Attachment_A.pdf

ATTACHMENT A

SOLICITATION NO. EV00000681

PLAN YEAR 2026 HEALTH

This Solicitation is a Contract Document and is a request for proposal in connection with the Contract awarded by and through the Office of Management and Enterprise Services on behalf of the Oklahoma Health Care Authority Employees

Group Insurance Division (EGID) as more particularly described below. Any defined term used herein but not defined herein shall have the meaning ascribed in the General Terms or other Contract Document.

PURPOSE

The Contract is awarded on behalf of the Oklahoma Health Care Authority Employees Group Insurance Division (EGID) for qualified HMOs, Medicare Supplements, and Medicare Advantage Prescription Drug health plans to offer managed care benefits to eligible OEIBA Program participants who live in the state of Oklahoma. OMES/CP, on behalf of EGID intends to also solicit a standalone MAPD proposal on an exclusive basis with only one national MAPD to be primarily offered as an alternative for retired OEIBA Program members living outside the state of Oklahoma.

BACKGROUND

Identification of EGID

EGID was established by, and operates pursuant to, the Oklahoma Employees Insurance and Benefits Act (OEIBA), 74

O.S. § 1301, et seq., hereinafter (Act). The Act was established for the benefit of state and education employees, employees of other state governmental entities and quasi-state governmental entities authorized by the Act to participate in the insurance plans offered by EGID.

EGID is a covered entity subject to HIPAA. Pursuant to legislative authority, EGID adopts Rules that set forth the eligibility, type of participation and benefit guidelines for all participating employers. A copy of the official agency Rules is on file with the Office of the Secretary of State beginning at 260:45-1-1, or the Rules may be found at https://www.rules.ok.gov/home.

Identification of the Program

EGID is responsible for administering the OEIBA and the benefit contracting elements of the Oklahoma State Employees

Benefits Act. 74 O.S. § 1361 et seq. As such, EGID must provide for health benefit choices for the eligible participating population. Currently, there are approximately 900 participating employer groups, each with unique Section 125 plans.

Identification of OEIBA Program Participants

Health benefits are available to current and former state and education employees, employees of other state governmental entities and quasi-state governmental entities authorized by the OEIBA to participate in the OEIBA Program. For most employees, insurance coverage is optional.

Identification of OEIBA Program Census Data (as of February 28, 2025):

Category Total Lives Primary Dependents

Medicare 34,570 31,085 3,485

Current Employees 176,142 114,737 61,405

Pre-Medicare Former Employees 5,478 4,252 1,226

TOTAL 216,190 150,074 66,116

https://www.rules.ok.gov/home

OBJECTIVES

EGID intends to offer cost effective managed care service alternatives to the OEIBA Program’s covered population statewide and provide improvements and initiatives in health care benefits that are available in Oklahoma while maintaining a cost-efficient program and a rising level of quality health care services.

A. CONTRACT TERM AND RENEWAL OPTIONS

A.1. The initial Contract term is January 1, 2026, through December 31, 2026, and there are two one-year options to renew the Contract.

A.2. For each contract renewal, Supplier shall offer the plan in place at the time of the renewal request if it is still an option in the solicitation, plus it may offer an alternative plan design. OEIBA Program may request updated documentation found in this Solicitation to review for purposes of the renewal.

B. SOLICITATION CRITERION

B.1. The Bid will be evaluated using a best value criterion, based on the following:

B.1.1. Technical Response

B.1.2. Pricing Proposal

B.1.3. Past Performance

B.2. The Bid response shall show the ability of the Bidder to meet or exceed the following mandatory specifications based on the plan combination:

B.2.1. Attachment A Section C.2.

B.2.2. Attachment A Section C.4.1.

B.2.3. Attachment A Section C.7.

B.2.4. Attachment E Section A.11

C. REQUIREMENTS AND LIMITATIONS ON THE PLAN(S) TO BE OFFERED UNDER THIS

SOLICITATION

C.1. Per Oklahoma State Employees Benefits Act, 74 O.S. § 1371(C), bids involving current employee coverage may be rejected or enrollment restricted for which the benefit price is determined to be excessive. Standalone MAPD plans will be evaluated by Best Value evaluation criteria. If a Bidder submits an HMO and an MAPD plan, and the HMO plan is rejected, then the entire bid combination will be rejected. The determination of compliance with proposal requirements shall be made by OMES/CP and EGID. EGID shall be responsible and have the final decision regarding compliance with administrative rules and regulations.

C.2. Bidder shall offer only one of the following bid combinations:

C.2.1. HMO and Medicare Supplement

C.2.2. HMO and MAPD

C.2.3. HMO and Medicare Supplement and MAPD

C.2.4. Standalone national MAPD

C.3. Bidders with current contracts with the OEIBA Program are required to offer the current plan design for this solicitation. In addition, they may offer an alternative plan design. Only one plan design will be selected.

C.4. For all plans offered to pre-Medicare employees, excessive pricing shall result in rejection of the bid combination.

A rejection of a Bidder’s HMO plan shall result in the elimination of the entire bid combination.

C.4.1. For purposes of evaluating “excessive pricing”, refer to Exhibit 26.

C.5. Bidder shall offer only one single bid combination. If a Bidder offers more than one bid combination for this

Solicitation, all of the Bidder’s bid combinations will be automatically rejected.

