AttachB_Definitions_v2.pdf

PEBB Medical & Pharmacy Benefits RFP OregonBuys Bid No. S-44300-00014758 Attachment B

Attachment B Definitions [non-negotiable unless otherwise indicated]

I. Overview. Definitions provided in this Attachment B govern this RFP, unless specifically defined elsewhere. In the event that a term included in this RFP is not defined below, Proposers will refer to PEBB’s administrative rules and ORS 243.105.

Addenda means any amendments, clarifications, or changes to the terms of the RFP as posted on OregonBuys and ProposalTech’s Proposal Submission Website.

Administrative or Admin Fees for Contractor is defined as the [to be negotiated with

ASP].

Administrative Overpayments mean payments that exceed the benefit amount payable under the Benefit Plan design resulting from a Provider billing error, retroactive or inaccurate eligibility information, coordination of benefits, third-party liability, Medicare disputes, missing information, or similar circumstances.

Affiliate of a Proposer means all assignees, subsidiaries, parent companies, successors and transferees, and persons under common control with the Proposer; any officers, directors, partners, agents and employees of such Proposer; and all others acting or appearing to act on their behalf or in concert with them [to be negotiated with ASP].

Amendment means a written modification to the terms and conditions of a contract.

Appeal means the same as “internal appeal”, as defined in ORS 743B.001.

APM means Alternative Payment Methodology

ASP means Apparent Successful Proposer, which refers to the organization selected as the ASP to this RFP but who has not yet successfully negotiated and executed a Contract with

PEBB.

Bank means U.S. Bank located in Portland, Oregon.

Bank Accounts mean the accounts maintained by Contractor at the Bank for purposes of providing PEBB with a means for payment of plan benefits, expenses, and fees for its statewide Benefit Plan and regional Benefit Plan(s).

Benefits Claim or Claim means any electronic or paper request for payment or reimbursement where a Member received benefits. Benefit Plan includes, but is not limited to, insurance or other benefits, including:

a. Medical (including non-integrated health reimbursement arrangements, or Health FSAs);

b. Dental;

c. Vision;

d. Life, disability, and accidental death;

e. Long term care;

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f. Employee Assistance Program;

g. Health FSA as defined by OAR 101-010-0005(25);

h. Supplemental medical, dental, and vision coverages;

i. Any other remedial care recognized by state law, and related services and supplies;

and,

j. Self-insurance programs managed by the Board.

Board means either the governing board of PEBB or, collectively, its staff, depending upon context.

Broker means a person who is under, or is expected to, or has responded to, a Procurement to be under, a contract as a consultant, broker, agent, representative, or other person responsible for evaluating insurance services.

CEAC means Counties with Extreme Access Considerations.

Client means an Eligible Employee, Qualified Dependent, or participating Entity (as context requires) either actively receiving services from Contractor or an Employee or Qualified Dependent eligible to receive services from Contractor through their respective agency’s participation in the program.

Clinical Overpayments means payments that exceed the appropriate amount payable due to errors in clinical coding, incorrect application of Provider contracts and other clinical audit items.

CMS means Centers for Medicare and Medicaid Services

Confidential Member Information or Confidential Information means information that contains personally identifiable health information about a Member. More specifically, it means any and all information of any form obtained by Contractor or its employees, subcontractors, or agents in the performance of this Contract, including PEBB data, as well as any reports or other documents or items (including data aggregations) that result from the use of PEBB information and data that are relied upon to produce the reports or other documentation or items, are deemed to be confidential information of PEBB (“Confidential Information”). Confidential Information does not to include information that (i) is or becomes (other than by disclosure by Contract) publicly known; (ii) is furnished by PEBB to others without restrictions similar to those imposed by this Contract; (iii) is rightfully in Contractor’s possession without the obligation of nondisclosure prior to the time of its disclosure under this Contract; (iv) is obtained from a source other than PEBB without the obligation of confidentiality, (v) is disclosed with the written consent of PEBB, or; (vi) is independently developed by employees, agents or subcontractors of Contractor who can be shown to have had no access to the Confidential Information.

