2018 ARTHUR J. GALLAGHER & CO. &"Arial,Regular"&7AJG.COM
General Information
| General Information | ||
| Please consider the following information for your proposal. | ||
| 1. | EFFECTIVE DATE: | September 1, 2026 |
| 2. | CONTRACT DURATION: | ASO: 3 years with 2 optional renewals |
| FI: 1 Year |
3. VENDOR HISTORY: BCBSTX
| 4. | ELIGIBILITY: |
| Full Time Employees (EEs) as defined by the Client and variable EEs working ACA 30 Hours/week; Retirees are not covered. Full-time professional and para-professional - coverage is effective the first of the month following the employment date - i.e. employees hired on February 15th, will receive coverage as of March 1st. |
5. District Plan is a PPACA is a "non-grandfathered" plan.
6. The client has three current BCBSTX Plans. Please refer to the 2025 SBCs for further information. The client will consider these three models for weighted average scoring. Proposals will be scored on these three models.
7. Assume that current 2025 benefit coverage will remain intact for purposes of developing your cost, network, utilization management, modeling strategies.
8. Please include the below commissions and targeted allowances.
| Product | Inforce Carrier | Requested Commissions | Targeted Allowances | |
| 1 | ASO Medical, FI Medical, PBM (carved in only), Stop Loss | BCBSTX (Fully Insured) | $12.50 PCPM | $100,000 annually**** |
****Please pay credits/allowances annually and confirm if credits/allowances are paid 1x and/or ongoing.
If you have any documents that outline what is an allowable or permitted usage based on each type of allowance, please provide with your RFP response.
Gallagher is requesting that you allow reimbursements to be issued either by paying the vendor, including Gallagher, directly OR reimbursing the client. Please outline the documents needed to submit for reimbursement in your RFP response – Invoice, W-9, description of the services provided, proof of payment, etc.
| 9. | All reporting files and other supporting documentation can be found attached to the bid posting. |
| 10. | All workbook pages must be completed and returned with your proposal. |
| 11. | The client does not want competing multiple proposals from the same vendor, so manage your internal proposal process to assure that one (1) proposal is presented. |
| 12. | PLEASE provide an Executive Summary, as well as your standard Proposal with this submission. PLEASE note, you MUST provide your responses in our standard template in order to be considered for this RFP. |
| Disclaimer: | |
| Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please reach out to please submit through Bonfire. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Scope of Work Scope of Work
| Please consider the following information / requirements for your proposal. | |
| A. | Network Disruption Report |
| Vendors will be required to complete a Network Disruption Report as part of their RFP submission. Please refer to the separate exhibit that was included in the documentation attached to the bid. |
| B. | Claims Repricing Exercise |
| Vendors will be required to provide a Claims Repricing Exercise Report as part of their RFP submission. Please refer to the separate exhibit "Claims Repricing File" that will be provided with the addendum on March 2nd. |
| C. | Claims Target Guarantees |
| Vendors will be required to provide a Claims Target Guarantee. Please provide us with your standard format when responding to this RFP. |
| D. | Stop Loss Reinsurance Coverage |
| Please quote the following specifications: | |
| ISL Deductibles: $200,000, $225,000, $250,000 | |
| Contract Period: 12/12 or 12/15 | |
| Corridor: 125% | |
| Include ASL |
| E. | Pharmacy Benefit Management |
| The client is requesting vendors to include PBM administration as a part of their Medical proposal response. The client will not consider any standalone PBM vendors quotes. |
| F. | Medical Plan Options |
| BCBSTX HMO 3000 | |
| BCBSTX HDHP PPO 3400 | |
| BCBSTX PPO 1400 |
| G. | Scoring Matrix | |
| Plan Design to Rates | 40.0% | |
| a) Indicated plan design requests matched or exceeded. | ||
| b) Rates | ||
| c) Availbility of Carrier Credits | ||
| Quality of Goods and Services | 30.0% | |
| a) Response to contract terms/banking arrangements/timelines | ||
| b) Experience and Qualifications of Client/Customer Service team | ||
| c) Size and coverage of Networks | ||
| d) Performance Standards and Guarantees | ||
| e) Quantity and Quality of services promised. | ||
| Administration | 15.0% | |
| a) All lines offered by one carrier | ||
| b) Single Point of Contact | ||
| c) Reference Feedback | ||
| d) Carrier Credit amounts | ||
| Reputation | 7.5% | |
| a) Financial Stability - AM Best | ||
| b) Years Writing Proposed Benefits | ||
| Proposal Specifications | 7.5% | |
| a) Adherence to Proposal Specifications |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Proposal Specifications
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| All vendors must complete this section. | ||
| Proposal Specifications | ||
| # | Specification | Agree / Disagree |
| 1 | The effective date of coverage, September 1, 2026, is acknowledged and accepted. | |
| 2 | Administrative fees must be guaranteed for a minimum of three (3) years from the effective date with the option to renew for an additional two years for ASO quotes. | |
| 3 | All fees / premiums are requested on the General Information tab. | |
| 4 | Preliminary renewal rates must be submitted six months prior to the effective date. | |
| 5 | You completed all sections of the workbook in their entirety, in the format requested. | |
| 6 | The vendor will be responsible for producing an Rx addendum to be added to the Summary Plan Description. The client reserves the right to review / revise the addendum. | |
| 7 | Vendor agrees to provide an Rx addendum within 90 days of the effective date. | |
| 8 | The vendor will be responsible for producing the Summary Plan Description. The client reserves the right to review / revise the SPD prior to final printing. | |
| 9 | Vendor agrees to provide an SPD draft within 60 days of the effective date. | |
| 10 | Vendor agrees to provide all communication materials in electronic (pdf) format. | |
| 11 | Vendor agrees to provide Summary of Benefits and Coverage (SBC) within 14 business days after notification of final plan designs. | |
| 12 | Vendor agrees to provide all standard reports to the client and its professional advisor. | |
| 13 | Do you agree to provide the consultant with monthly reports for the data warehouse at no additional charge? | |
| 14 | Claims experience must be provided at least monthly, including each renewal. | |
| 15 | You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security Regulations and will use HIPAA 834 (ASC X12N 834) for the file transmission layout. | |
| 16 | You have reviewed and accept the Plan’s eligibility provisions. | |
| 17 | Your contract must require no more than a 90-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off anniversary. | |
| 18 | Vendor agrees to comply with the Performance Guarantees, and penalties for non-compliance, as provided in this RFP. | |
| 19 | Vendor has specifically listed all deviations from the RFP and coverage requirements. NOTE: Deviations MUST be listed; vendors cannot simply make “general” references to the proposal. | |
| 20 | If the client wishes to carve-out the pharmacy benefit, TPA agrees to take weekly feeds from the pharmacy vendor and will mine/integrate the data into the medical management program. | |
| 21 | Vendor agrees to provide Rx integration files for OOP / ACA compliance. | |
| 22 | Vendor agrees to administer a spousal surcharge if the client decides to implement such a program. | |
| 23 | Vendor agrees to provide a dedicated reporting contact for the client and its consultant. This person would be responsible for running ad hoc reports for the client and/or its consultant’s discretion, at no additional cost to the client. | |
| 24 | Vendor agrees to allow the client to interview and select the account management team of its choice within your organization. | |
| 25 | Your organization has online capabilities in the following areas: |
1) Provider selection – tools that will help members select reputable and effective providers
2) Quality comparison – tools that will help members compare quality outcomes of providers and facilities
3) Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.