C.6. To participate, Bidders must offer an HMO option meeting the Solicitation Specifications, unless the Bidder submits the bid as a standalone MAPD offer.

C.7. Bidders may offer a commercial plan for current and pre-Medicare employees and a Medicare Advantage plan for retirees. Bidders shall not offer an HMO or a Medicare Supplement on a standalone basis for this RFP.

C.7.1. To participate, Bidders must offer an HMO option that meets the Solicitation Specifications unless the

Bidder submits the bid as a standalone national MAPD offer.

C.7.2. MAPD plans must be qualified by the Centers for Medicaid Services, hereinafter “CMS” and must be qualified and accepted according to the OMES/EGID Supplier’s process to offer these services to eligible participants.

C.7.3. Bidder may submit either an MAPD HMO or an MAPD PPO response to this RFP, but not both.

C.7.4. In accordance with State law under 74 O.S. §1366.1, if the Bidder additionally offers a Medicare

Supplement benefit to any population within the State of Oklahoma other than the one within the OEIBA

Program, it must also offer a Medicare Supplement benefit within this Program in accordance with the

Solicitation Specifications.

C.8. Bidder affirms their understanding of all contractual provisions and agrees to those provisions for the duration of the contract.

C.9. Bidder shall furnish evidence that it complies with all requirements imposed by the Oklahoma Insurance

Department necessary for it to provide the services herein.

C.10. Minor Deficiencies. The State Purchasing Director has the right to waive minor deficiencies or informalities in a proposal provided that the State’s best interest would be served without prejudice to the rights of the other

Bidders.

D. SCOPE AND DESCRIPTIONS

SPECIFICATIONS APPLYING TO ALL PROPOSALS

(HMO, MEDICARE SUPPLEMENT, MAPD)

D.1. Eligibility Transmission.

D.1.1. EGID will maintain individual eligibility records. EGID will communicate all eligibility data and remit all premium dollars to carriers. At a minimum, eligibility transmissions shall be on a weekly basis.

Suppliers should only accept eligibility from EGID, not from employers or other sources.

D.1.2. The Supplier must accept EGID's eligibility file layout as described in Exhibit 25. The following is a list of various eligibility transactions included in a typical incremental file. The listing is provided for informational purposes and should not be considered an all-inclusive list of eligibility transactions. Any of the following could have future or retroactive dates.

D.1.2.1. New member/dependent enrollment

D.1.2.2. Member/dependent termination/disenrollment

D.1.2.3. Member/dependent adding and/or dropping various benefits

D.1.2.4. Eligibility changes due to ESRD determinations

D.1.2.5. Member moves between participating employer groups

D.1.2.6. Dependent moves from participating primary member to another primary member

D.1.2.7. Member/dependent status changes from current to pre-Medicare or COBRA status

D.1.2.8. Member/dependent becomes eligible for Medicare

D.1.2.9. A lapse is added to a member/dependent coverage

D.1.2.10. Member address changes

D.1.3. Confirmation must be provided to EGID after eligibility information has been received. Notice to EGID should be sent to sib.edi@sib.ok.gov stating that the eligibility file has been received. Confirmation must also be provided to EGID if eligibility has not been processed within three (3) business days of receipt.

Notice to EGID should be sent to sib.edi@sib.ok.gov stating what has not been processed and the reason it wasn’t processed.

D.1.4. The Supplier will be required to maintain its eligibility records from the data provided in a timely and accurate manner.

D.1.5. Eligibility information sent by EGID as “urgent” must be processed and confirmed within two (2) business hours. Supplier must fully process “non-urgent” requests within two (2) business days. EGID’s business hours are 7:30 AM CT – 4:30 PM CT, Monday – Friday.

D.1.5.1. Response time: Urgent Workflow issues should be resolved within two (2) business hours of receipt. If the issue cannot be resolved within two (2) business hours, the workflow should be noted within two (2) business hours of receipt as to the action that is being taken to resolve the issue.

D.1.5.2. Response time: Non-urgent Workflow issues should be resolved within two (2) business days of receipt.

D.1.5.3. Urgent issues will be identified with a “high” priority and non-urgent issues will be identified as

“medium” priority. Both urgent and non-urgent issues are tracked and routed back and forth between EGID and the Supplier through the Workflow Application.

D.1.6. For the categories Medicare Retiree and Pre-Medicare-Retiree, the retirement system contribution ranges from $100 to $105 per month for the primary member only. The contribution applies to health coverage only. For employees, contribution levels vary widely. In the majority of cases, the employer contribution for the employee will be at least equal to the HealthChoice High Option Premium. In the majority of cases, there is no employer contribution towards the cost of dependent coverage.

D.1.7. Information on eligibility reconciliation will also be furnished on a quarterly basis upon request of

Supplier.

D.1.8. PCP information is only transmitted on the basis of the PCP name. No other code or identifier is available.

Note that not all OEIBA Program members supply this information at the time of plan selection.

D.1.8.1. The status of the patient with the PCP will be included in the transmission as either “N” for New

Patient or “C” for Current Patient if the information is supplied to EGID.

D.1.8.2. If awarded the contract, Suppliers will receive enrollment information for members as early as

Option Period and should work directly with new members to confirm the member’s selection of the PCP.

D.2. Premium Accounting.

D.2.1. EGID will communicate all eligibility data and remit all premium dollars to carriers. EGID remits premiums to Suppliers based on enrolled members.

