Attachment_E.docx

ATTACHMENT E

EV00000681

BIDDER RESPONSES

PLAN YEAR 2026 HEALTH

Bidder must respond to each of the below items. If Bidder is also providing an exhibit, it should be referenced within this Attachment E.

All bids Identify which one of the below bid combinations Bidder is offering:

HMO and Medicare Supplement HMO and MAPD HMO and Medicare Supplement and MAPD Standalone national MAPD Financial Standing Does the Bidder warrant and represent that it is in good financial standing, not in any form of bankruptcy or the zone of insolvency, and is current in the payment of all taxes and fees?

Fraud and Abuse Investigations.

Describe how the Bidder will accomplish monitoring for fraud and abuse and provide EGID with a quarterly report of fraud and fraud-prevention activities and discoveries relating to the OEIBA Program, as well as when any fraudulent or suspicious activity relating to the OEIBA Program is detected or brought to the Bidder’s attention by EGID or others.

Eligibility Transmission What is the Bidder’s policy regarding retroactive changes/terminations/adds?

Network Changes Describe how Bidder will provide notification to members as required.

Internal Grievance Procedures Provide the third-party company information (i.e., name, location, contact information) that members appeal to for grievances, if applicable.

How many grievances has Bidder had regarding the network in the prior calendar year per 1,000 members?

Reporting Indicate (by report number in Exhibit 27) which of the reports the Bidder already makes public in some form.

Acquisitions and Mergers Are there any known or planned name change for the Bidder’s company over the next twelve (12) to twenty-four (24) months?

Summarize any mergers with or acquisitions of other organizations completed in the past twenty-four (24) months and summarize how these actions directly impact this solicitation.

Describe, to the best of Bidder’s knowledge, any acquisitions or mergers which Bidder is expected to be involved within the next twelve (12) months.

Implementation New Supplier Transition Process. Provide the following information:

Provide the Transition Manager name and contact information.

How many other implementation projects will the Transition Manager work on in addition to this contract?

Provide a copy of a typical implementation project plan.

Premium Calculation Describe the methodology used for developing the rates being proposed.

License To be eligible to submit a proposal under this RFP, an organization must meet all legal requirements for doing business in the State of Oklahoma. The Bidder must provide a copy of its license issued by the Insurance Commissioner for the State of Oklahoma. Refer to Exhibit 18.

Actuary Certification Bidders are required to submit a statement from a qualified actuary certifying that the Bidder’s information submitted in response to Exhibits 6-9 and Exhibits 15 and 16 are true, complete, and accurately reflects the experience of this account. The qualified actuary certification shall be submitted as part of the Bidder’s response to this RFP (Exhibit 19). A “qualified actuary” as used herein shall be a person recognized by either the American Academy of Actuaries or the Society of Actuaries as being qualified for such actuarial evaluation and certification. Proposals received without the required signed actuary certification for each proposed plan will not be accepted and the Bidder shall be ineligible for award of contract.

Lawsuits and Litigation Disclose, unless prohibited by securities law, any prior lawsuits and litigation involving alleged or actual violations of administrative rules and hearings, or any lawsuits, litigation, or administrative proceedings, threatened or pending, involving the Bidder and any person or entity, the State of Oklahoma or any political subdivisions, and/or any state officer and/or any state employee acting in the capacity of a state employee arising from services rendered that are the same or similar to the work defined in the Solicitation Specifications in this RFP, and any settlements, compromises (if confidential, a statement of that fact) or Judgments of Record resulting from the foregoing described litigation or administrative proceedings for the past five (5) years preceding the Plan Year or affirm there are none.

List and disclose Contract cancellations or negligent causes of action that arose from work performed that is the same or similar to work identified in the Solicitation Specifications in this RFP that was initiated by persons or entities against the Bidder that resulted in a settlement with or judgment against the Bidder in any jurisdiction in the United States in an amount of One Hundred Thousand Dollars ($100,000.00) or more within the previous five (5) years or affirm there are none.

Disclose any data security breaches and specifically HIPAA security breaches that required notification to affected persons or a regulatory authority.

List and describe any current malpractice suits filed against the Bidder or a provider in the network.

