_DBM_SLEOLA_MDOT-MTA_Medical_JointRFP_6FAs__FINAL_8.9.25_.pdf

DBM HEALTH PLAN ADMINISTRATION AND SERVICES RFP NO. F10B6600001 /

BPM051063; AND

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

ADMINISTRATION AND SERVICES RFP NO. AGY-24-026-SR-A / BPM051063

RFP Document

RFP for DBM OPSB AND MDOT-MTA Page 1 of 99

STATE OF MARYLAND

REQUEST FOR PROPOSALS (RFP)

DEPARTMENT OF BUDGET AND MANAGEMENT, OFFICE OF PERSONNEL

SERVICES AND BENEFITS (DBM OPSB)

HEALTH PLAN ADMINISTRATION AND SERVICES

[PREFERRED PROVIDER ORGANIZATION, SELF-FUNDED (PPO-SF) AND EXCLUSIVE

PROVIDER ORGANIZATION, SELF-FUNDED (EPO-SF); INTEGRATED HEALTH MODEL,

FULLY-INSURED (IHM-FI); AND POINT SOLUTIONS]

RFP NO.: F10B6600001 / BPM051063

AND

STATE LAW ENFORCEMENT OFFICERS LABOR ALLIANCE (SLEOLA) MEDICAL PLAN

ADMINISTRATION AND SERVICES (PPO, EPO, & POS, SELF-FUNDED)

RFP NO.: F10B6600004 / BPM051063

AND

MARYLAND DEPARTMENT OF TRANSPORTATION MARYLAND TRANSIT

ADMINISTRATION (MDOT-MTA)

MDOT-MTA REPRESENTED MEDICAL & STOP LOSS INSURANCE (PPO-SF AND HMO-

SF) AND VISION (SELF-FUNDED) PLAN HEALTH BENEFITS ADMINISTRATION AND

SERVICES

[PREFERRED PROVIDER ORGANIZATION, SELF-FUNDED (PPO-SF) AND HEALTH

MAINTENANCE ORGANIZATION, SELF-FUNDED (HMO-SF)]

RFP NO.: AGY-24-026-SR-A / BPM051063

ISSUE DATE: AUGUST 9, 2025

A Prospective Offeror that has received this document from a source other than eMarylandMarketplace

Advantage (eMMA) https://procurement.maryland.gov should register on eMMA https://emma.maryland.gov/

MINORITY BUSINESS ENTERPRISES ARE ENCOURAGED TO RESPOND TO THIS

SOLICITATION.

https://procurement.maryland.gov/ https://emma.maryland.gov/

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 2 of 99

STATE OF MARYLAND

DEPARTMENT OF BUDGET AND MANAGEMENT, OFFICE OF PERSONNEL SERVICES AND

BENEFITS (DBM OPSB)

DBM HEALTH PLAN ADMINISTRATION AND SERVICES (PPO-SF/EPO-SF, IHM-FI,

AND POINT SOLUTIONS)

AND

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES (PPO,

EPO, & POS, SELF-FUNDED)

AND

MDOT-MTA REPRESENTED MEDICAL (PPO-SF AND HMO-SF) AND VISION (SELF-

FUNDED) PLAN HEALTH BENEFITS ADMINISTRATION AND SERVICES

KEY INFORMATION SUMMARY SHEET

Request for Proposals Services DBM Health Plan Administration and Services

RFP NO. F10B6600001 / BPM051063

Functional Area 1: Preferred Provider Organization, Self-Funded (PPO- SF) and Exclusive Provider Organization, Self-Funded (EPO-SF) Functional Area 2: Integrated Health Model, Fully-Insured (IHM-FI) Functional Area 3: Point Solutions

AND

DBM SLEOLA Medical Plan Administration and Services

RFP NO. F10B6600004 / BPM051063

Functional Area 4: Preferred Provider Organization, Self-Funded (PPO- SF), Exclusive Provider Organization, Self-Funded (EPO-SF), and Point of Service Plan, Self-Funded (POS-SF)

AND

MDOT-MTA Represented Medical and Vision Plan Health Benefits Administration and Services

RFP NO. AGY-24-026-SR-A / BPM051063

Functional Area 5: Preferred Provider Organization, Self-Funded (PPO- SF) and Health Maintenance Organization, Self-Funded (HMO-SF) Medical Plan Benefits

Functional Area 6: Vision (Self-Funded) Plan Benefits

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 3 of 99

Solicitation Number: F10B6600001 / BPM051063 [DBM Health Plan] F10B6600004 / BPM051063 [DBM SLEOLA Plan]

AGY-24-026-SR-A / BPM051063 [MDOT-MTA MEDICAL/VISION

PLAN]

RFP Issue Date: August 9, 2025

RFP Issuing Office: Department of Budget and Management, Office of Personnel Services and Benefits (DBM OPSB or the "Department")

AND

Maryland Department of Transportation, Maryland Transit Administration

(MDOT-MTA)

Procurement Officer: Andrea R. Simmons 45 Calvert Street, Room 264 Annapolis, Maryland 21401

Email:

Phone Number(s):

Andrea.Simmons@maryland.gov O: (410) 260-7374 C: (443) 906-0136

Proposals are to be sent to:

Submit on eMMA.Maryland.gov under Solicitation Number:

F10B6600001 / F10B6600004 / AGY-24-026-SR-A / BPM051063

To submit a proposal, offerors must first register on emma.maryland.gov.

We recommend registering in advance to become acquainted with the site.

