ESBD_360338_1716477849668_Attachment A - Response Forms.xlsx

XLSX spreadsheet 2 MB Posted May 23, 2024

Attached to: RFP 2024-P11 Employee Group Health, Dental, and Employee Assistance Plans
Solicitation number: RFp2024-P11
Issued by: Hays County, Texas

About this file

Written by GovTribe AI · Jun 7, 2024

This document contains response forms for RFP 2024-P11 Employee Group Health & Dental Plan issued by Hays County, Texas. The RFP seeks proposals from qualified companies to provide comprehensive employee health, dental, and employee assistance plans effective January 1, 2025. The County is looking to partner with an insurance provider that can offer competitive long-term and stable financial solutions while providing robust benefit packages. The RFP includes detailed specifications, exceptions, pricing sheets for medical, dental, stop loss, pharmacy, and EAP, as well as performance guarantees, geo access standards, and a detailed questionnaire.

The pricing sheets require vendors to provide guaranteed minimum discounts, rebates, and administrative fees for a 5-year term with optional 2-year renewals. Vendors must agree to provide 100% of pharmacy rebates to the County. The RFP also outlines specific performance guarantees related to ID cards, account management, claims administration, financial accuracy, and member services, with fees at risk if guarantees are not met. Geo access standards are specified for medical, pharmacy, and dental networks.

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Other files

File	Type	Posted
ESBD_360338_1716477848050_Attachment K - Medical Disruption File.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477854452_Attachment L - Rx Usage for Disruption and pricing April 2023-March 2024.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477846456_Attachment N - PY 2024 Funded Insurance Rates.pdf	PDF	May 23, 2024
ESBD_360338_1717797769305_Attachment S - DHMO Fee Schedule.pdf	PDF	May 23, 2024
ESBD_360338_1716477843854_Attachment G - Hays County Structure.pdf	PDF	May 23, 2024
ESBD_360338_1717797769699_Attachment R - Dental PPO Summary of Benefits.pdf	PDF	May 23, 2024
ESBD_360338_1716477845643_Attachment H - March 2024 Invoice with Counts.pdf	PDF	May 23, 2024
ESBD_360338_1717797768907_Addendum 1 - RFP 2024-P11.pdf	PDF	May 23, 2024
ESBD_360338_1716477853396_Attachment B - Hays County Census (April 2024).pdf	PDF	May 23, 2024
ESBD_360338_1716477849236_Attachment P - 2024 Medical Renewal.pdf	PDF	May 23, 2024
ESBD_360338_1717797770098_Attachment B - Hays County Census (April 2024) Excel.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477847667_Attachment Q - 2024 Dental Renewal.pdf	PDF	May 23, 2024
ESBD_360338_1716477852919_RFP 2024-P11 Employee Group Health, Dental and Employee Assistance Plans.pdf	PDF	May 23, 2024
ESBD_360338_1717797768324_Attachment I - Updated - Additional Supporting Claims and Enrollment Information.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477846068_Attachment O - Stop Loss amendment (2024).pdf	PDF	May 23, 2024
ESBD_360338_1716477847276_Attachment D.3 - Large Loss Claim Payments CY 2021-March 2024.pdf	PDF	May 23, 2024
ESBD_360338_1716477844264_Attachment D.1 - Aggregate Stop-Loss 2021-March 2024.pdf	PDF	May 23, 2024
ESBD_360338_1716477853901_Attachment E - Deer Oaks EAP Utilization.pdf	PDF	May 23, 2024
ESBD_360338_1716477843084_Attachment I - Additional Supporting Claims and Enrollment Information.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477846878_Attachment D.2 - March 2024 invoice with counts.pdf	PDF	May 23, 2024
ESBD_360338_1716477844656_Attachment J - Dental PPO and DHMO Disruption Information.xlsx	XLSX spreadsheet	May 23, 2024
ESBD_360338_1716477845223_Attachment M - PY 2024 Retiree Rates.pdf	PDF	May 23, 2024
ESBD_360338_1716477852456_Attachment F - Hays County SBCs 2022-2024.pdf	PDF	May 23, 2024

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Attachment A - Signature Page

RFP 2024-P11 Employee Group Health & Dental Plan

Attachment A - Response Forms

The following documents MUST be completed and returned with your proposal in order for your proposals to be deemed responsive. If any document is missing then your proposal will be deemed non-responsive and will not be considered.