D.2.2. EGID forwards premiums to the supplier on the 20th of the month (or the first business day thereafter) following the month of coverage (aka premium month). Example: Premiums due for the month of January are paid on February 20th. Payment and retroactivity detail files are sent by SFTP to the plan on the 21st.

D.2.3. Retroactive adjustments may occur to eligibility of individual participants because of eligibility provisions within the Act. In these circumstances, premiums must be refunded to a member or participating entity and EGID will recover those premiums from a future supplier remittance.

mailto:sib.edi@sib.ok.gov mailto:sib.edi@sib.ok.gov

D.2.4. EGID shall provide the Supplier with a premium report each month. A verification procedure will be used for compliance.

D.2.5. Monthly discrepancy reports received by EGID should not go back further than the month being reconciled. Discrepancies older than sixty (60) calendar days from premium remittance date for HMO or

MSP or thirty (30) calendar days from premium remittance date for MAPD will not be reconciled and

EGID will not assume financial responsibility for a Supplier’s failure to comply with reconciliation efforts. Note: no member coverage will be affected by a Supplier’s failure to comply with above. Refer to Exhibit 29.

D.3. Significant Events.

D.3.1. The Supplier shall immediately notify EGID and OMES of any current or prospective “significant event” on an ongoing basis. All notifications shall be submitted in writing to EGID Director of Compliance at

EGIDVendorReporting@omes.ok.gov and the State Purchasing Director. As used in this provision, a

“significant event” is any current or future occurrence or anticipated occurrence that might be expected to have a material effect upon the Supplier’s ability to meet its contractual obligations to EGID.

Significant events may include but not be limited to the following:

D.3.1.1. Disposal of major assets

D.3.1.2. Any major computer software conversion, enhancement or modification to the operating systems, security systems, and application software, used in the performance of this contract

D.3.1.3. Termination or addition of provider contracts

D.3.1.4. The Supplier’s insolvency or the imposition of, or notice of the intent to impose, a receivership, conservatorship or special regulatory monitoring or any bankruptcy proceedings, voluntary or involuntary, or reorganization proceedings

D.3.1.5. The withdrawal of, or notice of the intent to withdraw from the Joint Commission or the National

Committee for Quality Assurance (NCQA) certification Impairment of the security offered as a performance guarantee strikes, slow-downs or substantial impairment of the Supplier’s facilities or of other facilities used by the Supplier in the performance of this contract

D.3.1.6. Reorganization, reduction and/or relocation of key personnel such as, but not limited to, customer service representatives or claims adjusters

D.3.1.7. Known or anticipated merger or acquisition

D.3.1.8. Known, planned or anticipated stock sales

D.3.1.9. Any litigation filed by a member against the Supplier

D.3.1.10. Any sale or merger

D.3.1.11. Significant changes in market share or product focus

D.3.1.12. HIPAA violation

D.3.1.13. 6055 IRS reporting deficiencies

D.4. Workflow and Web Interfacing.

D.4.1. During the contract period, the Supplier will respond to EGID’s inquiries using EGID’s web-based application that tracks and reports member issues. This application is called “WorkFlow” and was developed by ViTech, creator of EGID’s premium accounting and eligibility system. There is no software to purchase, and it only requires a connection to the Internet using a Microsoft Internet

Explorer or compatible browser.

D.4.2. During the contract period, the Supplier will also utilize EGID’s Web Eligibility Application to resolve eligibility issues and payment discrepancies. Suppliers agree to log in to both applications every sixty

(60) days. Inactivity will result in termination of access. Send eligibility issues by email to the Member

Research and Resolution unit at MemberAccountsResearch&Resolution@omes.ok.gov.

mailto:EGIDVendorReporting@omes.ok.gov mailto:MemberAccountsResearch&Resolution@omes.ok.gov

D.4.2.1. Failure to log into Workflow and the Web Eligibility Application every sixty (60) days will lead to termination due to inactivity and will require new security forms to be completed and approved for reinstatement.

D.4.2.2. The Supplier will respond to EGID’s quarterly Vitech Security Verifications by reviewing and confirming current Supplier staff users of the web workflow and eligibility systems. The Supplier will notify EGID of employees no longer utilizing the system to terminate their access. New users will complete applications for access as needed.

D.5. Fraud and Abuse Investigations.

D.5.1. The Supplier shall aggressively monitor for fraud and abuse and provide EGID with a quarterly report of fraud and fraud-prevention activities and discoveries relating to the OEIBA Program. The Supplier shall investigate any fraudulent or suspicious activity relating to the OEIBA Program whenever detected or brought to the Supplier’s attention by EGID or others.

D.6. Participant Eligibility.

D.6.1. An individual’s eligibility to participate is subject to all federal and state laws governing the OEIBA

Program. EGID has the responsibility and authority to decide all questions of eligibility within the

Program. Highlights of eligibility include:

D.6.1.1. There is an annual option period which historically begins in mid-September and runs through early December. Elections made during this option period are effective January 1st of the following year.

D.6.1.2. Current employees may enroll in coverage the first day of the month following the month of employment or the date he/she becomes eligible. If the employee elects dependent coverage, the employee must cover all eligible dependents, unless the dependent is covered by other insurance.

The employee also has thirty (30) days after acquiring a new dependent in which to add that dependent. Members or dependents not enrolled when initially eligible or within thirty (30) days of a midyear qualifying event, cannot elect coverage until the next Option Period.