No Proposal Notice/Vendor Feedback Form

*If you are not submitting a proposal for this solicitation, submit Attachment 1 with your reasons why.

Pre-Proposal Conference:

August 18, 2025 @ 10 AM Local Time Virtual Teleconference (Login Information Provided by Procurement Officer Upon Receipt of Attachment 2) See Attachment 2 for instructions.

Questions Due Date and Time:

September 5, 2025 @ 3 PM Local Time

Proposal Due (Closing) Date and Time:

September 23, 2025 @ 10 AM Local Time Offerors are reminded that a completed Feedback Form is requested if a no-proposal decision is made (see Attachment 1 - No Proposal Notice/Vendor Feedback Form).

mailto:Andrea.Simmons@maryland.gov

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 4 of 99

MBE Subcontracting Goal:

DBM Health Plan Administration and Services

An overall Minority Business Enterprise (MBE) subcontract participation goal of 6% (PPO/EPO), 1.5% (IHM), and 1% (Point Solutions) percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, have been established for this procurement, as follows:

6%: Functional Area 1, Preferred Provider Organization, Self-Funded (PPO-SF) and Exclusive Provider Organization, Self-Funded (EPO-SF)

1.5%: Functional Area 2, Integrated Health Model, Fully-Insured (IHM-FI)

1%: Functional Area 3, Point Solutions

DBM SLEOLA Medical Plan Administration and Services

An overall Minority Business Enterprise (MBE) subcontract participation goal 6.1% percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, has been established for this procurement, as follows:

6.1%: Functional Area 4, Preferred Provider Organization, Self-Funded (PPO-SF), Exclusive Provider Organization, Self-Funded (EPO-SF), and Point of Service, Self-Funded (POS-SF)

MDOT-MTA Represented Medical and Vision Plan Health Benefits Administration and Services

An overall Minority Business Enterprise (MBE) subcontract participation goal 6% percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, has been established for this procurement, as follows:

6%: Functional Area 5, Preferred Provider Organization, Self-Funded (PPO-SF) & Health Maintenance Organization, Self-Funded (HMO-SF) Medical Plan Benefits, and Functional Area 6, Vision (Self-Funded) Plan Benefits

Refer to Exhibit 1 for information on how goal setting was determined.

Also, refer to Appendix 4 for information about the MBE program and goals.

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 5 of 99

VSBE Subcontracting Goal:

DBM Health Plan Administration and Services

An overall Veteran-Owned Small Business Enterprise (VSBE) subcontract participation goal 1% (PPO/EPO), 0.1% (IHM), and 0.5% (Point Solutions) percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, has been established for this procurement, as follows:

1% Functional Area 1: Preferred Provider Organization, Self-Funded (PPO-SF) and Exclusive Provider Organization, Self-Funded (EPO-SF)

0.1% Functional Area 2: Integrated Health Model, Fully-Insured (IHM-FI)

0.5% Functional Area 3: Point Solutions

An overall Veteran-Owned Small Business Enterprise (VSBE) subcontract participation goal 1% percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, has been established for this procurement, as follows:

1%: Functional Area 4: Preferred Provider Organization, Self-Funded (PPO-SF), Exclusive Provider Organization, Self-Funded (EPO-SF), and Point of Service Plan, Self-Funded (POS-SF)

MDOT-MTA Represented Medical and Vision Plan Health Benefits Administration and Services

An overall Minority Business Enterprise (MBE) subcontract participation goal 1% percentages (with no subgoals) of the Administrative Fees paid to the Contractor, including all renewal option terms, has been established for this procurement:

1%: Functional Area 5: Preferred Provider Organization, Self-Funded (PPO-SF) & Health Maintenance Organization, Self-Funded (HMO-SF) Medical Plan Benefits; and Functional Area 6: Vision (Self-Funded) Plan Benefits

Refer to Exhibit 1 for information on how goal setting was determined.

Also, refer to Appendix 5 for information about the VSBE program and goals.

Procurement Method: A Contract will be awarded in accordance with the Competitive Sealed Proposals method under COMAR 21.05.03.

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 6 of 99

Multiple or Alternate Proposals:

Multiple or alternate Proposals for a single Functional Area of this RFP will not be accepted. Please note, however, that submitting a Proposal for more than one Functional Area IS NOT considered to be multiple Proposals and is permitted unless otherwise specified in the RFP. See also §2.1.1.3.

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 7 of 99

Contract Type: DBM Health Plan Administration and Services

Functional Area 1 – PPO-SF and EPO-SF: Cost reimbursement (claims) contract, plus fixed fee for certain indefinite quantities. (COMAR 21.06.03.03, COMAR 21.06.03.02, and COMAR 21.06.03.06). Claims costs shall be reimbursable as provided in this RFP and administration fees shall be fixed as further described in the Financial Proposal Form, FA1 Appendix 2, identified as Apdx 2.FinProp FA1(PPO.EPO-SF) DBMHealth RFP.

Functional Area 2 – IHM-FI: Indefinite quantity with fixed unit prices (COMAR 21.06.03.02 and COMAR 21.06.03.06). Prices shall be fixed as further described in the Financial Proposal Form, FA2 Appendix 2, identified as Apdx 2.FinProp FA2(IHM-FI) DBMHealth RFP.

Functional Area 3: Point Solutions: Prices shall be as further described in the Financial Proposal Form, FA3 Appendix 2, identified as Apdx 2.FinProp FA3 (PtSol) DBMHealth RFP.

