Exhibit_4_-_RFP_Offeror_Questionnaire_Final_(revision_2).xlsx

XLSX spreadsheet 3 MB Posted Mar 1, 2024

Attached to: RFP for Claims Administration for the Self-Insured Preferred Provider Organization (PPO) Health Plans
Solicitation number: 017-202403-MC
Issued by: Orange County, San Francisco City, California

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Other files

File	Type	Posted
Exhibit_4_-_RFP_Offeror_Questionnaire_Final_(revision_2).xlsx	XLSX spreadsheet	Mar 1, 2024
Appendix_F_-_Active_Employee_and_Retiree_PPO_Plan_Census_(revised).xlsx	XLSX spreadsheet	Mar 1, 2024
Appendix_H_-_Active_Employee_and_Retiree_Health_Rates.pdf	PDF	Mar 1, 2024
Appendix_G_-_Plan_Enrollment_and_Average_Age.pdf	PDF	Mar 1, 2024
Appendix_I_-_Monthly_Medical_Claims_Information_and_Enrollment_Final.xlsx	XLSX spreadsheet	Mar 1, 2024
PPO_Medical_Claims_Administration_RFP_[Word_Version]_(revised).docx	DOCX document	Mar 1, 2024
PPO_Medical_Claims_Administration_RFP_(revised).pdf	PDF	Mar 1, 2024
Appendix_E_-_Monthly_Medical_Claims_Information_and_Enrollment.pdf	PDF	Feb 15, 2024
Appendix_D_-_Sharewell_Retiree_Health_Plan_Document.pdf	PDF	Feb 15, 2024
Appendix_C_-_Wellwise_Retiree_Health_Plan_Document.pdf	PDF	Feb 15, 2024
Appendix_B_-_Sharewell_Choice_Health_Plan_Document.pdf	PDF	Feb 15, 2024
Appendix_A_-_Wellwise_Choice_Health_Plan_Document.pdf	PDF	Feb 15, 2024
Attachment_M_-_County_of_Orange_Information_Technology_Security_Guidelines.docx	DOCX document	Feb 15, 2024
Test.docx	DOCX document	Feb 15, 2024

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A. Cover Sheet

EXHIBIT 4

RFP OFFEROR QUESTIONNAIRE
CLAIMS ADMINISTRATION FOR THE SELF-INSURED
PREFERRED PROVIDER ORGANIZATION (PPO) HEALTH PLANS	17588

COUNTY OF ORANGE
February 2024
	10400

	80% AD
	Same as deductible
		Same as deductible
	30
	$25 AD / $70 AD / $140 AD
* AD - After Deductible; N/A - Not Applicable; CY - Calendar Year; PA - Prior Authorization

B. Table of Contents B. Table of Contents

A	Cover
B	Table of Contents
C	Company Profile
D	General Info
E	Minimum Qualifications
F	Required Attachments
G	Plan Designs
H	Plan Design Alternatives
I	ASO Fees & Credits - SQ	17588
J	ASO Fees & Credits - HPN
K	Financial
L	Staffing & Communications Plans
M	Implementation, Ongoing Administration, Customer Service, Pharmacy
N	Provider Network
O	Claims & Reporting
P	Claim System Matrix
Q	Proposed Data Interfaces
R	High Performance Networks
S	Medicare
T	Other		10400
U	Disruption Analysis
V	Geo Access
W	References

	30
	$25 AD / $70 AD / $140 AD
* AD - After Deductible; N/A - Not Applicable; CY - Calendar Year; PA - Prior Authorization

C. Company Profile

Question		Response	Comments
1	Company Legal Name
2	Company Legal Status (corporation, partnership, etc.)
3	Business Address
4	Website Address
5	Telephone Number
6	Facsimile Number
7	Email Address
8	Description of services provided
9	Years of Experience
10	Length of Time the firm has been in business
11	Length of time at current location
12	Company size (number of employees in US and number worldwide including in US)
13	In your firm a sole proprietorship? (Yes or No)
13.1	If yes, Sole Proprietor's social security number
14	Is your firm a sole proprietorship doing business under a different name? (Yes or No)
14.1	If yes, please indicate sole proprietor's name and the name you are doing business under
15	Is your firm incorporated (Yes or No)
15.1	If yes, State of Incorporation
16	Federal Taxpayer ID Number
17	D-U-N-S # (The County requires a valid D-U-N-S number prior to Contract Award. If needed, your company may obtain one at no cost at www.dnb.com. If you are unable to provide/obtain a D-U-N-S number, please indicate so in your proposal/bid submission response.)
18	Regular business hours
19	Regular holidays and hours when business is closed
20	Contact person in reference to this RFP
20.a	Telephone Number
20.b	Facsimile Number
20.c	Email Address
21	Contact Person For Accounts Payable
21.a	Telephone Number
21.b	Facsimile Number
21.c	Email Address
22	Name of Service Manager
22.a	Telephone Number
22.b	Facsimile Number
22.c	Email Address
23	NOTICES (Legal/Contract) attention to:
23.a	Telephone Number
23.b	Facsimile Number
23.c	Email Address
24	In the event of an emergency or declared disaster, the following information is required
24.a	Name of contact during non-business hours
24.b	Telephone Number
24.c	Facsimile Number
24.d	Email Address
24.e	Cell or Page Number

D. General Info

Instructions:

- Please provide answers in the blue box to the questions below. Select from the dropdown menu, if provided.

