Attachment-A.Statment-of-Work.docx

Attachment A – Statement of Work (SOW)

DMS-24/25-258

Table of Contents

4050 Esplanade Way Tallahassee, FL 32399-0950 850-488-2786

Ron DeSantis, Governor Pedro Allende, Secretary

Comprehensive Medical and Surgical Procedures Bundled Services DMS-24/25-258

Attachment A: Statement of Work Last Revised: 4.24.2023 Page 11 of 27 Scope of Work

1. Purpose The Department of Management Services (“Department”) Division of State Group Insurance (“Division”) is seeking a qualified Contractor to provide the Department’s health insurance Members with comprehensive pricing and inclusive services for surgery and other medical procedures.

The purpose of the Contract is to contract with an “entity that provides comprehensive pricing and inclusive services for surgery and other medical procedures which may be accessed at the option of the enrollee.” The Contractor must be able to meet the requirements set forth in section 110.12303(2), F.S., and the Contract. The Department seeks to partner with an entity that provides comprehensive surgical and medical services (or bundled services), to include cancer care coordination services, and is innovative and flexible in bundling healthcare services for Enrollees and the Division.

The Contract shall provide for Active Communication and Passive Engagement to Members. For purposes of the Contract, Passive Engagement means the following communications by the Department, its agents, or its other stakeholders: a) a description of the services within the open enrollment guide, b) a summary description of the Vendor or its services on the State’s benefits website(s), c) the response to individual Member questions either to the contractor or to DMS, or d) any broad-based communication to individual Members, groups of Members, or the overall membership about the suite of benefits the Department provides in the ordinary course of State business. For purposes of this Contract, Active Communications are communications except those identified as Passive Engagement herein. Active Communications by the Contractor shall include frequent, targeted, and cohort marketing and communications to Members. Individual, Member-initiated communications to the Contractor or the Department shall not impact the determination of Active Communications or Passive Engagement as described herein.

The Department or its agents may provide Passive Engagement communications to Members at any time. The Contractor shall provide Active Communications to Members who are designated for Active Communications and for which the Contractor is compensated under the Active Communications Fee. The Department shall not provide any Active Communications to Members who are not designated for Active Engagement and for which the Contractor is not compensated under the Active Engagement fee. For payment purposes, the number and population of Members receiving Active Communication or Passive Engagement shall be determined and documented by the Department in consultation with the Contractor. The Department shall review and approve all Active Communications and Passive Engagement prior to dissemination.

All work completed under the Contract will be considered the intellectual property of the Department.

Definitions Account Management Team: The individuals employed by the Vendor primarily responsible for the Department’s account.

Active Communications: Communications except those identified as Passive Engagement herein.

Benefits Document: The document approved by the Florida Legislature in accordance with section 110.123(5), F.S., describing the scope of coverage, benefits available, limitations, restrictions and exclusions of the plan, and the conditions under which Service Provider will pay claims. The Benefits Document is subject to modification by the Florida Legislature and the Department at any time. The covered and excluded services in the Benefits Document will be equivalent to those set forth in the Benefits Document, together with any additional services expressly approved by the Department. The Benefits Document in effect as of the date of this ITN is listed on the DMS website (https://www.mybenefits.myflorida.com/health/resources).

Bundled Service: A surgical and/or medical service that is performed to treat a Member undergoing a specific episode of care for a single payment.

Bundled Service Program: The program established under this Contract that allows Members to select a Bundled Service and receive Reward Payments when eligible.

Business Day: Monday through Friday, inclusive, except for those holidays specified in section 110.117, F.S., from 8:00 a.m. to 5:00 p.m., Eastern Time.

Calendar Day: Any day in a month, including weekends and holidays.

Claim(s): An application for payment of or reimbursement for health care expenses incurred by Participants, which is filed in accordance with the Summary Plan Description, Contract, Vendor’s requirements, and/or the Department’s requirements.

Confidential Information: Information in the possession or under control of the State or Vendor that is exempt from public disclosure pursuant to section 24, Article I of the Constitution of the State; the Public Records Law, Chapter 119, Florida Statutes; or to any other Florida law or federal law or regulation that serves to exempt information from public disclosure.

Contract: Any binding agreement for Bundled Services and cancer care coordination between the Department and a Contractor.

Contract Administrator: The person designated pursuant to an executed Contract resulting from the successful award of the Bundled Services and cancer care coordination solicitation.

Contract Manager: The person designated pursuant to an executed Contract resulting from the successful award of the Bundled Services and cancer care coordination solicitation.

Contractor or Service Provider: The business entity that enters into a contract with the Department for Bundled Services and cancer care coordination.

Data or State of Florida Data: Data means a subset of structured information in a format that allows such information to be electronically retrieved and transmitted.

Deliverables: Those services, items and/or materials provided, prepared and delivered to the Department in the course of performance under this Contract by the Contractor.