D.6.1.3. Coverage for newborn dependents will be effective the first of the birth month. The member may enroll the newborn within thirty (30) days of the birth event. Premiums for the newborn are due for each month the child is covered through the employer. For members who choose not to add the newborn within thirty (30) days of the birth event, the Supplier will handle expenses of the newborn limited coverage in accordance with State law.

D.6.1.4. Continuation of coverage must be extended to all qualified members in such a manner as to fully comply with State law and the Consolidated Omnibus Budget Reconciliation Act of 1985

(COBRA) and all amendments thereto that have been or may be enacted. EGID will handle the administration of eligibility, premium billing, collection and termination procedures for all

COBRA participants, while the Supplier shall provide the health coverage services for those enrolled in the Supplier’s OEIBA plans. Qualified COBRA beneficiaries will have the option of changing enrollment elections during any Option Period, which occurs during the term of their coverage continuation.

D.6.2. In order to select an HMO option, the employee must reside or be employed (live or work) within the selected HMO’s service area. Eligible dependents must reside within the selected HMOs service area to participate in the HMO. Service areas shall be limited to those zip codes approved by relevant licensure as of May 1 preceding the Plan Year to which the service area applies.

D.6.3. Prevention of enrollment of employees during the aforementioned Option Period or during the plan year as mentioned previously is prohibited. Furthermore, unilateral disenrollment of a member by the

Supplier, unless agreed to in writing by EGID, is not allowed except in the event of relocation of service area.

D.6.4. Additional eligibility/enrollment requirements apply to plans for Medicare-eligible participants. These include:

D.6.4.1. Eligibility for MAPD is limited to EGID/Medicare eligible former employees and their eligible dependents.

D.6.4.2. Eligible EGID former employees with their covered dependents:

D.6.4.2.1. May enroll in coverage the first day of the month following termination of active employment. The former employee also has thirty (30) days after acquiring a new dependent in which to add that dependent. Failure to maintain continuous health insurance coverage through the OEIBA Program shall result in permanent loss of eligibility for coverage under the Program.

D.6.4.2.2. Those who are not enrolled when initially eligible or within thirty (30) days of a mid-year qualifying event cannot add coverage.

D.6.4.2.3. Cannot add health coverage that was not elected at separation from active employment.

D.6.4.3. Members must enroll in an OEIBA Program Medicare plan upon turning age sixty-five (65) or attaining early eligibility for Medicare, as permitted by federal guidelines.

D.6.4.4. Split Coverage. When there is a retiree situation where the primary and the dependent(s) are not both Medicare eligible:

D.6.4.4.1. So long as there is a dependent relationship, both individuals must be on plans offered through the same Supplier through the OEIBA Program.

D.6.4.4.2. The Medicare eligible member is enrolled in the Supplier’s MAPD/Medicare

Supplement and the other covered individual is enrolled in the commercial offering from the same Supplier with the appropriate non-Medicare rate applied.

D.6.4.5. A change from one insurance carrier to another may be permitted in the following circumstances:

D.6.4.5.1. During Option Period elections (historically October 15 to December 7) to be effective

January 1 of the proximate Plan Year.

D.6.4.5.2. Changes in service areas.

D.6.4.5.3. At the time an individual becomes Medicare primary in accordance with CMS requirements or when CMS approves the change. This does not apply to a spouse or dependent becoming Medicare eligible after the primary member has enrolled in

Medicare coverage. Refer to OEIBA Program materials for more detailed eligibility at https://oklahoma.gov/omes/divisions/employees-group-insurance-division.html.

Exception: split coverage rules apply.

D.6.4.6. As required by CMS and applicable federal regulations, the MAPD shall provide Prescription

Drug Benefit Creditable Coverage Notices to all its MAPD participants and affected persons.

D.7. Annual Deficiency Report.

D.7.1. At its discretion, EGID may draft and issue a periodic report to Central Purchasing detailing instances of each of the HMO, MAPD and MSP Commercial Carriers failing to uphold their contractual responsibilities.

D.8. Marketing and Communications Guidelines.

D.8.1. Failure to abide by marketing and communication guidelines may result in one (1) or more of the following consequences:

D.8.1.1. The Supplier being barred from accepting new enrollees for the balance of this contract.

D.8.1.2. The Supplier being barred from accepting new enrollees for the contract immediately succeeding this contract.

D.8.1.3. The Supplier being deemed ineligible from bidding in subsequent RFPs for the OEIBA Program.

https://oklahoma.gov/omes/divisions/employees-group-insurance-division.html

D.8.2. Approval. Each Supplier must receive approval for its marketing and communications plan with EGID prior to distribution to employees. EGID reserves the right to have the Suppliers amend or modify such information to meet its requirements. All requests for any marketing and communication by the Suppliers must be submitted to EGID at least ten (10) business days in advance of the scheduled advertising date using the Advertising Approval Form in Exhibit 38. Mass media advertising (newspapers, outdoor advertising, transit advertising, radio and broadcast television) is permitted only if the Supplier has filed the appropriate request using the Advertising Approval Form referenced above and has received written approval for publication of the material by EGID. Suppliers must request and receive advertising approval each Plan Year.

D.8.3. Name Change. In the event that a change in name of the Supplier occurs, the change must be communicated to EGID by the designated print deadlines (typically at the end of August preceding the

Plan Year to which the plan design applies) to be included in the Option Period print materials for the specified plan year. Plan design name changes are not allowed for the duration of the contract.

