PEBB Medical & Pharmacy Benefit RFP OregonBuys Bid Number S-44300-00014758 Attachment A

1 Overview and Requirements Questionnaire

1.1 Introduction

This Request for Proposal (RFP) is to facilitate the selection of medical and pharmacy plans for the Oregon Public Employees’ Benefit Board effective January 1, 2027. Please refer to the main RFP document as well as supporting attachments to complete this questionnaire.

Unless the RFP explicitly requests or allows additional documents to be submitted in relation to a question, they will not be considered.

1.1.1 RFP Set Up

1.1.1.1 [TOGGLE] Which of the following proposals are you submitting?

Single, Pull-down list.

1: Combined medical and pharmacy, 2: Medical only, 3: Pharmacy only

1.1.1.2 [COMBINED & MEDICAL ONLY | TOGGLE] Which of the following plan options are you proposing?

Single, Pull-down list.

1: Statewide PPO, 2: Regional CCM, 3: Regional HMO

1.1.1.3 [REGIONAL ONLY] Confirm the region(s) where you are proposing a coordinated care plan.

Response

Portland Metro Single, Pull-down list.

1: Yes, 2: No

I-5 Corridor Single, Pull-down list.

1: Yes, 2: No

Oregon Coast Single, Pull-down list.

1: Yes, 2: No

Southwest Oregon Single, Pull-down list.

1: Yes, 2: No

Eastern Oregon Single, Pull-down list.

1: Yes, 2: No

Attachment A

Central Oregon Single, Pull-down list.

1.1.1.4 [REGIONAL ONLY | TOGGLE] Which funding arrangement are you proposing?

1: Fully-insured, 2: Self-insured

1.1.1.5 [COMBINED ONLY] Confirm you are submitting a combined medical and pharmacy proposal.

Single, Radio group.

1: Confirmed, 2: Not confirmed

1.1.2 Background Information

1.1.2.1 [COMBINED & MEDICAL ONLY] Please describe the plan you are proposing to Oregon PEBB. If you are not proposing both a Combined Medical and Pharmacy plan as well as a Stand-Alone Medical plan only, please explain your rationale for not submitting both.

500 words.

1.1.3 Minimum Requirements

1.1.3.1 [COMBINED & MEDICAL ONLY - REGIONAL ONLY] Confirm your proposal is not contingent upon being the only plan offered in the service area.

Single, Radio group.

2: Not confirmed, explain: [ 200 words ]

1.1.3.2 [MEDICAL ONLY] Confirm that your proposal is not contingent on being the Pharmacy Benefit Manager (PBM) as well.

Single, Radio group.

1.1.3.3 [PHARMACY ONLY] Confirm that your offer is not contingent on administering Oregon Public Employees' Benefit Board's medical plan.

Single, Radio group.

1.1.3.4 [MEDICAL ONLY] Confirm your organization's ability to integrate with a PBM should PEBB chose a separate PBM vendor.

Attachment A

Single, Radio group.

1.1.3.5 Confirm your proposal does not include minimum participation or employer contribution requirements.

1.1.3.6 Confirm your plans will be offered to all eligible employees, as determined by PEBB, with no exclusions or waiting periods.

Single, Radio group.

1.1.3.7 Provide proof your company is licensed to provide health insurance in the State of Oregon. If not currently licensed, how and when will you be licensed?

Single, Radio group.

1: Licensed, 2: Not licensed, explain: [ 200 words ]

1.1.4 Organizational Information

1.1.4.1 Why should PEBB select you?

1000 words.

1.1.4.2 Please describe the insights your organization has gained from working with large and complex organizations (25K+ members) and public clients. Provide three accomplishments your organization is proud of regarding this experience, as well as three lessons learned. Include how your organization has incorporated these lessons learned into your business model or philosophy to provide the best possible services.

1.1.4.3 Include the names of the clients as well as potential contact information.

Client 1 Client 2 Client 3

Client Name 20 words. 20 words. 20 words.

Client Address 20 words. 20 words. 20 words.

Primary Contact 20 words. 20 words. 20 words.

Title 20 words. 20 words. 20 words.

Telephone Number 20 words. 20 words. 20 words.

E-mail Address 20 words. 20 words. 20 words.

# of Employees & Retirees 20 words. 20 words. 20 words.

Attachment A

Scope of Services 100 words. 100 words. 100 words.

1.1.4.4 In a short summary, provide an overview of your organization. Key elements to include: Total annual revenue # of employees Headquarters and key locations Affiliated entities that you're proposing as part of the services for PEBB

200 words.

1.1.4.5 What are your top three strategic priorities in the next 2 - 3 years? How will these strategies improve the care provided to PEBB's members?

1.1.4.6 What are your top three challenges? How are you addressing these challenges?

1.1.4.7 Describe your company's vision and values and how they are demonstrated on an everyday basis.

1.1.4.8 [COMBINED AND PHARMACY ONLY] In what year was your PBM established?

To the year.

1.1.4.9 How many clients do you currently service by type based on the table below?

Public Sector Integer.

Commercial Clients Integer.

Total Clients Integer.

1.1.4.10 Please provide your organization's most recent financial rating or filing from each of the following agencies. (Please provide rating or "not applicable".) Do not respond by providing information about your organization's credit ratings:

Response

A.M. Best 10 words.