Department: The Florida Department of Management Services or its designee. The Department reserves the right to contract with a third-party contractor to assume responsibility for the Department’s administration of the Contract.

Division: The Department’s Division of State Group Insurance.

Eligible Dependents: As defined in Rule 60P-1.003(8), Florida Administrative Code.

Enrollee or Subscriber: As defined in section 110.123(2)(c), F.S.

Health plan member (Member) or Participant: Any person participating in a state group health insurance plan, a TRICARE supplemental insurance plan, or a health maintenance organization plan under the state group insurance program, including Enrollees and Eligible Dependents thereof, as defined in section 110.123(2)(g), F.S.

Healthcare Provider: Any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the State.

High Quality Provider: A Healthcare Provider or facility that has been identified as being high quality based on Contractor’s quality rating methodology.

Household: All Members under a particular Enrollee’s policy.

Implementation Plan: The written description provided by the Contractor, as approved by the Department, of the schedule of actions necessary to implement the services and begin fulfilling the Contract in a timely manner.

Invoice: A billing statement provided by the Contractor to the Department for reimbursement of Services.

Notice: Written notification from one Party to the other Party regarding performance under the Contract.

Passive Engagement to Members: Communications by the Department, its agents, or its other stakeholders include a) a description of the services within the open enrollment guide, b) a summary description of the Vendor or its services on the State’s benefits website(s), c) the response to individual Member questions either to the Contractor or to DMS, or d) any broad-based communication to individual Members, groups of Members, or the overall membership about the suite of benefits the Department provides in the ordinary course of State business.

Performance Guarantees: Specific measurement indicators assigned to Contract tasks representing timeliness and quality of task output.

Plan Year: Based on the calendar year from January 1st to December 31st.

Protected Health Information: Protected Health Information shall have the same meaning and effect as defined in 45 C.F.R. 160 and 164, limited to the information created, received, maintained or transmitted by the Contractor from or on behalf of the Department.

Reward Payment: The reward amount that shall be received by an Enrollee for utilizing the Contractor’s Services for the selection of a Rewardable Service.

Run-Out Claims: A Claim for medical expenses incurred by a Member during the term of the Contract which is received by the Service Provider after termination of the Contract and within sixteen (16) months from the date that the health care services relating to such Claim were rendered.

Service Commencement Date: January 1, 2026, at 12:01 A.M., Eastern Time, the first date Services are provided to Members.

Services: Tasks to be performed by the Contractor as specified in the Contract. The term “Services” includes, but is not limited to, any unspecified task that is inherent in proper delivery or administration of a specified Service.

State: The State of Florida.

Subcontractor: The Contractor’s subcontractors and agents that deliver the Services required by the Contract. The term “Subcontractor” does not include Healthcare Providers.

Summary Plan Description: The Bundled Services benefit plan as written by the awarded Contractor. The Summary Plan Description will outline the Services and conditional requirements to obtain the Services.

Deliverables Comment by Guerra, Christina: @Morgan, Alisha Where are the financial consequences for specific deliverables? I’m probably overlooking them. Comment by Morgan, Alisha: See section 6 for Performance Guarantees. Comment by Guerra, Christina: @Morgan, Alisha performance guarantees are separate from deliverable financial consequences. Comment by Morgan, Alisha: See the draft contract. Comment by Guerra, Christina: @Morgan, Alisha Draft contract doesn’t address it unless im totally missing the connections. I probably am. I set up mine differently.

With the exception of any deviations identified in the Contract, the Contractor shall provide all Services as specified in the Contract, including all attachments thereto. The Department authorizes the Contractor to use its standard procedures for the provision of the Services that have been designed to ensure that the administration of Services is in compliance with applicable statutes and regulations. The Contractor shall provide the Services in accordance with the framework of policies, interpretations, rules, practices, and procedures as set forth in the Contract and Florida law, and as otherwise mutually agreed upon by the Parties or as directed by the Department. In the event of any conflict between this Contract and any of the Contractor’s policies and procedures, the Contract shall govern. Deliverables shall meet the applicable specifications described in Section 4. Minimum Service Requirements.

1. Bundled Services Comment by Guerra, Christina: @Morgan, Alisha Are these part of deliverables or a new section that is out of order?

The Contractor shall provide comprehensive pricing and inclusive services for surgery and other medical procedures (“Bundled Services”) which may be accessed at the option of Members.

The Contractor shall provide Members with Summary Plan Description outlining the services provided by the Contractor with Department approval.

The Contractor shall have procedures and evidence-based standards in place to ensure the inclusion of only High-Quality Providers in its network.

The Contractor shall assist Members in accessing and coordinating care.

Cost Methodology The Contractor shall determine the cost of each Bundled Service.