P-Cards The State of Oklahoma has issued payment cards to most State agencies. The current P-Card contract holder utilizes VISA. If awarded a contract, will your company accept the State of Oklahoma approved purchase card? Indicate whether “Yes” or “No.”

Electronic Funds Transfer (EFT) The State of Oklahoma passed legislation in 2012 requiring funds disbursed from the State Treasury be sent electronically. If awarded a contract will your company accept payment for invoices from the State by EFT? Indicate whether “Yes” or “No.”

HMO Proposal (excluding Medicare Supplement or MAPD lines of business) Bidder Identification. Provide a response to each requested item below:

Bidder’s legal name.

Address (including city, state, and zip code).

Office location responsible for this account. If this office will be located outside of Oklahoma, explain the Bidder’s plans to interact closely with EGID.

Trade name that the Bidder intends to use for marketing purposes.

Provide an electronic copy of the Bidder’s brand logo that the Bidder intends to use for marketing purposes. This should be in the form of a vector graphic or a high-resolution JPG/PNG of at least 300 dpi (Exhibit 21).

Name and contact information (e.g., title, phone number(s), and email address) for Account Manager that will be assigned to the OEIBA Program.

Include years of experience, the number of other clients, and the size and industry of clients.

Name and contact information (e.g., title, phone number(s), and email address) for highest ranking official with direct involvement with the OEIBA Program’s account.

The name and contact information (e.g., title, phone number(s), and email address) for the Bidder’s designated personnel authorized to enter into BAFO competitive negotiations.

Outline the account management team that will be assigned to EGID upon contract.

Are any services outsourced? If so, provide name, location and function of the company.

Attach a complete organizational chart for the Bidder, including all departments/functions listed in Bidder Operating Staff in Attachment A section D.18., as well as lines of authority, and relationships among the Bidder’s Board of Directors, administration, medical services, and other functions (Exhibit 21). If expansions or changes are anticipated, show as much detail as possible reflecting the changes.

Web Capabilities What is the Bidder’s web address?

How often is the Bidder’s website updated?

How often does scheduled downtime occur?

Complete the below chart regarding capabilities for participants on the Bidder’s website:

Provider Locator

Plan Benefit Information

Out-of-Network Claim Form

Print ID Cards Online

Request additional replacement ID cards to be mailed

Online Explanation of Benefits (EOBs)

Claims History and Claims Status

How long is claim history accessible online for a termed member, if applicable?

Educational Information about HMO

Cost estimation/budgeting tools

Member Grievance Resolution

Pharmacy Information

Members can download and print forms

Wellness program activities

Is a mobile app available?

Other (Describe)

Licensure. Bidder must meet all legal requirements for doing business in the State of Oklahoma and all EGID requirements for a State defined Supplier as specified in the laws of Oklahoma and the rules of the Oklahoma Insurance Department. Provide a copy of the Bidder’s relevant licensure for the programs it intends to bid. Refer to Exhibit 18.

Bidder Profile. Provide a profile of the Bidder’s HMO insurance business for each of the latest three calendar years (2023, 2024 and through March 2025):

Calendar Year

Calendar Year 2024

Calendar Year (As of March 1, 2025)

Total number of clients (employer groups, state programs, etc.)

Total number of enrollees covered

Number of public sector clients

Average number of public sector enrollees

Number of plans terminated

Average number of members in terminated plans

Member Services Telephone Assistance.

Provide the hours that this service will be available.

How are after-hour phone calls handled?

How does the Bidder’s Member Services (call center) accommodate non-English speaking and hearing-impaired callers?

Call Center Performance.

Provide the standards that the HMO Member Services staff achieved during 2024 in the following categories.

Average telephone answer time in seconds (This is the amount of time it takes for a member to speak to a live customer service representative.)

Percentage of calls answered within 30 seconds or less.

Total number of calls per month Total number of abandoned calls per month Average monthly abandonment rate for customer service calls.

First Call Resolution Rate. (This is the percentage of telephone inquiries completely resolved within a “window period” of time. A call is considered “resolved” when the same participant or a family member under the same subscriber ID has not contacted the administrator's customer service facility again regarding the same issue within sixty (60) calendar days of the initial call.)

Member Satisfaction.