Consultant has the meaning described in OAR 101-005-0030. For purposes of this RFP, PEBB has retained Mercer Health & Benefits as its Consultant.

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Contract or Group Benefits Contract are synonymous with “Contract” and mean the contracts that result from this RFP process. The terms Contract, Groups Benefits Contract, and Agreement may be used interchangeably.

Contract Period means the period from January 1, 2027 and unless extended or terminated earlier in accordance with the Contract, terminating on December 31, 2029.

Contractor means the party providing medical or pharmacy services to Clients and Entities under the future Group Benefits Contract.

Contractor Intellectual Property means any intellectual property owned by Contractor and developed independently from the Work.

Contractor Proprietary Information means any information marked or designated in writing by Contractor as “confidential” prior to initial disclosure, or information disclosed orally that is confirmed in writing as “confidential” within 10 (ten) calendar days of disclosure.

Directly Contracted Network means a Network whose contractual arrangements with Contractor or Contractor’s affiliate, or subcontractor are not third-party leasing of providers described in ORS 743B.502.

Document Management Module or Document Management Portal refers to the secure module in PDB where Contractor and other partners submit reports and other documents.

Domestic Partner has the meaning defined in OAR 101-010-0005.

EDI means Electronic Data Interchange, as defined under HIPAA.

Effective Date means the date that Contracts awarded under this RFP will begin, which is when they are fully executed by the parties and after they receive all necessary approvals from the State of Oregon, including legal sufficiency approval from the Oregon Department of Justice.

Eligible Employee or Employee means an individual eligible to enroll in PEBB Benefit Plans by reason of his or her employment with a PEBB-participating employer, and includes:

a. Active eligible employee means an employee of a PEBB participating employer, including a state official, in an exempt, unclassified, classified, or management service position who works at least half-time or in a position classified as job share and is expected to work at least 90 days. The term active eligible employee can apply to an employee in an initial or standard measurement period, or in a stability period and includes:

i. A permanent employee who is appointed to a permanent position (as defined by OAR 105-101-0000(40)) that is a benefit eligible position, including but not limited to a full time, half-time, job share, or seasonal position; or

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ii. A temporary or impermanent worker who is not appointed to a permanent position, but by following the ACA regulations and policy for full time employees, becomes benefit eligible on a specific date after appointment due to work expectations or becomes benefit eligible following an initial measurement period.

b. Retired eligible employee means a previously active eligible employee, who meets retiree eligibility as defined in OAR 101-050-0005. A retired eligible employee can enroll in PEBB retiree benefit plans as established in OAR Division 50 of chapter 101 and must pay premiums.

c. Other eligible employee means an individual of a specific self-pay group as established by ORS 243.140 and 243.200. These groups are eligible only for medical and dental benefits as approved by PEBB.

EMR means Electronic Medical Records, also synonymous with EHR (Electronic Health Record).

EOM means the end of the month.

EOQ means the end of the calendar quarter.

ERISA means the Employee Retirement Income Security Act.

Family Member has the meaning defined in OAR 101-010-0005.

FFS means Fee for Service.

Financial Services Team or FS Team is a unit within PEBB to send reports for reconciliation and processing invoices as well as designated reports with credit or retroactive payment information, etc.

Health Care Facilities or Facilities mean places that provide health care that have 50 or more employees including, but not limited to, acute care hospitals, psychiatric hospitals, long-term care facilities, ambulatory surgical centers, home health programs, hospice facilities, clinical laboratories, inpatient rehabilitation facilities, outpatient dialysis facilities, offices of physicians and other health care professionals, and nursing facilities. A “Health Care Facility” or “Facility” also means a facility has less than 50 employees but is operated by an organization that operates multiple health care facilities employing 50 or more employees in the aggregate. For purposes of this Attachment B, “Health Care Facilities” or “Facilities” are limited to those that are Directly Contracted with Contractor and do not include those places that provide health care that are part of Contractor’s large leased network.

HEDIS means the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is a tool used by health plans to measure performance on important dimensions of care and service.

HIPDB means Healthcare Integrity and Protection Data Bank.