- If applicable, please follow additional instructions in the Comments section.

Company Information
Question		Response	Comments
1	Name and address of person to receive notices and who is authorized to make decisions, represent and legally bind the Offeror. Also provide the name, title, address, e-mail address and telephone and fax numbers of the person(s) who the County should contact with questions regarding your response.
2	Are you the Offeror, a subsidiary or affiliate of another company?
2.1	Give full disclosure of all direct or indirect ownership and type of relationship with affiliate companies. If Offeror is a foreign corporation, submit a copy of Certificate of Good Standing for State of California.
3	Indicate whether any services will be subcontracted to another company, in accordance with Paragraph 11, “Assignment or Sub-Contracting,” and list the company name and services for anticipated sub-contractors.		<Include list of subcontractors following the template in Attachment C. Staffing Plan, and indicate the document name here>
4	Describe any pending discussions, negotiations or agreements to merge, spin off, or sell Offeror.
5	Has Offeror been cited or threatened with citation within the last five (5) years by any federal or state regulators for violations of any state or federal law or regulations? If yes, describe in the Comments section.
6	In the last five (5) years, has Offeror had a contract terminated by a client for cause? If so, describe by whom and under what circumstances in the Comments section? Provide the name and telephone number of each client that has terminated Offeror's services for cause.
7	In the last five (5) years has Offeror failed or refused to complete a contract? If so, provide a detailed explanation in the Comments section.
8	Provide complete information and proof of existing and/or proposed legal organization structure within the County of Orange and where applicable, outside the County of Orange. Specifically, that Offeror is licensed to conduct business in the State of California. If not, attach an opinion of counsel giving his or her opinion as to whether he or she anticipates any difficulties in obtaining all necessary licenses prior to the effective date of the Contract.
9	In the past five (5) years, has Offeror been denied a license to do business or reprimanded by a licensing agency? If so, state the date of the denial, the license denied, the state in which the license was denied, the reason given for denial of the license, whether Offeror has had a bona fide change of ownership or management since Offeror license was denied and whether Offeror has eliminated the cause for which the license was denied.
10	Do you have appropriate physical and electronic safeguards in place to prevent inappropriate use or disclosure of Protected Health Information? Please describe key safeguards that are in place.
11	Do you have the capability to comply with all HIPAA Electronic Transactions and Security Standards?
12	Confirm if your organization has experienced any data breaches that impacted HIPAA compliance in the last five (5) years.
13	How many PPO members are in your current book-of-business commercial plan membership in California and Nationally for 2021, 2022, and 2023?

Organizational and Financial Stability
Question		Response	Comments
1	Provide your most recent financial ratings from the following rating bureaus:
	Standard & Poor’s
	Moody’s
	Fitch
2	During the last five (5) years, has your firm had any lawsuits brought against it covering the administration or claims processing of any plan? If so, explain in the Comments section. Provide court and case numbers for litigation.
3	Confirm that upon termination of the Offeror's business relationship with the County, the Offeror agrees to provide reasonable assistance and data to enable smooth transition at no additional expense to the County, assuming responsibility for the services that Offeror had provided. Please provide a summary of your transition process, how you will coordinate with the new vendor and if there are any costs associated with the transition.

4	Confirm that Offeror agrees not to take action that would result in discharge of plan participants or beneficiaries confined to one of the Offeror’s network facilities prior to the completion of their course of treatment.
5	Confirm the Offeror will indemnify the County and its plan for all damages, fines, penalties, costs and fees related to any act or omission of Offeror or any of its employees or agents as to the services described in the Contract between the parties.
6	Provide history of acquisition, buyouts or mergers with other entities for the past ten years.

Statement of Qualifications and Vendor Experience
Question		Response	Comments
1	Provide your Annual Report for the last two (2) years. Offeror must also include independently audited financial statements for the last two (2) fiscal years. Audited financial statements are required; un-audited financial statements will not be accepted.		<Include under separate cover, and indicate the document names here>

Eligibility Connections Standards
Question		Response	Comments
1	Confirm you will perform at least quarterly, full eligibility reconciliations with the County 's Benefits Center.
2	Confirm the County 's Benefits Center or Authorized County Benefits team employees can request urgent eligibility updates and that the updates will be made within 24 hours and transmitted to the pharmacy benefits administrator.
2.1	Please confirm that eligibility reports can be accessed in an electronic format or via the Internet.
3	Indicate whether you can accept eligibility information by electronic media (i.e., internet), tape or hard copy. Confirm you can accept HIPAA-compliant ANSI 834 format, currently used by the County’s Benefits Center to provide files to vendors.
4	Confirm you will perform at least annually, full database audits with the County’s Pharmacy Benefits Manager.