4) Wellness information and tools (i.e. BMI calculator, target heart rate calculator)
| 26 | You must permit the employer to have access to all files on request (e.g., a claims audit). |
| 27 | Run-out claims will be paid by the existing carrier. Your pricing should assume no processed-in claim payments. ASO fees are mature and void of IBNR fee during the initial 12 month period. |
| 28 | Please include any programs or tools that can enhance a member’s experience. |
| 29 | Benefits should be payable based on the plan documents of the coverages being quoted and the Stop Loss contract should not supersede those plan documents of the quoted coverages. |
| 30 | Stop Loss Contract basis: 12/12, 12/15 |
| 31 | Stop Loss ISL options: $200,000, $225,000, $250,000 |
| 32 | Pharmacy is included in the Aggregate |
| 33 | Include an overall composite rate covering all available medical plans. |
| 34 | Corridor: 125% |
| 35 | Max Aggregate Annual Payment: Options of $1,000,000 and Unlimited |
| 36 | Spec & Agg Advance Funding option. If there is a cost associated with it, please break it out in your proposal. |
| 37 | Include Plan Mirroring option. If there is a cost associated with it, please break it out in your proposal. |
| 38 | Vendor must waive any “actively-at-work provisions |
| 39 | Vendor must waive any late entrant penalties |
| 40 | Run-in should not be limited |
| 41 | Please include 12 months of run-out coverage in your rates |
| 42 | Vendor must agree to no new lasers at renewal. |
| 43 | As part of your proposal response, please compare the employer’s current plan document, which has been included, to your proposed stop loss policy and identify any areas where there are gaps in coverage or include in your proposal a statement that you will mirror the employer’s plan document. |
| 44 | Vendor must agree to release the stop loss renewal proposal within 120 days of expiration |
| 45 | The client intends to include your RFP responses as part of the overall Contract. Please acknowledge you understand and agree to this expectation. |
| 46 | Vendor agrees to provide bi-lingual benefit summaries and SPDs at no additional cost. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Deviations Tab
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| If you have any Deviations to the Proposal Specifications, OR need to add additional commentary on any item of the Questionnaire, please include this here | ||
| Proposal Specifications | ||
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
ASO Pricing Sheet
| ASO Medical Pricing Sheet |
| Company Legal Business Name: __________________________________________________________________ |
In order to ensure we're measuring all financial elements correctly, please clearly outline your proposed solutions for this project. Please also ensure you line up network / costs as it compares to the client's current plan offerings to ensure we accurately capture your proposed intent.
| Current Plans | BCBSTX HMO 3000 | BCBSTX HDHP PPO 3400 | BCBSTX PPO 1400 |
| Name of YOUR Proposed Network | |||
| Enrollment Assumptions - Employees | |||
| Enrollment Assumptions - Members (if applicable) | |||
| Base Administration Fee | |||
| Plan Year 1 | |||
| Plan Year 2 | |||
| Plan Year 3 | |||
| Plan Year 4 | |||
| Plan Year 5 | |||
| Indicate PEPM or PMPM | |||
| The client wants 24-months runout. This needs to be included in your final fees. |
| OUTLINE EVERYTHING COVERED IN THE BASE ADMINISTRATION FEE: |
| Programs/Services INCLUDED in Base ASO Fee: |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Please insert additional lines as needed. |
| Indicate PEPM or PMPM |
| Additional Program Fees Required for Programs / Guarantees |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Please insert additional lines as needed. |
| Indicate PEPM or PMPM |
| PLEASE INDICATE ANY / ALL FEES & COSTS THAT WILL BE BILLED THROUGH THE CLAIM WIRE, INCLUDING ANY CAPITATED SERVICES, SUCH AS BEHAVIORAL HEALTH, ETC: |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Please insert additional lines as needed. |
| Indicate PEPM or PMPM |
| ANY OTHER FEES / COSTS THAT THE CLIENT SHOULD FACTOR FOR YOUR PROPOSED RFP SOLUTIONS: |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Name of Fee / Program |
| Please insert additional lines as needed. |
| Indicate PEPM or PMPM |
| FOR THE OVERALL MEDICAL PROGRAM, PLEASE PROVIDE THE FOLLOWING: | |
| Please confirm you have included the annual allowances/credits as requested | Answer here |
| If more than one allowance, please elaborate here. | Answer here |
| Confirm this allowance is included for all 5-years of the RFP contract. | Answer here |
| Claim Target Guarantee / Penalty Corridor (PEPM) | Go to Additional Guarantees tab |
| Network Discount Target Guarantee / Penalty Corridor (Discount %) | Go to Additional Guarantees tab |
PLEASE NOTE, ANY / ALL PROGRAM COSTS THE CLIENT WILL NEED TO COVER MUST BE DISCLOSED ON THIS SPREADSHEET.
