Dental and Vision Addendum.pdf

Phone: (o)850-983-5130 E-mail: pavlicekw@santarosa.k12.fl.us

Website:

https://sites.santarosa.k12.fl.us/purchasing/

6544 Firehouse Road, Milton, Florida 32570-3411

Purchasing Agent Wesley Pavlicek

Amendment to RFP 23-06-WP Insurance Worksite Products Scope of Work

Date: 04/17/2023

RE: RFP 23-06-WP Insurance Worksite Products

The scope of work now includes the addition of Group Dental and Group Vision coverage for Santa Rosa County District Schools. Scope of Coverage and Scope are services will be as follows:

SCOPE OF COVERAGE (Dental) The School Board is interested in proposals for plan designs that most closely match the School Board’s current plan designs: High Option PPO dental plan and Low Option PPO dental plan.

SCOPE OF SERVICES (Dental) The successful Proposer shall perform all services indicated below, including Managed Care Services, Administrative Services and Additional Services. Proposals must include claims administration, network access and utilization review services. Any sub-contracted services to be provided in connection with these requirements must be identified in the proposal.

All proposals should include copies of any contract which the School Board will be required to execute. All proposals should include copies of standard communication materials that are sent to members, such as explanation of benefit (EOB) type forms.

MANAGED CARE SERVICES

Proposer should maintain a provider managed care network consisting of dentists in the following counties: Santa Rosa, Escambia and Okaloosa. These arrangements should:

1. Provide services with reasonable promptness with respect to geographical location, hours of operation, and after hour care.

2. Contract with network physicians that:

a. Hold appropriate occupational and professional licenses;

b. Hold active and unrestricted privileges in their specialty;

c. Have a valid Drug Enforcement and Administration (DEA) number and hold unrestricted prescribing privileges;

d. Have not been convicted of a felony or greater crime;

e. Are specialty board certified (80% or greater); and

f. Have not been suspended, placed on probation or restricted from receiving payments from Medicare, Medicaid, or other third party programs during the last five years

3. Provide a network that includes the following most utilized services:

mailto:pavlicekw@santarosa.k12.fl.us

(1) General Dentistry

(2) Pediatric Dentistry

(3) Periodontal

(4) Endodontal

(5) Orthodontists

(6) Oral Surgeons Provider network should not count dentist with more than one office multiple times as this practice falsely inflates network participation.

4. Provide a network consisting of providers that have the capacity to provide treatment throughout the state of Florida.

5. Provide the School Board with information relative to network discounts that the Proposer receives from local providers.

6. Provide employees with on-line access to current directory information and printed copies upon request.

7. Require that network providers hold the employees/dependents and the School Board harmless from any fees for services which are rendered that are plan eligible charges (except deductibles, co-payments and coinsurance), regardless of the reason for non-payment.

8. Prohibit network providers from balance billing the patient for any excess of contracted amount, except for deductibles, co-payments and coinsurance.

9. Dental Plan highlights should include the following:

a. All services paid at Fee Schedule Allowance. Would like alternate rates based on 90% of usual and customary.

b. Optional waive preventive charges from annual maximum

c. Match current annual maximum and provide alternates for $1,500

d. Annual calendar year deductible of $50.00 single and $150.00 family (does not apply to Type 1 services).

e. Cleanings 2x in 12-month period. Alternates of 4x per year will be considered.

f. Orthodontia for child only. Optional orthodontia for adult and child.

g. Include Panoramic x-ray under Type 1 services.

h. Waiting period applies to late entrants only.

i. Maximum Allowable Charge (MAC) will be considered. Fee schedule must be included in RFP.

ADMINISTRATIVE SERVICES

Except for the collection of premiums to the successful Proposer and, as except otherwise noted in this RFP, the successful Proposer shall be totally responsible for the administration of the plan. These activities should include, but are not limited to, the following:

1. Subject to the exercise of professional judgment, the successful Proposer shall accept and settle or deny all reported claims. Successful Proposer will also be responsible for adjudication of claims appeals.

2. Furnish an electronic version of the certificates/booklets for the School Board to use on their website.

3. Issue ID cards within three (3) calendar weeks (plus four (4) days’ mailing time) after completion of open enrollment periods or after new hire electronic enrollment records are received. ID cards will be mailed directly to members.

4. Establish claims reporting procedures that are compatible with the needs and organizational structure of the School Board.