From Title	Checklist
Attachment A: Signature Page
Tab 1: Proposal Specifications
Tab 2: Exceptions to RFP
Tab 3: Medical Pricing Sheet
Tab 4: Pricing Dent EAP Cobra Ret
Tab 5: Stop Loss
Tab 6: PBM Pricing
Tab 7: Questionnaire
Tab 8: Performance Guarantees
Tab 9: Med and Rx Claims Guarantees
Tab 10: Geo Access Standards

The undersigned authority affirms that they are duly authorized to execute this contract, that this proposal has not been prepared in collusion with any other respondent, and that the contents of this proposal has not been communicated to any other respondent prior to the official opening of this proposal

Company Name:

Printed Name:

Siganture:

Email Address:

Phone:

1. Proposal Specifications Proposal and Scope of Work Specifications

Company Legal Business Name: __________________________________________________________________

Proposal Specifications
#	Specification	Agree / Disagree
1.	The effective date of coverage January 1, 2025 is acknowledged and accepted.
2.	Administrative fees must be guaranteed for a minimum of three (3) years from the effective date with the option to renew for an additional two years.
3.	All fees / premiums are quoted NET of commissions; no commissions or fees are to be paid to any entity.
4.	Confirm your quote includes the following disruption reports specific to the networks and formulary quoted, with a summary report (by count and dollar) and the detail: Medical, Dental PPO, DHMO, Medications (tiering and exclusions), and Pharmacies.
5.	Confirm your quote includes claims repricing for medical and separately for pharmacy, with a summary of the financial impact of your networks and pharmacy discounts, plus rebates.
6.	Preliminary renewal rates, factors, fees, pharmacy pricing (discounts, rebates) and all other pricing (stop loss premiums and factors, other fees not in rate guarantee) must be submitted five months prior to the effective date.
7.	Your completed all sections of the workbook in their entirety, in the format requested.
8.	Vendor agrees to provide a Summary Plan Description draft within 60 days of the effective date.
9.	Vendor agrees to provide all communication materials in electronic (pdf) format.
10.	Vendor agrees to provide Summary of Benefits and Coverage (SBC) within 30 business days after notification of final plan designs.
11.	Claims experience must be provided at least monthly, including each renewal.
12.	You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security Regulations and will use HIPAA 834 (ASC X12N 834) for the file transmission layout.
13.	You have reviewed and accept the Plan’s eligibility provisions.
14.	Your contract, including the PBM agreement, must require no more than a 90-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off anniversary.
15.	Vendor has specifically listed all deviations from the RFP and coverage requirements. NOTE: Deviations MUST be listed; vendors cannot simply make “general” references to the proposal.
16.	If Hays wishes to carve-out the pharmacy benefit, TPA agrees to take real time/daily feeds from the pharmacy vendor and will mine/integrate the data into the medical management program.
17.	Vendor agrees to provide a designated reporting contact for the client and its broker/consultant. Your contact will be responsible for running ad hoc reports for the client and/or its consultant’s discretion, at no additional cost to the client.
18.	Your organization has online capabilities in the following areas:

1) Provider selection – tools that will help members select reputable and effective providers

2) Quality comparison – tools that will help members compare quality outcomes of providers and facilities

3) Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.