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Performance Guarantees
| Medical Performance Guarantees |
| Company Legal Business Name: _______________________________________________________________________ |
| Answers are limited to 50 characters | ||
| Implementation | Metric | $ PEPY at Risk |
| ID Card Production & Distribution |
| Account Management | Metric | $ PEPY at Risk |
| Overall Account Management |
| Claim Administration | Metric | $ PEPY at Risk |
| Turnaround Time | ||
| Financial Accuracy | ||
| Total Claim Accuracy |
| Member Satisfaction | Metric | $ PEPY at Risk |
| Member Satisfaction |
| Member Services | Metric | $ PEPY at Risk |
| Telephone Service Factor | ||
| Average Speed of Answer | ||
| Abandonment Rate | ||
| First Call Resolution |
Total $ PEPY at Risk $0.00
<Please enter your Guarantees Disclaimer here>
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Additional Guarantees
| *ADDITIONAL GUARANTEES |
| Please record all answers on this excel spreadsheet |
| Discount Guarantees | ||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | ||
| Carrier | Carrier | |
| Network | Network | |
| Guaranteed Discount % | ||
| % of Admin Fee at Risk | ||
| Annual Fees at Risk $ |
| In-Network Utilization Guarantees | |||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | |||
| Carrier | Carrier | ||
| Network | Network | ] | |
| Guaranteed In-Network Utilization % | |||
| % of Admin Fee at Risk | |||
| Annual Fees at Risk $ |
| Claim Target/Net Cost Guarantees | |||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | |||
| Carrier | Carrier | Carrier | |
| Network | Network | Network | |
| Is this network the only network you are proposing? | |||
| If not, do you provide guarantees on the other network? | |||
| Applicable up to Claim $ Amount | |||
| Billed or Paid Claims? | |||
| Estimated Annual Admin. Fee Subject to Discount | |||
| % of Admin Fee at Risk | |||
| Annual Fees at Risk $ | |||
| PEPM Fees at Risk | |||
| Target Claim Factor | |||
| Risk-Free Corridor Range (PEPM) | |||
| *Risk Corridor Range - Customer Pays (PEPM) | |||
| *Amount at Risk | |||
| *Risk Corridor Range - Administrator Pays (PEPM) | |||
| *Amount at Risk | |||
| <Please enter your Guarantees Disclaimer here> |
| Billed | Yes |
| Paid | No |
&A Page &P of &N
Stop Loss Quote
| MEDICAL/RX STOP LOSS PROPOSAL WORKSHEET |
| ANY ASO PROPOSAL MUST INCLUDE AN INTEGRATED STOP LOSS PROPOSAL; The current BCBSTX plan is an insured contribution plan; no IBNR runoff. |
| Plan Provisions | $200k ISL | $225k ISL | $250k ISL | |||||||||||
| Stop Loss Carrier | ||||||||||||||
| Contract Basis | 12/12 | 12/15 | 12/12 | 12/15 | 12/12 | 12/15 | ||||||||
| PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | PEPM | Annual | |||
| # EE | ||||||||||||||
| Coverages Included in SL Coverage | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | Med/Rx | ||
| Individual Policy Year Stop Loss Payment Limit | ||||||||||||||
| Individual Lifetime Stop Loss Payment Limit | ||||||||||||||
| Maximum Annual Aggregate Claim Reimbursement | ||||||||||||||
| Reimbursement Percentage | ||||||||||||||
| Retirees Included | No | No | No | No | No | No | ||||||||
| Agree to waive any "actively at work" provisions | ||||||||||||||
| Agree to mirror employer's plan document | ||||||||||||||
| Terminal Liability Option | ||||||||||||||
| INDIVIDUAL STOP LOSS PREMIUM | ||||||||||||||
| Single | 878 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Spouse | $0 | $0 | $0 | $0 | $0 | $0 | ||||||||
| Children | $0 | $0 | $0 | $0 | $0 | $0 | ||||||||
| Family | 160 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Composite | 1038 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| AGGREGATE STOP LOSS PREMIUM | ||||||||||||||
| Single | 878 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Spouse | 0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Children | 0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Family | 160 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Composite | 1038 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| TOTAL ANNUAL STOP LOSS PREMIUM | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | ||
| Monthly Projected Aggregate Liability Factors | ||||||||||||||
| Single | 878 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Spouse | 0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Children | 0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Family | 160 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Composite | 1038 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Monthly Maximum Aggregate Liability Factors | 125% Corridor | 125% Corridor | 125% Corridor | 125% Corridor | 125% Corridor | 125% Corridor | ||||||||
| Single | 878 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Spouse | 0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Children | 0 | $0 | $0 | $0 | $0 | $0 | $0 | |||||||
| Family | 160 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Composite | 1038 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | $0.00 | $0 | |
| Minimum Attachment Point | $0 | $0 | $0 | $0 | $0 | $0 | ||||||||
| TOTAL COMBINED ESTIMATED MAX LIABLITY | 1038 | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | ERROR:#REF! | |
| Lasers | ||||||||||||||
| Text is limited to 25 characters | 1. | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | Enter Member Name | Enter Laser Amount | |
| 2. | ||||||||||||||
| 3. | ||||||||||||||
| 4. | ||||||||||||||
| Proposal Contingencies | ||||||||||||||
| Text is limited to 60 characters | 1. | |||||||||||||
| 2. | ||||||||||||||
| 3. | ||||||||||||||
| 4. | ||||||||||||||
| 5. |
| No | ||||
| Yes - 3 months | ||||
| Yes - 6 months | ||||
| Per Member | Yes | Per Member | Yes | |
| Per Family | No | Per Family | No |
Stop Loss RFI
| Gallagher Benefit Services | 2019 notes | 2019 notes | 2019 notes |
| Request for Information | |||
| Specific and Aggregate Stop Loss Insurance |
Questions RESPONSES