5 Provide enrollment assistance, including educational materials pre-approved by the School Board in advance of distribution, to the School Board during open enrollment period on an annual basis. These tasks may include requiring Proposer representatives to attend scheduled benefit/enrollment meetings if needed.

6. Assign a staff person as the School Board’s account representative.

7. Meet with the District Insurance Committee as needed to discuss the status of the plan, performance, audits, reports, and planning.

8. Attend School Board meetings, if requested by the School Board.

9. Verify claimant’s eligibility for benefits based on eligibility requirements furnished by the School Board.

10. Maintain covered dependent information by dependent’s name, date of birth, gender, and relationship to insured and social security number.

11. Prepare a monthly report on any covered dependents (excluding dependents who are mentally and physically handicapped) who will be turning age 30 the following month. Provide a copy of this report to the School Board within five (5) working days from the end of the reporting period.

12. The Patient Protection and Affordable Care Act (PPACA) requires benefit plans that provide coverage for dependents to cover adult children to age 26*. This applies to all group health plans and issuers of group or individual insurance, including fully insured and self-funded plans. In general, coverage must be allowed to continue until the child reaches the age of 26. The obligation to make dependent coverage available to children ends the day before the child’s 26th* birthday.

*Although PPACA only requires coverage up to age 26, the School Board desires to continue coverage up to age 30.

13. Use fully automated online clinically-oriented claims adjudication and auditing system that analyzes coded claims data to ensure correct identification.

14. Identify and maintain separate Coordination of Benefits COB information for each applicable claimant, as well as distinguish between the various types of COB.

15. Maintain the confidentiality requirements of Florida law by having adequate systems security features.

16. Turnaround 95% of all "clean" claims within ten (10) working days and 100% of all claims within thirty (30) working days. A “clean” claim is a claim submitted with all needed information for proper processing and adjudication.

17. Issue EOBs (print or electronic version) to the claimant within five working days of processing claims.

19. Prepare and furnish the School Board with quarterly exposure and loss data statistics. Loss data reports should include, but not be limited to, the following information: (Data subject to compliance with HIPAA privacy guidelines.)

a. Report should show claims data on a monthly basis for current plan year with cumulative totals, separately for participants in each plan offered, preferably in a format that will provide data separately for employees and their dependents, retirees and their dependents and COBRA and their dependents, and total for all participants and all dependents. Claim reports should be provided additionally for 12 months after plan termination or until there are no run-out and/or extension of benefits claims.

b. Claims data should be provided monthly detailing all claims where more than annual maximum has been paid in the current plan year. Data should indicate type of plan participant (employee, dependent, retiree, etc.).

20. Identify and pursue claims that should be properly payable through automobile insurance and/or coordination of benefits (COB). Additionally, report on the savings produced.

21. Provide COBRA and HIPAA administration and pay COBRA beneficiary claims.

22. Establish and maintain a toll-free line for employees. This line should be operational from at least 8 a.m. to 6 p.m. (Central Standard Time). A voice mail system or equivalent system should be available to take off-hour or weekend calls.

23. Administer the plan on a detail billing remittance basis by division, separated by active employee, retiree and COBRA beneficiary.

24. Conform accounting procedures and practices to generally accepted accounting principles.

25. Maintain proper records for tax reporting purposes.

26. Retain dental claims history online for minimum of 24 months.

27. Prepare, maintain, and file with any applicable federal, state or local governmental agencies, any forms or reports as may be required from time to time by law.

28. Provide assistance with regard to: (1) problems arising in connection with insurance laws, (2) tax aspects of the Plan, (3) litigation arising out of the administration of the Plan, and (4) any other legal matters that may arise in the course of the operation of the Plan.

29. Establish claim denial and grievance procedures which are clearly communicated to members.

Grievance procedures should be consistent with all applicable federal and state laws, rules and regulations. Proposer will be responsible for adjudication of claims appeals/grievances.

ADDITIONAL SERVICES

1. Supply all postage required to service the School Board’s account.

2. Provide an EOB that meets with the School Board's approval that uses a format and terminology such that a person not of an insurance background can easily understand the content.

3. Send correspondence using School Board approved pre-formatted letters to the claimant or provider. The content of these letters must be easily understandable by a person not of a medical or insurance background.

4. The School Board will have first review and pre-approval of any correspondence that will be sent to claimants or providers that includes changes/amendments to the plan.

