ESBD_521004_1780004464564_Exhibit A-13 Medical ASO, Dental, Vision Questionnaire 3.31.26kle.xlsx
XLSX spreadsheet 29 KB Posted
- Attached to
- HR Benefits - Medical, Dental, and Vision
- Solicitation number
- 2605-004
- Issued by
- Travis County, Austin City, Texas
About this file
This is a Medical, Dental, and Vision Administrative Services Organization (ASO) questionnaire for Central Health, a public health system seeking to procure comprehensive health benefits administration services. Central Health is requesting proposals for medical claims administration, pharmacy benefit management (PBM), dental coverage, and vision coverage for employee and dependent populations. The contract term is one year with the option to extend for up to three additional years at the district's discretion. Proposers must deliver renewal information annually by April 1, provide 120 days written notice for contract termination, and implement all services with an effective date of January 1, 2027. Central Health requires carriers to accept weekly electronic eligibility file feeds integrated with their UKG benefits administration system and accommodate integration with their Personify App platform. The incumbent carriers are Aetna for medical, PBM (CVS Caremark), dental, and vision services as of 2023.
Current employer contributions are approximately 90% for medical and PBM services and 75% for dental coverage, with vision representing approximately 8% employer contribution. Current medical claim administration is handled by Aetna with no commissions, and dental and vision premiums are provided with multi-plan options (low and high plans). Central Health requires detailed reporting including full claims data extracts at no cost to their consultant, MMA, monthly claims reports with utilization analytics, and provider disruption reports showing network coverage of previously utilized providers. Proposers must demonstrate capabilities in large case management, fiduciary liability assumption, shared savings programs, mental health parity analysis, and various cost containment initiatives. Additional requirements include wellness fund management with rollover provisions, subsidies for BRFocus bill reconciliation services, implementation manager assignment, and benchmarking data capabilities. All contracts must include no loss/no gain provisions protecting employee coverage during carrier transitions.
View the file
Other files
Show all 35
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
General
| Requirements | Confirm / Not Confirmed | Additional Remarks |
| The System finalizes their budget in June. Will you be able to deliver the renewal annually by April 1, provided all necessary data is submitted and approved? | ||
| Company must provide 120 days written contract termination notification. | ||
| If subcontractors are used, the proposal must include the subcontractor's name and identification of functions to be performed | ||
| Proposals must be for a one year term, with the right to extend the contract additional years (up to a total of 4 years) at the discretion of the district. Please indicate if you are providing multi-year rate guarantees (three years is preferred). | ||
| All "actively at work" provisions must be waived. | ||
| Questions/Requests | Confirmed / Not Confirmed | Additional Remarks |
| Name of firm (legal name and d.b.a., if any) | ||
| Financial rating for each proposed entity and provide source | ||
| Provide an overview of the account management team to be assigned to Central Health, including a description of their responsibilities. | ||
| Indicate the hours of operation (CST) for the Customer Service office that will service this account. | ||
| Detail your open enrollment support (i.e. promotional materials, onsite and virtual presentations). | ||
| Please provide an implementation plan/timeline of the services proposed assigning accountability and indicating the anticipated time frame for completion for timely implementation by January 1, 2027. Please note that open enrollment starts in October of each year. | ||
| Central Health will require the carrier to take an electronic eligibility file feed on a weekly basis. Please confirm you can accept an electronic file and any cost associated are included in your administrative fee. The benefits administration vendor is UKG. | ||
| How does your firm measure its performance in areas such as implementation, customer service responsiveness, document completion and delivery, claim accuracy, and network discount? | ||
| Would your firm be willing to guarantee Central Health's satisfaction regarding these subjective areas on a “pass/fail” basis? If so, how much of the fees/premiums would your firm be willing to attach to each area of service? | ||