| Stop Loss Provider Name | ||
| Date Completed | 2018 Johns notes | |
| Responses Effective Through | sample answer: 12/31/2021 or 1/1/2022 |
Questions RESPONSES Category Previous Question
| 1 | Explain your ownership structure in detail. | Please explain: | organizational structure | RFI 1 | ||
| 2 | How long has your organization been in business for stop loss insurance? | Year established | organizational structure | RFI 2 | ||
| Additional Information: | ||||||
| 3 | Has your company done business under other names? If yes, please provide historical background information. Identify any interests your organization may have with associated vendors (claims administrators, brokerage firms, managed care firms, etc.). | Yes No | organizational structure | RFI 3 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 4 | Have you ever been suspended from writing this line of coverage? | Yes No | organizational structure | RFI 4 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 5 | Is your organization licensed to do business in all 50 states and U.S. territories? If no, identify the states/territories in which you are not currently licensed. | Yes No | organizational structure | RFI 5 | ||
| If no, please explain: | ||||||
| Additional Information: | ||||||
| 6 | What percentage of the risk does your company assume? If less than 100%, please identify additional reinsurer(s) and the respective percentage of assumed liability. | % | organizational structure | RFI 8 | ||
| If less than 100%, please explain: | ||||||
| Additional Information: | ||||||
| 7 | Do you allow your paper to be used by MGUs? If yes then please identify those MGU(s). | Yes No | organizational structure | RFI 8 | ||
| If yes, then list the MGU(s) | ||||||
| Additional Information: | ||||||
| 8 | Do you have a relationship with another carrier that would prohibit your ability to quote a particular case? | Yes No | organizational structure | RFI 8 | ||
| If yes, please explain: | ||||||
| Additional Information: | ||||||
| 9 | Who has final claim decision-making authority with respect to specific and aggregate claims? | Details: | organizational structure | RFI 9 | ||
| 10 | How many stop loss clients do you currently have in your block of business and what is the annualized premium? | # of Clients | organizational structure | RFI 6 | ||
| Annualized premium | ||||||
| 11 | How many stop loss clients do you currently have with Gallagher and what is the annualized premium? | # of Clients | organizational structure | New | ||
| Annualized premium | ||||||
| 12 | BUCA Block of Business: What percentage of your block of business is with BUCA's? | Aetna | marginally important | organizational structure | ||
| BCBS | Key Question 7 (split into 2 questions) | |||||
| Cigna | ||||||
| UHC | ||||||
| 13 | Do you have ineligibles industries or other ineligible categories? | Yes No | less important | organizational structure | RFI 12 | |
| a. Captives | Eligible Ineligible | RFI 12 | ||||
| b. Casinos | Eligible Ineligible | RFI 12 | ||||
| c. Employee Leasing / PEOs | Eligible Ineligible | RFI 12 | ||||
| d. Hospitals | Eligible Ineligible | RFI 12 | ||||
| e. Indian Tribes | Eligible Ineligible | RFI 12 | ||||
| f. METS / MEWAs | Eligible Ineligible | RFI 12 | ||||
| g. Mining | Eligible Ineligible | RFI 12 | ||||
| h. Other ineligible industries or categories | Please list: | RFI 12 | ||||
| 14 | Do you have a minimum specific deductible amount? | Yes No | RFI 12 | |||
| If yes, add minimum amount: | ||||||
| 15 | Do you have a minimum group size? | Yes No | RFI 12 | |||
| If yes, add minimum # of EEs: | ||||||
| 16 | Do you offer a pharmacy only policy? | Specific: Yes No | less important | organizational structure | New | |
| Aggregate: Yes No | less important | organizational structure | ||||
| Additional Information: | less important | organizational structure | ||||
| 17 | Claims covered period: Do you agree to offer a Paid claims covered period? If yes, under what criteria? | Yes No | less important | organizational structure | ||
| If no, please explain: | less important | organizational structure | Key Question 1 | |||
| Additional Information: | less important | organizational structure | ||||
| Define a paid contract. | Details: | New | ||||
| 18 | Formal Disclosure: Will you agree to no client signature required at new business or renewal? | Yes No | less important | organizational structure | ||
| If no, please explain: | less important | organizational structure | RFI 10/Key Question 5 | |||
| Additional Information: | less important | organizational structure | ||||
| 19 | In most cases, we require that your organization work directly with Gallagher Benefit Services rather than our client’s claims administrator (TPAs, BCBS plans, carriers, etc.) on such things as: | Agree Disagree | less important | organizational structure | RFI 11 | |
| 10 | Ø Renewals | If disagree, please explain: | less important | organizational structure | ||
| Ø Specific & Aggregate contract concerns | ||||||
| Ø Plan Document/SPD adoption / approval | Additional Information: | less important | organizational structure | |||
| Ø Plan amendments | ||||||
| 20 | Does your stop loss policy contain an Actively at Work provision? | Yes No | ||||
| If yes, please explain: | RFI 14/Key Question 8 | |||||
| Additional Information: | terms | |||||
| 21 | Waive Active at Work: On new business and renewals, do you agree to waive actively at work for covered employees and dependents per the employer's plan document other than any lasers put in place on new business? | Agree Disagree | less important | organizational structure | ||
| If disagree, please explain: | RFI 13/Key Question 10 | |||||
| Additional Information: | ||||||
| 22 | If a client acquires a new company during the contract year, do you agree to waive the actively at work, dependent non-confinement and pre-existing condition limitation provisions for the newly acquired employees, their dependents, spouses, domestic partners, FMLA, retirees (if applicable), and COBRA beneficiaries? | Agree Disagree | RFI 18 | |||