Member Service Quality Assurance.

Describe the Bidder’s internal performance standards for accuracy, responsiveness and courtesy and how are they measured for each customer service representative. Describe any other measures and standards used in the Bidder’s Customer Service Representative Audit Scores at its customer service facility.

What measures are taken for poor or unacceptable performance?

What is the ratio of full-time customer service representatives to covered members?

What number of customer service representatives has the Bidder dedicated to this contract?

Satisfaction Services.

Provide a copy of the Bidder’s customer satisfaction survey for year 2024. If Bidder participated with the OEIBA program in 2024, the data should be specific to the OEIBA Program. Otherwise, the data should be for the book of business. Attach a copy of the most recent survey instrument completed and a summary of the results (Exhibit 22).

Describe the frequency and methodology of the Bidder’s member satisfaction surveys.

What is the overall member satisfaction rate from the most recent survey?

What are members least satisfied with?

Provide a summary of the member survey methods.

Systems and Eligibility.

Identify the systems the Bidder will use in the performance of this RFP. This includes, but is not limited to, eligibility and claims processing systems.

Describe how these systems will integrate to administer these services.

Identify any changes to systems that the Bidder will make to fulfill this RFP.

Benefit Plans for Participants Living Out of State.

Describe in detail the zip code areas, provider networks and plan of benefits that would be available to participants who live outside the State of Oklahoma.

Section 125.

Does the Bidder agree to provide information, where available, to assist in verifying purchases made through State sponsored FSAs?

Provider Network Requirements.

List the Bidder’s current ratio of PCPs to member in Exhibit 3 Complete the Detailed Network Reports in Exhibit 14.

Bidder’s Provider Contracting.

Identify the model or type of HMO: Staff, Group, Network, IPA, Other. If the HMO is a mixed model, describe and include percentage of participation in each type.

Identify any use of sub-contracted or “leased” network(s).

Briefly describe all service areas covered by the Bidder’s response. Include a map showing boundaries of all service areas by zip code covered in this solicitation including areas available to participants that live outside the State of Oklahoma. Bidders may also elect to include separately any areas being considered for future expansion.

Provide an Excel list of every zip code that is part of Bidder’s service area (Exhibit 1).

Provider Turnover.

How many providers, by region and location, have been sanctioned and/or removed from Bidder’s managed care networks within the last three (3) years?

Provide the percentage of Bidder’s PCPs retained based on length of contract below:

Over 3 years (%) 2 to 3 years (%) Less than 2 Years (%) How many PCPs and specialists have terminated contracts with the Bidder in the last calendar year at the physician's request? State the reason(s) for the termination.

What has been the turnover rate of PCPs in the Bidder’s network during the last calendar year (due to all reasons)? Express as a percent of total PCPs. Separate turnovers by voluntary and involuntary.

Network Reimbursement.

Describe the Bidder’s hospital reimbursement mechanisms, differentiate between acute and psychiatric, and include the mix (percentages of each) for the following methods: fee for service, discounted fee schedule, per diem, DRG, capitation, other.

Describe the Supplier’s physician reimbursement mechanism or mechanisms, differentiate between PCPs and specialists, and include the mix (percentages of each) for the following methods: salary, fee for service, discounted fee schedule, capitation, other.

Pharmacy.

Describe the Bidder’s pharmacy retail network capabilities in all service areas proposed, including point-of-service capabilities, mail order, and/or delivery methods used.

Describe in detail the Bidder’s pharmacy network arrangements. If the Bidder subcontracts these services, provide complete information about the pharmacy benefit manager including name, contractual relationship, ownership interest (if applicable), etc.

Describe in detail the retail network (number of pharmacies) and provide a directory of pharmacies as of January 1, 2022. Also provide the location of the customer service center and toll-free number for member inquiries Describe in detail the mail order pharmacy program, including location of mail order prescription fill center(s), and customer service center, with toll-free number for member inquiries. Also provide information on methods of requesting refills (i.e., telephone, internet, mail, etc.).

Describe in detail any pharmacy health care management programs, outreach, consumer education, and health promotion programs that apply to the membership covered by this RFP. Describe specialty pharmacy program details separately.