4) Wellness information and tools (i.e. BMI calculator, health risk assessments)

19.	The current medical and dental administration fees include runout administration. Confirm your quoted medical and dental administration fees include runout administration.
20.	The client intends to include your RFP responses as part of the overall Contract. Please acknowledge you understand and agree to this expectation.
21.	Confirm you agree to pay 100% of pharmacy rebates through both the medical plan and pharmacy plan to the County. This will consist of a monthly PEPM credit to the administration fees with an annual reconciliation within 120 following the end of the plan year to return any remaining portion of rebates attributable to Hays County.
22.	Confirm your proposal includes minimum guaranteed pharmacy discounts for retail and mail order, brand, generic, specialty, and the dispensing fees are quoted as well. Your quote should include performance guarantees for achieving the minimum discounts quoted.
23.	All rebates earned during the contract period are payable to the County. Any rebates earned which are paid after the contract terminates will be paid to the County
24.	Audit Requirements; Client retains access to 100% of all claims data including all data fields necessary to perform a 100% analysis of claims paid by plan for the applicable period, including but not limited to all claims payment fields, provider name, provider billing address, and all provider contact information including phone number. The carrier will remove any restrictions that may restrict client access to service including selection of a third party audit vendor. Willingness to provide a copy of the administrators written audit policy.

2. Exceptions To RFP

Proposal Specifications

Company Legal Business Name: __________________________________________________________________

If you have any Deviations to the Proposal Specifications, OR need to add additional commentary on any item of the Questionnaire, please include this here
Proposal Specifications
#	Specification	Deviation/Commentary
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6.
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8.
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12.
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3. Medical Pricing Sheet

Medical Pricing Sheet

Company Legal Business Name: __________________________________________________________________

Medical Administration Fees	Base Administration Fee PEPM (excluding Network Fees)*	Network Access Fee PEPM	Other Fees PEPM**	PBM Rebate Offset PEPM***	Net Monthly Fees PEPM
Plan Year 1
Plan Year 2
Plan Year 3
Plan Year 4
Plan Year 5
*Administration fees should include: Runout Administration, Nurseline, Enhanced Reporting access, Member Advocacy Services, Non-Network Price Negotiation, Care Coordination, Complex Condition Management (Bariatric, Cancer, Congential Heart Disease, Healthy Pregnancy, Kidney Reources), Smoking Cessation, Behavioral Health Management, Managed Pharmacy. Using your standard underwriting workup, separately provide your detailed listing of all the fees, breaking them out by line item and amount.
**Other fees may include optional programs include programs and services that you offer such as diabetes programs, virtual behavioral coaching, virtual musculoskeletal programs, etc. Using your standard underwriting workup, separately show the amounts for each of the programs quoted.
***Hays is to receive 100% of the rebates. Carrier must guarantee a minimum monthly rebate credit to the administration fee, with an annual reconciliation with 120 days following year-end to return any other rebates received by the carrier attributable to Hays County.
Annual Wellness Credit (Include in your response the list of eligible services)
Plan Year 1
Plan Year 2
Plan Year 3
Plan Year 4
Plan Year 5

Claims Performance Net Cost Guarantee
	Description	Confirm the Net Cost Guarantee will Automatically renew
Explain your proposed target claims guarantee and portion of fees at risk		Yes/No

Network Discount Target Guarantee
	Description	Confirm the Net Cost Guarantee will Automatically renew
Network Discount Target Guarantee / Penalty Corridor (Discount %)		Yes/No

OUTLINE EVERYTHING COVERED IN THE BASE ADMINISTRATION FEE:

Programs/Services INCLUDED in Base Fee:

Name of Fee / Program

Please insert additional lines as needed.

Indicate PEPM or PMPM

Additional Program Fees Required for Programs / Guarantees (Examples: Audit Services, Subrogation)

Name of Fee / Program

Please insert additional lines as needed.

Indicate PEPM or PMPM

ANY OTHER FEES / COSTS THAT APPLY:

Name of Fee / Program

Please insert additional lines as needed.