Company Experience/Background
Question		Response	Comments
1	For any business structure, provide history of acquisition, buyouts or mergers with other entities for the past ten years.
2	Provide a list of all hub/locations and include the following information for each location: business hours, organizational chart for each location.
3	How many years of experience does your firm have in providing Claims Administration for Self-Insured Preferred Provider Organization (PPO) plans in Orange County? (Provide name and address if prior business name is not the same as Offeror)

Past Experience / Services with the County
Question		Response	Comments
1	Please list any previous or current contracts with the County of Orange within the last 5 years. Include:
1.1	Agency/Department name, address and contact person
1.2	Contract Number
1.3	Amount of Contract

E. Minimum Qualifications

Instructions:

- The following is the criteria for an Offeror to be considered an eligible candidate to bid on the requested services described in this RFP. Please provide a concise description in the Response section of how Offeror meets the qualification listed in each question. Offeror must meet all of the following requirements:

- If applicable, please follow additional instructions in the Comments section.

Company Information
Question		Response	Comments
1	Three (3) years previous experience with at least three public sector clients of similar size and complexity, providing administration for self-insured PPO health plans.
2	Have a broad network of independent hospitals, physicians and ancillary providers in California, specifically in Orange County, as well as neighboring communities.
3	Have a National Network of independent hospitals, physicians and ancillary providers.
4	Have three (3) years experience working with third party PBMs (e.g. Optum Rx)
5	Ability to assume claims administration services beginning January 1, 2025.
6	Submit proposal in the manner as requested in Section II of this RFP.
7	Agree to comply with terms and conditions of the County’s Model Contract as stated in Section III of the RFP, unless Offeror’s Proposal identifies specific exceptions and exclusions to such terms and conditions as required by this RFP by mandatory submission of a redline of the County’s Model Contract and complete Part 1: Offeror’s Concurrence/Compliance, section 10.B. Failure to submit required documentation, including a redlined County Model Contract, may result in your bid being considered non-responsive. If there are no exceptions proposed, complete Part 1: Offeror’s Concurrence/Compliance section 10.A.

Retiree Pop. ASO Fee Details

Self-funded Fixed Fee Detail

All Fees are PEPM Unless Otherwise Caveated

Fixed Fees	Proposal
Base Fees	$0.00	Caveats
ASO Fee - PPO	$0.00
ASO Fee - Rx*	$0.00
Pharmacy Rebate Offset	$0.00
ASO Fee - CDHP	$0.00
Transfer of Fiduciary Liability	$0.00
Network Access Fee (NAF)	$0.00
Broker Commission - Net of Commission	$0.00		17588
Program Fees	$0.00
Banking	$0.00
Management Reports	$0.00
HRA/HSA admin	$0.00
FSA admin	$0.00
HIPAA Certificates	$0.00
High Performance Network	$0.00
Behavioral Health	$0.00
Utilization Review	$0.00
Disease Management	$0.00				10400
MSK (musculoskeletal)*	$0.00
Oncology
Maternity
Wellness	$0.00
Case Management	$0.00
Run-out Claims Administration	$0.00
Integration / File Transfer Fees	$0.00
Stop Loss	$0.00			80% AD
Pharmacy (carve-out) / OOP Accumulator	$0.00			Same as deductible
HSA / FSA	$0.00				Same as deductible
COBRA	$0.00			Yes
Wellness	$0.00
Other Fees	$0.00
Telehealth	$0.00
Please add any additional fees	$0.00
Please add any additional fees	$0.00
Annualized Cost	$0.00
ASO Fee Guarantee / Rate Cap

(Increase in Year 2 and 3) Bundling Discount

Participation Requirement

AM Best Rating

AM Best Carrier ID | Rating Date

* Please don't use rebate to offset the ASO. Quote expected rebates only, client is not interested in Rx credit
*Nissan currently has this in place
		30
		$25 AD / $70 AD / $140 AD
	* AD - After Deductible; N/A - Not Applicable; CY - Calendar Year; PA - Prior Authorization

F. Required Attachments

Instructions:

- Please provide confirmation that you have provided each item in the blue boxes below.

- Please follow additional instructions in the Comments section to track attachments.

Company Information
Question		Response	Comments
1	Model Contract: If taking exception to any language in the Model Contract, identify specific exceptions and exclusions to such terms and conditions as required by this RFP by mandatory submission of a redline of the County’s Model Contract.		<Include file name here>
1.1	Staffing Plan: Please fill out Attachment C - Staffing Plan as part of your redline of the Model Contract.
1.2	Performance Standards: Please review the guarantees suggested in Attachment F - Performance Standards and redline any changes as part of your review of the Model Contract.
2	Implementation Plan: Provide an implementation plan outlining the necessary tasks needed to install the County’s plans and begin providing medical benefits to eligible employees. Include a timetable and name the parties responsible. Indicate all procedures and time frames.		<Include file name here>
3	Communications Plan: Provide a detailed Communications Plan and project timetable beginning with the Contract award and continuing through the complete assumption of all services within this Contract. Indicate the level of involvement you will need from Blue Shield of California and the County. Provide the location where each process step takes place.		<Include file name here>
4	Team Biographies and Organization Chart: submit a biography/resume for each person proposed on the implementation and account team as well as an organization chart		<Include file name here>
5	Plan Summaries: If you propose any alternate plan provisions, please provide plan summaries		<Include file name here>
6	Network Discount: Provide the proposed methodology for confirming and reporting network discounts to the County.		<Include file name here>
7	Explanation of Benefits: Provide several samples of EOBs showing a variety of claims processing results, including claim denials for non-covered items, claims paid, claims partially paid, in-and-out of network benefits paid, member liability, etc.		<Include file name here>
8	Annual Report: Provide your Annual Report for the last two (2) years. Offeror must also include independently audited financial statements for the last two (2) fiscal years. Audited financial statements are required; un-audited financial statements will not be accepted.		<Include file name here>
9	Service Organization Controls (SOC) Report: Provide your audited SOC (Service Organization Controls) 2 - Type 2 report for the last two (2) years.		<Include file name here>
10	Cybersecurity Policies: Provide the policies requested on Tab X - Cybersecurity.		<Include file names here>