Identify each provider who is a part of the Bidder’s centers of excellence program, the nature of illnesses/conditions treated, and the criteria used in selecting these facilities.

Provide details of services, i.e., location, limitations, etc. pertaining to offering eligible services outside the State of Oklahoma to eligible dependents residing at an address different from the employee’s address.

What is the Bidder’s standard advanced notice time before terminating a network location (facility) or a provider?

What changes have been made in the Bidder’s service area in the past year? Include a map showing the changes.

Complete the provider spreadsheets in Exhibit 14 in an Excel workbook format. Each spreadsheet must be completed exactly as it appears on the template. Any deviation from this format may result in the Bidder’s disqualification.

Match employee data to providers and present the results in a map and in numerical format (by service area, county, and zip code). The census report (Exhibit 24) is to be used for mapping.

Describe any financial incentive programs (such as bonuses, penalties, or other) for PCPs.

Provider Satisfaction Surveys.

Provide a copy of the most recent provider satisfaction survey (Exhibit 22). Include details on the percentage of providers surveyed. If the Bidder participated with the OEIBA Program in Plan Year 2024, the data should be specific to the OEIBA Program. Otherwise, the data should be for the book of business.

Standardized Service Areas and Access Standards.

The Bidder shall provide a Geo-Access report to show the network access strength. Refer to Exhibit 2. Access standards require a minimum of one (1) provider within 25-mile radius for each of the following:

PCPs.

Specialty physicians.

Pharmacies, Urgent care.

Hospitals.

Geo-Access report should include a minimum of the following:

Oklahoma counties (all 77).

City.

Zip code.

Number of providers (separate PCPs, specialty physicians, pharmacies, urgent care, and hospitals).

Claims Administration.

Is the Bidder’s managed medical care claims system fully integrated and automated for in-network and out-of-network claims processing? Does it have procedures that prevent direct member billing (balanced billing)? If so, describe the procedures. If not, how will the HMO ensure members are not billed inappropriately for covered services?

Describe in detail the Bidder’s claim cost-control program. How are overcharges detected for medically unnecessary care or provider abuses? What program(s) has the Bidder developed to address special areas of concern? Who performs these functions?

Describe in detail the HMO’s fraud prevention capabilities/ claims auditing.

Does the HMO routinely send out EOBs or only upon member request?

Does the HMO track member out-of-pocket maximums or is this the member to notify the HMO when the maximum is met?

Claims Processing. Provide the following information for the most recent Plan Year:

Turnaround time - Turnaround time is measured from the date a paper claim, or an electronic claim submission is received by the administrator, or by a subcontracted Supplier responsible for the initial receipt of claims, to the date the claims are resolved).

Financial accuracy rate - Financial Accuracy is the absolute dollar value of all claim payment errors in an audit sample, subtracted from the total benefits paid in the same audit sample. The result is then divided by the total medical benefits paid in the audit sample.

Overall accuracy - Overall Accuracy is the total number of claims within an audit sample processed without any type of error, divided by the total number of claims within the audit sample.

Contingency Plan. Provide a general summary of the Bidder’s contingency plans that illustrate its ability to respond to the following items. Do not provide sensitive or confidential company information.

Rapid increase in enrollment.

Rapid decrease in enrollment.

Loss of one or more facilities.

Voluntary provider termination.

Work stoppage.

Financial insolvency.

Loss of license or contract revocation.

Pandemic Health Emergency.

Disaster Recovery Plan.

Provide a general summary of the Bidder’s disaster recovery plans that illustrate its ability to respond to the following items. Do not provide sensitive or confidential company information.

Describe the disaster recovery protocols, procedures and backup systems in place, including the ability to rapidly shift phone service and claims processing to alternative sites.

Provide frequency of disaster recover testing.

Credentialing and Peer Review. Identify which physician credentialing criteria the Bidder actively monitors on an ongoing basis and provide frequency that the Bidder re-credentials providers.

State Licensure Board Certification DEA License Verification of Medical Education and Training Admitting Privileges at Network Hospitals Office Hours Proof of Malpractice Insurance Reputation Malpractice History History of litigations/disciplinary action Fraud and/or felony convictions Other- Describe Medical Management.