Indicate PEPM or PMPM

4. Pricing Dent EAP Cobra Ret

Pricing for Dental Administration, DHMO, Administration of COBRA and Retirees, and Employee Assistance Program (EAP)

Company Legal Business Name: __________________________________________________________________

Self-Funded Dental Plan Administration Fees	Dental Administration Fees PEPM	Network Access Fees PEPM
Plan Year 1
Plan Year 2
Plan Year 3
Plan Year 4
Plan Year 5
Projected claims PEPM 2025

Dental Runout administration fees if policy cancelled after	Base Runout Fees PEPM
Runout fees if cancelled after Plan Year 1*		**Note: The group will not pay network access fee during the claims runout period.
Runout fees if cancelled after Plan Year 2*
Runout fees if cancelled after Plan Year 3*
Runout fees if cancelled after Plan Year 4*
Runout fees if cancelled after Plan Year 5*

DHMO Rates	Rates
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Rate Guarantee Period

Cobra Administration
Monthly administration fee
Takeover Fee
Initial Rights Notfication
Open Enrollment Notification
Other Fees
Rate Guarantee Period
Retiree Billing Administration	Per Retiree Per Month
Monthly administration fee
Takeover Fee
Rate Guarantee Period
Employee Assistance Program	PEPM
Plan Year 1
Plan Year 2
Plan Year 3
Plan Year 4
Plan Year 5
Optional EAP Services	Rate per Case, Hour, or PEPM
DOT Substance Abuse Professional (SAP) Evaluations
Full-Service Mediation
Additional Training beyond included hours
Executive Coaching
Wellness Coaching Programs

5. Stop Loss

Stop Loss Pricing

Company Legal Business Name: __________________________________________________________________

Individual Stop Loss Level $200,000	Response
Confirm contract period of 48/12 (incurred from January 1, 2022 through December 31, 2025 and paid from January 1, 2025 through December 31, 2025)	Yes/No
Confirm includes Medical and Pharmacy (whether Pharmacy is Integrated with the Medical TPA or through a Separate PBM)	Yes/No
Confirm reimbursement rate of 100%	Yes/No
Confirm unlimited annual Individual benefit per covered person	Yes/No
Maximum annual increase
Confirm no laser provider	Yes/No
Premium per Subcriber per Month	$

Aggregate Stop Loss based on $200,000 Individual Stop Loss
Confirm contract period of 48/12 (incurred from January 1, 2022 through December 31, 2025 and paid from January 1, 2025 through December 31, 2025)	Yes/No
Confirm includes Medical and Pharmacy (whether Pharmacy is Integrated with the Medical TPA or through a Separate PBM)	Yes/No
Confirm reimbursement rate of 100%	Yes/No
Confirm $1,000,000 maximum aggregate benefit per policy year	Yes/No
Confirm Aggregate Accommodation is included	Yes/No
Describe the formula used to calculate the minimum annual aggregate Deductible

Aggregate Factor and Premium
Aggregate Factor per Subscriber per Month	$
Aggregate Stop Loss Premium Per Subcriber Per Month	$

Capitations, Value Based Payments, Etc
Describe the fees and indicate the amounts that will be going through the claims fund. Be specific and indicate the amount PEPY or PEPM for each item.
Mental Health	$
Value Based Payments	$
Other Payments - describe	$

Sheet1

6. PBM Pricing

Pharmacy Pricing Sheet, 2025 through 2027

Company Legal Business Name: __________________________________________________________________

Formulary Name

Guaranteed Minimum Discounts January 1, 2025 - December 31, 2025

		Retail
1-83 Day Suply	Retail Maintenance
84-90 Day Supply	Mail Order

30-90 Day Supply

Brands	Average Wholesale Price (AWP) less
	Dispensing Fee
Generics	Average Wholesale Price (AWP) less
	Dispensing Fee

Exclusive/Proprietary Pharmacy Limited Distribution Specialty Medications

Specialty Medications	Average Wholesale Price (AWP) less
	Dispensing Fee

All Sources

Compounds not included in AWP discounts	Pricing Methodology
	Dispensing Fee
Guaranteed Minimum Rebates, with 100% of actual rebates to be Reconciled at Year End and Compared to PEPM Rebate Credit Applied to the Administration Fee.
	Retail 1-83 Days	Retail 84-90 Days	Mail Order
Brand Rebate Guarantee Per script	$	$	$
	Exclusive/Proprietary Pharmacy	Limited Distribution Specialty Medications