Functional Area 4 – PPO-SF, EPO-SF, and POS-SF: Cost reimbursement (claims) contract, plus fixed fee (administration fees) for certain indefinite quantities (COMAR 21.06.03.03, COMAR 21.06.03.02, and COMAR 21.06.03.06). Claims costs shall be reimbursable as provided in this RFP and administration fees shall be fixed as further described in the Financial Proposal Form, FA4 Appendix 2, identified as Apdx 2-FinProp FA4 SLEOLA RFP (combined financial).

MDOT-MTA Represented Medical and Vision Plan Health Benefits Administration and Services

Functional Area 5 – Medical Plan Benefit Administrative Fee: Shall be firm fixed price as further described in the Financial Proposal Forms, identified as Apdx 2.FinProp FA5 (Medical HMO Plans) and Apdx 2.FinProp FA5 (Medical PPO Plans).

Stop Loss Insurance – Insurance premium guaranteed for the initial 12 months and guaranteed renewal for each subsequent 12-months of the 5-year contract term and all optional renewal years as further described in the Financial Proposal Forms, identified as Apdx 2.FinProp FA5 (Medical HMO Plans) and Apdx 2.FinProp FA5 (Medical PPO Plans).

Functional Area 6 – Vision Plan Benefit Administrative Fee: Firm fixed price.

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 8 of 99

Network Access Fee – Firm fixed price as further described in the Financial Proposal Forms, identified as Apdx 2.FinProp FA6 (Medical Vision Plans).

Contract Duration: DBM Health Plan Administration and Services

Five (5) year base period, with two (2), three (3) year option periods.

NOTE: Run-out, audits, and reconciliation processes will conclude within 18 months of the last day of the last plan year covered by the Contract.

Five (5) year base period, with two (2), three (3) year option periods.

NOTE: Run‐out, audits, and reconciliation processes will conclude within 18 months of the last day of the last plan year covered by the Contract.

MDOT-MTA Represented Medical and Vision Plan Health Benefits Administration and Services Transition Period: Up to six (6) months Base Period: Five (5) years with two (2), three (3) year renewal option periods.

Primary Place of Performance:

As proposed by Offeror

SBR Designation: No

Federal Funding: No

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 9 of 99

TABLE OF CONTENTS – RFP

1 Minimum Qualifications

1.1 Offeror Minimum Qualifications, Functional Areas 1 and 2

1.2 Offeror Minimum Qualifications, Functional Area 3

1.3 Offeror Minimum Qualifications, Functional Area 4

1.4 Offeror Minimum Qualifications, Functional Areas 5 and 6

2 Contractor Requirements: Scope of Work

2.1 Summary Statement

2.2 Background and Purpose

2.3 Scope of Work – General Requirements and Responsibilities for All DBM Health Plan

Administration and Services Functional Areas (Functional Areas 1 – 4)

2.4 Scope of Work – General Requirements and Responsibilities for All MDOT-MTA

Represented Medical and Vision Plan Health Benefits Administration and Services, Functional Areas 5 & 6

3 Standard Terms and Conditions

3.1 Implementation Schedule

3.2 Implementation Schedule Functional Areas 1, 2, 3, & 4 Specifications – PPO-SF/EPO-SF, IHM-FI, and Point Solutions Attachments (DBM Health Plan Administration and Services) and PPO, EPO & POS Attachments (DBM SLEOLA Medical Plan Administration and Services)

3.3 Optional Service – Functional Area 1 Only (DBM Health Plan Administration and Services) 54

3.4 Contractor Experience and Personnel ~ Functional Areas 1, 2, 3, 4, 5, and 6

3.5 Contractor Experience and Personnel ~ ALL Functional Areas 1, 2, 4, 5, and 6 ONLY

3.6 Substitution of Personnel ~ All Functional Areas

3.7 Supplemental Category of Work Requirements and Responsibilities

3.8 Contract Initiation Requirements

3.9 End of Contract Transition

3.10 Return and Maintenance of State Data

3.11 Invoicing

3.12 Liquidated Damages

3.13 Problem Escalation Procedure

3.14 Work Orders

3.15 Payments by Electronic Funds Transfer

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 10 of 99

3.16 Prompt Payment Policy

3.17 Federal Funding Acknowledgement

3.18 Conflict of Interest Affidavit and Disclosure

3.19 Non-Disclosure Agreement

3.20 Maryland Healthy Working Families Act Requirements

3.21 The State of Maryland’s Commitment to Purchasing Environmentally Preferred Products and

Services (EPPs)

3.22 Insurance Requirements, Functional Areas 1 through 4

3.23 Insurance Requirements, Functional Areas 5 and 6

3.24 Technology Professional Liability Errors & Omissions, Functional Areas 5 and 6

3.25 General Insurance Provisions, Functional Areas 5 and 6

3.26 Non-Compete Clause Prohibition

3.27 NAIC 120-1 Model COB Contract Provisions

4 Proposal Submission Information and Instructions

4.1 eMaryland Marketplace Advantage (eMMA)