| Are you able to accommodate integration with Central Health's Personify App. If so, is there a fee associated? |
Medical Claims Administration
| General Information | ||
| Carrier History | 2023 - Current: Aetna | |
| Contributions | Approx. 90% Employer contribution | |
| Commissions | None | |
| Questions/Requests | Confirmed / Not Confirmed | Additional Remarks |
| Service / General | ||
| Please confirm you are able to hold regular monthly meetings to include information regarding claims, trends, customer service issues, utilization and company solutions. | ||
| Please confirm you are able to send to and receive files from the pharmacy benefit manager to manage eligibility, accumulators, and stop loss. Please confirm that any fees associated with this feed are included in the administration cost. | ||
| Confirm that you will create required documents (SBC, SPD) for the client that can be distributed to employees. | ||
| Central Health currently utilizes Hello Heart and Hinge Health as digital point solutions through Aetna. Please explain similar programs available under your solution, if any. | ||
| Is the cost of providing ID cards and all other printed materials included in the cost of your services? | ||
| Please provide a copy of your medical contract. | ||
| Can you provide in your contract a no loss/ no gain provision to assure that no one will lose coverage due solely to a change in carriers? | ||
| Claims Administration & Processes | Confirmed / Not Confirmed | Additional Remarks |
| Central Health prefers the flexibility to work with creative point solution vendors. Are you willing to carve out services and/or specific procedure codes or coordinate with other vendors integral to Central Health's overall health plan (Personify, Hinge, etc.)? | ||
| Will your firm allow an outside audit by a vendor selected by Central Health/MMA? If yes, what type of notice is required and what are the parameters when allowing audit (e.g. day limit, onsite audit only, etc.)? | ||
| What financial liability do you accept for the overpayment of claims? | ||
| Please provide an overview of your large case management program. Include what diagnosis, services, dollar amount, etc. will triggers case management. Also include overview of any reports provided to client/consultant. | ||
| Is your company willing to assume Fiduciary Liability on behalf of Central Health? If so, please provide the cost associated with this service and provide details on the scope of this service. | ||
| Provide details on all shared savings programs and PEPM fee equivalents in lieu of the shared savings percentages, if allowed. | ||
| If PEPM is not available, what reporting is available to ensure transparency related to how shared savings are earned? | ||
| Do you have a capitated mental health program? What is the fee to remove this program? | ||
| Provide information on any other programs that are available and state if the cost for such program(s) is included in the fees quoted. If there is a separate fee, please outline fees for each such program. Some examples may be: cost management, cancer, kidney, cardiac programs to help members seek specialist care (Centers of Excellence), transparency, incenting efficient utilization, reference-based pricing, steerage strategies, etc. | ||
| Reporting Requirements | Confirmed / Not Confirmed | Additional Remarks |
| Central Health will require a "full reveal" medical claims extract with eligibilty to be provided to our consultant, MMA, at no cost. Please indicate yes or no below to each requirement, with a description if applicable. | ||
| Provide timely and detailed management reports (monthly, quarterly, as needed), preferably via a secure internet portal to allow for custom data visibility and enable the System access to monitor financial performance and claims experience. If a portal cannot be provided, reports can be sent via encrypted email. | ||
| Reports will include enrollment and premiums paid. | ||
| Reports will include detailed paid claims data with case-level analytics. | ||
| Reports will include utilization reports and consultative insights to support risk management and cost containment. | ||
| Claims extracts will be provided at no additional charge. | ||
| Claims extracts will be provided on a monthly basis. | ||
| Data extracts will include a variable which differentiates active employees from other class of participants specified. | ||
| Claims data will be provided on a “paid” basis. | ||
| Please provide an example of your standard monthly claims reports. | ||
| Do you provide access to claims data through online portals or reporting tools? What level of detail is available? | ||