Describe the Bidder’s procedures to ensure that every member has a PCP and that the PCP coordinates all of the member's medical care.

Describe in detail the HMO’s procedures for after-hours care and emergencies in the service area and outside the service area.

Provide the following HMO contact person for the State’s Employee Assistance Program: name, address, telephone number, email address, and brief clinical/professional description.

Describe in detail the care management initiatives the HMO will be administering in the contract year. This pertains to a program of pro-active outreach to all members to ensure that appropriate detection, prevention, acute, and chronic care is delivered.

Describe in detail how the Bidder will educate members about their health and actively involve them in treatment decisions.

Does the Bidder offer a 24-hour Nurse Line service? If so, describe the program and utilization results.

Provide the following statistics for the Bidder’s utilization management programs for 2024. If the Bidder participated with the OEIBA program in 2024, the data should be specific to the OEIBA Program. Otherwise, the data should be for the book of business.

Number of admission requests.

Number of denials.

Admission denial rate.

Admissions per 1,000 covered lives.

Average length of stay (days).

Inpatient days per 1,000 covered lives.

Medical Quality Assurance.

Describe in detail the Bidder’s quality assurance program and address the following component activities:

Chart review.

Focused studies.

Facility inspection.

Social service intervention.

Discharge planning.

Frequency of QA activities (e.g., how often QA committee meets, number and frequency of focused studies, etc.).

Does the Bidder maintain a Quality Assurance Committee? If so, include the names and credentials of those involved and describe the programs used to monitor, evaluate, and emphasize quality health care.

Describe in detail the systems in place to ensure follow-up and correction of identified problem areas found because of the QA activities.

Describe in detail how Bidder monitors and detects underutilization or overutilization of services by providers, including follow-up actions.

Describe in detail the utilization review programs the Bidder uses. If Bidder does not utilize these programs, explain the reasoning. Address: peer review, pre-admission certification, second surgical opinion, concurrent review, discharge planning, standards of care/profile analysis, quality review, mental health/substance abuse, utilization review, and other.

Describe in detail any quality assurance (QA)/utilization review (UR) service and identify each subcontractor and describe its services.

Describe in detail the internal grievance procedure for members and providers.

What continuous quality improvement process is the Bidder utilizing in enrollment procedures, appointment scheduling, and other member services operations?

What type of care management initiatives does the Bidder intend to implement in the contract year? This pertains to a program of pro-active outreach to all members to ensure that appropriate detection, prevention, acute, and chronic care is delivered.

What percentage of a network provider's case volume is reviewed for quality and appropriateness each year?

Service Enhancements.

Describe in detail the service enhancements to be offered by the Bidder or affirm that there are none.

Compliance and Privacy Procedures and Standards. The Bidder shall describe its compliance procedures in general. Specifically explain how it will comply with privacy and security standards and describe how the Bidder will electronically and operationally interface with its business associates according to HIPAA security and X12 standards for electronic transmissions. The Bidder shall describe how it will interface with EGID as a Plan Sponsor and maintain confidentiality/privacy of members’ health information.

Member Education. Describe in detail the methods which will be used by the Bidder to educate and communicate the proper use of the plan to members. Describe all that apply, including:

Enrollment Meetings Mass Mailings Mass media Provider Directories Interactive Phone Marketing Brochures Website and/or mobile app Welcome calls (or other communication method) to new members Other Member Materials.

Furnish copies of the membership I.D. Card (Exhibit 20).

Describe the process that providers and the HMO call center staff utilize to determine member eligibility when a member calls for information or to make an appointment.

Medicare Supplement Plan Proposal Does the Bidder confirm that the benefits listed in Exhibit 12 contain benefits actuarially equivalent to Medicare G with pharmacy benefits actuarially equivalent to the HealthChoice SilverScript High Option?

Does the Bidder have a Medicare Supplement Plan within Oklahoma outside of the OEIBA Program? If so, the Bidder must:

Complete a copy of Exhibit 12 listing the benefits provided under this plan.

Complete Exhibit 13 Medicare Supplement premium quotes table.

Identify any networks that may be involved (Medicare Select).

Does the MSP require members to have a PCP? If so, complete Exhibit 3.

Bidder Identification. Provide a response to each requested item below:

Bidder’s legal name.