Specialty Rebate Guarantee per script	$	$
Guaranteed Minimum Discounts January 1, 2026 - December 31, 2026

		Retail
1-83 Day Suply	Retail Maintenance
84-90 Day Supply	Mail Order

30-90 Day Supply

Brands	Average Wholesale Price (AWP) less
	Dispensing Fee
Generics	Average Wholesale Price (AWP) less
	Dispensing Fee

Exclusive/Proprietary Pharmacy Limited Distribution Specialty Medications

Specialty Medications	Average Wholesale Price (AWP) less
	Dispensing Fee

All Sources

Compounds not included in AWP discounts	Pricing Methodology
	Dispensing Fee
Guaranteed Minimum Rebates, with 100% of actual rebates to be Reconciled at Year End and Compared to PEPM Rebate Credit Applied to the Administration Fee.
	Retail 1-83 Days	Retail 84-90 Days	Mail Order
Brand Rebate Guarantee Per script	$	$	$
	Exclusive/Proprietary Pharmacy	Limited Distribution Specialty Medications

Specialty Rebate Guarantee per script	$	$
Guaranteed Minimum Discounts January 1, 2027 - December 31, 2027

		Retail
1-83 Day Suply	Retail Maintenance
84-90 Day Supply	Mail Order

30-90 Day Supply

Brands	Average Wholesale Price (AWP) less
	Dispensing Fee
Generics	Average Wholesale Price (AWP) less
	Dispensing Fee

Exclusive/Proprietary Pharmacy Limited Distribution Specialty Medications

Specialty Medications	Average Wholesale Price (AWP) less
	Dispensing Fee

All Sources

Compounds not included in AWP discounts	Pricing Methodology
	Dispensing Fee
	Program Name	Description	Fees
Describe other fees which may apply:

Guaranteed Minimum Rebates, with 100% of actual rebates to be Reconciled at Year End and Compared to PEPM Rebate Credit Applied to the Administration Fee.
	Retail 1-83 Days	Retail 84-90 Days	Mail Order
Brand Rebate Guarantee Per script	$	$	$
	Exclusive/Proprietary Pharmacy	Limited Distribution Specialty Medications

Specialty Rebate Guarantee per script $ $

7. Questionnaire

Medical Administration Questionnaire
Company Legal Business Name: __________________________________________________________________
		EAP Questions
Affirmation / discussion must be given on each of the following topics.		Dental Questions
Section I - General Company Information
1.	Please confirm your organization will be ready to begin services on January 1, 2025.
2.	What is the total number of public sector employer clients that you have for the services you are proposing? What is the average size of your public sector client as well as the largest?
3.	What is the name of your parent organization if you have one?
4.	Provide the contact information of the individual authorized to answer questions related to this RFP, including their name, title, physical address, direct office phone number, cell phone number and email address.
5.	To the extent applicable, are you now and will you remain duly licensed and in full compliance with all federal and state statutory administrative requirements?
6.	Do you agree to do what is necessary to execute an agreement within 30 days of award of service(s)?
7.	Provide three references for three current accounts comparable in size to the client (prefer public sector account, school district and/or Texas based references). Provide two former accounts lost in the past year also in comparable size to the client. Include reference contact name, office phone number and email address. Include the length of relationship, number of employees of the reference and services provided to the reference.
8.	If you plan on using any third-party organizations please provide a detailed list of who will participate in the execution of the services you will provide as a part of your proposal response (name, nature of relationship, length of affiliation).
9.	Please provide the ratings of your company (A.M. Best, Moody's, Standard & Poor's).
10.	Have you recently been acquired or been involved with any mergers/acquisitions? If yes, please describe.
11.	Provide the background for the proposed account team member that includes years with organization, public sector experience, percent of time they will dedicate to the County, the number of accounts the account team has in their servicing book, and their location.
12.	Provide a one page diagram of your account team service hierarchy.
Section II - Claims, Runout, Fraud and Abuse
1.	Any and all administrative fees must be noted on Pricing Sheet. Services performed via claims fund transfers must be noted on the grid; as a fixed cost PEPM (Transparency).
2.	Discuss your Claim subrogation process and recovery fees charged to the plan.
3.	Discuss internal quality assessment programs; internal audit procedures including additional protocols in place for ICD-10 accuracy.
4.	Discuss fraud and abuse programs.
Section III - General Administration Information
1.	What is the normal lead-time required to implement a group?
2.	Describe your eligibility file feed process.
3.	Describe your client billing process.
4.	Can you house employee’s location/department in your system for billing and claims reporting? If this requires additional lines of code to accommodate, confirm there will be no additional cost.
5.	If you are awarded this business, how soon after the notification of the award would you be able to have a draft of the Administrative Agreement(s)?
6.	With respect to ID cards:
	Do you charge for replacement cards?
	Can you put the plan sponsor name and logo on the ID cards? Is there an additional cost for this?
	Can you do a combination medical / Rx card (if the PBM is carved-out)? Is there an additional cost for this?
7.	Will your communication and ID cards for the client's employees be sent to employee’s residence?
8.	Describe the capabilities your member website has for the following items:

• Price comparison RX– tools that will allow members to compare the price of prescription drugs by pharmacy

• Price comparison Medical– tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.

• Search for lower cost care providers and medications

• Provider selection – tools that will help members select reputable and effective providers

• Quality comparison – tools that will help members compare quality outcomes of providers and facilities

• Wellness information and tools (i.e. BMI calculator, health risk assessments)

• Price comparison Dental– tools that will allow members to compare the price for dental services

9.	Describe the self-service features that members can perform through your member portal, such as EOB look-up, requesting new ID cards, etc.
10.	Do you issue dental ID cards for both the DHMO and PPO plan?
11.	Are special or ad hoc reports available to the client? Are there any additional costs associated with any of these reports?
12.	Describe your banking procedures.
13.	Describe your services for the Disabled Dependent Eligibility Verification process for disabled dependents. Please confirm you can handle this on behalf and provide detail on how your processes work and how you share the final decision.
Section IV - Network Contracts
1.	Describe your Centers of Excellence of programs and indicate any facilities with Texas which are part of your COE network.
2.	What fees or capitations will be going through the claims funding ACH account? Can you provide an estimate of these costs based on the date provided?
3.	Describe how your organization prices out-of-network claims and the measures you take to ensure the County's overall costs are being minimized when Out-of-Network utilization occurs.
4.	Describe how out-of-network providers are reimbursed by your organization. Provide an overview of your process, including discussion on initiatives to negotiate single case provider contracts.
5.	Discuss your ability to offer “navigating tools” and strategies to direct patient care to lower cost procedural codes like OP X-Ray and Lab services.
6.	Discuss any Air Ambulance contracts to minimize balance billing issues for plan members.
7.	Does your network include clinician-staffed clinics in a retail setting? (e.g. CVS Clinics, RediClinic, etc.) Please elaborate.
8.	What are your options for out of network reimbursement rates: % o Medicare, RBP, other?
9.	What options, other than % of savings, do you have for out of network shared savings. Hays prefers a fixed fee arrangement and not a % of savings.
10.	Please describe any pay for performance initiatives your organization has in place with providers used by Hays County member (use the disruption file) or will have in place by the effective date of this contract. Include details related to the cost and quality metrics that are considered.
Section V - Case Disease Management
1.	Discuss Telemedicine initiatives including your traditional telemedicine services for acute care, and non-traditional such as mental health, musculoskeletal, etc.
2.	Describe your processes for pre-certification and utilization review procedures for inpatient and outpatient surgical procedures.
3.	What predictive modeling resources do you use (AI, third party services, etc) and describe the member outreach approach?
4.	Does your organization provide any "Nurse Lines"? If so, please provide some commentary regarding this service.	stop
5.	Does your organization provide any Wellness programs, smoking cessation programs, web based publications, health risk assessments, wellness reminders, etc. to promote overall population health?
6.	Discuss your communication efforts and campaigns to engage members identified as high-risk?
7.	Describe your Advocacy process for transitioning care from in-hospital to out-patient/home settings.
8.	Describe any Web based wellness incentive programs.
9.	Describe your Case Manager advocacy on-site at strategic Hospital systems, if available.
10.	How will you promote and encourage members to use high quality, lower cost providers?
11.	What results are you able to provide as it pertains to wellness programs and initiatives?
12.	Describe in detail your large case/catastrophic case management program.
13.	How do you identify potential disease management candidates? What sources of data do you use?
14.	If you have included a wellness allowance, describe or provide a detailed list of the type of services/programs/expenses that Hays County can use the funds for.
Section VI - Utilization Management
1.	Do you have a standard pre-certification requirement for any of the following:

(Respond Y / N)

	Hospitalizations
	Outpatient Surgery
	Specified Diagnosis Procedures
	Durable Medical Equipment
	Corrective Appliances / Prosthetics
	Skilled Nursing Facility
	Home Health Care
	Musculoskeletal Services (e.g. chiropractic)
	Medical Services (e.g. physical therapy)
	Inpatient Mental Health / Substance Abuse
	Outpatient Mental Health / Substance Abuse
	Other
2.	What percentage of ALL preservice reviews requires your physician advisor review for decision making?
3.	Does your organization perform hospital bill audits? If yes, describe the program and the basis of your compensation.
Section VII - Pharmacy Benefit Management
1.	Does your pharmacy program integrate any third party discount services automatically at the point of sale, such as Amazon Rx, Cost Plus, or GoodRx? If yes, please describe
2.	Describe your step therapy, pre-authorization programs, and other cost and utilization management programs.
3.	Describe the formulary specifically quoted for Hays.
4.	Describe the Rx pricing comparison tool available to members on their portal.
5.	Will your Pharmacy Administrative Services Agreement be integrated with the Medical Administrative Services Agreement or separate?
6.	How do you monitor drug interactions?
7.	Describe your process to ensure members are not receiving duplicate prescriptions for the same prescription through multiple pharmacies?
8.	Do you conduct outreach informing members of the option to use mail service for maintenance medications? If yes, describe you various outreach approaches.
9.	If the County were to implement international sourcing of medications, would that impact your pricing and rebate guarantees?
10.	Name the retail outlets members may obtain medications of 84 days or longer?
11.	Describe your MAC pricing program--how it works, pricing source, types of medications included.
12.	Can you notify the group for pre-appoval of medications which cost above a specified threshold?
13.	Do you offer a program to provide diabetic testing strips to members at no charge?
14.	What are the prerequisites for a member to be approved for coverage of a GLP-1 medication (Ozempic, Mounjaro, Wegovy, etc?)
15.	Will you agree to waive at the contract effective date all step therapy and pre-authorization requirements for members currently medications that have previously been approved or for members who are taking medications that are on your PA and/or Step Therapy list?
Section VIII. Employee Assistance Program
1.	Confirm your proposed EAP includes DOT Substance Abuse Professional Evaluations
2.	The County's program currently covers six counseling visits. Under what circumstances would your program refer individuals to providers within the medical plan prior to the completion of six counseling sessions?
3.	Does the initial assessment that occurs following the intake count as a visit?
4.	Desribe your network in the Central Texas area, including number of providers available for face to face visits, number of providers available virtually, the credentials of your providers, and how you monitor providers and ensure quality.
5.	Describe any requirements or restrictions which apply to a minor.
Section IX. Dental PPO
1.	Have you agreed to match the inforce plan design? If there are deviations, whether in terms of benefit levels, limits (such as frequency to replace crowns/bridges, etc), or other plan design differences, describe those in detail.
2.	Describe the different R&C levels that you can apply to out of network claims.
3.	Looking at the current plan design, are there any programs or services that you would like for the County to consider? Please describe.
4.	What historically is your average claim payment turnaround time and accuracy rate?
Section X. Dental DHMO
1.	We understand that your DHMO plan may have different copay/cost sharing levels as compared to current. To ensure a proper comparison, confirm you have provided a side by side of the cost sharing by each ADA code on the current plan.