| If disagree, please explain: | ||||||
| Additional Information: | terms | |||||
| 23 | Firm Rate Guarantee: Will you commit to a rate guarantee at least 3 months prior to effective date and for public sector more than 3 months? | Yes No | ||||
| If no, please explain: | RFI 14/Key Question 8 | |||||
| Additional Information: | terms | |||||
| How many months of claims are needed to produce an illustrative quote and a firm quote? | Details: | New | ||||
| 24 | Laser Policy: Do you agree to offer a no new lasers at renewal option? If yes, at what cost and under what terms? | Yes No | RFI 15/Key Question 2 | |||
| If yes, please explain: | ||||||
| Additional Information: | terms | |||||
| 25 | Rate Cap Guarantee at Renewal: Will you offer a rate cap at renewal? If yes, please provide details including any additional cost. | Yes No | ||||
| If yes, please explain: | Key Question 3 | |||||
| Additional Information: | ||||||
| What various rate caps are offered? 35%, 40% etc. | Details: | New | ||||
| 26 | What fees will be considered as part of claims (example, shared savings fees, negotiated savings, and state surcharges) | Details: | RFI 16 | |||
| 27 | Will you allow “non-covered” alternative care, if approved by your case managers or negotiated as part of an out of network cost negotiation? | Yes No | terms | RFI 17 | ||
| If no, please explain: | ||||||
| Additional Information: | terms | |||||
| 28 | Do you offer advance funding or quick pay options for stop loss claims? If yes, please provide details including any additional cost. | Yes No Specific | ||||
| Yes No Aggregate | RFI 19 | |||||
| If yes, please explain: | ||||||
| Additional Information: | terms | |||||
| 29 | Dividend Eligible: Do you offer the potential for a client dividend? If yes, please explain and note any additional costs? (Include any renewal requirements) | Yes No | ||||
| If yes, please explain: | changed wording slightly. | terms | Key Question 4 | |||
| Additional Information: | ||||||
| 30 | Changes in Rates and Terms: Do you agree to no change in rates or terms unless the nature of the risk is impacted by 15% or more from changes in enrollment, benefits, networks, and/or claim administrators? | Agree Disagree | ||||
| If disagree, please explain: | Key Question 6 | |||||
| Additional Information: | terms | |||||
| 31 | Specific Coverage Maximums: All GBS clients must have unlimited specific coverage maximums. Do you agree to this? | Agree Disagree | ||||
| If disagree, please explain: | terms | Key Question 9 | ||||
| Additional Information: | terms | |||||
| 32 | When do you require notification of a specific claim? | % of Specific Deductible or | ||||
| Amount of Claim, or | RFI 20 | |||||
| Or other, please explain: | ||||||
| Additional Information: | Less important | terms | ||||
| How often do you require aggregate claim reporting information? | Details: | RFI 21 | ||||
| What is the timing for filing of an aggregate claim? | Details: | RFI 21 | ||||
| What is the timing for filing of an specific claim? | Details: | RFI 21 | ||||
| How is the claim filing period extended due to COVID-19 ("Outbreak Period" or other extensions) | Details: | RFI 21 | ||||
| Define specific deductible claim accumulation definition vis-à-vis individual v family? | Details: | RFI 21 | ||||
| 33 | Will you guarantee you are responsible for getting claims data directly from the payor? | Yes No | organizational structure | RFI 8 | ||
| If no, then please explain. | ||||||
| Additional Information: | ||||||
| 34 | BUCA Reconciliation: Will you commit to reconcile issues with BUCA's? | Yes No | ||||
| If no, please explain: | Key Question 7 (split into 2 questions) | |||||
| Additional Information: | less important | terms | ||||
| 35 | Who are your preferred TPA's? Will you commit to reconcile issues with them? | Preferred TPA's | ||||
| Yes No | ||||||
| If no, please explain: | less important/all typically have this | terms | New | |||
| Additional Information: | ||||||
| 36 | Do you offer any special contract provisions or features (please include potential cost)? | Details: | New | |||
| 37 | If you cover hospitals then what is your domestic reimbursement percentage? | Details: | New | |||
| 38 | Does your organization offer “preferred provider network” pricing based upon the client’s network(s)? | Details: | New | |||
| If yes, provide a listing of the preferred provider networks your organization has rated; identify the status level for each and the associated percentage of savings discount. | ||||||
| Details: | New | |||||
| 39 | Are there any networks ineligible? | Details: | New | |||
| 40 | How are you effectively managing large claims? | Details: | New | |||
| 41 | How many business days, on average, does it take to underwrite stop loss for a group? Does the amount of time change during peak season? | Details: | New | |||
| 42 | Will you offer 2, 3, 4 and 5 tier quote options when requested? | Details: | New | |||
| less important/all typically have this | terms | |||||
| HEALTHCARE REFORM RELATED | RESPONSES | |||||
| 43 | External Review Appeals | Please explain: | ||||
| Under health care reform, non-grandfathered plans must include an external review option. A claim filed in a timely manner (consistent with the requirement of the stop-loss policy) and denied by the claim administrator is subject to appeal. A claim properly incurred and adjudicated (denied) in one coverage period and subsequently appealed by the participant, including an external review, could easily extend beyond that coverage period. | Less important | procedure | RFI 22 |
| How does your organization address claims that were denied in one coverage period and paid in another coverage period? | ||
| less important | procedure |
| I understand and hereby certify that all information provided in this RFI is true and correct. | ||||