4.2 Electronic Means

4.3 Pre-Proposal Conference

4.4 Questions

4.5 Proposal Due (Closing) Date and Time

4.6 Economy of Preparation

4.7 Public Information Act Notice

4.8 Oral Presentation

4.9 Duration of Proposals

4.10 Revisions to the RFP

4.11 Cancellations

4.12 Incurred Expenses

4.13 Protest/Disputes

4.14 Offeror Responsibilities

4.15 Acceptance of Terms and Conditions

4.16 Compliance with Laws/Arrearages

4.17 Verification of Registration and Tax Payment

4.18 False Statements

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 11 of 99

5 Proposal Submission Information and Instructions

5.1 Two Part Submission

5.2 Proposal Delivery and Packaging

5.3 Volume I - Technical Proposal

5.4 Volume II – Financial Proposal

6 Evaluation and Selection Process

6.1 Evaluation Committee

6.2 Technical Proposal Evaluation Criteria

6.3 Financial Proposal Evaluation Criteria

6.4 Reciprocal Preference

6.5 Selection Procedures

6.6 Documents Required upon Notice of Recommendation for Contract Award RFP Attachments

(Table B)

7 RFP Appendices and Exhibits

7.1 Appendices (Table C)

7.2 Exhibits (Table D)

7.3 Exhibits (Table E)

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 12 of 99

1 Minimum Qualifications

1.1 Offeror Minimum Qualifications, Functional Areas 1 and 2

The Offeror must document in its Proposal that it satisfies the following Minimum Qualifications:

1.1.1 The Offeror shall be registered as a Third-Party Administrator (“TPA”) with the Maryland Insurance Administration under Md. Ann Code, Insurance Art., Title 8, Subtitle 3.

1.1.1.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal a copy of its current registration as a TPA with the Maryland Insurance Administration.

1.1.2 The Offeror shall have at least three (3) years of experience providing Health Plan Administration services for more than 25,000 active employees per year and an established national network of Providers, including Family/General Practice, General Internal Medicine, Pediatrics, OB/GYN, and Hospitals.

1.1.2.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal one (1) reference showing proof of having provided Health Plan Administration services for at least one (1) group with more than 25,000 active employees for at least three (3) years utilizing its established national network of Providers.

1.2 Offeror Minimum Qualifications, Functional Area 3

The Offeror must document in its Proposal that it satisfies the following Minimum Qualifications:

1.2.1 The Offeror shall have at least three (3) years of experience providing at least one (1) Point Solution (as defined in Appendix 1, MMM) for more than 25,000 active employees per year.

1.2.1.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal one (1) reference showing proof of having provided at least one (1) Point Solution for at least one (1) group with more than 25,000 employees for at least three (3) years.

1.2.2 The Offeror shall have experience providing at least one (1) Point Solution (as defined in Appendix 1, MMM) for a public sector entity with more than 25,000 active employees.

1.2.2.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal one (1) reference showing proof of having provided at least one (1) Point Solution for a public sector client with more than 25,000 active employees.

1.2.3 The Offeror shall have at least one (1) third-party independent evaluation of the effectiveness of each Point Solution, as identified and submitted in response to §1.2.1.1.

1.2.3.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal a copy of a prior third-party independent evaluation evidencing the effectiveness of each Point Solution, as identified and submitted in response to §1.2.1.1.

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 13 of 99

1.2.4 The Offeror shall have completed at least one (1) case study, with client names and tangible results qualified, on each Point Solution, as identified and submitted in response to §1.2.1.1.

1.2.4.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal a discussion of its case study, with client names and tangible results qualified, on each Point Solution, as identified and submitted in response to §1.2.1.1

1.3 Offeror Minimum Qualifications, Functional Area 4

The Offeror must document in its Proposal that it satisfies the following Minimum Qualifications:

1.3.1 The Offeror shall be registered as a TPA with the Maryland Insurance Administration under Md. Ann. Code, Insurance Art., Title 8, Subtitle 3.

1.3.1.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal proof of registration as a TPA with the Maryland Insurance Administration.

1.3.2 The Offeror shall have at least five (5) years of experience providing Medical Plan Administration services for more than 5,000 employees per year and an established national network of Providers.

1.3.2.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal proof of providing services for at least one group with more than 5,000 employees for five (5) years or more.

1.4 Offeror Minimum Qualifications, Functional Areas 5 and 6

The Offeror must document in its Proposal that it satisfies the following Minimum Qualifications:

1.4.1 The Offeror shall be licensed in the State of Maryland at the time of proposal submission to provide the medical plan healthcare services outlined in this RFP.

1.4.1.1 Required Documentation: As proof of meeting this requirement, the Offeror shall provide with its Proposal a copy of its Certificate of Authority issued by the Maryland Insurance Administration for the type of plan(s) proposed, available as follows:

https://www.apps.insurance.maryland.gov/CompanyProducerInfo/InsCompanySearch.aspx?NAV=

HOME.

THE REMAINDER OF THIS PAGE IS INTENTIONALLY LEFT BLANK.

https://www.apps.insurance.maryland.gov/CompanyProducerInfo/InsCompanySearch.aspx?NAV=HOME https://www.apps.insurance.maryland.gov/CompanyProducerInfo/InsCompanySearch.aspx?NAV=HOME

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 14 of 99

2 Contractor Requirements: Scope of Work

2.1 Summary Statement

2.1.1 Functional Areas 1, 2, & 3

The DBM OPSB is issuing this RFP to procure the goods or services, as specified in this Section 2, from a contract between the selected offeror(s) and the State of Maryland (“State”), DBM OPSB.

DBM OPSB seeks to obtain Health Plan Administration and Services for eligible members and their dependents as part of the State of Maryland Employee and Retiree Health and Welfare Benefits Program (the “Program”) beginning with the anticipated plan year effective January 1, 2027. The State’s goal is to offer a full complement of benefits in order to attract and retain valued employees as well as ensure their long-term health and well-being. In addition, the State is seeking to partner with selected Offeror(s) in order to refine and update the State’s wellness program in 2027 and beyond. To this end, the State would like to establish specific performance metrics in coordination with selected Offeror(s) in order to drive efficiencies and improve participant experience with the Program.