Address (including city, state, and zip code).

Office location responsible for this account. If this office will be located outside of Oklahoma, explain the Bidder’s plans to interact closely with EGID.

Trade name that the Bidder intends to use for marketing purposes.

Provide an electronic copy of the Bidder’s brand logo that the Bidder intends to use for marketing purposes. This should be in the form of a vector graphic or a high-resolution JPG/PNG of at least 300 dpi (Exhibit 21).

Name and contact information (e.g., title, phone number(s), and email address) for Account Manager that will be assigned to the OEIBA Program.

Include years of experience, the number of other clients, and the size and industry of clients.

Name and contact information (e.g., title, phone number(s), and email address) for highest ranking official with direct involvement with the OEIBA Program’s account.

The name and contact information (e.g., title, phone number(s), and email address) for the Bidder’s designated personnel authorized to enter into BAFO competitive negotiations. In the event the Bidder’s designated personnel changes, the Bidder shall notify OMES/CP and EGID immediately in writing.

Outline the account management team that will be assigned to EGID upon contract.

Attach a complete organizational chart for the Bidder, including all departments/functions listed above, as well as lines of authority, and relationships among the Bidder’s Board of Directors, administration, medical services, and other functions (Exhibit 21). If expansions or changes are anticipated, show as much detail as possible reflecting the changes.

Are any services outsourced? If so, provide name, location and function of the company.

Member Materials.

Membership I.D. Card. Does Bidder provide membership I.D. cards? If so, furnish a copy of the membership I.D. Card (Exhibit 20).

Describe the process that providers and the MSP call center staff utilize to determine member eligibility when a member calls for information or to make an appointment.

MAPD Proposal The Bidder shall complete Exhibit 9 that indicates the level of benefits that the MAPD will be providing under this Contract. For benefits requiring a mixture of fixed dollar and percentage copayments, indicate the fixed dollar amounts first. All maximums should clearly specify if they are based on copayments or on benefit charges.

Bidder Identification. Provide a response to each item listed below.

Bidder’s legal name.

Address (including city, state, and zip code).

Office location responsible for this account, if different than above. If this office will be located outside of Oklahoma, explain the Bidder’s plans to interact closely with EGID.

Trade name that the Bidder intends to use for marketing purposes.

Provide contact information (name and phone number) of a customer service supervisor for MAPD plan.

Provide an electronic copy of the Bidder’s brand logo that the Bidder intends to use for marketing purposes. This should be in the form of a vector graphic or a high-resolution JPG/PNG of at least 300 dpi (Exhibit 21).

Name and contact information (e.g., title, phone number(s), and email address) for Account Manager that will be assigned to the OEIBA Program.

Include years of experience, the number of other clients, and the size and industry of clients.

Name and contact information (e.g., title, phone number(s), and email address) for highest ranking official with direct involvement with the OEIBA Program’s account.

The name and contact information (e.g., title, phone number(s), and email address) for the Bidder’s designated personnel authorized to enter into BAFO competitive negotiations. In the event the Bidder’s designated personnel changes, the Bidder’s shall notify OMES/CP immediately in writing.

Outline the account management team that will be assigned to EGID upon contract.

Are any services outsourced? If so, provide name, location and function of the company.

Web Capabilities.

What is Bidder’s web address?

How often is the Bidder’s website updated?

How often does scheduled downtime occur?

Complete the attached chart regarding capabilities for participants on the Bidder’s website:

Provider Locator

Plan Benefit Information

Out-of-Network Claim Form

Print ID Cards Online

Request additional replacement ID cards to be mailed

Online Explanation of Benefits (EOBs)

Claims History and Claims Status

How long is claim history accessible online for a termed member, if applicable?

Educational Information about MAPD

Cost estimation/budgeting tools

Member Grievance Resolution

Pharmacy Information

Members can download and print forms

Wellness program activities

Is a mobile app available?

Other (Describe)

Bidder Eligibility.

Bidder must be a registered Supplier with OMES/CP and must meet all legal requirements for doing business in the State of Oklahoma and all EGID requirements for a State defined Supplier as specified in the laws of Oklahoma and the rules of the Oklahoma Insurance Department. In addition, a MAPD must be qualified by the Centers for Medicare and Medicaid Services, hereinafter “CMS”. Provide a copy of the Bidder’s relevant licensure for the programs it intends to bid (Exhibit 18).