D.8.4. Option Period Activities. Each Supplier must participate in preparation or review of materials in the format specified for the Option Period. All Option Period marketing shall be conducted in accordance with policies and procedures approved and established by EGID in connection with the Annual Option

Period. This is the only marketing that will be allowed for participating members administered by the

EGID. This does not prohibit plans from sending materials to its current members.

D.8.5. Network Changes. Changes in the network and updates of providers must be communicated to affected members and to EGID at the Supplier’s expense. All updates to a Supplier’s provider network must be submitted to EGID for reference and informational purposes per required reports. Those same changes/updates must also be made current and available on the Supplier’s website to which EGID will provide links for member access.

D.8.6. Training of Coordinators. If requested by EGID, the Supplier will provide a representative to assist employer insurance and benefit coordinators in understanding the benefit plan structure, particularly during designated training sessions or as requested by EGID for special employee benefit education sessions or Annual Option Period Meetings. All those meetings shall be specified and authorized by

EGID or otherwise specified in this RFP.

D.8.7. Encouraged Marketing and Communications Activities. The following is encouraged:

D.8.7.1. Attendance at health fairs and employer sponsored meetings throughout the year is strongly encouraged.

D.8.7.2. Post-election enrollment follow-ups are allowed.

D.8.8. Prohibited Marketing and Communications Activities. The following is not permitted:

D.8.8.1. Use of marketing inducements (such as paid lunches, pizza parties, and other non-employer sponsored events) directed to individual prospective members or to employer personnel, which includes Benefit/Insurance Coordinators. Plan benefit information for members and giveaway items of nominal value (such as eyeglass cleaning cloths, etc.) may be made available for distribution at EGID-sponsored events with/without the company representative present.

D.8.8.2. Solicitations or attempts by the Supplier or any affiliate or subsidiary to induce an employer participating in the OEIBA Program to enter into an agreement for any type of health insurance coverage other than that provided under this contract. The Supplier must not use any information obtained as a result of this contract, including information about participating employers, employees, dependents, and claim experience, for any purpose other than processing claims and providing such other services as are required under this contract. In the event the Supplier or any affiliate or subsidiary receives from a participating employer a request for a proposal and/or a request for claim information for coverage of the type being provided under this contract, the

Supplier must advise the EGID Director of Compliance of the request. Claim information will only be released with EGID approval. Suppliers should not attend, create, or hold any meetings with employer groups unless invited by EGID or approval has been received from the EGID

Director of Compliance.

D.8.8.3. Advertising directed specifically to the individual prospective member using direct mail, direct selling, and direct-action advertising by phone (such as telemarketing), mail or personal visit.

D.8.8.4. Mass quantity promotions, not in an advertising medium, that are issued from the carrier by mail or personal distribution to prospects by way of folders, leaflets, throwaways, letters and delivered by mail, salespeople, or dealers. This does not include materials handed out at health fairs and employer-sponsored employee meetings and events.

D.8.8.5. Presentations by Suppliers during employee meetings for current state, education, county and local government employees unless pre-approved by EGID and as permitted by law.

D.8.8.6. Oklahoma State Ethics Commission Administrative Rules, 74 O.S. Chapter 62, App. 1, Rule 4.10 states the following: “Except as permitted by these Rules, no state officer or employee shall accept any gift for himself or herself or for his or her family member from any person or entity or agent of any person or entity that is regulated or licensed by the state officer or employee's agency;

provided, however, this prohibition shall not apply to gifts that are made by the employer of the state officer or employee or his or her family member under circumstances that make it clear that the gift is not motivated by the state officer or employee's status as a state officer or employee.”

D.8.9. Member Materials. Supplier shall be responsible for the following:

D.8.9.1. Each Supplier must develop a comprehensive member handbook, which shall be available no later than January 1 of the Plan Year. Copies of the Supplier’s current drug formulary must be made available for the annual Option Period. The member handbook must be specific to the

OEIBA Program and benefits covered in this RFP.

D.8.9.2. Suppliers shall provide an online listing of network providers which shall be updated at least weekly and made available to plan participants twenty-four (24) hours a day, seven (7) days a week. Those physicians accepting new enrollees must be clearly identified.

D.8.9.3. Member identification cards will be mailed at the Supplier’s expense directly to each member's home so that the card(s) is received no later than December 31 preceding the Plan Year to which the card applies, or no more than two (2) weeks following delivery of new member enrollment data from EGID. ID cards are to reflect accurate information and cannot contain the member’s

Social Security number (SSN) unless the number has been encrypted in an alpha and/or numerical method so it is not distinguishable. The member’s account number should not be the same as their SSN in the Supplier’s system.

D.8.9.4. The Supplier is required to provide a written status report regarding the distribution of ID cards to the Director of Compliance no later than December 15 of each Plan Year. Status information includes but is not limited to Supplier name, number of member ID cards generated, beginning and ending dates for mailing of cards, and the latest date expected for members to receive cards.

D.8.9.5. Summary of Benefits and Coverage for the Supplier’s approved HMO plan is due to EGID no later than 5:00 p.m. Central Time, October 1 preceding the Plan Year to which the benefits apply.

D.9. Malpractice Liability.

D.9.1. EGID requires all network providers to maintain malpractice liability limits equal to or greater than the

State of Oklahoma requirement for licensure. By submitting a proposal, the Supplier agrees these limits of coverage shall be maintained during the term of the contract.