It is the State’s intention to obtain goods and services, as specified in this RFP, from a contract between the selected Offeror and the State for services to be provided for the following functional areas:

Functional Area 1 – Preferred Provider Organization, Self-Funded [PPO-SF] and Exclusive Provider Organization, Self-Funded [EPO-SF]

Functional Area 2 – Integrated Health Model, Fully Insured [IHM-FI]

Functional Area 3 – Point Solutions

2.1.2 Functional Area 4

The DBM OPSB is also issuing this RFP in order to obtain medical insurance benefits for members of the State Law Enforcement Officers Labor Alliance (SLEOLA) and their dependents. The scope of this RFP is to provide medical benefits plans for eligible members of SLEOLA and their dependents as part of the Program beginning with the anticipated plan year effective January 1, 2027.

The State’s goal is to offer a full complement of benefits in order to attract and retain valued employees as well as ensure their long-term health and well-being.

DBM OPSB is requesting service be provided for the following functional areas:

Functional Area 4:

Preferred Provider Organization, Self-Funded [PPO-SF], Exclusive Provider Organization, Self-Funded [EPO-SF], and

Point of Service Plan, Self-Funded [POS-SF]

2.1.3 DBM OPSB intends to award each Functional Area, as a result of this RFP, as follows:

2.1.3.1 Up to two (2) awards for Functional Areas 1 and 2; and

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 15 of 99

2.1.3.2 One (1) award for Functional Area 4.

2.1.3.3 If awarded, Functional Area 3 will be awarded on a separate timeline from the remaining

Functional Areas (with a likely effective date later than January 1, 2027) and there is no limit to the number of potential awards.

2.1.3.4 If an Offeror submits a proposal for Functional Areas 1, 2, or 4, it IS NOT eligible to submit a proposal for Functional Area 3. Conversely, if an Offeror submits a proposal for Functional Area 3, it IS NOT eligible to submit a proposal for Functional Areas 1, 2, or 4.

2.1.3.5 See RFP § 6.5 Selection Procedures for more Contract award information.

2.1.3.6 The Segal Company (Eastern States), Inc. and Managed Care Advisors, as the State’s benefits consultants for DBM, will be assisting the State in this procurement.

2.1.3.7 A Contract award does not ensure a Contractor will receive all or any State business under the

Contract.

2.1.3.8 Maryland State and local entities as defined in Finance and Procurement 13-110(a)(5)(i) and not-for-profit entities within the State of Maryland may purchase from the Contractor goods or services covered by the Contract at the same prices chargeable to the State. All such purchases by non-executive branch entities, non-State governments, government agencies or not-for-profit entities.

A. Shall constitute Contracts between the Contractor and that government, agency or not-for-profit entity;

B. Shall not constitute purchases by the State or State agencies under the Contract;

C. Shall not be binding or enforceable against the State; and D. May be subject to other terms and conditions agreed to by the Contractor and the purchaser.

2.1.3.9 All Contract prices, terms, and conditions must be provided to any Maryland local government or not-for-profit entity requesting services under the Contract. The Contractor bears the risk of determining whether or not a government, agency or organization with which the Contractor is dealing is a State entity.

2.1.4 Functional Areas 5 & 6

The Maryland Department of Transportation Maryland Transit Administration (MDOT-MTA) is issuing this Request for Proposals (RFP) to obtain medical and vision plan health benefits and administration services for its represented employees, retirees, and their eligible dependents, in accordance with MDOT-MTA’s Collective Bargaining Agreements. The coverage includes services to be provided for a Medical PPO and HMO Plan (Functional Area 5) and a Vision Plan (Functional Area 6).

MDOT-MTA is requesting service be provided for the following functional areas:

Functional Area 5 – Preferred Provider Organization, Self-Funded Plan [PPO-SF] and Health Maintenance Organization, Self-Funded Plan [HMO-SF]

Functional Area 6 – Vision Plan

2.1.4.1 MDOT-MTA intends to award Functional Areas 5 & 6, as a result of this RFP, as follows:

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 16 of 99

2.1.4.1.1 One (1) for Functional Areas 5 and 6.

2.1.4.1.2 It is the State’s intention to obtain goods and services, as specified in this RFP, from a

Contract between the selected Offeror(s) and the State.

2.1.4.1.3 MDOT-MTA intends to award one (1) Contract as a result of this RFP for both Functional

Areas 5 and 6. See RFP § 6.5 Selection Procedures for more Contract award information.

2.1.5 All health benefits resulting from this RFP shall be effective January 1 to December 31 during the term of the Contract.

2.1.6 An Offeror, either directly or through its subcontractor(s), must be able to provide all goods and services and meet all of the requirements requested in this solicitation and the successful Offeror (the Contractor) shall remain responsible for Contract performance regardless of subcontractor participation in the work.

2.2 Background and Purpose

2.2.1 DBM Health Plan Administration and Services

2.2.1.1 The State is seeking proposals from qualified Offerors to provide DBM Health Plan Administration and Services (Functional Areas 1 and 2) that will include services for medical network administration, claims administration, and population health management (to include case management, utilization review, disease management, and wellness program).

2.2.1.2 The State is also seeking proposals from qualified Offerors to provide Point Solutions (Functional Area 3) as defined in Appendix 1, Abbreviations and Definitions. The State may decide to award multiple Point Solutions contracts or may not award a contract for Point Solutions during this RFP solicitation process.