Moody's 10 words.

Standard & Poor's 10 words.

Fitch 10 words.

1.1.4.11 What was your client retention rate?

YTD current year Percent.

Previous year Percent.

1.1.4.12 Provide information about your financial stability (financial ratings, annual reports, and financial statements, etc.).

1.1.4.13 Which services related to the requested scope of services will you subcontract? Provide brief details of how and by whom these services are provided and your role in managing their delivery.

1.1.4.14 Provide a description of any company initiatives, either current or planned, over the next 18 to 36 months, which will impact the delivery of services to PEBB during the contract period. Examples include system changes or migrations, call center opening/closing, mail service pharmacy opening/closing or network re-contracting.

1.1.4.15 If your organization has been involved in a merger or acquisition within the past three years, specify when the merger took effect, and how you have or will assimilate(ed) operations, account management and claims and clinical systems into your organization.

1.1.4.16 If your organization is involved in a merger or acquisition expected to close within the next 18 months, please provide the details of that transaction and expected close date.

1.1.4.17 What planned investments does your organization have for the next 3 years? Please indicate the amount of the planned investments, where resources will come from and what your expected outcome is. This should include any and all investments including M&A Activity.

1.1.4.18 Confirm you will provide any support required regarding any new groups or populations added to Oregon Public Employees' Benefit Board that may occur during the term of the contract.

Single, Radio group.

2: No; Explain [ 100 words ]

1.1.4.19 In the event of a group or population departing from Oregon Public Employees' Benefit Board, confirm Proposer will provide identical contracts to all populations including current pricing arrangement until current contract term expires.

Single, Radio group.

2: No; explain [ 100 words ]

Attachment A

1.1.5 Account Management

1.1.5.1 [COMBINED & MEDICAL ONLY] Please provide the following key personnel:

Account Manager

Physician Pharmacist Behavioral Health Clinician

Implementation Member Services

Claims

Name Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Title Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Location Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Years with company Integer. Integer. Integer. Integer. Integer. Integer. Integer.

Dedicated or designated?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Current # of clients Integer. Integer. Integer. Integer. Integer. Integer. Integer.

Primary responsibilities

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Relevant experience with public sector clients

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

What does this team member specifically bring to PEBB?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Please indicate the percentage of time that each assigned person will be dedicated to working with PEBB.

Percent. Percent. Percent. Percent. Percent. Percent. Percent.

Is your organization willing to guarantee this percentage?

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1.1.5.2 [PHARMACY ONLY] Please provide the following key personnel:

Executive Sponsor

Account/Operations Manager

Account Coordinator

Pharmacist/Clinical Program Director

Implementation

Name Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Title Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Location Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Years with company Integer. Integer. Integer. Integer. Integer.

Dedicated or Designated?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Current # of clients Integer. Integer. Integer. Integer. Integer.

Attachment A

Primary responsibilities Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Relevant experience with public sector clients

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

What does this team member specifically bring to PEBB?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Please indicate the percentage of time that each assigned person will be dedicated to working with PEBB.

Percent. Percent. Percent. Percent. Percent.

Is your organization willing to guarantee this percentage?

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1.1.5.3 [PHARMACY ONLY] Proposer confirms it will assign a designated financial analyst.

1.1.5.4 Confirm that the assigned Key Person will be no more than one time zone away from Oregon Public Employees' Benefit Board's location (Salem, Oregon).

Single, Radio group.

1.1.5.5 Confirm members of the account management team are expected to respond to all account inquiries from the PEBB staff within one business day.

Single, Radio group.

1.1.5.6 Describe the working relationship between your member service and account management teams.

1.1.5.7 Please identify the Key Person/Account Manager you are proposing for PEBB:

Name Unlimited.

Title Unlimited.

Role for PEBB Unlimited.

Anticipated # of meetings attended per year Integer.

Attachment A

1.1.5.8 Proposer will not ask any PEBB participant to individually enter into any agreement with your organization or agree in any way to waive any legal rights or to obligate himself or herself to indemnify or hold harmless your organization in any way when interacting with the member website. This includes via click through, in consideration for using the member website, participating in any program, or otherwise. Any such language contained in the member website or in any materials provided by you shall be void and of no force and effect.

Single, Radio group.

1: Agree, 2: Disagree

1.1.5.9 Confirm PEBB will contract directly with your organization for all services. Any outsourcing agreements are made solely between your organization and the organization providing services.

Single, Radio group.

1.1.5.10 Confirm all employees working on and/or having access to PEBB data will be based in the U.S. In addition, any and all technology that will be used to administer these benefits will be accessible to the employees in the U.S. only, and all technology systems will be housed in the U.S. In the event your organization makes changes to the processes/systems access/location of the personnel that conflicts with the prior statements, PEBB will be notified in writing within 120 days' notice.

Single, Radio group.

1.1.5.11 Proposer agrees to provide necessary data files free of charge to PEBB in response to government requests or to respond to legal actions for the length of the contract. Such services shall be provided at the PEBB custom reporting rate after the contract has terminated.

Single, Radio group.

1.1.5.12 Confirm your organization reviews system access on a periodic basis to ensure proper maintenance procedures are in effect (e.g. terminated users no longer have system access, only senior staff are given sensitive systems access and no one person is given inappropriate combinations of system access).