The Contractor must share details of their cost and cost savings methodology with the State of Florida. An independent validation of the methodology may be completed if desired by the State. The State of Florida reserves the right to approve methodology.

Data The Contractor shall receive and transfer data from and to the Department and/or its third-party vendor(s).

Educational Campaign The Contractor shall provide an educational campaign for Members to learn about the Services offered by the Contractor.

Minimum Service Requirements (MSR)

1. Bundled Services Program The Contractor shall make available to Members and shall administer the Bundled Services Program as follows:

The Contractor shall facilitate the delivery of Bundled Services to Members in order to reduce waste and improve quality of care. Bundled Services shall not include any surgical or medical procedures that are excluded under the Department’s health plans. Exclusions will be shared directly with Contractor.

The Contractor shall present the Department with a draft Summary Plan Document for approval no later than December 1, 2025, for the initial contract year and no later than October 1 for all subsequent contract and/or renewal years. The Summary Plan Document must outline the coverage provided, the manner(s) in which eligible participants may access the services, coverage exclusions, etc.

The Contractor shall maintain a network of Healthcare Providers capable of providing the Bundled Services offered in the Bundled Services Program. Upon written demand from the Department and in the sole discretion of the Department, the Contractor shall exclude Healthcare Providers specifically identified by the Department from providing the Bundled Services.

An Enrollee’s eligibility for a Reward Payment is based on the Member’s use of the Bundled Service.

The Contractor, upon approval from the Department, shall determine the methodology(ies) for rating or determining the quality of a Healthcare Provider or facility from reliable, industry-accepted sources.

The Contractor shall determine cost savings to the State for a Bundled Service and the Reward Payment due to Enrollees by utilizing the Department's claims data and other Department-approved information.

The Contractor shall adjudicate Claims associated with Members’ receipt of a Bundled Service.

The Contractor shall notify the Department of the determined Reward Payment for each Enrollee via monthly file. The Reward Payment file must include the recipient's name, the amount of the award, the date of service, and the type of procedure performed. The Contractor shall exchange Reward Payment data on a frequency and in a file format approved by the Department. The Contractor shall establish and use procedures and evidence-based standards to ensure that only High Quality Healthcare Providers provide Bundled Services.

The Contractor shall provide assistance to Members in accessing and coordinating care for Bundled Services. The Contractor shall engage members to identify appropriate healthcare services and coordinate care accordingly.

The Contractor shall be responsible for program development and management, including updating cost and quality data available to Members. The Contractor shall regularly monitor utilization and costs in order to develop, recommend, and implement enhancements to the Bundled Services Program subject to Department approval.

The Contractor shall make available a toll-free telephone number and website that Members may access to obtain information about the Bundled Services Program. The Contractor's customer service hours shall be on a schedule approved by the Department.

The Contractor shall provide coordination of cancer care support services. Included in this program, at minimum, is access to a one-on-one to an oncology nurse coordinator to answer questions and provide personalized guidance throughout each Member’s cancer care experience, provide available information and contact information for the program on a website and any other platform, and include information about the program in Department-approved communications plan under section 3.2.

1.1.1. Members diagnosed with cancer have the option to enroll in the program on an as needed basis.

Reward Payments The Contractor shall determine and facilitate Reward Payments to Enrollees, as follows:

The Contractor, upon approval from the Department, shall determine the Reward Payment methodologies, Reward Payment amounts, and the Bundled Services that are available for a Reward Payment. Reward Payment methodologies, Reward Payment amounts, and Bundled Services may only change upon approval by the Department.

An Enrollee will be eligible to receive a Reward Payment if the Enrollee or his or her covered dependent receives a Bundled Service.

The Contractor shall determine Reward Payments to eligible Enrollees based upon a Reward Payment methodology(ies) mutually agreed upon by the Contractor and the Department.

The Contractor shall determine the amount of each Reward Payment on a frequency approved by the Department.

The Contractor shall notify the Department of each Reward Payment determination to each Enrollee on a frequency approved by the Department.

The Contractor shall send a confirmation notice to an Enrollee for each Reward Payment that is earned.

Bundled Services Program Materials and Communications Plan The Contractor shall develop and distribute Enrollee educational materials to promote the Bundled Services Program, at the sole cost and expense of the Contractor. Such educational materials may require customization for the Bundled Services Program at no additional cost to the Department. Costs associated with printing, distributing, and mailing all materials shall be borne by the Contractor.

The Contractor shall be responsible for writing, printing, and distributing (electronically or by mail) Bundled Services Program materials.

The Contractor shall develop a Department-approved communications plan for the Bundled Services Program. At a minimum, the communications plan shall include 1) documents educating Enrollees about the Bundled Services Program, which shall include the cancer care coordination program 2) open enrollment brochures and promotional pieces, and 3) other Bundled Services Program-related printed materials (e.g., brochures, flyers, letters, and other written materials).