2.2.1.3 The State provides an expansive range of employee benefit plans to approximately 71,000 Active Employees, 9,000 non-Medicare Retirees, 44,000 Medicare-Eligible Retirees, 3,200 Satellite Account Employees, 2,200 Direct Pay Enrollees, and their covered dependents.

Benefit plans include health (including behavioral health), dental, group term life, accidental death and dismemberment, flexible spending accounts, and prescription drugs. These benefits are offered to a diverse workforce that include clerical, administrative, technical, professional, maintenance, educational (State colleges and universities), public safety, and appointed and elected officials at multiple worksites across the State.

2.2.1.4 The State currently offers its members two (2) self-funded Preferred Provider Organization (PPO) plans, two (2) self-funded Exclusive Provider Organization (EPO) plans, and one (1) fully insured Integrated Health Management (IHM) plan, as follows:

Vendor Plan Type Funding Arrangement

CareFirst of Maryland, Inc. PPO, EPO Self-Funded

United Health Care Services, Inc. PPO, EPO Self-Funded

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. IHM Fully-Insured

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 17 of 99

2.2.1.5 There are approximately 144,200 Members eligible for the State’s medical plans. There are approximately 128,970 currently enrolled in the medical plans, as follows:

Vendor PPO EPO IHM

CareFirst of Maryland, Inc. 50,420 55,220 --

United Health Care Services, Inc. 7.850 11,590 --

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

-- -- 3,890

2.2.1.6 Participants currently receive State-subsidized medical benefit coverage. The State currently provides a subsidy at 85% of premium rates for EPO and IHM plans and 80% for PPO plans.

The State reserves the right to change the employee contribution structure prior to or during the contract period. Summaries of current plan coverage for both Active Employees and retirees are provided on the DBM website:

https://dbm.maryland.gov/benefits/Pages/MedicalPlansalt.aspx

Summaries of the current and proposed designs for the medical plans are provided in FA1 Exhibit 5-3: Self-Funded PPO and EPO Plan Designs, FA2 Exhibit 5-3: Fully-Insured IHM Plan Design, FA3 Exhibit 5-3: Services Requested, and FA4 Exhibit 5-3: SLEOLA Self- Funded PPO, EPO and POS Plan Designs. Offerors shall clearly and explicitly delineate, in Exhibit 5-2: Explanations and Deviations of each applicable Functional Area, any deviations between the coverage being proposed and the State's plan design as contained in this RFP.

Otherwise, the Offeror's submission of a proposal will be considered the Offeror's agreement to provide all proposed plan provisions, as specified in this RFP.

2.2.1.7 The State’s Contracts with the current Contractors performing medical claim administration services expire on December 31, 2026. For Functional Areas 1 & 2, the Offeror(s) awarded the Contracts pursuant to this RFP will be required to provide services with effective dates of coverage beginning January 1, 2027 through December 31, 2031, with a start-up implementation period prior to January 1, 2027 according to the schedule in §3.1.1.1. Upon Board of Public Works approval, the Contractor(s) shall begin the necessary implementation services in the second quarter of calendar year 2026.

2.2.1.8 The State of Maryland currently has a wellness program in place including the completion of wellness activities and screenings in order to earn copay reductions. Calendar year 2025 wellness activities are shown at the following link:

https://dbm.maryland.gov/benefits/Documents/CY25%20Wellness%20Plan%20Activities.pdf

Additionally, current medical carriers are required on an annual basis to provide reporting on various clinical compliance metrics, including diabetes, hypertension, hyperlipidemia, preventive screenings, and utilization rates as noted in Exhibit 5. Beginning in 2027, the State would like to partner with carriers to refine and update the State’s wellness program.

2.2.1.9 Each plan year begins on January 1 and runs to the succeeding December 31. An annual open-enrollment period is held each year, with elections generally for all plans. Plan enrollment is conducted in accordance with cafeteria plan (Internal Revenue Code Section https://dbm.maryland.gov/benefits/Pages/MedicalPlansalt.aspx https://dbm.maryland.gov/benefits/Documents/CY25%20Wellness%20Plan%20Activities.pdf

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 18 of 99

125 ~ Cafeteria Plans) regulations. New employees shall elect or waive coverage within the first 60 calendar days of hire. Mid-year coverage election changes may be made within 60 calendar days of a qualifying event, as that term is defined in Internal Revenue Code Section 125.

2.2.1.10 Due to the large number of State employees, a diverse population, and numerous employee work locations, the State sponsors annual benefit fairs during each annual open enrollment period. The State expects to conduct up to 60 open enrollment and health fairs plus 40 or more annual wellness events throughout the State each year to answer employee and retiree questions and enhance engagement in the plans offered. The Contractor(s) shall be required to attend all open enrollment health fairs and wellness events, both in-person and virtually when specified. The State reserves the right to adjust the number of events if needed. The selected Contractor(s) for Functional Area 3 shall participate in these benefit and wellness fairs to educate the population on its services.

2.2.1.11 For Functional Area 1, the State may or may not decide to add a High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA) as part of this procurement. Providing administration for an HDHP with HSA at an additional cost to the State is an optional service further explained in RFP § 3.3.