D.10. Provider Discussion of Treatment Options and Reimbursements.

D.10.1. The Supplier must warrant and agree that there will be no provisions in the Supplier’s provider contracts that prohibit providers from discussing any treatment options and/or reimbursements with members in their provider contracts.

D.11. Prohibited Limitations and Exclusions.

D.11.1. The Supplier agrees to waive all pre-existing condition limitations and evidence of insurability requirements for all beneficiaries covered under the OEIBA Program.

D.12. Reinsurance.

D.12.1. The Supplier must have adequate reinsurance or adequate risk-based capital to protect against catastrophic financial loss due to unusually high medical claims in accordance with the requirements of the Oklahoma State Insurance Department or other agencies of the State of Oklahoma with regulatory authority over the Supplier.

D.13. Internal Grievance Procedures.

D.13.1. The Supplier must establish and operate an internal member grievance procedure pursuant to the requirements of the Oklahoma Insurance Department as appropriate.

D.14. Affordable Care Act Rebate Issues.

D.14.1. The Supplier must notify EGID if the Supplier’s medical loss ratio is at a level that would require rebates to consumers under the Patient Protection and Affordable Care Act. Procedures for ensuring that rebates are properly allocated between individuals and employees must be discussed and approved by EGID.

D.15. Dependents Residing at a Different Address.

D.15.1. Eligible dependents residing at an address different from the employee’s address may select a primary care physician (PCP) in the service area covering the dependent’s address within the state of Oklahoma.

D.16. Family Units with combined Medicare/non-Medicare Coverage.

D.16.1. Excluding the one national MAPD standalone plan, if a Bidder provides a Medicare plan, such Bidder must be able to provide service to members and dependents when the primary member is eligible for

Medicare but the dependent is not. For example, if a member is pre-Medicare and the dependent is eligible for Medicare, EGID will bill the pre-Medicare rate for the primary member and the Medicare dependent rate for the dependent.

D.17. Consolidated Omnibus Budget Reconciliation Act (COBRA).

D.17.1. The monthly rates for which eligible participants under COBRA are charged for plan coverage will include the various loadings (e.g., administrative, reserves, etc.) also charged current employees as discussed in this RFP. COBRA premiums will be subject to a two percent (2.0%) administrative fee and as allowed by law retained by the State to offset the administrative costs. Based on CMS guidance, the two percent (2%) administrative fee will not be assessed on any PDP.

D.18. Supplier Operating Staff.

D.18.1. The Bidder must have sufficient operating staff to comply with all requirements and standards described in this RFP. At a minimum, the Bidder must identify qualified staff in the following areas.

D.18.1.1. Executive management with clear oversight authority for all other functions

D.18.1.2. Medical director’s office

D.18.1.3. Accounting and budgeting function

D.18.1.4. Member services function

D.18.1.5. Provider services function

D.18.1.6. Medical management function, including quality assurance and utilization review

D.18.1.7. Internal complaint resolution function

D.18.1.8. Claims processing function

D.18.1.9. Management information system. This can be addressed in various methods such as how technology is utilized to ensure and monitor healthcare compliance, methods of targeting services areas, etc.

D.18.1.10. The Supplier may combine functions (e.g., Member services and internal complaint resolution) as long as it is able to demonstrate that all necessary tasks are being performed. The Supplier may also use management contractors or administrative service firms to perform any or all of the above functions.

D.19. Systems and Eligibility.

D.19.1. During the length of the contract, the Bidder agrees it shall provide no less than thirty (30) days’ notice to EGID prior to performing changes, fixes, modifications and enhancements that may affect the exchange of eligibility or any other shared business process. The Bidder must also include a test plan and provide resources to EGID to verify changes are valid and will not disrupt business processes. Changes will not be implemented until all parties mutually agree the changes are ready to be put into production.

D.20. Service Enhancements.

D.20.1. Bidders may offer enhancements in an effort to make their plans more attractive and competitive. The enhancements must be clearly identified and consolidated into one page in the Bidder’s response to this

RFP and in any material submitted to EGID to be disseminated to members, including, but not limited to: 24-Hour Toll-Free Nurse Line; Well Woman Self-Referral; Wellness/Health Education; Health and

Fitness Discounts; Healthy Pregnancy Program; Dental; or Vision.

D.21. Claims Experience.

D.21.1. Bidders who are currently under contract with the State for Plan Year 2025 must complete Exhibits 6-8 and Exhibit 16. Bidders who are not under contract with the State for Plan Year 2025 must provide the information contained in Exhibit 15 for their Oklahoma book of business. Compliance with this shall be strictly enforced. Proposals that fail to provide the information requested shall be deemed non-responsive and the Bidder shall be ineligible to bid on this RFP.

D.22. Reporting.

D.22.1. The statistical information contained throughout this RFP is believed to be accurate for the date specified but is not intended as, and must not be considered, an express or implied warranty by EGID. EGID and the State shall not be liable for any damages resulting from inaccuracies contained in statistical information.

D.22.2. The Supplier shall deliver all reports listed in Exhibit 27 in the exact format, frequency, timeframe and to the intended recipient noted in the list or as otherwise instructed by EGID. The reports shall include subgroups, which at a minimum are current employees, COBRA, retirees not eligible for Medicare, and retirees eligible for Medicare. A verification procedure will be used for compliance

D.22.3. The OEIBB is interested in increased OEIBA Program transparency to the public. Supplier agrees to allow the OEIBB to make HMO and Medicare aggregate summary claims data public at its quarterly

Board meetings. This information is not identifiable by Supplier.