The Contractor shall provide, upon request, printed materials in a medium widely accepted for the visually impaired.

All printed material shall be provided in electronic format with final versions submitted to the Department in a PDF file format.

The Contractor shall submit copies of all promotional and Enrollee educational materials to the Department for prior approval. All materials shall be approved in writing by the Department prior to use.

The Contractor shall participate in all locations of the annual open enrollment benefit fair locations that are sponsored by the Department or its designee. The Contractor’s representatives attending the benefit fairs shall be employees of the Contractor (not subcontractors or temporary personnel) and adequately trained and knowledgeable about the Bundled Services Program and website. The Contractor shall educate Enrollees on the Bundled Services Program and website benefits, services, and other tips to ensure a positive Member experience. Open enrollment is held annually in the fall for enrollment coverage effective the following January 1st.

The Contractor shall be responsible for all costs associated with participating in benefit fairs, including travel and a proportionate share of facility fees.

The Contractor shall not discuss with Enrollees or prospective Enrollees or in any manner allude to coverage, products, or materials other than those explicitly related to the Online Transparency Program without the permission of the Department.

Member Website Tools The Contractor shall provide and maintain a State of Florida-specific Member website with 24/7 access for the Bundled Services Program. This website shall include links to the Department's website and other state, federal, and condition-specific websites as appropriate to make available a variety of information to Members. The website should show the estimated Reward Payment for selecting a Bundled Service.

Account Manager and Management Team The Contractor shall assign a dedicated, but not necessarily exclusive, account manager as the primary contact for the Department. The account manager shall participate on the implementation team and coordinate, troubleshoot, advance, and track the State’s interests and requests throughout the organization.

Pursuant to section 287.057(26), F.S., if applicable, the Contractor shall answer all questions of, and ensure a representative will be available to, a continuing oversight team.

The Contractor shall assign a dedicated, but not necessarily exclusive, account management team which may include an executive sponsor, an account manager, a data/fiscal analyst, enrollment/eligibility manager, Claims manager, customer service manager, and medical director.

The account management team shall be able to devote the time and resources needed to successfully manage the account including being available for frequent telephonic, email, and on-site consultations.

The Contractor shall maintain a current account management team organizational chart. The Contractor shall promptly notify the Department of any changes and provide detailed information regarding new personnel including name, professional background, mailing and physical address, email address, and work and cell phone numbers, along with an updated organizational chart.

The Department may give a performance review to the account management team or separately to each team member. If requested by the Department, the Contractor shall develop and submit a Corrective Action Plan (CAP) to the Department for approval within ten (10) Calendar Days following delivery of a performance review from the Department. Implementation of the CAP shall be in accordance with the approved CAP.

Customer Service Unit The Contractor shall maintain a customer service unit dedicated, but not necessarily exclusive, to performing all aspects of Member-related customer service. Calls to this unit shall be accepted and answered promptly by a live customer service representative in accordance with the measurement criteria listed in the Performance Guarantees section during normal business hours (8:00 AM-5:00 PM Eastern Time) or as agreed upon by the Department.

The Contractor shall maintain an exclusive toll-free customer service number, which will permit access anywhere in the United States. The Customer service unit is subject to pertinent requirements in the Performance Guarantees section.

The Contractor shall record 100 percent of all customer service calls from Members in a manner that does not violate section 934.03, F.S. Audio copies of call recordings must be provided to the Department within three (3) Business Days upon request. For any request for the transcript of a recorded call(s) comprising less than five (5) transcripts, such requests shall be provided to the Department within three (3) Business Days upon request; any larger transcript request shall be provided on a timely and commercially reasonable basis. Call recording and transcripts of call notes must be provided electronically. Recordings shall be retained in accordance with the General Records Schedule GS1-SL for State and Local Government Agencies as maintained by the State of Florida Department of State.

Customer Service Unit Operations The customer service operation shall include, at a minimum, the following:

1.1.2. Assist Members who contact the Contractor’s customer service unit with only their name and birthdate;

1.1.3. Maintain an enrollment file that identifies eligible Members and other pertinent information regarding Members;

1.1.4. Adequate and appropriate access to both online and telephonic customer service system, in accordance with Title II of the Americans with Disabilities Act;

1.1.5. Ability to provide multi-lingual service; and

1.1.6. Maintain a service disruption plan or procedure to continue customer service activities when temporarily unavailable due to either scheduled or unforeseen events (e.g., weather events, relocating offices, repairing/restoring utility or power supply, upgrading phone systems, and other events). The Department shall be notified as soon as possible of scheduled disruptions.

Member Satisfaction Surveys The Contractor shall conduct an annual Member satisfaction survey to measure overall satisfaction with the Bundled Services Program. Survey instrument and methodology are subject to the Department’s approval.