G. Plan Designs G. Plan Designs

Instructions:

- Below is a summary of the current plan designs (Wellwise PPO and Sharewell PPO)

- Note that if there are any discrepancies between this plan design summary and the plan documents, the plan documents overrule the plan design summary

- Indicate in the blue boxes if any of the plan design elements cannot be accommodated and how the plan design would be changed so it could be administered

- Indicate in the blue boxes if any of the plan design elements could only be accommodated with a manual process, as well as your recommended plan design change to avoid manual intervention

- If the plan design element is standard and there would be no issues with adjudication, leave the blue box blank

- Note that pharmacy benefits for Wellwise and Sharewell are carved out to OptumRx; pharmacy is not part of this RFP

			CURRENT PLANS TO MATCH
	Carrier		Blue Shield	WELLWISE PPO
DEVIATIONS / COMMENTS		SHAREWELL PPO

DEVIATIONS / COMMENTS

Option/Proposal	Current Plans				Proposed Plans
Plan	Wellwise PPO		Sharewell PPO		Wellwise PPO		Sharewell PPO
Effective Date	January 1, 2024		January 1, 2024		January 1, 2025		January 1, 2025
Eligibility	Active Employees and Retirees		Active Employees and Retirees		Active Employees and Retirees		Active Employees and Retirees
	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network
General Plan Information
Annual Deductible - Individual	$500	$750	$5,000 combined for In-Network

and Out-of-Network

Annual Deductible - Family	$1,000	$1,500
Embedded Deductible	Yes	Yes	No	No
Coinsurance	90%	70%	90%	70%
PCP Office Visit	90%	70%	90%	70%
Telehealth	90%	N/A	90%	N/A
Specialist Office Visit	90%	70%	90%	70%	`
Annual Out-of-Pocket Maximum - Individual	$2,500	$5,000	$6,000	$12,000
Annual Out-of-Pocket Maximum - Family	$5,000	$10,000	$6,000	$12,000
Deductible Included in OOP Maximums	Yes	Yes	Yes	Yes
Cross Accumulation IN/OON	Yes	Yes	Yes	Yes
Inpatient Hospital Services
Inpatient Hospitalization	90%	70%	90%	70%
Pre-Authorization (PA) of Services Required	No	Yes, otherwise 50%	No	Yes, otherwise 50%
Emergency / Urgent Services
Emergency Room	90%	90%	90%	90%
Medical Transportation	90%	90%	90%	90%
Urgent Care Facility	90%	70%	90%	70%
Outpatient Services
Diagnostic X-Ray and Lab Tests	90%	70%	90%	70%
Ambulatory Surgery Centers	90%	70%, up to a maximum of $1,500/ day	90%	70%, up to a maximum of $1,500/ day
Substance Abuse
Inpatient	90%	70%	90%	70%
Pre-Authorization (PA) of Inpatient Services Required	No	Yes, otherwise 50%	No	Yes, otherwise 50%
Outpatient	90%	70%	90%	70%
Mental Health
Inpatient	90%	70%	90%	70%
Pre-Authorization (PA) of Inpatient Services Required	No	Yes, otherwise 50%	No	Yes, otherwise 50%
Outpatient	90%	70%	90%	70%
Outpatient Rehab Therapy Services
Physical Therapy	90%	70%	90%	70%
Occupational Therapy	90%	70%	90%	70%
Speech Therapy (covered for illness and accidental injury)	90%	70%	90%	70%
Chiropractic Services (25 visits maximum per year)	90%	70%	90%	70%
Acupuncture Services (25 visits maximum per year)	90%	70%	90%	70%
Home Health Care (prior authorization required)	90%	70%	90%	70%
Skilled Nursing Facility (100 days maximum per year)	90%	70%	90%	70%
Durable Medical Equipment (prior authorization for claims over $5,000)	90%	70%	90%	70%
Hospice Service (prior authorization required)	90%	70%	90%	70%