D.22.4. The Supplier shall deliver Exhibit 37B upon request for individual employer data requests, on an incurred basis. Refer to Exhibit 37A for detailed instructions. Data will be provided to the employer in aggregate so the individual health plan will not be identified. The template represents the maximum amount of information that will be requested. In all cases, the Supplier will only be asked for the minimum amount of data necessary to meet the employer’s request. Often, this will be no more than the “Medical and

Pharmacy” section of the tab labeled “Experience” along with the same year section of the tab labeled

“Request #1a”.

D.22.5. Failure to Abide by Reporting Guidelines.

D.22.5.1. Suppliers meeting the requirements outlined in 36 O.S. 6901 et seq. are required to submit the minimum reporting requirements as specified within this RFP (Exhibit 27). The specifications made in prior years shall not serve as precedent for specifications that may be specified in this

RFP. Failure to abide by reporting guidelines may result in one or more of the following consequences.

D.22.5.1.1. The Supplier being barred from accepting new enrollees for the balance of this contract.

D.22.5.1.2. The Supplier being barred from accepting new enrollees for the contract immediately succeeding this contract.

D.22.5.1.3. The Supplier being deemed ineligible from bidding in subsequent RFPs for the

OEIBA Program.

D.22.5.2. In addition to the benefits specified within this RFP, Suppliers must provide any benefits and reporting otherwise required by state or federal law.

D.23. Implementation.

D.23.1. Suppliers may be required to meet with EGID to ensure smooth transition for the upcoming plan year.

D.23.2. Administrative Procedures Reference Manual. The Supplier shall furnish EGID with accurate up-to-date information as requested for an administrative reference manual to enable staff to refer to the same when member questions arise about the Suppliers operations, coverage, and grievance procedure or provider networks. Specific information for the administrative reference manual will include updates of provider networks and other material as requested by EGID and shall be delivered to EGID within fifteen (15) business days of its request, prior to January 1 of the Plan Year to which the Supplier’s plan(s) applies.

Suppliers will receive specific instructions regarding this manual material after the award of contract by

EGID. One (1) electronic copy of the administrative reference manual will be provided to EGID.

D.23.3. Pharmacy Network Download. Suppliers must have a process for Option Period data to be downloaded to all pharmacy networks no later than December 31 preceding the Plan Year for which the network applies. This process could include downloading pharmacy benefit information to a Supplier’s pharmacy benefits manager.

D.23.4. Readiness Reviews. OMES/CP and EGID may annually conduct scheduled meetings to the Supplier for purposes of testing the readiness of the Supplier.

D.23.4.1. Submission of a proposal in response to this RFP commits the bidding Supplier to cooperate and participate in these reviews, as required by EGID.

D.23.4.2. These reviews will take no more than one (1) business day each. EGID staff members, as well as consultants for the State as needed, will interview appropriate HMO personnel in all major organizational areas, and will perform document and process reviews where appropriate.

D.23.4.3. Details of the schedules, agendas, and content of the readiness review(s) will be distributed to the contracting Suppliers in a timely manner.

D.23.4.4. Prior to the Readiness Review meetings, OMES/CP and EGID may submit a written list of questions to the Supplier. These questions should be completed by the Supplier and returned to

EGID no later than the time scheduled for the Supplier’s meeting.

D.24. Annual Review.

D.24.1. After the completion of each Calendar Year, the Supplier must be available upon request to meet with

OMES/CP and EGID personnel and consultants to review the Plan’s claim experience. The review topics may include, but not be limited to, the following:

D.24.1.1. Medical management initiatives.

D.24.1.2. Summary by reporting division – Displays Claims, CMS Revenue, and Premiums paid by

Programs delineated by State, Local Government and Local Education Employers.

D.24.1.3. Claimant characteristics (demographics).

D.24.1.4. Experience by diagnostic grouping, type of service, and claimant cost by age/gender.

D.24.1.5. Large claims report (>$25,000).

D.24.1.6. Plan utilization compared to Supplier’s book of business report.

D.24.2. For each contract renewal, each Supplier shall offer the plan in place at the time of the renewal request, plus it may offer an alternative plan design. Supplier is required to provide OMES/CP and EGID any requested updated documentation found in this Solicitation for purposes of the renewal.

SPECIFICATIONS APPLYING TO HMO PROPOSAL

(EXCLUDING MEDICARE SUPPLEMENT OR MAPD LINES OF BUSINESS)

D.25. Supplier Identification. In the event the Supplier’s designated personnel changes, the Supplier shall notify

OMES/CP and EGID Director of Compliance immediately in writing.

D.25.1. EGID Director of Compliance contact information:

D.25.1.1. EGID Compliance/HIPAA Privacy Officer

P.O. Box 11137

Oklahoma City, OK 73136

EGIDVendorReporting@omes.ok.gov

D.26. Financial Stability and Standing.

D.26.1. EGID reserves the right to audit (or designate an independent third-party to audit) the selected medical plan at any time during and up to three (3) years following the termination of the Contract/Administrative

Agreement (with prior written authorization).

D.26.2. The Supplier agrees to be available for reasonable inquiry by EGID regarding financial statements.