2.2.1.12 Functional Area 3 is designed with flexibility that allows offerors to propose multiple services and is provided to allow the State the flexibility to select best in class vendors for various services. Due to the unique nature of this functional area, while also recognizing the different structures of pricing for Point Solutions, the State will evaluate this Functional Area with a different evaluation structure. Technical evaluations will be conducted by the Point Solution proposed (individual programs or combined programs) based on the most urgent needs of the State’s population. This means that the State may review all proposals received for a specific Point Solution category prior to evaluating all other proposed Point Solution categories. Examples include diabetes, infertility, cancer, weight management, and chronic disease management, or women's health.

2.2.1.13 The State reserves the right to award any Point Solution in whole or in part, if proposals suggest that doing so would be in the State’s best interest. The State also reserves the right to issue multiple awards, no award, or to cancel or alter the procurement at any time, and to extend the Duration of Proposals (see RFP § 4.9), if needed. The State recognizes that factors other than cost are important to the ultimate selection of the provider or providers of the services set forth in the RFP. A contract award shall not be based solely on cost, but on the evaluation of the full package of capabilities, cost, and guaranteed outcomes as set forth in the RFP.

2.2.1.14 Offerors are required to select the applicable components of coverage for which they are submitting a proposal and would meet the minimum qualifications. Offerors who are determined to have met the minimum qualifications will be evaluated.

Based on the initial technical proposal evaluations, the State may choose qualified Offerors to move forward with in the evaluation. If proposals for certain Point Solution categories require additional information, Offerors may be invited to participate in oral presentations for specific Point Solution categories. Oral presentations may include a request for online demonstrations to view the differences in technology, content, and Members experience

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 19 of 99 between Offerors. This important step may be necessary for the State to understand the differences in pricing structures.

2.2.2 DBM SLEOLA Medical Plan Administration and Services

2.2.2.1 The State provides an expansive range of employee benefit plans to approximately 1,600 active SLEOLA employees and their covered dependents.

2.2.2.2 Current benefit plans include medical (including behavioral health and vision), dental, optional term life, optional accidental death and dismemberment, flexible spending accounts, and prescription drug.

2.2.2.3 These benefits are offered to public safety personnel at more than 200 different worksites.

2.2.2.4 Due to the large number of SLEOLA employees, diverse population and numerous employee work locations, the State sponsors annual benefit fairs during each annual open enrollment period. The State expects to conduct up to 60 open enrollment and health fairs plus 40 or more annual wellness events throughout the State each year to answer employee and retiree questions and enhance engagement in the plans offered. The Contractor(s) shall be required to attend all open enrollment health fairs and wellness events, both in-person and virtually when specified. The State reserves the right to adjust the number of events if needed. The State reserves the right to adjust the number of events if needed.

2.2.2.5 The State is seeking Contractors that can provide the best-in-class Medical Plan administration and services and together with the State, support overall member health improvement and increase access to quality care and efficiency of service delivery.

2.2.2.6 The scope of this RFP is to provide administrative and nationwide provider network management services for eligible Participants of the SLEOLA’s employee medical benefits program beginning with the anticipated plan year effective January 1, 2027.

2.2.2.7 The State of Maryland currently offers its SLEOLA Members one (1) self-funded Preferred Provider Organization (PPO) plan, one (1) self-funded Point-of-Service (POS) plan, and one

(1) self-funded Exclusive Provider Organization (EPO) plan, as follows:

Current Contractor Plan Type Funding Arrangement

CareFirst of Maryland, Inc. PPO, POS, EPO Self-Funded

2.2.2.8 There are approximately 1,600 Members enrolled in the State’s SLEOLA medical plans. The percentages enrolled by current plan type are, as follows:

Plan Type Percent Enrolled

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 20 of 99

Preferred Provider Organization (PPO) 60%

Exclusive Provider Organization (EPO) 28%

Point of Service (POS) 12%

2.2.2.9 The State currently provides a subsidy of 80% of premium rates for EPO, 78% for POS, and 75% for PPO. The State reserves the right to change the employee contribution structure prior to or during the contract period. Summaries of current plan coverage for Active Employees are provided on the DBM website:

http://dbm.maryland.gov/benefits/Pages/SLEOLA.aspx.

2.2.3 MDOT-MTA Represented Medical [PPO & HMO] and Vision [Self-Funded] Plan Health Benefits and Services

2.2.3.1 The Maryland Transit Administration (MTA) is a division of the Maryland Department of Transportation (MDOT), and one of the largest multi-modal transit systems in the United States. MDOT-MTA directly operates local buses, metro subway, light rail, and mobility transit services in Baltimore City and surrounding counties. MDOT-MTA also contracts with several companies to operate statewide and commuter bus services, mobility services, and commuter rail services ("MARC").

2.2.3.2 MDOT-MTA has approximately 2,510 benefit-eligible employees currently, with authorization to fill an additional 150 positions. There are approximately 2,200 active pensioners (retirees).

2.2.3.3 Not all employees and retirees are enrolled in the MDOT-MTA plans.

2.2.3.4 Medical and Vision benefits are a standard and important component of the MDOT-MTA employee benefits package. Please note that the enrollment information shown in this section is inclusive of primary subscriber enrollment only and does not reflect dependent enrollments.

2.3 Scope of Work – General Requirements and Responsibilities for All DBM Health Plan Administration and Services Functional Areas (Functional Areas 1 – 4)

2.3.1 General Requirements for Functional Areas 1, 2, & 4 (DBM Health Plan Administration and Services)

2.3.1.1 Contractor(s) shall permit all eligible Members, as determined by the State, to obtain health insurance benefits for themselves and their eligible Dependents.