| Questionnaire Completed By | ||||
| (typed signature is acceptable) | marginally important/usually don't have issues | procedure | ||
| Title | ||||
| Stop Loss Provider Name | ||||
| Date | ||||
| Email Address | ||||
| Phone Number | ||||
| procedure |
Page &P mailto:rreeves@conroeisd.net Medical Plan Designs
| Medical Plan Designs |
| Company Legal Business Name: ______________________________________________________________________________________________________________________________________________________________________ |
| Please record all answers on this excel spreadsheet. | ||||||||||||
| CURRENT | PROPOSED | |||||||||||
| Carrier Name | BlueCross BlueShield of Texas | CARRIER NAME | ||||||||||
| Plan Name | HMO $3,000 Plan | HDHP PPO $3,400 Plan | PPO $1,400 Plan | PLAN NAME | PLAN NAME | PLAN NAME | ||||||
| Network | BLUE ESS | BLUE CH | BLUE CH | NETWORK | NETWORK | NETWORK | ||||||
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Deductible Type | Embedded | N/A | Embedded | Embedded | Embedded | Embedded | ||||||
| Calendar Year (CY) Deductible (Individual / Family) | $3,000 / $6,000 | N/A | $3,400 / $6,800 | $5,500 / $11,000 | $1,400 / $4,000 | $2,000 / $6,000 | ||||||
| Out-of-Pocket Max Type | Embedded | N/A | Embedded | Embedded | Embedded | Embedded | ||||||
| CY Out-of-Pocket Max (Individual / Family): To include copays, coinsurance any charges that apply to your deductible | $9,000 / $16,300 | N/A | $8,000 / $16,000 | $20,250 / $40,500 | $7,000 / $14,000 | $23,700 / $47,400 | ||||||
| Coinsurance (member pays after deductible) | 30% | N/A | 30% | 50% | 20% | 40% |
| Preventive Care | Covered 100% | Not Covered | Covered 100% | 50% after deductible | Covered 100% | 40% after deductible |
| Primary Care Visit | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | 40% after deductible |
| Specialist Visit | $70 Copay | Not Covered | 30% after deductible | 50% after deductible | $70 Copay | 40% after deductible |
| Virtual Visits | $50 Copay | Not Covered | 30% after deductible | Not Covered | $15 Copay | Not Covered |
| Urgent Care | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | 40% after deductible |
| Emergency Room | 30% after deductible | 30% after deductible | Facility: $500 Copay then 20%; |
Physician: 20% after deductible
| Inpatient Hospital | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible |
| Outpatient Surgery | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible |
| Chiropractic (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 50% after deductible | $70 Copay; |
Outpatient Services: 20% after deductible
| (Combined 120 visits) | 40% after deductible | |
| Phys/Occ/Speech Therapy (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 30% after deductible | |
| (Combined 35 visits) | $70 Copay; |
Outpatient Services: 20% after deductible (Combined 120 visits) 40% after deductible (Combine 120 visits)
| Diagnostic Test (X-ray, blood work) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | PCP: $50 Copay | ||||||||
| SPC: $70 Copay | 40% after deductible | ||||||||||||
| Imaging (CT/PET scan, MRI) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible | |||||||
| PRESCRIPTION DRUG BENEFIT | |||||||||||||
| Deductible (Individual / Family) | N/A | Not Covered | Combined with Medical | $200 Per Person | |||||||||
| Retail | 30 Days | Not Covered | 30 Days | 30 Days | |||||||||
| Tier I / Tier II / Tier III | $15 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | 20% / 25% / 50% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | $20 / $45 / $95 after deductible + 50% coinsurance | |||||||
| Specialty | 30% Copay | Not Covered | 20% after deductible | 20% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | $20 / $45 / $95 after deductible + 50% coinsurance | |||||||
| Mail Order | 90 Days | Not Covered | 90 Days | 90 Days | |||||||||
| Tier I / Tier II / Tier III | $30 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | Not Covered | $50 / $112.50 / $237.50 after deductible | Not Covered | |||||||
| COST ANALYSIS | |||||||||||||
| PEPM Rates - Enrollment per AMP | HMO | HDHP | PPO | HMO $3,000 Plan | HDHP PPO $3,400 Plan | PPO $1,400 Plan | PLAN NAME | PLAN NAME | PLAN NAME | ||||
| Employee (EE) Only | 454 | 295 | 129 | $525.53 | $508.30 | $680.16 | $0.00 | $0.00 | $0.00 | ||||
| EE + Spouse | 6 | 2 | 2 | $1,467.39 | $1,510.23 | $1,665.09 | $0.00 | $0.00 | $0.00 | ||||
| EE + Child(ren) | 63 | 35 | 35 | $991.74 | $980.93 | $1,144.99 | $0.00 | $0.00 | $0.00 | ||||
| EE + Family | 6 | 4 | 7 | $1,751.05 | $1,804.27 | $2,016.15 | $0.00 | $0.00 | $0.00 | ||||
| Total Enrollment | 529 | 336 | 173 | ||||||||||
| Estimated Monthly Premium | $320,381 | $194,519 | $145,259 | $0 | $0 | $0 | |||||||
| Estimated Annual Premium | $3,844,571 | $2,334,223 | $1,743,102 | $0 | $0 | $0 | |||||||
| Dollar Difference from Current | -$3,844,571 | -$2,334,223 | -$1,743,102 | ||||||||||
| Percent Change from Current | -100.0% | -60.7% | -45.3% | ||||||||||
| Total Combined Annual Cost | |||||||||||||
| CURRENT | PROPOSED | ||||||||||||
| Estimated Annual Premium | $7,921,896 | $0 | |||||||||||
| Dollar Difference from Current | -$7,921,896 | ||||||||||||
| Percent Change from Current | -100.0% | ||||||||||||
| PLAN PROVISIONS | |||||||||||||
| Rate Guarantee | 1 Year rate guarantee ending 08/31/2026 |
&G
© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Questionnaire
| Medical Administration Questionnaire |
| Company Legal Business Name: __________________________________________________________________ |
| Affirmation / discussion must be given on each of the following topics. | ||
| Section I - General Company Information | ||
| # | Question | Vendor Response |
| 1. | Please confirm your organization will be ready to begin services on September 1, 2026 | |
| 2. | Indicate what year the company was founded. | |
| 3. | Describe the ownership structure. | |