Bidder Operating Staff. Refer to Attachment A Section D.18.

Attach a complete organizational chart for the Bidder, including all departments/functions listed above, as well as lines of authority, and relationships among the Bidder’s Board of Directors, administration, medical services, and other functions (Exhibit 21). If expansions or changes are anticipated, show as much detail as possible reflecting the changes.

MAPD Networks.

Identify any use of subcontracted or “leased” network(s).

Does the MAPD require members to have a PCP? If so, complete Exhibit 3.

How many providers, by region and location, have been sanctioned and/or removed from the MAPD’s managed care networks within the last three (3) years?

List the MAPD’s current ratio of PCPs to members:

Tulsa Number of PCPs Number of Members Ratio Oklahoma City Number of PCPs Number of Members Ratio All Other/Rural Number of PCPs Number of Members Ratio Provide the percentage of MAPD’s PCPs based on length of contract.

Over 5 Years (%) 3 to 5 Years (%) 2 to 3 Years (%) Less than 2 Years (%) How many PCPs and Specialists have terminated contracts with the MAPD in the last two (2) years (at the physician’s request)?

What has been the turnover rate of PCPs in the MAPD network during the last two (2) years (due to all reasons)? Express as a percentage of total PCPs.

Describe the termination procedures contained in the MAPD’s provider contracts, including the length of notice a PCP must give to terminate its contract with the MAPD. Attach a sample copy (or copies, if more than one form is used) of the MAPD’s contracts with its PCPs.

Describe any financial incentive programs (such as bonuses, penalties, or other) for PCPs. Specify between individual and group incentives and address the MAPD’s experience and use of withholds and risk pools. Risk adjustments will not apply to Medicare Advantage.

Describe the MAPD’s pharmacy retail network capabilities in all service areas proposed, including point- of-service capabilities, mail order, and/or delivery methods used. Describe the pharmacy program that will be offered to the members, specifically the actuarial equivalence and CMS certification of a Medicare Part D Prescription Drug Plan offered to Medicare eligible members. Actuarial equivalence is defined as (Total Pharmacy Allowed – Member Pharmacy Cost Sharing)/Total Pharmacy Allowed. Federal reinsurance, Low Income Cost Sharing, Coverage Gap Discount, and Rebates should not be reflected in the actuarial equivalence calculation. As a point of comparison, the actuarial value of the Medicare High Option plan for 2026 is approximately 90%.

Provide the name, address and contact name for the Pharmacy Benefit Manager (PBM) who handles the MAPD’s pharmacy plan of benefits.

Describe the MAPD’s procedures to ensure that every member has a PCP and that he/she coordinates all of the member’s medical care.

Briefly describe all service areas covered by the Bidder’s response. Include a map showing boundaries of all service areas by zip code covered in this solicitation including areas available to participants that live outside the State of Oklahoma. Bidders may also elect to include separately any areas being considered for future expansion.

Provide an Excel list of every zip code that is part of Bidder’s service area (Exhibit 1).

What changes have been made in the Bidder’s service area in the past year? Include a map showing the changes.

What are the MAPD Bidder’s procedures for after-hours care and emergencies in the service area and outside the service area?

Based upon the OK Medicare retiree census data (Exhibit 24), identify any counties of the state in which the Bidder is filed to operate where its provider network may not have adequate capacity to meet the potential Oklahoma demand.

Does the Bidder foresee any significant provider contracts coming up for negotiation in the next three (3) years based on the Oklahoma Retirees locations?

Provide a listing of all acute care Oklahoma hospitals that are considered out-of-network hospitals in the Bidder’s Medicare Advantage plans.

Describe the Bidder’s MA network growth and development plans.

Describe the Bidder’s approach for selecting and recruiting providers to participate in its MA networks.

Describe the Bidder’s process for collaborating with employers and key providers to address provider acceptance issues that may surface over time.