Single, Radio group.

1.1.5.13 Confirm any material operational changes that result from a merger or acquisition will be communicated to PEBB by phone and in writing at least 90 calendar days prior to the effective date.

Single, Radio group.

Attachment A

1.1.5.14 Confirm that you will review and respond to any new supplier (program or company) forms, questionnaires, or other such documents that may be requested from you by PEBB.

Single, Radio group.

1.1.5.15 Has an employer/carrier partner terminated a contract with you due to your company's breach of the contract?

Single, Radio group.

1: Yes, explain: [ 200 words ] ,

1.1.6 Organizational Commitment to Health Equity

1.1.6.1 The following questions are meant to capture the commitment your organization has to diversity, equity, and inclusion.

Question Response

Confirm if your organization has a leader solely dedicated (1.0 FTE) to leading equity and inclusion internally.

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you have specific policies in place to address diversity, equity, and inclusion for your employees, such as a written diversity, equity, and inclusion plan?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Does your organization adhere to all 15 of the National Standards for Culturally and Linguistically Appropriate Services (CLAS)? If not, which of the 15 do you not currently adhere to and what is the plan to do so?

200 words.

Has your organization earned external accreditation or recognition for excellence in inclusive health or health equity (e.g. Human Rights Campaign Corporate Equality Index, EDGE certification, NCQA Health Equity Accreditation, etc.)?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

If not, do you plan to seek accreditation or recognition? Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Other, please describe 200 words.

Nothing required

Attachment A

1.1.6.2 The following questions are meant to capture how your organization assesses and requires a commitment to diversity, equity and inclusion with vendor partners that you propose for PEBB:

Question Response

Do you assess or require vendor partners to have a leader solely dedicated (1.0 FTE) to leading equity and inclusion internally?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you assess or require vendor partners to have specific policies in place to address diversity, equity, and inclusion for your employees, such as a written diversity, equity, and inclusion plan?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you require vendor partners to adhere to all 15 of the National Standards for Culturally and Linguistically Appropriate Services (CLAS)? If not, what is the plan to do so?

200 words.

Do you assess or require vendor partners to earn external accreditation or recognition for excellence in inclusive health or health equity (e.g. Human Rights Campaign Corporate Equality Index, EDGE certification, NCQA Health Equity Accreditation, etc.)?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Provide any additional comments you have to demonstrate how your organization may or may not assess vendor partners’ commitment to diversity, equity, and inclusion.

1.1.6.3 Please define what health equity means to your organization and provide realized examples of how this is demonstrated.

1.1.6.4 Does your organization have an action plan in place to address at least one health disparity? Please describe.

1.1.6.5 Does your organization annually assess progress in reducing identified disparities?

1.1.6.6 What is your organization's commitment to achieving inclusive health for your clients' members?

Describe your inclusive health strategy including how you define inclusive health and what levels of investment have been made to reduce disparities.

1.1.6.7 Is there a solely dedicated (1.0 FTE leader within your organization working to address your clients' inclusive health needs? What responsibilities are included in their portfolio?

1.1.6.8 How does your organization promote inclusivity within the organization including training, policies and practices? Please also highlight any recognition your organization has received (e.g., Human Rights Campaign Corporate Equality Index).

1.1.6.9 To what extent does your organization develop and engage in community and multi-disciplinary partnerships to improve population health? Please describe relevant examples.

1.1.6.10 Describe how you are engaged locally and nationally in initiatives to address the key areas of social determinants of health (examples: insecurity, housing issues, and personal safety concerns).

1.1.6.11 Does your organization use its financing power internally or externally to support inclusive health or social drivers of health initiatives? Please describe.

100 words.

1.1.6.12 PEBB feels strongly that all members should be able to identify as the gender they choose and an “other” field should not be used for ease of grouping.

Question Response

Confirm if your system can accept and administer claims for members identified as non-binary or a gender other than M/F.

Compound, Pull-down list.

1: Confirmed, 2: Not confirmed

If your system can accept and administer claims for members identified as non-binary or a gender other than M/F, please confirm that the gender marker will not be labeled as “other.”

Compound, Pull-down list.

1: Confirmed, 2: Not confirmed, explain: [ 200 words ]

Does your member electronic health record have a distinct field that captures the various gender expressions (7 or more) separate from sex assigned at birth?

Compound, Pull-down list.

1: Confirmed, 2: Not confirmed, explain: [ 200 words ]

If yes, please describe the gender expressions. 200 words.

1.1.7 Open Enrollment Support

1.1.7.1 Proposer confirms it will provide Open Enrollment support at no charge that includes

Attachment A

Call center services Single, Pull-down list.

1: Yes, 2: No

Printed pharmacy materials Single, Pull-down list.

1: Yes, 2: No

Virtual benefit fairs Single, Pull-down list.

1: Yes, 2: No

In-person support at onsite meetings (upon request) Single, Pull-down list.

1.1.7.2 Proposer will provide onsite resources at no charge to attend Oregon Public Employees' Benefit Board's annual benefit fairs and at locations determined by Oregon Public Employees' Benefit Board. Proposer resources must be core competent in Oregon Public Employees' Benefit Board's plan design and will not be outsourced.

Single, Radio group.