| 4. | What is the total number of employer clients that you have for the services you are proposing? What is the average size of your client as well as the largest? | |
| 5. | What is the legal name of your organization as it should appear on the Agreement? | |
| 6. | What is the name of your parent organization if you have one? | |
| 7. | Please provide the main address, phone number, fax number, email address, web address for your company as well as your internal identification code for this RFP. | |
| 8. | Provide the contact information of the individual authorized to answer questions related to this RFP, including their name, title, physical address, direct office phone number, fax number, cell phone number and email address. | |
| 9. | To the extent applicable, are you now and will you remain duly licensed and in full compliance with all federal and state statutory administrative requirements? | |
| 10. | Do you agree to do what is necessary to execute an agreement within 30 days of award of service(s)? | |
| 11. | How many school districts or other public institutions do you provide similar services for? What is the largest school district you currently service? | |
| 12. | Provide three references for three current accounts comparable in size to the client (prefer public sector account, school district and/or Texas based references). Provide two former accounts lost in the past year also in comparable size to the client. Include reference contact name, office phone number and email address. Include the length of relationship, number of employees of the reference and services provided to the reference. | |
| 13. | Where will the account team be located? | |
| 14. | If you plan on using any third-party organizations please provide a detailed list of who will participate in the execution of the services you will provide as a part of your proposal response (name, nature of relationship, length of affiliation). | |
| 15. | Please provide the number of employees in your organization. | |
| 16. | Please provide the ratings of your company (A.M. Best, Moody's, Standard & Poor's). | |
| 17. | Have you recently been acquired or been involved with any mergers/acquisitions? If yes, please describe. | |
| 18. | Will you need to hire additional customer service personnel if awarded this business? | |
| 19. | Provide a detailed implementation plan, including action items and due dates. Include support for implementation and open enrollment | |
| 20. | Will you agree to comply with the proposed medical plan Performance Guarantees (as outlined in this RFP)? If you are unable to comply with the proposed guarantees, provide your alternate proposal. |
| Section II - ASO Discuss Topics | ||
| # | Question | Vendor Response |
| 1. | Any and all administrative fees must be noted on ASO Pricing Sheet. Services performed via claims fund transfers must be noted on the grid; as a fixed cost PEPM (Transparency). | |
| 2. | Please confirm you will provide the District with 24 month's Run-Out upon termination | |
| 4. | Discuss your Claim subrogation process and recovery fees charged to the plan. | |
| 5. | Discuss internal quality assessment programs; internal audit procedures including additional protocols in place for ICD-10 accuracy. | |
| 6. | Discuss fraud and abuse programs. | |
| 7. | Discuss disaster recovery and emergency operations pertaining to data back ups. | |
| 8. | Audit Requirements; Client retains acces to 100% of all claims data including all data fields necessary to perform a 100% analysis of claims paid by plan for the applicable period, including but not limited to all claims payment fields, provider name, provider billing address, and all provider contact information including phone number. The carrier will remove any restrictions that may restrict client access to service including selection of a third party audit vendor. Willingness to provide a copy of the adminstrators written audit policy. |
| Section III - General Administration Information | ||
| # | Question | Vendor Response |
| 1 | What is the normal lead-time required to implement a group? | |
| 2 | Do you require a deposit or imprest claims? If so, how much do you require? | |
| 3 | What mediums do you accept for plan enrollment? | |
| 4 | Describe your eligibility file feed process. | |
| 5 | How often is membership updated? | |
| 6 | Can you maintain membership by employee and dependent? | |
| 7 | Describe your client billing process. | |
| 8 | Can you house employee’s location/department in your system for billing and claims reporting? If this requires additional lines of code to accommodate, confirm there will be no additional cost. | |
| 9 | If you are awarded this business, how soon after the notification of the award would you be able to have a draft of the Administrative Agreement(s) / ID Cards? | |
| 10 | With respect to ID cards: | |
| 11 | Do you charge a fee for card preparation? | |
| 12 | Do you cahrge for replacement cards? | |
| 13 | Can you put the plan sponsor name and logo on the ID cards? Is there an additional cost for this? | |
| 14 | Can you do a combination medical / Rx card (if the PBM is carved-out)? Is there an additional cost for this? | |
| 15 | Will your communication and ID cards for the client's employees be sent to employee’s residence? | |
| 16 | Will you agree to submit to independent audits at no expense to the client? | |
| 17 | Will you allow the client a 60 day grace period to pay your monthly invoice? | |
| 18 | Describe internal performance standards for the customer service unit. | |
| 19 | Describe the capabilities your website has for the following items: |
• Price comparison – tools that will allow members to compare the price of prescription drugs by pharmacy
• Lower cost alternatives available
• Provider selection – tools that will help members select reputable and effective providers
• Quality comparison – tools that will help members compare quality outcomes of providers and facilities
• Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.