Meetings/Conference Calls Quarterly Meetings: The Contractor’s account management team shall attend all quarterly meetings at the State offices in Tallahassee, Florida, or by telephone conference call as directed by the Department. The Contractor shall not be entitled to additional compensation for meeting preparation, attendance, or travel. Quarterly reports are due within forty-five (45) calendar days following the applicable quarter end and meetings/calls are to be held within sixty (60) calendar days following the applicable quarter end. The fourth quarter meeting shall include both quarterly and annual calendar year reports and Deliverables. Quarterly reports will continue to be provided to the Department through the sixteen (16) month period following termination or expiration of the Contract.

1.1.7. Agenda: At the Department's request, the Contractor shall provide for the Department's approval a draft agenda five (5) business days in advance of a meeting allowing changes to the agenda and a reasonable opportunity to prepare for the meeting. At a minimum, the Contractor and Department will review the Contractor’s quarterly reports (e.g., thoroughly explain based on data the reasons for increases and decreases in utilization and cost), and other issues such as performance guarantees, quality assurance, operations, network status and access, benefit and program changes or enhancements, audits, cost trends, utilization patterns, program outcomes, customer service issues, future goals and planning, and other issues reasonably related to the Contract. The Contractor shall address past performance, anticipated future performance, and compare the Bundled Services Program's experience to 1) the Contractor’s total book of business and 2) other governmental clients.

1.1.8. Minutes: Within five (5) business days after any meeting, the Contractor shall provide the Department with detailed draft meeting minutes. The Department will review and revise the draft minutes as appropriate and return them to the Contractor. The Contractor shall provide the Department with final minutes within three (3) business days after revised minutes. Minutes shall include a list and description of follow-up Deliverables, with assigned person and due date.

Other Meetings: progress meetings, issue meetings, and emergency meetings shall be held as necessary. Either party may call such a meeting, subject to reasonable notice. Any meeting held in person shall be at the State's offices in Tallahassee, Florida. The Contractor shall not be entitled to additional compensation for meeting preparation, attendance or travel. Minutes will be provided as specified in subsection 9.1.2 of Meetings/Conference Calls. An Agenda should be provided as specified in subsection 9.1.1 of Meetings/Conference Calls, unless it is an emergency meeting with shorter notice, at which point an agenda shall be provided when scheduling the meeting.

Notify the Department The Contractor shall, within twenty-four (24) hours of announcement, notify the State if the Contractor or a provider within the Contractor’s network loses any licenses or liability insurance coverage.

The Contractor shall, within twenty-four (24) hours of announcement, notify the Department with a statement of justification in the event of a significant loss of a network Healthcare Provider or disruption to the network (e.g., loss of a hospital, facility, provider group, and so forth). The statement shall include a description of how the Contract action impacts the interests of the State including the number of impacted Members.

Coordination of Care The Contractor shall be responsible for assisting Members in accessing and coordinating care for a Bundled Service. Coordinating care includes, but is not limited to scheduling appointments, locating providers, and arranging lodging and transportation if needed. The Contractor shall share medical data and information with the Department's third-party providers, in compliance with all applicable state and federal law, to ensure Members receive appropriate care before and after the provision of a Bundled Service.

Continuity of Care / Healthcare Provider Terminations The Contractor shall ensure Members continue to receive coverage, including, but not limited to, performing the following under certain circumstances:

Unexpected terminations: the Contractor shall notify impacted Members as soon as administratively possible, but no later than five (5) business days of the Contractor receiving formal notice of when a Healthcare Provider’s contract unexpectedly terminates (e.g., death or loss/suspension of a license to practice medicine and so forth).

1.1.9. When an unexpected termination occurs, the Contractor shall assist Members in selecting another Healthcare Provider. If the provider does not properly notify the Contractor of intent to terminate, then the Contractor shall pursue disputes with the provider’s contract without interruption of patient care.

Expected terminations: the Contractor shall notify impacted Members at least thirty (30) calendar days prior to the expected termination date of the Healthcare Provider's contract when due to failure to renew, unsuccessful negotiations, etc.

The Contractor terminates a Healthcare Provider without cause: the Contractor shall allow Members to continue treatment when medically necessary through the completion of the applicable portion of the episode of care.

Subsections 12.1 through 12.3 of Continuity of Care/Provider Terminations shall not apply to Healthcare Providers terminated by the Contractor for cause.

Enrollment File Transfers from the Department The Contractor shall maintain an information system capable of electronically receiving and updating Enrollee information on a weekly, monthly, and/or ad hoc basis (e.g., eligibility, change of address, coverage information, and so forth). The Contractor shall accurately convert and load the Department's enrollment files in a secure point-to-point connection format.

The Contractor shall maintain enrollment records for all Enrollees based on the Department's weekly and monthly enrollment files.