5. Maintain all records of business transacted in accordance with this RFP. At the end of the contract period, all documents, papers, records, canceled checks and claims history shall be captured in such a manner for media storage and delivered to the School Board.

6. Provide access to archived data within ten (10) working days of a request by the School Board.

PERFORMANCE GUARANTEES

Proposers should confirm that they are willing to offer performance guarantees and that they are willing to permit the School Board access to claims offices, personnel and files to conduct audits necessary to verification of performance standards. Performance may be evaluated on a variety of issues, such as:

Timely delivery of finalized contracts for the selected program.

Timely delivery of identification cards, at and subsequent to initial enrollment.

Timely delivery of plan documents.

Claims turnaround time Accuracy of claims coding and payments.

Telephone response time and abandonments.

Quality of service to plan participants, as measured by periodic surveys.

Quality and timeliness of claims experience reports.

Network provider participation, with penalties for drops below pre-specified levels.

Rate of provider turnovers.

Access to standards of care.

Collection or other threats to participants by providers not paid by the insurer.

Please confirm your firm’s willingness to enter into such an agreement and to negotiate appropriate terms and recommend appropriate incentives or disincentives (meaningful penalties) to make the performance guarantee practical.

Include Group Dental in proposal as -- Tab 9

SCOPE OF COVERAGE (Vision) The School Board is interested in proposals for plan designs that most closely match the School Board’s current vision plan design.

The School Board reserves the right to negotiate with proposer finalist(s) on alternative designs.

SCOPE OF SERVICES (Vision) The successful Proposer shall perform all services indicated below, including Managed Care Services, Administrative Services and Additional Services. Proposals must include claims administration, network access and utilization review services. Any sub-contracted services to be provided in connection with these requirements must be identified in the proposal.

All proposals should include copies of any contract which the School Board will be required to execute. All proposals should include copies of standard communication materials that are sent to members, such as EOB type.

MANAGED CARE SERVICES

Proposer should maintain a managed care network of vision care providers in the following counties:

Santa Rosa, Escambia and Okaloosa. These arrangements should:

1. Provide services with reasonable promptness with respect to geographical location and hours of operation.

2. Contract with network physicians that:

a. Hold appropriate occupational and professional licenses;

b. Hold active and unrestricted privileges in their specialty;

c. Have a valid Drug Enforcement and Administration (DEA) number and hold unrestricted prescribing privileges;

d. Have not been convicted of a felony or greater crime;

e. Are specialty board certified (80% or greater); and

f. Have not been suspended, placed on probation or restricted from receiving payments from Medicare, Medicaid, or other third party programs during the last five years

3. Provide a network that includes the following specialty areas:

(1) Optometry

(2) Ophthalmology Provider network should not count providers with more than one office multiple times as this practice falsely inflates network participation.

4. Provide a network consisting of providers that have the capacity to provide care and treatment throughout the state of Florida.

5. Provide the School Board with information relative to network discounts that the Proposer receives from local providers.

6. Provide employees with on-line access to current directory information and printed copies upon request.

7. Require that network providers hold the employees/dependents and the School Board harmless from any fees for services which are rendered that are plan eligible charges (except deductibles, co-payments and coinsurance), regardless of the reason for non-payment.

8. Prohibit network providers from balance billing the patient for any excess of contracted amount, except for deductibles, co-payments and coinsurance.

9. Vision Plan highlights should, at a minimum, include the following:

a. Eye health examinations once every 12 months.

b. Frames once every 24 months.

c. Eyeglass lenses once every 12 months.

d. Contact lenses once every 12 months.

e. Discounts for Lasik surgery.

ADMINISTRATIVE SERVICES

Except for the collection of premiums to the successful Proposer and, as except otherwise noted in this RFP, the successful Proposer shall be totally responsible for the administration of the plan. These activities should include, but are not limited to, the following:

1. Subject to the exercise of professional judgment, the successful Proposer shall accept and settle or deny all reported claims. Successful Proposer will also be responsible for adjudication of claims appeals.

2. Furnish an electronic version of the certificates/booklets for the School Board to use on their website.

3. Issue ID cards within three (3) calendar weeks (plus four (4) days’ mailing time) after completion of open enrollment periods or after new hire electronic enrollment records are received. ID cards will be mailed directly to members.

4. Establish claims reporting procedures that are compatible with the needs and organizational structure of the School Board.