D.26.3. The Supplier shall remain in compliance with all requirements of the Oklahoma Insurance Department, including those that pertain to financial solvency. In the event of a failure to remain in compliance, Supplier shall inform EGID as soon as such failure is known.

D.27. Member Services Telephone Assistance.

D.27.1. The Supplier will provide telephone assistance through a toll-free telephone number by customer service representatives regarding plan benefits and network service inquiries/problem resolution during normal business hours.

D.27.2. The Supplier’s customer service telephone response performance must meet the below standards for each month of each Plan Year:

D.27.2.1. The Supplier shall answer at least eighty percent (80%) of all calls in thirty (30) seconds or less.

D.27.2.2. The call abandonment rate shall not exceed five percent (5%) of the total number of calls per month.

D.27.3. The Supplier’s customer service representatives must be trained and familiar with all aspects of the program covered by this RFP. The Supplier must have written policies and procedures, specific to the enrollments covered under this RFP, in place for the use of its member services staff prior to the opening of each Option Period.

D.27.4. Member Service’s telephone numbers must be accessible from the Supplier’s website. If there is a network specific requirement, there must be an online directory. However, if a potential or current member is unable to access the online directory, Supplier must be able to provide printed material within a (48) forty-eight-hour turnaround via mail at no cost to employees or retirees.

D.28. Member Satisfaction.

D.28.1. Satisfaction Surveys. For Plan Year 2026 and for renewal year, the Supplier shall conduct a member satisfaction survey at least annually that compiles and analyzes its survey results for submission. Refer to Attachment 30. Supplier may leverage existing surveys to address these focus areas so long as all required areas are addressed.

D.29. Benefit Plans for Participants Living Out of State.

D.29.1. The Supplier may provide a plan of benefits for those participants who live outside the State of Oklahoma.

A census report is available as Exhibit 24 which identifies participants by age, sex, and zip code. The premium for coverage to participants outside the State of Oklahoma must be the same as quoted for participants within the State of Oklahoma.

D.30. Prohibition on Direct Member Billing.

D.30.1. The Supplier must have procedures in place which prevent direct member billing (balance billing) for covered services during the plan year of this solicitation.

D.31. Section 125.

D.31.1. An Internal Revenue Code, Section 125 Cafeteria plan with a Flexible Spending Account (FSA) for medical reimbursement is offered to Oklahoma State education and local government current employees.

Within the FSA, a debit card program allows a participating member to use a pre-loaded debit card that works like any other debit MasterCard or debit Visa Card, except that it is charged only against the cardholder’s personal FSA balance, not against a general bank balance. EGID requests that the Supplier shall interface with the debit card company and provide paid claims utilization on a weekly basis. Exhibit

26 is the file format required by the current debit card company.

D.32. Provider Network Requirements.

D.32.1. The Suppliers must comply with all gatekeeper requirements as outlined in the Patient Protection and

Affordable Care Act of 2010, PL 111-148 as amended by The Health Care and Education Reconciliation

Act of 2010, PL 111-152.

D.32.2. The network must provide access to PCP services, specialty physician services, and emergency care and tertiary care services. It shall be sufficient in size and scope to furnish all covered health benefits listed in Exhibit 4. No less than fifty percent (50%) of the PCP in the Supplier’s network must be accepting new patients at any point during each plan year. Any Supplier quoting a value-based network must demonstrate that its network has adequate capacity to service its members. The Suppliers must include

State of Oklahoma licensed practitioners performing within their legal scope of practice sufficient to meet its members’ needs.

D.32.3. Each member must have a PCP from one of the following practice areas: family practice, general practice, internal medicine, general pediatrics (for children), and OB/GYN (for women, at the option of the

Supplier). Established patients must be assured acceptance by the existing provider in a new plan year unless that provider is no longer in the Supplier’s network of providers.

D.32.4. Each Supplier must have sufficient numbers of contracted specialists to adequately provide the entire range of benefits covered in this RFP to all its enrolled members. Such specialty services, such as laboratory and/or minor surgery must be available within a reasonable geographic area. Any changes in the benefit provisions must be reviewed by the EGID Director of Compliance.

D.32.5. Where the Supplier contracts with health care practitioners to render services, such contracting arrangements must promote quality and cost-effective care by ensuring that:

D.32.5.1. Every enrollee has a PCP, and the PCP coordinates all of the enrollee's comprehensive health care; and

D.32.5.2. Practitioners' agreements require them to observe the plan's practice guide and/or to share the plan's financial risk.

D.32.6. Covered services may also be rendered by non-contracting providers through reimbursements to members who receive and pay for these services, provided such services are used only to supplement the plan's primary mode of health care delivery through its network of contracting providers.

D.32.7. Eligible dependents residing at an address different from the employee’s address may select a PCP in the service area covering the dependent’s address within the State of Oklahoma. The Supplier will provide all eligible services outside the State of Oklahoma for covered dependents.

D.33. Supplier’s Provider Contracting.

D.33.1. The Supplier must offer eligible services outside the State of Oklahoma to eligible dependents residing at an address different from the employee’s address.

D.33.2. The Supplier shall provide no less than thirty (30) days’ notice to EGID prior to performing changes, fixes, modifications and enhancements that may impact the exchange of eligibility or any other shared business process.

D.33.2.1. As part of this process, the Supplier must provide a test plan and provide resources to EGID to verify changes are valid and will not disrupt business processes.