The Contractor agrees that the Department's enrollment file shall be the official system of record. The Contractor shall not overwrite, update or in any way change the enrollment information.

The Contractor shall accept the enrollment files in a format and according to the schedule required by the Department.

Enrollment file transfers and subsequent discrepancy reports between the Contractor and the Department shall be exchanged using a method required by the Department.

Paid Claims Exchange with Third Party Administrators (TPAs) and Other Entities On a monthly basis or more frequently as mutually agreed, the Contractor shall:

Provide a file of all paid Claim activity to the Department and/or TPAs designated by the Department.

Accept a paid Claim file from the Department’s TPAs and/or other required parties.

Files outlined in subsections 14.1 and 14.2 of Paid Claims Exchange with TPAs and Other Entities shall be formatted as agreed upon by the parties and approved by the Department.

Claims Processing and Adjudication The Contractor shall establish processing guidelines and perform, in accordance with such guidelines, all aspects of Claims processing, coordination of benefits, adjudication, and payment in accordance with the Summary Plan Description. The Contractor shall verify Members benefits and eligibility before authorizing services.

Standard Claims Administration Practices The Contractor shall receive, process, and adjudicate Claims in accordance with best industry practices using nationally recognized standards, as determined by the Department.

The Contractor shall maintain a system for statistically profiling charges and allowances by procedure code and by ZIP code. Regarding Claims edits within the Claims adjudication process, the Contractor shall use, in accordance with the CMS National Correct Coding Initiative (NCCI), Procedure-to-Procedure (PTP) edits, Outpatient Code Editor (OCE) and Medically Unlikely Edits (MUE).

Paid Claims File to the Department and/or Department’s Designee The Contractor shall provide a secured file including all Claims data related to the Bundled Services Program in the data file layout and timeframe as agreed upon by both parties and approved by the Department in writing. Data shall be provided in a secure method to the Department and/or a third party designated by the Department. The Contractor shall provide Data in a secure method to the Department and/or a third-party designated by the Department.

System Upgrades, Enhancements and Problems The Contractor shall provide at least six (6) months prior notice of any significant planned system upgrades, migrations, or other material changes. System upgrades, migrations, and other material changes constitute systems used to process claims, relay customer/member information, receive or transmit electronic files and/or communications, websites, applications and any other "system" that impacts the Services delivered under the awarded contract.

The Contractor shall immediately notify the Department upon the discovery of problems or issues impacting claims processing related to the Bundled Services Program.

Failure to timely notify the Department of the information outlined in subsections 18.1 and 18.2 of System Upgrades, Enhancements and Problems shall be considered a material breach of Contract.

Recovery Procedures The Contractor shall have procedures in place for recovery of fees and financial errors identified in all audits (e.g., Contractor self-audit, Department audit, etc.).

The Contractor shall reimburse the Department for any and all overpayments regardless of how the error was discovered. Reimbursement shall be made to the Department via an electronic fund transfer within sixty (60) days of identifying the overpayment.

Accounting System The Contractor shall maintain an accounting system and employ accounting procedures and practices conforming to generally accepted accounting principles and standards. The Contractor’s accounting records and procedures shall be open to inspection by the Department, or its authorized representatives, at any time during the Contract period and for so long thereafter as the Department requires, in accordance with General Records Schedule GS1-SL for State and Local Government Agencies.

Explanation of Benefits (EOB) Statement The Contractor shall furnish an Explanation of Benefits (EOB) Statement for all Claims processed via regular mail to the Enrollees last known address. In lieu of hard copy EOB, the Contractor may provide a per-Claim electronic EOB, subject to authorization of the Enrollee. The EOB shall include all Claim details.

Inaccurate Payments and Reward Payments Upon discovery, notification, or recoveries as part of audits (e.g., Contractor self-audit or Department/Contract-required audit) or other Claim review activities, the Contractor shall fully rectify the inaccurate payment, including, but not limited to, reprocessing incorrect Claims and reimbursing the Department, whenever payment is made that is not in accordance with the terms of the Contract. The Contractor shall also fully rectify inaccurate Reward Payments, including, but not limited to, reimbursing the Department whenever payment is made that is not in accordance with the terms of the Contract or Department-approved methodology. The Contractor shall reimburse to the Department one hundred percent (100%) of all identified overpayments. Such overpayments shall not be reduced by contingency fees or other fees charged by an audit or other recovery service.

The Contractor shall reimburse the Enrollee in the event a recovery impacts the Enrollee's cost share.

The Contractor shall reimburse the Department in accordance with subsection 19.2 of Recovery Procedures. Claims funding may be reduced or otherwise offset by these overpayment recovery amounts. The Contractor must provide to the Department a monthly reconciliation report in a format including details approved by the Department.