Complete pharmacy disruption of the top utilized Oklahoma pharmacies. List the pharmacies utilized for the OEIBA Program during 2024 and provide the number of utilizers, the number of prescriptions, and the plan paid dollar amounts. If the Bidder was not a participant in 2024, then the report should be for its book of business specific to Oklahoma.

Medicare Experience.

Provide Bidder’s total Medicare enrollment for 2023 and 2024.

Describe the Bidder’s experience participating in Medicare as a private plan option. Include the number of years that Bidder has participated in Medicare and a brief history of key developments over this time, such as when Bidder’s first group Medicare plan was offered.

Has Bidder been sanctioned by CMS in the past five (5) years? If so, describe further.

Describe the Bidder’s strategy and key initiatives to assure that Medicare Advantage will offer the Plan a sustainable value proposition.

Member Services Telephone Assistance.

Provide the hours that customer service representatives regarding plan benefits and network service problem resolution will be available for telephone assistance.

How are after-hours phone calls handled?

How does the Bidder’s Member Services (call center) accommodate non-English speaking and hearing-impaired callers?

Call Center Performance.

Provide the standards that the MAPD Member Services staff achieved during Plan Year 2024 in the following categories Average telephone answer time in seconds. (This is the amount of time it takes for a member to speak to a live customer service representative.)

Percentage of calls answered within 30 seconds or less.

Total number of calls per month.

Total number of abandoned calls per month First call resolution rate. (This is the percentage of telephone inquiries completely resolved within a “window period” of time. A call is considered “resolved” when the same participant or a family member under the same subscriber ID has not contacted the administrator's customer service facility again regarding the same issue within sixty (60) calendar days of the initial call.)

Member Service Quality Assurance.

What is the Bidder’s internal performance standards for accuracy, responsiveness and courtesy and how are they measured for each customer service representative? Describe any other measures and standards used in the Bidder’s Customer Service Representative Audit Scores at its customer service facility.

What measures are taken for poor or unacceptable performance?

What is the ratio of full-time customer service representatives to covered members?

What number of customer service representatives has the Bidder dedicated to this contract?

Member Materials.

Does Bidder provide membership I.D. cards? If so, furnish a copy of the membership I.D. Card (Exhibit 20).

Describe the process that providers and the MAPD call center staff utilize to determine member eligibility when a member calls for information or to make an appointment.

Medical Management/Staff.

Does the Medicare Advantage include a 24-hour Nurse Line that would be available to members under this contract?

Provide details on which medical management programs in place now (either retiree or eligible current employee population) that would be most effective for a retiree-only population.

Describe the Bidder’s medical management experience with groups that have significant retiree population.

Describe how the Bidder’s medical management program design enhances quality of care, including improvements in health status and clinical outcomes.

How does the Bidder’s approach differ in its MA products vs. its commercial plans?

MAPD CAHPS Survey Results. Provide annual CAHPS results for 2024 (Exhibit 23). If Bidder is unable to provide CAHPS, annual submission of HEDIS results may be used in place of this requirement.

CMS Stars Quality.

Describe the Bidder’s commitment to the Stars quality rating program.

Briefly describe the Bidder’s CMS Stars quality rating, enhancement strategy and timeline. Describe the continuous quality improvement initiatives in this strategy.

Describe how the Bidder’s Stars enhancement strategy fits with its overall Medicare Advantage strategy.

Provide the Bidder’s previous three (3) years CMS Stars quality ratings.

Customer Service Experience.

What methods/service support does the Bidder have in place to ensure consistency of experience for retirees?

Describe required CSR training, with emphasis on any retiree-sensitivity training.

Provide any additional customer service differentiators for the Bidder’s proposed MA plans.

Describe how the Bidder differentiates its service from its competitors.

On an ongoing basis, what are the Bidder’s standards in assuring transition of care for new members to the Bidder’s Medicare Advantage PPO/HMO?

Pharmacy.

Does the Bidder’s Medicare Advantage PPO plan utilize a drug formulary beyond the drugs covered and reimbursed under traditional Medicare?

Describe under what circumstances prior authorization of a drug is required.

For MAPD plan, will the Bidder issue a combined ID card for medical care and PBM services?

Organizational Infrastructure. Describe the organizational infrastructure responsible for administering a Group Medicare Advantage program.