2: No; explain [ 100 words ]

1.1.8 Implementation Support

1.1.8.1 Attach a detailed project implementation work plan that illustrates all key activities and the person on your team who would be responsible for each activity and achieves successful completion by December 31, 2026. Call out any critical dates that must be met in order to keep the implementation on schedule. The file MUST be attached to this question.

Answer and attachment required

1: Yes, attached, explain: [ 200 words ]

1.1.8.2 Proposer confirms that the dedicated toll-free customer service number will be available (for use in printed materials, not for live calls) within 30 days of award of business.

Single, Radio group.

2: No; Explain [ 50 words ]

1.1.8.3 Proposer confirms it will provide all customer service representatives and service staff with information and training regarding Oregon Public Employees' Benefit Board's plan design and program at least 10 business days prior to the open enrollment commencement date.

Single, Radio group.

1.1.8.4 All implementation support shall be provided to Oregon Public Employees' Benefit Board at no cost.

Attachment A

Single, Radio group.

1.1.8.5 Proposer will maintain an implementation project plan and issue log documenting all implementation issues, actions, due dates and responsible parties.

Single, Radio group.

1.1.8.6 Proposer will proactively test plan design set-up and provide report of results including any elements that needed to be fixed to Oregon Public Employees' Benefit Board and Oregon Public Employees' Benefit Board's consultant for review at least three (3) weeks prior to Go-Live as long as plan documents are approved by Oregon Public Employees' Benefit Board 90 days in advance of Go-Live.

Single, Radio group.

1.1.8.7 Oregon Public Employees' Benefit Board and Oregon Public Employees' Benefit Board's consultant has the right to approve assigned implementation manager.

Single, Radio group.

1.1.8.8 Confirm ongoing account team--inclusive of account executive (strategist), account manager (day to day support), and clinical account executives--will be active participants in the implementation process to ensure understanding of why decisions were made during implementation.

Single, Radio group.

1.1.9 Member Services and Communications

1.1.9.1 Proposer understands Public Employees' Benefit Board by way of their Staff reserves the right to review and approve all member-facing communications, whether digital, verbal, or written. This also includes communications from subcontracted vendors.

Single, Radio group.

1.1.9.2 Confirm you have provided a sample ID card with your RFP response and that it is compliant with the Transparency in Coverage and CAA requirements (42 USC 300-gg-111(e)) in place as of the effective date of coverage. The file MUST be attached to this question.

Attachment A

Single, Radio group.

Answer and attachment required

1: Attached

1.1.9.3 Explain your capabilities to customize ID cards to meet client's specification and include special wording for carved out vendors (as applicable). Also confirm that external carved-out phone numbers can be included.

1.1.9.4 Proposer will provide customization of ID cards at no additional cost.

2: No; explain [ 50 words ]

1.1.9.5 Please provide the font size for your ID cards. If smaller than size 12 font, please confirm what options are available to members who have vision impairments.

50 words.

1.1.9.6 How often do you issue new ID cards to members?

1.1.9.7 Are you moving away from physical ID cards and encouraging use of electronic ID cards via app? Will members have the option to obtain a physical card without cost if desired?

1.1.9.8 How many ID cards will families receive and who is listed on them? Does everyone in the family receive an ID card in the mail or is there a limit to the number of ID cards per family? Is there a cost difference?

1.1.9.9 Proposer will NOT charge for physical replacement ID cards.

1.1.9.10 Proposer confirms that due to its errors it will reproduce ID cards (including priority shipping) at no cost to Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.9.11 Proposer will provide ID cards to Oregon Public Employees' Benefit Board's Participants in compliance with all state and federal regulatory requirements at no cost to Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.9.12 Proposer will reissue physical and electronic ID cards at no cost to Oregon Public Employees' Benefit Board should state and/or federal regulations require changes.

Single, Radio group.

1.1.10 Data and Reporting

1.1.10.1 Confirm you will provide All-Payer, All Claims (APAC) reporting to the Oregon Health Authority (OHA), pursuant to ORS 442.373, with the ability to identify PEBB Members.

Single, Radio group.

1.1.10.2 Confirm you will provide PEBB's data warehouse vendor with pharmacy claims feeds in the output required (see Attachment J) and on a monthly basis. PEBB's consultant will specify format changes and penalties may apply for missed reporting per contractual requirements.

Single, Radio group.

2: No, explain: [ 200 words ]

1.1.10.3 PEBB is often required to perform legislative analyses or pull data to respond to legal inquiries, public records requests, or other instances. Please confirm that there will be no additional charge for these requests, analysis, or reporting.

Single, Radio group.

1: Confirmed, explain: [ 200 words ] ,

1.1.10.4 Complete the following table regarding ongoing reporting to PEBB and their Consultant:

Report Detail Requested Frequency

Ability to Provide?