Pharmacy Benefits	In-Network	Out-of-Network	In-Network	Out-of-Network
Note: Pharmacy benefits are carved out to Optum Rx
Prescription Drug Deductible	$0	Not covered	Included in medical deductible
Prescription Drug Out-of-Pocket Max (Individual / Family)	$4,100 / $8,200	Not covered	Included in medical OOPM	Included in medical OOPM
Retail
Tier 1 / Tier 2 / Tier 3	80% / 75% / 70%	Not covered	80%	Not covered
Specialty	Members pay applicable tier coinsurance, up to a maximum $150	Not covered	80% (all specialty drugs must be filled by OptumRx Specialty Pharmacy for Sharewell only)	Not covered
Mail-Order
Tier 1 / Tier 2 / Tier 3	80% / 75% / 70%	Not covered	80%	Not covered
Specialty	Members pay applicable tier coinsurance, up to a maximum $150 per 30 day supply	Not covered	80% (all specialty drugs must be filled by OptumRx Specialty Pharmacy for Sharewell only)	Not covered
Non-Standard Plan Provisions
Medicare Coordination of Benefits (COB)	See Tab S		See Tab S	0%
Complex Radiology	Prior authorization required		Prior authorization required
Non-Emergency Spine Surgery & Pain Management Procedures (such as lumbar spine surgery, cervical spine surgery, injections, epidurals, and joint blocks).	Prior authorization required		Prior authorization required
Out-of-Network Providers at In-Network Facilities	If emergency, covered as in-network; subject to balance billing. If non-emergency, radiologist, anesthesiologist, pathologist, and ER physician covered as in-network; subject to balance billing.		If emergency, covered as in-network; subject to balance billing. If non-emergency, radiologist, anesthesiologist, pathologist, and ER physician covered as in-network; subject to balance billing.
HPN
Network Coverage - please confirm your plan can administer a High Performance Network and indicate if there are any impacts to plan design or network (e.g. in-network only)

Derrick, Kim: Derrick, Kim:

corrected spelling of administer.

	NA		NA
Mid-year changes to Accumulators
		NA		NA

H. Plan Design Alternatives H. Plan Design Alternatives

Instructions:

- Below is a summary of changes the County is considering for 2025

- Indicate in the blue boxes any plan design deviations, as well as your recommended plan design changes

- If the plan design element is standard and there would be no issues with adjudication, leave the blue box blank

	Carrier		Proposed Plan Changes	WELLWISE PPO
DEVIATIONS / COMMENTS		SHAREWELL PPO

DEVIATIONS / COMMENTS

Option/Proposal					Proposed Plans
Plan	Wellwise PPO		Sharewell PPO		Wellwise PPO			Sharewell PPO
Effective Date	January 1, 2025		January 1, 2025		January 1, 2025			January 1, 2025
Eligibility	Active Employees and Retirees		Active Employees and Retirees		Active Employees and Retirees			Active Employees and Retirees
	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	Estimated Claim Impact (%)	In-Network	Out-of-Network	Estimated Claim Impact (%)
Deductible (These changes apply to Sharewell only)
Annual Deductible - Individual	NA	NA	$3,000 single/ $5,000 family

combined for In-Network

and Out-of-Network

Annual Deductible - Family

Embedded Deductible

Yes

Out of Pocket Maximum (These changes apply to Sharewell only)

Annual Out-of-Pocket Maximum - Individual

$6,000

$12,000

Annual Out-of-Pocket Maximum - Family

$9,000

$18,000

Deductible Included in OOP Maximums

Yes

Cross Accumulation IN/OON

Yes

Hearing Aids

Device Coverage

$2,500 per year, every three years

Fertility Coverage

Diagnose and Treat Infertility

90%

70%

90%

70%

Artificial Insemination

90%

70%

90%

70%

IVF, GIFT, ZIFT, Embryo Transfer, Genetic Testing and Egg Freezing

Not Covered

Elective Abortion

Coverage for elective abortion

90%

70%

90%

70%

Foot Orthotics

Coverage for foot orthotics, must be medically necessary

100%

I. ASO Fees & Credits - SQ

Instructions:

- This is 1 of 2 ASO Fees & Credits worksheets; this worksheet is for Status Quo plans

- Fill in PEPM fees for each item outlined below for years 1 - 5 of the contract (if fee is not on a PEPM basis, indicate this in the comment section)

- Enter the total estimated annual cost for each category of fees, as well as a grand total

- Indicate the number of participants each item below would apply to (if applicable)

- If you are unable to provide a 5 year fee guarantee, provide the formula upon which the fees for years 4 and 5 will be calculated