8. Performance Guarantees

Medical Performance Guarantees

Company Legal Business Name: _______________________________________________________________________

	Answers are limited to 50 characters
ID Card Distribution	Metric	$ PEPY at Risk
ID Card Production & Distribution
ID cards received at Covered Persons’ mailing address on file following the Open Enrollment file transfer must be error free.
Correct ID cards received at Covered Persons’ mailing address on file by December 31 of each year
Account Management	Metric	$ PEPY at Risk
Overall Account Management
Phone calls an emails from Hays administration to dedicated account team will be returned within 24 hours of inquiry
Eligibility updates will be processed within 24 hours of receipt of the participant’s complete information
Plan Documents received at Covered Persons’ mailing address on file by January 31 of each year
Claim Administration	Metric	$ PEPY at Risk
Turnaround Time
Payment of claims within 14 calendar days of receipt
Payment of claims within 30 calendar days of receipt
Financial Accuracy
Financial Accuracy- determined by audit
Total Claim Accuracy
Overall Accuracy- determined by Audit

Member Services	Metric	$ PEPY at Risk
Telephone Service Factor
Average Speed of Answer
Abandonment Rate
First Call Resolution

Other Guarantees

9. Med and Rx Claims Guarantees

Medical and Pharmacy Guarantees

Company Legal Business Name: _______________________________________________________________________

Discount Guarantees

Guaranteed Discount %

% of Admin Fee at Risk

Annual Fees at Risk $

In-Network Utilization Guarantees

Guaranteed In-Network Utilization %

% of Admin Fee at Risk

Annual Fees at Risk $

Medical Claim Guarantees

Is the Guarantee based on Billed or Paid Claims?

Annual Fees at Risk $

PEPM Fees at Risk

Target Claim Factor

Risk-Free Corridor Range (PEPM)

Risk Corridor Range - Administrator Pays (PEPM)

Amount at Risk

Pharmacy Discount Guarantees

Outline your specific discount guarantees by retail and mail, generic, brand and specialty.

Billed	Yes
Paid	No

&A Page &P of &N

10. Geo Access Standards

Geo Access Standards
Company Legal Business Name: _______________________________________________________________________
Note: Base your Geo Access on the actual employee address provided in the census.
*Based on the addresses of the employees in the census file.
Medical	Standard	% with Access	% without Access	# of Providers In-Network*
Primary Care	2 providers within 10 miles
Pediatricians	2 providers within 15 miles
OBGYNs	2 providers within 10 miles
Other Specialists	2 providers within 15 miles
Hospitals	2 inpatient facilities within 10 miles
Pharmacy	Standard	% with Access	% without Access	# of Providers In-Network*
Pharmacies	2 pharmcies within 10 miles
Dental PPO	Standard	% with Access	% without Access	# of Providers In-Network*
General Dentists	2 dentists within 10 miles
Orthdontists	2 dentists within 15 miles
Oral Surgeons	1 provider within 10 miles
Endodontists	1 provider within 10 miles
Periodontists	1 provider within 10 miles
DHMO	Standard	% with Access	% without Access	# of Providers In-Network*
General Dentists	2 dentists within 10 miles
Orthdontists	2 dentists within 15 miles
Oral Surgeons	1 provider within 10 miles
Endodontists	1 provider within 10 miles
Periodontists	1 provider within 10 miles

Cognos_Office_Connection_Cache

Sheet5 (13)

File details come from the government source that posted it. Updated Jun 7, 2024.