Comments / Response

Claims and Enrollment Claims:

- Must be reported on a paid basis

- Medical, Rx and Total per plan for medical coverage Enrollment:

- By plan

- Employee and Member count

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Attachment A

Lag Triangles Medical and Rx Lag Triangles reporting split out as follows:

- Medical Plan

- Rx Plan

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Large Claims Report

(YTD)

Claims above $50K

Include the following:

- Diagnosis

- Member Type

- Member Plan

- Amount by Individual Claimant per incident

- Likelihood of ongoing treatment

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Variable Fee Reporting For all variable fees (e.g., OON shared savings):

- Identify expense components and estimated associated amounts that are NOT included in the claim or lag triangle reports

- Provide historical reporting, as applicable, summarizing variable fee amounts, separated by program

This is in addition to the annual requests by Consultant during the renewal process

Quarterly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Large Claims over $250K Notification

The purpose of this communication is to provide early notification of potential high dollar claim payment in the future. This notification is based on detection of an inpatient confinement that satisfies pre-determined criteria for the possibility of a payment in excess of $250K.

Report should include:

- Pre-Authorizations

- Denied Claims

- Live Claims from Carrier

- Diagnosis

- Comorbidities

- Ongoing claims potential

Ad Hoc & Quarterly

Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Online access to experience reports and ad-hoc reporting tools capable of reporting at plan or location level of detail

Always Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Provide regular and ad hoc reports covering claim detail, medical utilization and trends, operational activity, etc.

Ad Hoc Single, Pull-down list.

1: Yes, 2: No

200 words.

Attachment A

Custom reporting Ad Hoc Single, Pull-down list.

1: Yes, 2: No

200 words.

1.1.10.5 Confirm you will provide the other routine and ad hoc reports as defined in the Sample Contract.

Report Response

PDB Eligibility Discrepancy Report Single, Radio group.

1: Confirmed, 2: Not confirmed

Monthly Payment Discrepancy Report Single, Radio group.

1: Confirmed, 2: Not confirmed

Authorized Claims Payment Single, Radio group.

1: Confirmed, 2: Not confirmed

Health Program Invoices as outlined in Exhibit D Single, Radio group.

1: Confirmed, 2: Not confirmed

[COMBINED & MEDICAL ONLY] Alternate Payment Methodologies (APMs) Single, Radio group.

1: Confirmed, 2: Not confirmed

ID Card Mailing and Accuracy: PEBB Members will receive ID cards Single, Radio group.

1: Confirmed, 2: Not confirmed

Ad Hoc Reporting Single, Radio group.

1.1.11 Compliance

1.1.11.1 Proposer will comply with all applicable federal laws and regulations, including but not limited to HIPAA and CAA.

Single, Radio group.

1.1.11.2 Proposer will comply with all CAA transparency and reporting requirements for any year where Proposer provides services to Oregon Public Employees' Benefit Board at no additional cost. This confirms Proposer will provide required data reporting for the time period serviced even if Oregon Public Employees' Benefit Board terminates the contract with Proposer.

Single, Radio group.

1.1.11.3 Confirm Proposer will provide PEBB with the files submitted on their behalf to comply with Federal transparency requirements.

Single, Radio group.

1.1.11.4 Proposer agrees to provide machine readable files post-termination as required by the plan. Costs for file production and file hosting will be the same as the standard pricing for an active Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.11.5 Proposer will detail how the process works for its external Independent Review Organization (IRO) appeals.

1.1.11.6 Proposer will manage all process and resources related to the management of external IRO appeals and any costs are outlined in this Proposal.

Single, Radio group.

1.1.11.7 The Proposer agrees that as it relates to use and disclosure of PHI, electronic transaction standards and security of electronic PHI under the Health Insurance Portability and Accountability Act of 1996, as amended, Proposer is a “Covered Entity” and that it may, from time to time, enter into Subcontracts with a “Business Associate” as both such terms are defined under 45 CFR § 160.103. Accordingly, Proposer will ensure it enters into Business Associate agreements with its Subcontractors when required under, and in accordance with, HIPAA. Notwithstanding the foregoing, Proposer and PEBB acknowledge that in providing services to Members, Proposer Specialty Pharmacy and the Mail Service Pharmacy are acting as separate health care provider covered entities under HIPAA and not as business associates to the plan covered by the Business Associate Agreement. In providing services, Proposer Specialty Pharmacy and the Mail Services Pharmacy shall abide by all HIPAA requirements applicable to covered entities and shall safeguard, use and disclose Member PHI accordingly.

Single, Radio group.

1.1.11.8 Confirm Proposer has attached a flow chart of Proposer claim denial appeals process (including post-service appeals, prior authorization, step therapy, safety, and other, if applicable) and address the following:

(a) Standard response time guidelines; (b) Notification of denial and appeal rights; (c) Qualifications for determining the need for pharmacist and/or physician review. The file MUST be attached to this question.

Single, Pull-down list.

1: Attached

1.1.11.9 [SELF-INSURED ONLY] Proposer has a process for monitoring state and federal legislation that impacts Proposer's business models and/or Oregon Public Employees' Benefit Board and its members.

Single, Radio group.

1.1.11.10 Proposer will provide an interpretation of any new state or federal legislation and possible impact to Oregon Public Employees' Benefit Board within thirty (30) days of such legislation being passed.

Single, Radio group.

1.1.11.11 Proposer agrees to notify Oregon Public Employees' Benefit Board immediately if there is a violation of law or regulation, or systemic issue affecting Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.12 Contractual Obligations

1.1.12.1 Reserved for potential questions added via an Addendum.

1.1.13 Data Sharing and Security

1.1.13.1 Reserved for potential questions added via an Addendum.

2 Medical Questionnaire

2.1 Member Experience

This section of the questionnaire is meant to capture your organization’s alignment with PEBB’s vision for their members’ experience as they interact with the healthcare system. See the main RFP document for specifics of this vision. Topic areas in this section of the questionnaire include health equity, Health Advocacy and Care Navigation, and Behavioral Health support.