Funding for Medical Claims Paid The Contractor shall provide the Department with an itemized Invoice for reimbursement of processed Claims, with Claims broken out by Enrollee subgroup (active, including variable hour (hourly) employees, COBRA participants, surviving spouse, retirees eligible for Medicare, and retirees not eligible for Medicare).

The Contractor shall send weekly Invoices to the State by 4:00 p.m. Eastern Time each Monday (next day if a State holiday) for Claims processed during the prior week. Weekly Invoices shall be specific to a given month, with the last weekly Invoice possibly having less than a full seven (7) Calendar Days to capture the period from the ending date of the previous invoice to the end of the specific month.

All Invoices shall set forth details specified by the Department to ensure a proper pre- audit and post-audit. Details shall include, but shall not be limited to, an Invoice statement provided on the Contractor’s letterhead, an Invoice number, the employer or client number, the billing period, an Invoice date, and addressed to the Department.

Contract Termination The Contractor shall continue to process and adjudicate Run-Out Claims in accordance with the terms of this Contract and perform any related necessary Claim services, including medical review and adjustments, customer service activities, appeals services, coordination of care and benefits, Department and Auditor General audit and support services, banking activities, including the continued transmission of related data files to the Department and its third party administrators, and any other mutually agreed upon activities through the end of the Run-Out Claims period following the effective date of termination of the Contract.

Fraud and Abuse Investigations The Contractor shall develop and/or maintain protocols and procedures to monitor for fraud, abuse, and waste. The Contractor shall timely notify the Department of any fraudulent or abusive Claims or other activities which it uncovers and shall fully cooperate with and assist the Department, law enforcement, and State agencies in their investigations or inquiries regarding any such matters and in any related recovery efforts.

Audit Trail The Contractor shall establish and maintain an effective audit trail for each Claim.

Care Management and Utilization Management The Contractor shall maintain policies and procedures in its care management and utilization review processes for the Bundled Services Program, including but not limited to:

Pre-certification and/or prior authorization;

Concurrent review and discharge planning for inpatient admissions;

Second surgical opinions;

Diagnosis Related Group (DRG) validation.

Required Format and Timeliness The Contractor shall electronically deliver all reports listed in Section 5. Report and File Exchange Requirements, in the format, frequency, timeframe and to the intended recipient noted in the list of reports or as otherwise required by the Department.

Redacted Copies Reports containing proprietary, trade secret, and/or confidential information shall be delivered in a redacted format at the same time as any non-redacted report, with redacted report delivered electronically and redacted in accordance with Contract subsection 10.17.2. Complete and detailed supporting documentation must be provided with the submission of each report. Supporting documentation must identify the source of the material.

Electronic Funds Transfer (EFT) The Contractor shall make payments to and accept payments from the Department through the Department’s standard transmittal process (i.e., electronic funds transfer (EFT) to the Contractor). The Contractor must complete a direct deposit authorization form (currently form number DFS-A1-26E rev.3/2022).

Banking Requirements The Contractor shall establish and maintain a medical Claims reimbursement demand deposit account at no cost to the Department to assign, report, and provide audit controls for the Department's Claim liability for medical Claims benefit payments made solely under the Contract.

This account shall only be used by the Contractor to:

1.1.10. Request funding;

1.1.11. Provide online detailed reconciliation data, which shall be provided within 24 hours of liability assignment;

1.1.12. Detail monthly issued/cashed reporting on medical Claim payments to or on behalf of those Members under the Bundled Services Program; and

1.1.13. Issue benefit payments using either tamper resistant drafts or secured electronic funds transfer (EFT).

The Contractor shall cover day one Claims liability prior to invoicing the Department on day two. The Contractor shall provide Invoice notices via email to the Department covering all checks presented (cleared), excluding outstanding issued checks, and EFT payments settled for the prior day and the Department will wire payment to the Contractor’s designated demand deposit bank account previously agreed to by the Department.

The Contractor shall provide at least ninety 90 days’ notice to the Department if the Contractor changes the bank account. The Contractor shall suspend issuance of drafts or electronic fund transfers in payment of medical Claims upon receipt of written notice of Contract termination to the designated representative of the Contractor by the Department.

The Department shall only reimburse the Contractor’s Invoices for EFT transaction and cleared checks that have been presented to the Contractor’s bank account. Issued and outstanding checks will not be included in the reimbursement.

The banking contract shall include, but not be limited to, a record of EFTs and/or transmission of daily written drafts registered by the Contractor to the bank for positive confirmation procedures. The transmission must include draft number, draft amount, payee's name and date of draft. The method of transmission shall be determined by mutual agreement between the Contractor and the Department's bank with approval by the Contractor’s bank.

