ESBD_540156_1784577532297_Exhibit A-2 Stop Loss Questionnaire.xlsx
XLSX spreadsheet 19 KB Posted
- Attached to
- RFP 2607-002 Stop Loss Insurance
- Solicitation number
- 2607002
- Issued by
- Travis County, Austin City, Texas
About this file
This is a Stop Loss Insurance Questionnaire and Exhibit A document for Central Health's RFP 2607-002 in Texas, outlining the requirements and evaluation criteria for stop loss insurance carriers. The procurement seeks annual renewal of stop loss coverage with specific deadlines requiring delivery by April 1, provided necessary data is submitted and approved. The contract is for a one-year term with the option to extend for additional years up to a total of four years at the System's discretion. Central Health is currently using Aetna as their carrier, and the questionnaire addresses general requirements, carrier history, account management, claims administration, technical and reporting capabilities, fee structures, and underwriting methodologies. Bidders must confirm their ability to waive all "actively at work" provisions, provide 60 days written termination notification, and submit proposals net of commissions with multi-year rate guarantees preferred (three years minimum).
The current pricing structure indicates an Indemnity Stop Loss (ISL) Composite PEPM rate of $112.60 and an Aggregate Stop Loss (ASL) Composite PEPM rate of $4.55, with a minimum aggregate stop loss amount of $35,819,095. Bidders must provide complete fee breakdowns on Exhibit B pricing sheets and confirm specific requirements including no renewal rate lasers, no run-in limits, renewal rate caps (30%, 40%, or 50%), and no new laser provisions at renewal. The questionnaire requires carriers to integrate with Aetna for claims reporting on at least a monthly basis, provide dedicated account management with defined primary contacts, and offer comprehensive technical and reporting capabilities including online portal access, customizable reporting, and benchmarking data. Additional requirements include HIPAA compliance protocols, fraud and abuse detection programs, and value-added services such as claims advocacy, risk consulting, and predictive modeling with demonstrated client outcomes and three current client references.
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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 60 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 System. 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 | ||
| What is the size of your stop loss book of business and how many years have you been reimbursing stop loss claims. | ||
| How does your firm measure its performance in areas such as implementation, responsiveness, claim accuracy, and timely payment? | ||
| 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? |
Stop Loss
| General Information | ||
| Carrier History | 3/1/2022 - Current: Aetna | |
| Commissions | None | |
| Current Pricing: | ||
| ISL Composite PEPM Rate | $112.60 | |
| ASL Composite PEPM Rate | $4.55 | |
| Current Claims Factors: | ||
| Aggregate Stop Loss Factor PEPM | $1,627.55 | |
| Minimum Aggregate Stop Loss Amount | $35,819,095 | |
| Projected Policy Period Aggregate Attachment point | $35,819,095 | |
| Questions/Requests | Confirmed / Not Confirmed | Additional Remarks |
| Account Management | ||
| Please confirm a dedicated primary account manager responsible for overseeing the stop loss insurance program for the System. | ||
| Please identify any additional team members (if applicable) who will provide stop loss-specific support. | ||
| Identify the primary contact(s) concerning billing, claims resolution, and service-related inquiries specific to stop loss coverage. | ||
| Please confirm you are able to attend meetings as requested (monthly, quarterly) to provide information regarding claims, trends, customer service issues, utilization and company solutions. | ||
| Provide an overview of your Implementation Plan that includes step-by-step your approach to ensure a smooth transition and stop loss coverage rollout, along with any related fees as well as key implementation contacts. | ||
| 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. | ||
| Please outline any value-added services your team can provide, including claims advoacy, risk consulting, and predictive modeling. Include examples of how these services have demonstrably helped other clients. Include pricing for these services on Exhibit B - Pricing Sheet. | ||
| Please provide three client references who are currently using your services. At least one reference should currently use a benefit plan similar to the option being strongly considered by Central Health. Please indicate which specific services/programs they use. | ||
| Claims Administration | Confirmed / Not Confirmed | Additional Remarks |
| Central Health currently utilizes Aetna as their TPA and PBM for the medical/rx plans. Please confirm you are able to integrate with Aetna for claims reporting on at least a monthly basis. Please outline any limitations. | ||
| Detail your procedure for requesting additional documentation or information from providers and participants when necessary to complete stop loss claim processing. | ||
| Describe coordination with other insurers or benefit plans to avoid duplication of payments or coverage gaps | ||
| Describe your process and turnaround times for receiving, adjudicating, and paying stop loss claims in accordance with Central Health’s plan design and contract terms. | ||
| Please outline your protocols for notifying clients on stop loss claim updates, including issuance of EOBs, claim denials, and appeal procedures. | ||
| Detail eligibility verification processes relevant to stop loss coverage, including handling dependent eligibility as applicable, frequency of eligibility verification occurrence, and if it is an ongoing process. | ||
| Describe your Fraud and Abuse Detection Program specific to stop loss claims. Include how findings would be reported to the Central Health and what actions are typically taken. | ||
| Please provide a copy of your stop loss 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? | ||
| Please provide all necessary claim forms and instructions on filing a claim. | ||
| Does your company accept monthly eligibility feeds to minimize the need for eligibility verification from Central Health? | ||
| Do you offer features including Specific Advance, Monthly Aggregate Accommodation, transplant coverage/programs, hemophiliac programs/limitations, cancer programs, maternity management, transplant Centers of Excellence, and gene therapy program(s)? Please elaborate and include additional features and innovation (along with pricing outlined in Exhibit B) you recommend based on the data provided within this RFP. | ||
| Technical and Reporting Requirements | Confirmed / Not Confirmed | Additional Remarks |
| Please provide an example of your standard monthly claims reports. | ||
| Please confirm that your Stop loss related reporting includes, but not limited to: enrollment and premiums paid undert the contract; detailed claims data with case-level analytics; utilization reports and consultative invites to support risk management and cost containment. | ||
| Do you provide access to claims data through online portals or reporting tools? What level of detail is available? | ||
| Clearly describe how specific and aggregate deductibles are tracked and accumulated towards satisfaction under the stop loss contract. Can reports be customized to Central Health’s specific needs beyond the listed items? | ||
| 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. | ||
| Clearly describe how specific and aggregate deductibles are tracked and accumulated towards satisfaction under the stop loss contract. Can reports be customized to Central Health’s specific needs beyond the listed items? | ||
| Fee Structure | Confirmed / Not Confirmed | Additional Remarks |
| Please confirm that your proposal is net commissions and disclose of any fees or administrative costs with a breakdown of these fees and costs | ||
| Please confirm that your proposal encompasses Specific and Aggregate Stop Loss Coverage (Medical & Rx) | ||
| Please confirm that your proposal is a No New Laser At Renewal contract | ||
| Please confirm that your proposal includes a renewal rate cap; Please specify if 30%, 40% or 50% renewal rate cap. | ||
| Please confirm that your proposal does not have a run-in limit | ||
| Please confirm that your proposal does not have any laser provisions or exclusions. | ||
| Please complete Exhibit B, with a complete list of all premium and fees (net commission), including the Aggregate Attachment Point. | ||
| Underwriting and Renewal Process | Confirmed / Not Confirmed | Additional Remarks |
| Describe your renewal process including the timeline for renewal offers, including the information required from Central Health. | ||
| Please confirm you can do accommodate an early renewal, provided you have all necessary data. | ||
| Describe your data requirements for renewal underwriting, and the methodology used to determine renewal rates. | ||
| Detail your underwriting methodology for developing initial rates and projected claims factors, addressing how specific and aggregate deductibles are considered, applications of any laser provisions, and your appreach to run-out coverage. | ||
| 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. |
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