Unless the RFP explicitly requests or allows additional documents to be submitted in relation to a question, they will not be considered.

2.1.1 Advocacy and Navigation

2.1.1.1 Overview

2.1.1.1.1 [TOGGLE] Are you proposing a carved in or carved out advocacy and navigation product/model?

Single, Pull-down list.

1: Carved in, 2: Carved out

2.1.1.1.2 [CARVED OUT] If you are proposing a carved out advocacy and navigation product/model, please explain your partnership.

2.1.1.1.3 Please answer the remainder of the advocacy and navigation questions based on the product/model you are proposing.

For comparison.

2.1.1.1.4 Provide information necessary to access Advocacy/Navigation demonstration website(s) (i.e., URL, log-on ID, and password).

2.1.1.1.5 Describe how you will serve as a single point of contact to assist members (and their families) to identify their holistic health, well-being and benefits needs, help them navigate to quality providers and programs, and monitor/follow-up to assure the member received the service they needed.

2.1.1.1.6 Describe your overall health management and clinical solution for PEBB as it relates to advocacy. Be explicit about which medical management and health management functions would be provided by the advocacy team and which would be provided by another vendor.

2.1.1.1.7 Please provide your current customer membership for clients that have this advocacy model in place.

If you have multiple advocacy products/models, please specify how many clients use the product/model you are proposing for PEBB and how long this product/model has been on the market.

2.1.1.1.8 Please describe what differentiates the advocacy product/model you are proposing for PEBB from other such offerings in the marketplace?

Attachment A

2.1.1.1.9 What connection, if any, is there between your advocates and clinical team?

2.1.1.1.10 Are you proposing a dedicated team that will solely work on PEBB or a designated service team that is assigned to PEBB and other clients? Explain.

2.1.1.1.11 Provide the average Customer Satisfaction Score (CSAT / 1-5) for the Customer Service / Advocacy model you are proposing for PEBB. CSAT is defined here: https://www.qualtrics.com/experience-management/customer/csat-vs-nps/

Integer.

2.1.1.1.12 Please provide the following information as it relates to the advocacy model you are proposing:

Question Response

Number of current customers in book of business (BOB) that have an advocacy solution in place Integer.

Number of those customers with any advocacy solution in place, and as a percentage of BOB 10 words.

Number of those customers with highest level of advocacy solution in place, and as a percentage of

BOB

10 words.

Length of time highest level of advocacy solution in place (if this is less than 2 years) 10 words.

Average length of time customers are in the highest level advocacy program? 10 words.

If the length of time of the highest level of advocacy solution in place is less than 2 years, what is the highest average number of years any client has been in any advocacy program?

10 words.

2.1.1.1.13 Please confirm you will offer enhanced customer service as the sole entry point for member inquiries for PEBB health related benefit offerings. (Including but not limited to medical, pharmacy, dental, vision, funding accounts, wellbeing, incentive administration, etc.). Enhanced customer service refers to high staff to member ratios; high levels of education, certification, licensure of staff; dedicated call center team;

and enhanced response times to calls and issues.

Single, Radio group.

2.1.1.1.14 Please confirm that you will provide a toll-free line with member services team that will answer participant calls from 8:00 AM PT - 8:00 PM PT, Monday through Friday (except Federal holidays). Can you offer services on Saturday as well?

Single, Radio group.

2.1.1.1.15 Confirm that the designated or dedicated member services team will respond to telephone, electronic mail, and written inquiries from participants, and that the team will also document all inquiries in secure issue tracking database.

https://www.qualtrics.com/experience-management/customer/csat-vs-nps/ https://www.qualtrics.com/experience-management/customer/csat-vs-nps/

Attachment A

Single, Radio group.

2.1.1.1.16 Confirm that the designated or dedicated member services team will also be accessible via in-app or online messaging. Advise which members of the services team (e.g., advocacy, clinical, etc.) are available to be reached via messaging service.

Single, Radio group.

2.1.1.1.17 Please describe the access you will provide members to in-network physician/office locator via online directory.

2.1.1.1.18 Will you provide a customized, client-specific website? If so, describe what it includes, for example, personal benefits, claims information, a well-being portal, and consumer decision support tools and services for executing common transactions that you will provide for our members.

2.1.1.1.19 What self-service reporting, if any, is available (e.g., dashboard, issues tracking) to members?

2.1.1.1.20 Please confirm your abilities to coordinate benefits for PEBB healthcare related services (i.e., medical, dental, vision, expert medical opinion vendor, wellbeing etc.).

Single, Radio group.

2.1.1.1.21 Please confirm your ability to expand to all benefit offerings including well-being, life and disability, etc.

Single, Radio group.

2.1.1.1.22 Which advocacy services provided do you subcontract? List the specific functions provided by any/each entity and describe the relationship (i.e. parent, subcontractor, affiliate, consultant or other organization), as well as your role in managing their delivery.