| Describe your data security protocols, HIPAA compliance measures, and data breach notification procedures relevant to all protected health information (PHI) and other sensitive data shared or processed under the medical contract. | ||
| Carrier / TPA acknowledges that MMA may share the claims data with subcontractors that provide services on behalf of the mutual client and has the appropriate agreements in place with all parties. This agreement will override other agreements in place that may restrict sharing of data. | ||
| Provider Network | Confirmed / Not Confirmed | Additional Remarks |
| Name the provider network your quote is based on. | ||
| Please provide additional information regarding network strategies you are able to implement, such as narrow networks and EPO options. Please include costs and pricing associated with these options, as well as expected savings. | ||
| Explain how your company provides notice to the Broker/Client when there are potential changes to your provider contracts. Central Health prefers a proactive approach, including: 90 days advanced notice of upcoming contracts slated for termination with commentary on negotiation status; copies of sample member communications provided at least 2 weeks prior to distribution; Disruption/impact reporting provided at least 60 days prior to contract termination | ||
| In order to determine which carriers will be a good fit based on provider availability, we would like for you to complete the Central Health Provider Disruption Report spreadsheet showing which of the providers Central Health members have utilized during the last year are in your proposed network versus out of your proposed network. Please return the disruption report along with your quote. DO NOT delete any lines from the provider utilization report. If the attachment includes 5,000 providers / rows, there should be 5,000 rows on your disruption report. DO NOT delete duplicates or any other information. | ||
| Implementation Plan and Schedule | Confirmed / Not Confirmed | Additional Remarks |
| Provide an overview of your Implementation Plan that includes step-by-step your approach to ensure a smooth transition and medical coverage rollout. | ||
| What are the anticipated timelines and any related fees? | ||
| Will there be an assigned Implementation Manager? | ||
| Identify any other key contacts responsible for implementation. | ||
| Are you capable of an electronic eligibility file submission (e.g. EDI, API), including integration with the existing HRIS system (UKG Ready) and Central Health’s Healthplan Administrator’s interface? | ||
| Please provide at least one (1) successful integration example with any other clients . | ||
| TPA must be able to integrate with any prospective systems per the needs of Central Health (such as other UKG products if adopted). | ||
| Underwriting and Renewal Process | Confirmed / Not Confirmed | Additional Remarks |
| Describe your renewal process including the timeline for renewal offers. | ||
| Describe your data requirements for renewal underwriting, and the methodology used to determine renewal rates. | ||
| Detail your underwriting methodology for developing initial fees. | ||
| What is your capability of providing benchmarking data or insights to Central Health, comparing their medical plan performance, costs, and risks against similar organizations in the marketplace? | ||
| Please include a sample benchmark report. | ||
| Fees | Confirmed / Not Confirmed | Additional Remarks |
| Please complete Exhibit B-1, with a complete list of all fees. | ||
| Please specify how much your company is willing to provide in credits/funds/subsidies for the following | ||
| Wellness | ||
| Central Health currently has in place a $50,000 Wellness Fund through Aetna to use for cost associated with Personify and other wellness vendors, such as Hello Heart and Hinge Health. Is this funded by Central Health through the Administration Fee, or is it funded by the Company? | ||
| Please provide details on how your wellness fund, if any, will address unused funds at the end of the plan year. It is Central Health's preference that all unused funds be rolled over for use in the next plan year | ||
| Compliance | ||
| Central Health is required to perform annual Mental Health Parity analysis. If your company does not perform this written analysis on behalf of the group, are you willing to provide a subsidy/fund/credit to cover the cost to have this analysis done by a third party vendor? | ||
| Technology / Communication | ||
| Costs associated with open enrollment updates, new product builds, file feed set ups, etc. | ||