The Department shall identify the necessary documentation and the related reporting requirements for the reconciliation. The Contractor shall submit to the Department recommended processes and internal controls developed by the Contractor to identify payments due to overbilling and other errors that may occur as part of the payment process. Reconciliation activities shall include but are not limited to:

1.1.14. Notification of amount of request.

1.1.15. Listing of charged Claim activity report (Claim charge activity by check/item and Member).

1.1.16. Detail report for transfer evaluation (all Claim charge items at Enrollee level).

1.1.17. Monthly bank account statement.

1.1.18. Monthly summary of bank activity for each calendar year.

1.1.19. Monthly Outstanding Report #1 (checks less than ninety (90) days old that have not cashed).

1.1.20. Monthly Outstanding Report #2 (checks that are more than ninety (90) days old that have not been cashed).

1.1.21. Monthly aged outstanding report with stop payment placed (details the in-house stop payments placed on items that remain uncashed twelve (12) months from issuance).

1.1.22. Monthly issue/cashed reconciliation report (issued vs. cashed items in policy month).

Quarterly Self Audits The Contractor shall perform at least quarterly internal audits on one hundred percent (100%) of Claims with results reported to the Department quarterly. Results shall be used to validate self-reported quarterly performance metrics for Claims timeliness, processing accuracy, payment accuracy and financial accuracy.

Audit of Host Plans/Reciprocal Agreements with Other Plans The Contractor shall provide one hundred percent (100%) transparency and audit ability to the Department and the Department's third-party auditor for any and all financial transactions related to Claims incurred by Members.

Quality Assurance Reviews for the Auditors Annually, the Contractor shall review its procedures and processes to assess quality performance on Claims as well as customer service inquiries. At the time of the review, the Contractor shall report to the Department on how the following areas are handled to ensure quality:

Coordination of care for bundled services;

Call center and customer service;

Claims processing; and Reward payment processing.

Audits The Contractor shall provide the Department and the Department's third-party auditor at least the following audit access, in addition to any other audit rights specified in the Contract:

To audit any data necessary to ensure the Contractor is complying with all Contract terms; such audit rights include, but are not limited to, one hundred percent (100%) of Claims data, approved and denied utilization management reviews, clinical program outcomes, appeals, and information related to the reporting and measurement of Performance Guarantees.

To perform ongoing post Claims audits as allowed in subsection 110.12301(1), F.S.

To audit post termination of contract; and To perform additional audits during the year of similar scope if requested as a follow-up to ensure significant or material errors found in an audit have been corrected and are not recurring, or if additional information becomes available to warrant further investigation.

The Contractor shall provide a response addressing all audit findings within fifteen (15) days of delivery to the Contractor, or at a later date if mutually determined to be more reasonable based on the number and type of findings.

If an audit finding determines that there are systematic issues affecting the adjudication of Claims related to the Bundled Services Program, the Contractor shall coordinate with the Department to develop and immediately implement a corrective action plan subject to the customization and approval of the Department.

Fiduciary Responsibility The Contractor shall agree to assume Claim fiduciary responsibility, including appeals, for Claim adjudication and defense of utilization review decisions.

Legal Defense The Contractor shall provide necessary legal defense and assistance as required in the event of litigation for goods and services related to the performance of this Contract.

The Contractor shall cover all fees and costs associated with legal defense, including attorneys’ fees, in the event of litigation related to the Contractor’s Services under the Bundled Services Program.

The Contractor shall, at no additional cost to the Department, defend the Department, the State and/or Members against any litigation brought by participating network Healthcare Providers seeking payment for covered services in excess of the applicable payment negotiated by the Contractor. The Contractor agrees to pay all resulting damages awarded or settlement amounts in any such litigation, provided that the Department, the State and/or the affected Members provided timely written notification to the Contractor of such litigation and provided that the Vendor had sole control of the defense of such litigation and any related settlement negotiations. The Department and Contractor agree that neither the Department nor Contractor is responsible for the health care that is delivered by health care providers, except as otherwise provided in the Contract. The defense of litigation and indemnification obligations of this Contract do not apply to any portion of any loss relating to the acts or omissions of Healthcare Providers with respect to Plan Participants.

Disaster Recovery Plan The Contractor shall develop, implement, and maintain a disaster recovery plan and shall submit a copy to the Department on the implementation date of this Contract. At a minimum, the disaster recovery plan shall ensure that all services are provided within 48 hours of activating the disaster recovery plan at the same level of service as before the disaster recovery plan was activated. Any changes to the plan throughout the term of the contract must be sent to the Department.

Compliance with Law The Contractor shall comply with and monitor federal and state legislation affecting the delivery of surgical and/or medical services under the Bundled Services.

Online Reporting and Management Tools The Contractor shall provide the Department online access to its reporting and other management services, systems, tools, and programs as it relates to the Bundled Services Program.

The Contractor shall, upon request of the Department, provide Department staff with training at the Department’s facilities for the Department’s use of Contractor’s online reporting and management tools utilized in the provision of the Bundled Services Program.

Protected Health…