2.1.1.1.23 List languages other than English that are available for telephonic customer service support.

Attachment A

2.1.1.1.24 For member-facing customer service, navigation and advocacy, describe how you will accommodate a member's desire to speak/work with someone with whom they can relate (e.g., race, culture, gender, identity, etc.).

2.1.1.1.25 Is there additional support available during Open Enrollment or other peak times?

2.1.1.1.26 If care management is included, describe your criteria for member identification into the various programs.

2.1.1.2 Staff and Training

2.1.1.2.1 Please provide details for how you will manage operations related to the Advocacy service below.

Attach an organization chart and biography for team members as applicable. Be sure to indicate any clinical staff overlap with the proposed care management solution. The file MUST be attached to this question.

2.1.1.2.2 Proposed Location(s) for Health Advocacy Team

Member Services

Clinical, if different than Member Services required

Will the member service team be co-located with any other team members (i.e., claims, clinical, etc.)?

2.1.1.2.3 Proposed Hours (for each location if multiple locations).

2.1.1.2.4 How are calls outside of business hours or on the weekends handled?

Attachment A

2.1.1.2.5 What is your turnaround time for responding to calls received after hours?

2.1.1.2.6 Are there other modalities in which a member can connect with a representative? If so, what are the business hours and turnaround time for responding?

2.1.1.2.7 Ratio of dedicated team members per PEBB member

2.1.1.2.8 Number of Teams that will service PEBB account in total

N/A OK.

2.1.1.2.9 Number of team members that will service PEBB account in total

Attachment A

2.1.1.2.10 Will your organization increase the member support team as PEBB headcount grows over time? If yes, how and when is this reviewed?

Single, Radio group.

2.1.1.2.11 Job title of each team member (e.g., Benefits Specialist, Nurse, Pharmacist, etc.)

2.1.1.2.12 Number of Health Advocacy accounts/clients serviced at each location

2.1.1.2.13 Number of Health Advocacy accounts/clients serviced by each team

2.1.1.2.14 Average and median tenure of team

Average Tenure Median Tenure

10 words. 10 words.

2.1.1.2.15 Percent of team with less than 2 years of experience

Percent.

2.1.1.2.16 Turnover rate of team members for the past 12 months

Attachment A

2.1.1.2.17 Do any Health Advocacy team members work from home? If so, what Percentage?

Work from home? Response

2: No

2: No, 3: Same as member services

2.1.1.2.18 Confirm no Health Advocacy team members are located offshore.

2.1.1.2.19 Are there any significant staffing model or member service department changes planned in the coming 12 months?

2.1.1.2.20 Please complete the following for each type of Health Advocacy team member.

Health Advocacy Team Member Type

Total number of each resource and the ratio of staff to PEBB team member

Educational Background and License/credentials

Average Work Experience in the Profession

Average Turnover Over Two Years

Employed or Contracted?

Triage/Intake Specialist

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Benefits Specialist (Health Advocates)

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Nurses (Clinical Advocates)

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Pharmacists 50 words. 50 words. 50 words. Percent. Single, Pull-down list.

Attachment A

1: Employed, 2: Contracted

Health Management Coaches

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Lifestyle Management Coaches

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Dieticians 50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Social Workers 50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Behavioral Health Specialist

50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Medical Director 50 words. 50 words. 50 words. Percent. Single, Pull-down list.

1: Employed, 2: Contracted

Others? Please list below.

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

Percent.

N/A OK.

Single, Pull-down list.

1: Employed, 2: Contracted, 3: N/A

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

Percent.

N/A OK.

Single, Pull-down list.

1: Employed, 2: Contracted, 3: N/A

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

Percent.

N/A OK.

Single, Pull-down list.

1: Employed, 2: Contracted, 3: N/A

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

50 words.

Nothing required

Percent.

N/A OK.

Single, Pull-down list.

1: Employed, 2: Contracted, 3: N/A

Attachment A

2.1.1.2.21 Please detail your process for identifying and hiring team members who will serve in the Health Advocacy function. (i.e., what industries do you hire from, what educational and work qualifications do you look for, how much work experience do they typically have prior to becoming a Health Advocate?). Please provide as much detail as possible.

2.1.1.2.22 Once you hire a candidate as a Health Advocate, please detail the training curriculum they undergo including duration, content of curriculum, whether they receive coaching/feedback based on role play and how and when you determine whether a new hire is ready to start handling client calls. What percent complete the training?

2.1.1.2.23 Is any training for cultural humility required for Health Advocates and member-facing staff by your organization? If yes, provide the required cadence (i.e. annually, semi-annually).

2.1.1.2.24 Describe how Health Advocacy team members are trained to manage clinical discussions.

2.1.1.2.25 Describe ongoing training and case rounds to discuss specific cases.

2.1.1.2.26 Describe your ongoing quality improvement program including how opportunities are identified, who is involved and how the outcome is measured.

2.1.1.2.27 How do you ensure your advocates are trained on PEBB programs and resources?

2.1.1.2.28 Will the after-hours/weekend team be designated, specifically trained on PEBB medical plans?

2.1.1.2.29 Please describe your process for instilling PEBB's values (referenced in the main RFP document) within the Advocacy team? How do you train on and reinforce the client values? Provide an example of the way training has been modified to meet the needs of a specific employee population.