• Wellness information and tools (i.e. BMI calculator, target heart rate calculator)
| 20 | Describe your internal and/or external data-warehousing capabilities. |
| 21 | Please confirm if members and plan sponsors can perform the following tasks ONLINE? |
| Enrollment (New Hires and Open Enrollment) | |
| Changes in Status | |
| Billing (Plan Administrators Only) | |
| Claim Inquiry | |
| Provider Search | |
| ID Card Request | |
| Electronic EOB | |
| Terminations | |
| Access Provider Directories | |
| Reinstatements | |
| Health Risk Assessments | |
| Other | |
| 22 | Is there an additional cost for online member self-service tools? If yes, describe. |
| 23 | Are provider directories available online? |
| 24 | Are special or ad hoc reports available to the client? Are there any additional costs associated with any of these reports? |
| 25 | Confirm you will handle Escheat for the client and provide an overview of your options. |
| 26 | Please let the client know if funding will be handled on a checks issued, or checks cleared basis. |
| 27 | Describe your banking procedures. |
| 28 | It is the client's preference to have their TPA handle Disabled Dependent Eligibility Verification process for disabled dependents. Please confirm you can handle this on behalf and provide detail on how your processes work and how you share the final decision. |
| 29 | The client has a plan year of 9/1-8/31 but accumulations for deductible and out of pocket run on a calendar year basis. Please confirm your systems can acommodate this structure. |
| 30 | The client expects it's chosen Medical TPA to provide monthly, ongoing claims feeds to it's Consultant's Data Warehouse. Please confirm you will do this at no additional charge |
| 31 | Are claims on an auto pay or auto notify cadence? |
| Section IV - Network Contractuals | ||
| # | Question | Vendor Response |
| 1 | Disruption report by network product. Disruption report must be on “PAID” claims basis and total “number” of provider matches. Each line item must note the match (yes/no) and a summary report on the two criteria noted must be included. Use proposed networks to match against all plans. | |
| 2 | Note Hospital contractual stability over the next three (3) years at highly utilized facilities. Highest utilizing hospital profile report found in bid attachments. | |
| 3 | Please provide some commentary regarding your organizations approach to Centers of Excellence networks, as well as your efforts to ensure Providers and Facilities in your networks meet or exceed all HEDIS measures? | |
| 4 | The client is committed to self-funding with full accountability/reporting of it's Health Plan. Please CONFIRM you have listed any and all capitations and/or any other fees that would be going through the claims funding ACH account in the ASO Pricing Sheet tab. | |
| 5 | Describe how your organization prices out-of-network claims and the measures you take to ensure the District's overall costs are being minimized when Out-of-Network utilization occurs. | |
| 6 | The District currently opts into the Mental Health Parity. Discuss how your organization approaches Mental Health Benefits and the measures you take to ensure costs are managed accurately and effectively when their members need these services. | |
| 7 | The current availability of formal ACO contractual models with risk sharing contractual; which hospitals, how your Carrier develops shared predictive/evidence medicine protocols/models, in the clinical relational culture? These models MUST be contractually in place not a simulation concept. What are these plan models branded under in the marketplace? Name? | |
| 8 | How various professional clinical ACO partnership agreements, such as Memorial Hermann, are embedded into each ACO plan model? Discuss the current availability of formal ACO contractual models with risk sharing, how your Carrier develops shared predictive/evidence medicine protocols/models, in the clinical relational culture. These models MUST be contractually in place not a simulation concept. Are these plan models branded under in the marketplace? Name? | |
| 9 | The availability of EPO plans, “skinny network” plan options, which systems are included, how the vendor measures cost and utilization efficacy benchmarks for participating hospitals. | |
| 10 | Describe how out-of-network providers are reimbursed by your organization. Provide an overview of your process, including discussion on initiatives to negotiate single case provider contracts. | |
| 11 | Initiatives to negotiate single case Provider contracts. | |
| 12 | Discuss “high performance “surgical network initiatives. | |
| 13 | Discuss the availability of “referenced based pricing” strategies. The client is NOT considering these plan models at this time but does not want to eliminate any possible options for it's Health Plans. | |
| 14 | Discuss your ability to offer “navigating tools” and strategies to direct patient care to lower cost procedural codes like OP X-Ray and Lab services. | |
| 15 | Discuss any Air Ambulance contracts to minimize balance billing issues for plan members. | |
| 16 | Provide details on how your plan handles out-of-area dependents, specifically as it relates to limited-network plans. | |
| 17 | How are out of network allowable amounts determined? Please explain methodology and any partnerships or vendors used in the determination of reasonable and customary. | |
| 18 | Do you own your Texas provider network or do you do subcontract the network quoted? If you should subcontract, please identify network. | |
| Describe the following: | ||
| Provider Selection Process | ||
| Credentialing Process | ||
| Recredentialing Process | ||
| 19 | Does your network include clinician-staffed clinics in a retail setting? (e.g. RediClinic, etc.) Please elaborate. | |
| 20 | Do you have tiered network capabilities? Please elaborate and provide suggestions for the client in this area. | |
| 21 | Are out of network charges applicable to discounts, percentage of savings arrangements, Medicare plus allowance? Please describe. | |
| 22 | The client is NOT interested in any Shared Savings Arrangements. Please confirm your proposals do not include this. If so, please clearly outline below when Shared Savings Arrangements would be applied and clearly outline any fees/costs associated with such programs. | |
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| Section V - Case Disease Management | ||
| # | Question | Vendor Response |
| 1 | Discuss Telemedicine initiatives; not exclusive to telephonic applications, but including audio/visual web based abilities. | |
| 2 | Describe the navigation tools available for increasing member advocacy as a consumer such as OP lab, imaging, ER, Urgent care, etc. | |
| 3 | Describe your processes for standard pre-certification and utilization review procedures for inpatient and outpatient surgical procedures. | |
| 4 | Discuss the integration capabilities of your managed behavioral healthcare programs with other programs/plans subject to the Mental Health Parity Act, such as EAP and utilization management treatment plans. | |
| 5 | Discuss in detail the integration of all the various data components that feed your predictive model and note any vendors that are outsourced and their function. | |
| 6 | Does your organization provide any "Nurse Lines"? If so, please provide some commentary regarding this service. | |
| 7 | Does your organization provide any Wellness programs, web based publications, health risk assessments, wellness reminders, etc. to promote overall population health? | |
| 8 | Discuss your communication efforts and campaigns to engage members identified as high-risk? | |
| 9 | Describe your Advocacy process of transitional care form in-hospital to out-patient settings. | |
| 10 | Describe your Health Risk Assessments and/or Personal Health Record capabilities? | |
| 11 | Does your organization provide focused disease management treatment groups? Please provide details if applicable. | |
| 12 | Describe any Web based wellness incentive programs. | |
| 13 | Describe your Case Manager advocacy on-site at strategic Hospital systems, if available. |
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