| Other | ||
| BRFocus - Central Health utilizes BRFocus for bill/enrollment reconciliation. Please provide a subsidy (PEPM or annual lump sum) for BRFocus. |
PBM
| General Information | ||
| Carrier History | 2023 - Current: Aetna / CVS Caremark | |
| Contributions | Approx. 90% Employer contribution | |
| Commissions | None | |
| Questions/Requests | Confirmed / Not Confirmed | Additional Remarks |
| For any vendors quoting pharmacy benefit management services, please complete Exhibit A-14: PBM Questionnaire in it's entirety. |
Dental
| General Information | ||
| Carrier History | 2023 - Current: Aetna | |
| Contributions | Approx. 75% Employer contribution | |
| Commissions | None | |
| Current Pricing: Low Plan | Total Premium | Employee Monthly Premiums |
| Employee Only | $38.82 | $4.25 |
| Employee + Spouse | $75.52 | $28.16 |
| Employee + Child(ren) | $83.91 | $34.62 |
| Employee + Family | $135.33 | $74.09 |
| Current Pricing: High Plan | ||
| Employee Only | $55.21 | $13.57 |
| Employee + Spouse | $91.69 | $40.79 |
| Employee + Child(ren) | $101.88 | $48.51 |
| Employee + Family | $164.31 | $94.05 |
| General / Service | Confirmed / Not Confirmed | Additional Remarks |
| Please confirm that you offer a true annual open enrollment each year with no waiting periods for employees who have previously waived coverage on the plan. | ||
| Outline any rollover feature or similar program. | ||
| Provide any information for other value add programs, and indicate if the cost for such programs are included in the fees as quoted. If there is a separate fee, please outline those. | ||
| Please provide a copy of your dental contract. | ||
| Can you provide in your contract a no loss/ no gain provision to assure that no one will lose coverage due solely to a change in carriers? | ||
| Provider Network | Confirmed / Not Confirmed | Additional Remarks |
| Name the provider network your quote is based on. | ||
| In order to determine which carriers will be a good fit based on provider availability, we would like for you to complete the Central Health Dental Provider Disruption Report spreadsheet showing which of the providers Central Health members have utilized during the last year are in your proposed network versus out of your proposed network. Please return the disruption report along with your quote. DO NOT delete any lines from the provider utilization report. If the attachment includes 5,000 providers / rows, there should be 5,000 rows on your disruption report. DO NOT delete duplicates or any other information. | ||
| Reporting Requirements | Confirmed / Not Confirmed | Additional Remarks |
| Central Health will require a "full reveal" dental claims extract with eligibilty to be provided to our consultant, MMA, at no cost. Please indicate yes or no below to each requirement. Please also review the attached Claims Data Requirement Document for additional details | ||
| “Full Reveal” dental claims extracts will be provided (matching the attached list of data elements). | ||
| Claims extracts will be provided at no additional charge. | ||
| Claims extracts will be provided on a monthly basis. | ||
| Data extracts will include a variable which differentiates active employees from other class of participants specified. | ||
| Claims data will be provided on a “paid” basis. | ||
| Carrier / TPA acknowledges that MMA may share the claims data with subcontractors that provide services on behalf of the mutual client and has the appropriate agreements in place with all parties. This agreement will override other agreements in place that may restrict sharing of data. | ||
| Please provide an example of your claims reports. | ||
| Do you provide access to claims data through online portals or reporting tools? What level of detail is available? | ||
| Provide all necessary claims forms and instructions for filing a claim. | ||
| Implementation Plan and Schedule | Confirmed / Not Confirmed | Additional Remarks |
| Provide an overview of your Implementation Plan that includes step-by-step your approach to ensure a smooth transition and medical coverage rollout. | ||
| What are the anticipated timelines and any related fees? | ||
| Will there be an assigned Implementation Manager? | ||
| Identify any other key contacts responsible for implementation. | ||
| Underwriting and Renewal Process | Confirmed / Not Confirmed | Additional Remarks |
| Describe your renewal process including the timeline for renewal offers. | ||
| Describe your data requirements for renewal underwriting, and the methodology used to determine renewal rates. | ||
| What is your capability of providing benchmarking data or insights to Central Health, comparing their dental plan design, performance, and costs against similar organizations in the marketplace? | ||