2.1.1.2.30 Describe how employees are trained to be empathetic and engaging. Share details on how this is assessed and measured during interactions.

2.1.1.2.31 How is success of training measured?

Attachment A

2.1.1.2.32 What types of ongoing quality monitoring are in place for the following:

Claims 200 words.

Customer Service 200 words.

Clinical 200 words.

2.1.1.2.33 How are advocates incentivized to be partners to PEBB and support PEBB culture and members?

2.1.1.2.34 Indicate your current CSAT score for proposed unit.

2.1.1.2.35 How do CSAT scores impact ongoing training? Please provide an example of how a lower CSAT influenced training or process. Additionally, how does CSAT help to identify advocacy gaps and therefore training needed?

2.1.1.2.36 Provide details on your ongoing training plan for more tenured employees, beyond the new hire training program.

2.1.1.2.37 Describe what steps are taken to correct errors (i.e., retraining) among customer service, claims adjudication.

2.1.1.2.38 Please describe the qualities that your most effective Health Advocate team members possess. On an ongoing basis, what evaluation criteria are used to determine the effectiveness of each Health Advocate?

How often are evaluations conducted and by whom?

2.1.1.2.39 What is your process for transitioning cases/members when a staff member is leaving the company?

2.1.1.2.40 What is your process for managing internal workflow when PEBB-dedicated support is on PTO or has scheduled or unscheduled time away from the office?

Attachment A

2.1.1.3 Program Navigation and Education

2.1.1.3.1 Please explain what happens once a member calls into the call center with an inquiry for the first time. Who answers the call and are they routed to other team members, how many team members might the member be handed off to? What information is the caller required to provide (Name, Date of Birth, Address, etc.) for verification purposes? How does a call typically end? Is the member provided a written summary?

Also describe the answer to these questions for repeat callers.

2.1.1.3.2 Confirm that you will provide call calibration sessions with PEBB to review recorded customer service calls and provide feedback.

Single, Radio group.

2.1.1.3.3 Please describe what happens if team members aren't able to resolve the member's inquiry. Who calls the member back? What channels are used to get back to the member (i.e., telephone, secure email, voice mail, etc.?) What is your next course of action if you call / email thrice and cannot reach a member?

2.1.1.3.4 Do you provide a customer service survey? How is it administered? Can it be customized by PEBB?

2.1.1.3.5 Do you provide the ability for an employee to send a secure email to customer service?

2.1.1.3.6 Please describe how you would handle a situation where you don't have any information on the member that has called your organization.

2.1.1.3.7 Describe how your customer service technology supports your representatives with understanding PEBB's third party programs and how appropriate, customized member information is pushed to them.

2.1.1.3.8 Describe when and how a member would be transferred to a clinical resource.

2.1.1.3.9 Do you offer secure email and/or text messaging for members to communicate with customer service and claims examiners?

Attachment A

Single, Radio group.

2.1.1.3.10 Do claims, customer service and clinical staff have access to the same systems or have access to each other's systems?

Single, Radio group.

2.1.1.3.11 Is your primary model an inbound or outbound approach to connecting with PEBB employees / families?

Single, Radio group.

1: Inbound, 2: Outbound

2.1.1.3.12 Please describe your process for obtaining HIPAA releases to contact other vendors, providers or facilities on the members' behalf. How long is the release valid? Are you able to accept releases verbally?

2.1.1.3.13 Please describe your interaction/process for working with family members of an employee if they are ill. What information can be provided to them? What documentation do you need prior to engaging in care discussions with family members? Will your organization proactively support patients' engagement with parents or other caregivers when they need additional support?

2.1.1.3.14 Supporting employees with employee medical leave needs and processes is very important to PEBB.

Confirm that (given the appropriate information provided by PEBB) you are able to help employees follow the necessary steps prior to going out on medical leave and ensure they have read the medical leave policy and understand it. Then triage to leave administrator can be facilitated.

2.1.1.3.15 Please include the most recent rolling 12 months book of business results for the following Member Services results:

Response

a. Member Satisfaction results for member service inquires (calls, emails, etc.) 200 words.

b. Total number of inquiries Integer.

c. Number of referrals out to other solutions/services Integer.

d. Number of appeals/escalations Integer.

e. Average response time 20 words.

f. Average time to close 20 words.

g. What are the top 5 reasons members call in? 200 words.

2.1.1.4 Advocate Services Checklist

2.1.1.4.1 Answer "Yes" if the services below are offered and included in the pricing detailed in the financial section of this proposal. If not, please provide an explanation.

Program Navigation and Education Response

Answer benefit coverage questions Compound, Pull-down list.

1: Yes, 2: No, explain:

[200 words]

Assist with eligibility questions and ID card replacement Compound, Pull-down list.

1: Yes, 2: No, explain:

[200 words]

Educate members about new or changing health plan benefits including account based high-deductible plan designs (Note: PEBB does not currently offer an CDHP)

Compound, Pull-down list.

1: Yes, 2: No, explain:

[200 words]

Assist members in selecting a medical plan during open enrollment Compound, Pull-down list.

1: Yes, 2: No, explain:

[200 words]

Assist in finding a PCP, Specialist or in-network facility or lab Compound, Pull-down list.

1: Yes, 2: No, explain:

[200 words]

Locate…