- Instructions for specific items are in the comment section

- Provide credits in the Credits section beginning in row 70

- Indicate any caveats or comments in the comments section

Self-Funded Fixed Fee Detail - Status Quo
Fixed Fees	Enrollment	Year 1	Year 2	Year 3	Year 4	Year 5	Comments
Base Fees
ASO Fee - Wellwise		$0.00	$0.00	$0.00	$0.00	$0.00
ASO Fee - Sharewell		$0.00	$0.00	$0.00	$0.00	$0.00
ASO Fee - HPN		N/A	N/A	N/A	N/A	N/A
Transfer of Fiduciary Liability		$0.00	$0.00	$0.00	$0.00	$0.00
Network Access Fee (NAF)		$0.00	$0.00	$0.00	$0.00	$0.00
Claims and Litigation Support Services for two years following termination of contract		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Program Fees
Banking		$0.00	$0.00	$0.00	$0.00	$0.00
Management Reports		$0.00	$0.00	$0.00	$0.00	$0.00
HSA administration		$0.00	$0.00	$0.00	$0.00	$0.00
Behavioral Health / ABA (ABA for actives only)		$0.00	$0.00	$0.00	$0.00	$0.00
Utilization Review		$0.00	$0.00	$0.00	$0.00	$0.00
Disease Management		$0.00	$0.00	$0.00	$0.00	$0.00			10400
Healthy Maternity		$0.00	$0.00	$0.00	$0.00	$0.00
Case Management		$0.00	$0.00	$0.00	$0.00	$0.00
Telehealth		$0.00	$0.00	$0.00	$0.00	$0.00
Value-Based Care Fee #1		$0.00	$0.00	$0.00	$0.00	$0.00	<Indicate name and basis of fee (i.e., per attributed member per month)>
Value-Based Care Fee #2		$0.00	$0.00	$0.00	$0.00	$0.00	<Indicate name and basis of fee (i.e., per attributed member per month)>
Annual Cost
Integration / File Transfer Fees
Rx Integration Fee		$0.00	$0.00	$0.00	$0.00	$0.00		Same as deductible
HSA / FSA		$0.00	$0.00	$0.00	$0.00	$0.00			Same as deductible
Reporting Fees**		$0.00	$0.00	$0.00	$0.00	$0.00
Programming Fees		$0.00	$0.00	$0.00	$0.00	$0.00
ID Cards / Medical		$0.00	$0.00	$0.00	$0.00	$0.00
Subrogation		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Other Fees
24 Hour Nurse Line		$0.00	$0.00	$0.00	$0.00	$0.00
Non-Smoker Incentive Program Administration Fee		$0.00	$0.00	$0.00	$0.00	$0.00	<See Model Contract for description of this program>
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Grand Total		$0	$0	$0	$0	$0

One Time Implementation Costs
One Time Set Up Fee (if applicable)	$0.00
Potential Additional Costs (describe if applicable)	$0.00
<Additional cost not yet outlined>	$0.00
Total Cost

Run-Out Claims Administration***
Medical Run-Out Claims Administration	$0.00	<Specify basis of fee (i.e., PEPM) and # of months the fee is due>
Total Cost

**75 AD-HOC hours included annually at no charge. In excess of 75 AD-HOC hours requires written approval to the County prior to the start of work. For additional work requested by County during the term of this Contract, consistent with administration of the Plans, the County will be charged at the programming and reporting rates above. Examples of such work would be a request to implement plan design changes, eligibility changes, etc. Contractor shall provide written estimate of the work and the related charges for written County approval prior to the start of work.

***Contractor will process run-out medical claims for a period of twelve months following the termination date. Any and all additional services needed by the County to administer and track Claims run-out, including but not limited to claims reporting, bank reconciliation reports, claim appeals, subrogation, etc., shall be included in the above fees.

Credits - these should already be built into the costs outlined above
Implementation Credit	$0	$0	$0	$0	$0
Pre-Implementation Audit Credit	$0	$0	$0	$0	$0
Wellness Credit (at least $250k)	$0	$0	$0	$0	$0
Communication Credit	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0

For additional compensation and payment terms, refer to Attachment C in the Model Contract.

J. ASO Fees & Credits - HPN J. ASO Fees & Credits - HPN (if implemented)

Instructions:
- This is 2 of 2 ASO Fees & Credits worksheets; this worksheet is for adding the HPN plan options alongside the current plan offerings, for both active and retiree populations
- Note that this scenario includes the plan design changes outlined on H. Plan Designs Alt, as well as adding HPN options alongside the County's current self-funded plans
- Fill in PEPM fees for each item outlined below for years 1 - 5 of the contract (if fee is not on a PEPM basis, indicate this in the comment section)
- Enter the total estimated annual cost for each category of fees, as well as a grand total
- Indicate the number of participants each item below would apply to (if applicable)
- If you are unable to provide a 5 year fee guarantee, provide the formula upon which the fees for years 4 and 5 will be calculated	If all fees, credits and terms are the same as

ASO Fees & Credits - SQ, enter No Changes:

- Instructions for specific items are in the comment section

- Provide credits in the Credits section beginning in row 70

- Indicate any caveats or comments in the comments section

Self-Funded Fixed Fee Detail - HPN
Fixed Fees	Enrollment	Year 1	Year 2	Year 3	Year 4	Year 5	Comments
Base Fees
ASO Fee - Wellwise		$0.00	$0.00	$0.00	$0.00	$0.00
ASO Fee - Sharewell		$0.00	$0.00	$0.00	$0.00	$0.00
ASO Fee - HPN		$0.00	$0.00	$0.00	$0.00	$0.00
Transfer of Fiduciary Liability		$0.00	$0.00	$0.00	$0.00	$0.00
Network Access Fee (NAF)		$0.00	$0.00	$0.00	$0.00	$0.00
Claims and Litigation Support Services for two years following termination of contract		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Program Fees
Banking		$0.00	$0.00	$0.00	$0.00	$0.00
Management Reports		$0.00	$0.00	$0.00	$0.00	$0.00
HSA administration		$0.00	$0.00	$0.00	$0.00	$0.00
Behavioral Health / ABA (ABA for actives only)		$0.00	$0.00	$0.00	$0.00	$0.00
Utilization Review		$0.00	$0.00	$0.00	$0.00	$0.00
Disease Management		$0.00	$0.00	$0.00	$0.00	$0.00			10400
Healthy Maternity		$0.00	$0.00	$0.00	$0.00	$0.00
Case Management		$0.00	$0.00	$0.00	$0.00	$0.00
Telehealth		$0.00	$0.00	$0.00	$0.00	$0.00
Value-Based Care Fee #1		$0.00	$0.00	$0.00	$0.00	$0.00	<Indicate name and basis of fee (i.e., per attributed member per month)>
Value-Based Care Fee #2		$0.00	$0.00	$0.00	$0.00	$0.00	<Indicate name and basis of fee (i.e., per attributed member per month)>
Annual Cost
Integration / File Transfer Fees
Rx Integration Fee		$0.00	$0.00	$0.00	$0.00	$0.00		Same as deductible
HSA / FSA		$0.00	$0.00	$0.00	$0.00	$0.00			Same as deductible
Reporting Fees**		$0.00	$0.00	$0.00	$0.00	$0.00
Programming Fees		$0.00	$0.00	$0.00	$0.00	$0.00
ID Cards / Medical		$0.00	$0.00	$0.00	$0.00	$0.00
Subrogation		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Other Fees
24 Hour Nurse Line		$0.00	$0.00	$0.00	$0.00	$0.00
Non-Smoker Incentive Program Administration Fee		$0.00	$0.00	$0.00	$0.00	$0.00	<See Model Contract for description of this program>
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
<Additional fees not yet outlined>		$0.00	$0.00	$0.00	$0.00	$0.00
Annual Cost
Grand Total		$0	$0	$0	$0	$0

One Time Implementation Costs
One Time Set Up Fee (if applicable)	$0.00
Potential Additional Costs (describe if applicable)	$0.00
<Additional cost not yet outlined>	$0.00
Total Cost

Run-Out Claims Administration***
Medical Run-Out Claims Administration	$0.00	<Specify basis of fee (i.e., PEPM) and # of months the fee is due>
Total Cost

Credits - these should already be built into the costs outlined above
Implementation Credit	$0	$0	$0	$0	$0
Pre-Implementation Audit Credit	$0	$0	$0	$0	$0
Wellness Credit (at least $250k)	$0	$0	$0	$0	$0
Communication Credit	$0	$0	$0	$0	$0
Other	$0	$0	$0	$0	$0

For additional compensation and payment terms, refer to Attachment C in the Model Contract.

K. Financial K. Financial

Instructions:

- Please provide succinct responses to the questions below in the respective blue box

Financial
Question		Response	Comments
1	Please confirm that you agree to defend, indemnify, and hold County of Orange harmless against any claim, demand, damages, or legal action which arise, or is alleged to arise, as a result of acts or omissions of Contractor in providing services under the terms and conditions of the contract?
2	Please confirm County of Orange can administer a self-bill method for premium payment.
3	How are runout claims handled?
4	Are there any other banking fees or claims processing fees that County of Orange will be responsible for that is not already listed on the ASO Fees & Credits worksheets? If so, explain in the Comments section.
5	What is your standard method of determining usual, customary, and reasonable (UCR) charges?
6	What is your standard out-of-network reimbursement URC percentile? In what circumstances would you deviate from this?
6.1	The County plans are currently set up so that OON claims are reimbursed at the 90th percentile of URC. Can you accommodate this?
7	How often/frequently is the bank account to be funded (daily/weekly/monthly/other)?
8	For self-funded accounts, do you require an initial or ongoing minimum balance in the bank account from which claims are paid? If yes, what is the minimum?
9	The County will reimburse you for claims only after checks are cleared. Confirm that you can accommodate this.
10	Please describe your standard banking arrangement, including any options available and clarify if these options entail any additional charge, specifically for multiple bank arrangements.
11	How often are claims processed and reimbursement requests sent to County of Orange?
12	How often are benefit payments and EOBs produced and released to members and providers?
13	Please confirm that administrative fees cannot be changed except on the policy anniversary.
14	Will you allow for 60 days grace for payment of fees?
15	When overpayments are made to providers and members, how are the overpayments recovered?
15.1	Provide the names of collection agencies used to collect overpayments made to providers and members?
15.2	What are the collection agency processes and do the processes differ for providers and members?
16	What is the process for refunding claims paid in error?
17	What is the process for returned checks and uncleared checks?
18	Please confirm that you agree to provide monthly stop loss reporting files to the County's 3rd party vendor at no additional cost.
19	Please confirm your agreement to "pass through" 100% of medical specialty rebates earned by the County's utilization
20	The County currently retains 100% of shared savings fees associated with Fraud, Waste & Abuse as well as OON negotiations. Please confirm your quote continues to provide these services with the County retaining the full savings.
20.1	Please confirm there are no other variable fees subject to shared savings within your quote.
21	Financial Statements:

Confirm offeror shall submit financial statements for the three (3) most recent fiscal years. Financial statements shall be prepared in conformity with generally accepted accounting principles.