| Please include a sample benchmark report. | ||
| Quoting Options | Confirmed / Not Confirmed | Additional Remarks |
| Please provide a multi-year quote matching current benefits as closely as possible. | ||
| Please complete Exhibit B-2, with a complete list of all fees/premiums. | ||
| Please specify how much your company is willing to provide in credits/funds/subsidies for the following | ||
| Technology / Communication | ||
| Costs associated with open enrollment updates, new product builds, file feed set ups, etc. | ||
| Other | ||
| BRFocus - Central Health utilizes BRFocus for bill/enrollment reconciliation. Please provide a subsidy (PEPM or annual lump sum) for BRFocus. |
Vision
| General Information | ||
| Carrier History | 2023 - Current: Aetna | |
| Contributions | Approx. 8% Employer contribution | |
| Commissions | None | |
| Current Pricing: Low Plan | Total Premium | Employee Monthly Premiums |
| Employee Only | $6.68 | $6.13 |
| Employee + Spouse | $12.02 | $11.04 |
| Employee + Child(ren) | $14.03 | $12.88 |
| Employee + Family | $17.36 | $15.94 |
| Current Pricing: High Plan | ||
| Employee Only | $9.97 | $9.42 |
| Employee + Spouse | $17.95 | $16.97 |
| Employee + Child(ren) | $20.94 | $19.79 |
| Employee + Family | $25.92 | $24.50 |
| Questions/Requests | Confirmed / Not Confirmed | Additional Remarks |
| Please indicate | ||
| Outline any rollover feature or similar program. | ||
| Please provide a copy of your vision contract. | ||
| Can you provide in your contract a no loss/ no gain provision to assure that no one will lose coverage due solely to a change in carriers? | ||
| Provide any information for other value add programs or discounts, along with any associated copay/fee schedules for the services. | ||
| Provide all necessary claims forms and instructions for filing a claim. | ||
| Provider Network | Confirmed / Not Confirmed | Additional Remarks |
| Name the provider network your quote is based on. | ||
| In order to determine which carriers will be a good fit based on provider availability, we would like for you to complete the Central Health Vision Provider Disruption Report spreadsheet showing which of the providers Central Health members have utilized during the last year are in your proposed network versus out of your proposed network. Please return the disruption report along with your quote. DO NOT delete any lines from the provider utilization report. If the attachment includes 5,000 providers / rows, there should be 5,000 rows on your disruption report. DO NOT delete duplicates or any other information. | ||
| Reporting Requirements | Confirmed / Not Confirmed | Additional Remarks |
| Please provide an example of your claims reports. | ||
| Do you provide access to claims data through online portals or reporting tools? What level of detail is available? | ||
| Describe your data security protocols, HIPAA compliance measures, and data breach notification procedures relevant to all protected health information (PHI) and other sensitive data shared or processed under the medical contract. | ||
| Implementation Plan and Schedule | Confirmed / Not Confirmed | Additional Remarks |
| Provide an overview of your Implementation Plan that includes step-by-step your approach to ensure a smooth transition and medical coverage rollout. | ||
| What are the anticipated timelines and any related fees? | ||
| Will there be an assigned Implementation Manager? | ||
| Identify any other key contacts responsible for implementation. | ||
| Underwriting and Renewal Process | Confirmed / Not Confirmed | Additional Remarks |
| Describe your data requirements for renewal underwriting, and the methodology used to determine renewal rates. | ||
| What is your capability of providing benchmarking data or insights to Central Health, comparing their vision plan design and costs against similar organizations in the marketplace? | ||
| Quoting Options | Confirmed / Not Confirmed | Additional Remarks |
| Please provide a multi-year quote matching current benefits as closely as possible. | ||
| Please complete Exhibit B-3, with a complete list of all fees/premiums. | ||
| Please specify how much your company is willing to provide in credits/funds/subsidies for the following | ||
| Technology / Communication | ||
| Costs associated with open enrollment updates, new product builds, file feed set ups, etc. | ||
| Other | ||
| BRFocus - Central Health utilizes BRFocus for bill/enrollment reconciliation. Please provide a subsidy (PEPM or annual lump sum) for BRFocus. |
File details come from the government source that posted it. Updated .