5 Provide enrollment assistance, including educational materials pre-approved by the School Board in advance of distribution, to the School Board during open enrollment period on an annual basis. These tasks may include requiring Proposer representatives to attend scheduled benefit/enrollment meetings if needed.

6. Assign a staff person as the School Board’s account representative.

7. Meet with the District Insurance Committee as needed to discuss the status of the plan, performance, audits, reports, and planning.

8. Attend School Board meetings, if requested by the School Board.

9. Verify claimant’s eligibility for benefits based on eligibility requirements furnished by the School Board.

10. Maintain covered dependent information by dependent’s name, date of birth, gender, and relationship to insured and social security number.

11. Prepare a monthly report on any covered dependents (excluding dependents who are mentally and physically handicapped) who will be turning age 25 the following month. Provide a copy of this report to the School Board within five (5) working days from the end of the reporting period.

12. Use fully automated online clinically-oriented claims adjudication and auditing system that analyzes coded claims data to ensure correct identification.

13. Identify and maintain separate COB information for each applicable claimant, as well as distinguish between the various types of COB.

14. Maintain the confidentiality requirements of Florida law by having adequate systems security features.

15. Turnaround 95% of all "clean" claims within ten (10) working days and 100% of all claims within thirty (30) working days. A “clean” claim is a claim submitted with all needed information for proper processing and adjudication.

16. Prepare and furnish the School Board with quarterly exposure and loss data statistics. Loss data reports should include, but not be limited to, the following information: (Data subject to compliance with HIPAA privacy guidelines.)

a. Report should show claims data on a monthly basis for current plan year with cumulative totals, preferably in a format that will provide data separately for employees and their dependents. Claim reports should be provided additionally for 12 months after plan termination or until there are no run-out and/or extension of benefits claims.

17. Establish and maintain a toll-free line for employees. This line should be operational from at least 8 a.m. to 6 p.m. (Central Standard Time). A voice mail system or equivalent system should be available to take off-hour or weekend calls.

18. Administer the plan on a detail billing remittance basis.

19. Conform accounting procedures and practices to generally accepted accounting principles.

20. Maintain proper records for tax reporting purposes.

21. Retain vision claims history online for minimum of 24 months.

22. Prepare, maintain, and file with any applicable federal, state or local governmental agencies, any forms or reports as may be required from time to time by law.

23. Provide assistance with regard to: (1) problems arising in connection with insurance laws, (2) tax aspects of the Plan, (3) litigation arising out of the administration of the Plan, and (4) any other legal matters that may arise in the course of the operation of the Plan.

24. Establish claim denial and grievance procedures which are clearly communicated to members.

Grievance procedures should be consistent with all applicable federal and state laws, rules and regulations. Proposer will be responsible for adjudication of claims appeals/grievances.

ADDITIONAL SERVICES

1. Supply all postage required to service the School Board’s account.

2. Send correspondence using School Board approved pre-formatted letters to the claimant or provider. The content of these letters must be easily understandable by a person not of a medical or insurance background.

3. The School Board will have first review and pre-approval of any correspondence that will be sent to claimants or providers that includes changes/amendments to the plan.

4. Maintain all records of business transacted in accordance with this RFP. At the end of the contract period, all documents, papers, records, canceled checks and claims history shall be captured in such a manner for media storage and delivered to the School Board.

5. Provide access to archived data within ten (10) working days of a request by the School Board.

PERFORMANCE GUARANTEES

Proposers should confirm that they are willing to offer performance guarantees and that they are willing to permit the School Board access to claims offices, personnel and files to conduct audits necessary to verification of performance standards. Performance may be evaluated on a variety of issues, such as:

Timely delivery of finalized contracts for the selected program.

Timely delivery of identification cards, at and subsequent to initial enrollment.

Timely delivery of plan documents.

Claims turnaround time.

Accuracy of claims coding and payments.

Telephone response time and abandonments.

Quality of service to plan participants, as measured by periodic surveys.

Quality and timeliness of claims experience reports.

Network provider participation, with penalties for drops below pre-specified levels.

Rate of provider turnovers.

Access to standards of care.

Collection or other threats to participants by providers not paid by the insurer.

Please confirm your firm’s willingness to enter into such an agreement and to negotiate appropriate terms and recommend appropriate incentives or disincentives (meaningful penalties) to make the performance guarantee practical.

Include Group Vision in proposal as -- Tab 10