2.3.1.2 Contractor(s) shall establish a no loss and no gain provision: All Members and Dependents covered under the prior plan as of December 31, 2026 shall be covered as of January 1, 2027.

2.3.1.3 Contractor(s) shall ensure that no administrative functions required under this Contract may be performed offshore.

http://dbm.maryland.gov/benefits/Pages/SLEOLA.aspx

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 21 of 99

2.3.1.4 Contractor(s) shall establish and provide a state-of-the-art customer service operation (including a dedicated toll-free phone number) available to plan Participants (both in-state and out-of-state) 24/7, staffed by live customer service representatives during the core hours, 7 am – 11 pm Local Time, seven (7) days a week at no additional charge. Note: This may be the same operation as provided for State employees, retirees, and Dependents under another active State contract, if applicable.

2.3.1.5 This dedicated toll-free customer service line shall be supported during the hours stated above by an automated voice-response system twenty-four (24) hours a day, seven (7) days a week. Participants (both in-state and out-of-state) can access this system directly to request and receive service authorizations or other pertinent data.

A. This operation should comply with PG-1 and PG-2, in "FA1, FA2, & FA4 of Exhibit 5- 12: Performance Guarantees.” Note: This may be the same operation as provided for Active Employees, Retirees, and Dependents under another active State contract.

B. During live customer service hours, the automated voice-response answering system shall include an automated answering system that picks up within 30 seconds and directs Participants into a queue to be serviced and shall allow the Participant to opt-out to a live representative at any time during the call.

C. During live customer service hours, a live service representative (with knowledge of State of Maryland’s account) shall pick up within 30 seconds and shall be able to address the Member’s concerns.

D. The customer service operation shall include:

1. Knowledgeable staff available to answer questions on plan eligibility, plan guidelines, benefit levels, and claims procedures.

2. The ability to access eligibility data that identifies eligible Participants and supporting demographic information.

3. A system for providing Explanations of Benefits, compliant with all current and future regulations, to eligible Participants detailing payments to facilities and providers for services rendered and the amounts applicable to each service.

4. A procedure for handling emergency requests and non-office hour admissions.

5. An integrated claims and customer service system enabling both claims and service team members to view all screens.

6. Adequate access to the customer service system for individuals with disabilities. (At a minimum, TTY and online access for deaf, full-service phone access for blind). In this context, full-service means that a live customer service representative may assist a Member or Retiree with any task (such as PCP selections) which ideally could be managed online; e.g. individuals with a sight or low vision disability.

7. The ability to track wellness activities.

8. The ability to track activities related to the All-Payer Health Equity Approaches and Development (AHEAD) Model, as noted in “Exhibit 5-13: AHEAD Model.”

DBM SLEOLA MEDICAL PLAN ADMINISTRATION AND SERVICES RFP NO.

SOLICITATION #: F10B6600004 / BPM051063; AND

MDOT-MTA REPRESENTED MEDICAL AND VISION PLAN HEALTH BENEFITS

RFP for DBM OPSB AND MDOT-MTA Page 22 of 99

2.3.1.6 Contractor(s) shall establish on-line web and mobile app access for Members to securely access plan information, participating providers, claim status and history of processed claims by October 1, 2026. This website shall include tools to enable Members to understand their financial responsibility for medical services, including out-of-pocket costs, co-pays, and coverage limitations. This website will be linked to the State’s internet home page.

2.3.1.7 Contractor(s) shall accurately convert enrollment data files, including the master enrollment file and any other relevant files, to the Contractor's data system. These files are securely transmitted in HIPAA 834 format.

2.3.2 General Requirements for Functional Areas 1, 2, & 4 (DBM Health Plan Administration and Services)

2.3.2.1 Contractor(s) shall provide Participant support services live and online for selecting and locating network physicians.

2.3.2.2 Contractor(s) shall provide online access to up-to-date network provider listings and locations to assist Participants with provider selection, including quality performance and outcome ratings, and other services with regard to provider selection. In so doing, Contractor(s) shall meet and comply with all requirements of Section 2799A-5 of the Public Health Service Act (42 U.S.C. 300gg-115).

2.3.2.3 Contractor(s) shall notify plan Participants, in writing, with at least sixty (60) calendar days advance notice, in the event the contract for a Participant's network physician terminates for any reason. The State shall review and approve the communications before release to Participants.

2.3.2.4 Contractor(s) shall notify the State, in writing, with at least seventy-five (75) calendar days advance notice or within three (3) Business Days upon notification if less than seventy-five

(75) calendar days, in the event the contract for a practice group or physician terminates for any reason.

2.3.2.5 Contractor(s) shall have a procedure in place to allow the State or plan Participants to nominate providers to be considered for inclusion in the network.

2.3.2.6 Contractor's physician and hospital contracts shall have a "continuity of care" clause which states if a physician or hospital cancels or fails to renew their contract, care which began with a network provider shall continue to be provided and reimbursed as a network provider in accordance with all current and future federal legislation, including but not limited, to Section 113 of the Consolidated Appropriations Act, 2021, codified under the Public Health Service Act, 42 U.S.C. § 300gg-138.

2.3.2.7 Contractor(s) shall maintain its established process for Participants to contact customer service to determine the maximum allowance for a specific procedure in advance of having the procedure performed.

2.3.2.8 Contractor(s) shall confirm procedures are in place for ensuring a network provider does not bill Participants or the plan sponsor any amount in excess of the network allowance.

2.3.2.9 Contractor(s) shall ensure its contracts with network providers prohibit providers…