HIPAA means the Health Insurance Portability and Accountability Act of 1996.

https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996

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Insurance Services includes but is not limited to the services of an insurance company, reinsurer, dental care service contractor, dental services manager, third-party administrator, insurance broker, insurance agent, risk manager, utilization review organization, consultant, Benefits Claims payment processor, or any other employee benefits management company or contractor.

Insurance Services Contractor means a company or person which is currently, or is responding to a Procurement to become, under contract with or otherwise furnishing Insurance Services to the State of Oregon.

IRS means Internal Revenue Service.

Labor Management Partnership means a legally binding agreement with a labor organization or coalition of labor organizations that are certified or recognized as the exclusive bargaining representative(s) of covered employees and that covers at least 60% of non-management and non-supervisory employees that includes:

a. A dispute resolution procedure culminating in a binding arbitration of disputes, including, but not limited to, disputes concerning the interpretation or application of any collective bargaining agreement;

b. A method for expeditious resolution of issues relating to employee efforts to designate an exclusive bargaining representative (or to decertify such representative); and,

c. Mechanisms for joint governance, including union and employee involvement in matters traditionally reserved to management, such as development of work processes and establishment of performance standards.

Legal Claim means any claim, suit, action, or proceeding between PEBB (or any other agency or department of the State of Oregon) and Contractor that arises from or relates to the future Contract.

Member or Members include the following and have the meaning provided in OAR 101- 010-0005:

a. “Eligible employee”;

b. “Dependent child”;

c. “Domestic partner”;

d. “Spouse”;

Member Handbooks mean the documents to be approved according to the guidelines set forth in Exhibit C to the Contract and that are provided to Participants describing the terms and conditions of coverage offered under the Plans in accordance with federal and state requirements, if applicable. This term is synonymous with EOC as defined in Attachment B.

Minimum Balance means the security deposit that must be maintained by PEBB in the Bank Accounts for each Plan, as specified in the Sample Group Benefits Contract, Exhibit C, Section III.

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MY means Measurement Year.

MYA means Measurement Year Actual.

NCQA means National Committee for Quality Assurance (NCQA), which develops HEDIS measures and tools for measuring certain types of health outcomes.

Network means a health care provider, group, or facility who has entered into or is governed by contractual arrangements with Contractor or a Contractor Affiliate or subcontractor, under which they agree to provide health care services to Members and to accept negotiated fees for such services under at least one of the Benefit Plans.

Network Provider or Groups means a Provider or group of Providers who have entered into or are governed by contractual arrangements with Contractor or a Contractor affiliate or subcontractor, under which they agree to provide health care services to Members and to accept negotiated fees for such services under the Plan in which the Member is enrolled

Network Pharmacy means a pharmacy which has entered into an agreement with Contractor, or a Contractor affiliate or subcontractor provide prescription drug services to Members under the Plan in which the Member is enrolled.

Noncompetitive Response means bidding, proposing, or otherwise responding to a Procurement, which response (as a result of actions of or circumstances that are created in whole or part by a Proposer or its Affiliates):

a. is not bona fide;

b. favors the incumbent Insurance Services Contractor;

c. restricts or allocates opportunities to sell Insurance Services to the State of Oregon;

d. is rigged, steered to a particular Insurance Services Contractor to avoid fee disclosures or for other reasons not specified in the Procurement, based on target premiums or fixed prices or chosen by the State of Oregon under false pretenses;

e. has a backup quote or protective quote, a so-called ‘B Quote’ not based on underwriting analysis, false or inflated quotes, or quotes that were deliberately inferior in order to manipulate market pricing or to present the quotes of Insurance Services Contractor or the Broker’s negotiating powers in a more favorable light;

f. is collusive, fictitious or otherwise noncompetitive; or,

g. induces or causes the State of Oregon to purchase Insurance Services at prices higher than it would have paid, or on terms less favorable than would have been available, in a competitive market.

NQF means National Quality Forum

OAR means Oregon Administrative Rule(s).

OHA means the Oregon Health Authority. PEBB is located within the OHA.

Open Enrollment (“OE”) means the period when Eligible Employees select Benefit Plan options for the upcoming Plan Year. PEBB’s OE period takes place annually between October 1 and October 31.

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OregonBuys means the State of Oregon website where procurement documents, including documents from this RFP, are publicly posted. PEBB will post official RFP documents on OregonBuys as well as instruct Proposal Tech to do the same in their Proposal submission site.

ORS means the Oregon Revised Statutes.

Participant means a PEBB Member who is covered by a Benefit Plan.

Pay for Performance Program (P4P) means the quarterly Provider reimbursement program. In order to provide an incentive to meet clinical quality goals, Contractor secured agreements with certain Network Providers to have a portion of their contracted rates withheld at the time Contractor pays a claim. On a quarterly basis, Contractor will evaluate whether the Provider has met specified Pay for Performance standards. If the standards are met, the withheld amounts are paid to the Providers. If the standards are not met, the withheld amounts shall be returned to PEBB within 90 days after the quarterly settlement with the P4P Providers. Payment may be postponed at PEBB’s request.

PCPCH means Patient-Centered Primary Care Home.

PDB means pebb.benefits, which is PEBB’s benefit management system. The system allows electronic enrollment and termination of an eligible individual’s Benefit Plans, personal information updates, and the transmittal of data to carriers, payroll centers, and third party administrators.

PEBB means the State of Oregon, acting by and through its Public Employees’ Benefit Board.

PEBB Member is synonymous with Member.

PG means Performance Guarantee.

PHI means Protected Health Information, as defined under HIPAA.

Plan Administrator means Contractor, who serves as the “Administrator” or “Plan Administrator”.

Plan Sponsor means PEBB in its capacity as the sponsor of the Benefit Plans to which the Contract applies.

Plan Year means January 1 through December 31.

PMPM means Per Member Per Month.

PPO or PPO Plan or Statewide PPO means the PEBB self-funded health Benefit Plan providing a statewide and national Preferred Provider Organization for Members.

PQI means Prevention Quality Indicators.

Premium Equivalent Rates means the expected costs of providing benefits to PEBB Members enrolled in the Benefit Plans administered by Contractor. The Premium

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Equivalent Rates are comprised of an estimate of the expected claim expense plus all program and administration fees paid to Contractor and PEBB program administration costs. These rates are used to compute the commission payment PEBB must pay to its Consultant.

Procurement means the action of obtaining goods or services under a public contract.

Proposal means a competitive document, binding on the Proposer and submitted in response to this RFP.

Proposal Submission Website refers to the website hosted by Proposal Tech where this RFP will be administered.

Proposer means an organization that submits a proposal responsive to this RFP and by the RFP’s stated timeline.

Provider means a health care practitioner or facility that is validly licensed by the appropriate state agency to diagnose or treat health care conditions and is providing services within the scope of that license.

PYB means Prior Year Baseline.

Qualified Dependent means a spouse, domestic partner, or dependent child, each as defined in PEBB’s administrative rules.

Recent Retiree means an employee of a participating Entity, who has retired within the last 30 calendar days.

RFP means Request for Proposals

RSR means Rate Stabilization Reserve

Self-Funded or Self-Insured means PEBB has the sole responsibility to provide all necessary funds for all plan benefits and that Contractor has no responsibility to provide such funds.

SPC means Single Point of Contact

Successful Proposer means the organization that is selected as this RFP’s ASP and who successfully negotiates and executes a Contract with PEBB.

Tax or Taxes means assessments, Taxes and all other similar charges that are levied by a federal, state, or local governmental or regulatory entity in relation to the operation of the Benefit Plans.

TBD means To Be Determined

Third Party Intellectual Property means any intellectual property owned by parties other than PEBB or Contractor.

VBP means Value Based Payment

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Vendor means a person who is under a contract with the State of Oregon for Insurance Services.

Work means the deliverables to be completed and services to be provided under the Contract resulting from this RFP.

Work Product means every invention, discovery, work of authorship, trade secret or other tangible or intangible item and all intellectual property rights therein that Contractor is required to deliver to PEBB pursuant to the Work.

YTD means Year to Date.

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