22 Bankruptcy Information:

Confirm offeror shall indicate whether Offeror, its principals, directors, or majority shareholder(s), or any company Offeror has held a controlling interest in, or which has held a controlling interest in Offeror, has ever filed for or has been involuntarily put into bankruptcy or has been declared bankrupt. If yes, attach a statement indicating the bankruptcy date, court jurisdiction, trustee’s name and telephone number, amount of liabilities, amount of assets and current status of bankruptcy.

23 Current/Past Litigation:

Offeror shall provide detailed information regarding litigation (court and case number), liens, or claims involving Offeror, or any company Offeror holds a controlling interest in, or any company that holds an interest in Offeror, or any of the principal officers of the Offeror’s firm in the past 5 years.

Please clearly indicate in the comments if you have:

- No action pending

- No prior action

- Action pending

- Information pending <If necessary, include under separate cover, and indicate the document name here>

L. Staff-Communication Plans L. Staffing & Communications Plans

Instructions:

- Please provide succinct responses to the questions below in the respective blue box

- If applicable, please follow the instructions in blue text

Staffing Plan
Question		Response	Comments
1	List all personnel who will be assigned to the County’s account and their responsibilities in an organizational chart. Include implementation personnel, ongoing account management personnel and the ongoing customer service manager.

a. For each person in the organization chart, indicate their job title, role on the County’s account, total years of experience in fields related to these services, years at your company and years in their current position.

b. For the implementation manager and the account manager, indicate the number of small (<1,000 employees), medium (1,000 to 4,999) and large (>5,000) clients to which they are currently assigned.		<Include under separate cover, and indicate the document name here>
	2	Who will be the primary liaison with the County for day to day and member related issues?
	3	Who will be the primary liaison with the County for contract / service issues?
	4	Alternate staff (for use only if primary staff are not available)

Substitution or addition of Contractor’s key personnel in any given category or classification shall be allowed only with prior written approval of the County Project Manager.

The Contractor may reserve the right to involve other personnel, as their services are required. The specific individuals will be assigned based on the need and timing of the service/class required. Assignment of additional key personnel shall be subject to County Project Manager approval. County reserves the right to have any of Contractor personnel removed from providing services to County under this Contract. County is not required to provide any reason for the request for removal of any Contractor personnel.

	<List names and classification/title for each staff member>
5	Confirm your account team and onsite staff's willingness to meet with the County on a quarterly basis (at a minimum).

Communications Plan
Question		Response	Comments
1	Provide a detailed Communications Plan and project timetable beginning with the Contract award and continuing through the complete assumption of all services within this Contract. Indicate the level of involvement you will need from Blue Shield of California, OptumRx, and the County. Provide the location where each process step takes place.		<Include under separate cover, and indicate the document name here>

2 Provide a list of reports you will require from the incumbent medical claims administrator.

M. Impl, Admin, Cust Serv, Rx M. Implementation, Ongoing Administration, Customer Service, Pharmacy

Instructions:

- Please provide succinct responses to the questions below in the respective blue box

Implementation
Question		Response	Comments
1	Provide a detailed implementation plan and project timetable beginning with the Contract award and continuing through the complete assumption of all services within this Contract, and also including a final section for termination of services at the completion of the Contract, following the claims run-out period. Indicate the level of involvement you will need from Blue Shield of California, OptumRx, and County of Orange. Provide the location where each process step takes place.		<Include under separate cover, and indicate the document name here>

2	Will your key implementation resources be allocated full time to County of Orange for the duration of the implementation, or will they be shared across groups?
3	How long after the go-live date will the implementation resources be available to ensure continuity and a smooth transition?
4	What specific data do you need from the incumbent vendor and County of Orange for an effective implementation and what is the minimum amount of time you recommend for efficient, effective implementation?
5	During the implementation process, how many days are typically required to produce enrollment materials, ID cards, SBCs and one-page benefit summaries? Is the timeframe the same for Active and Retiree plans?
5.1	Is there any additional cost? If so, outline these in the Comments section.
5.2	Please confirm that there is no additional cost for the following:
	- Enrollment kits
	- Policy / contract amendments
	- Actuarial services (for benefit changes, cost estimates)
	- Travel expenses
6	Please confirm if any of the following are subcontracted:

- ID card production

- ID card distribution

- Communication materials

7	How will you handle transition of care for those hospitalized, those with scheduled surgeries, pregnancy, etc.?
8	Confirm you will provide County of Orange with SBCs and one page retiree plan summaries for 2025 and subsequent plan years. SBCs should be available in both English and Spanish and compliant with all CMS requirements.

Ongoing Administration
Question		Response	Comments
1	The selected Offeror will be required to work with Alight on the 2024 open enrollment processing and files for plan year 2025. Confirm if you have experience working with Alight.
2	Confirm Offeror will not place a time limit on retroactive adjustments and retroactive recalculation of administration fees for eligibility changes for new hires, terminations, status changes and dependent changes.
3	Confirm Offeror will allow up to 60 days after a qualifying event for a dependent change.
4	Confirm Offeror will only make eligibility changes based on information received from the County’s Benefits Center or Authorized County Benefits team employees for urgent situations?
5	Confirm Offeror agrees to allow the County's Benefits Center to be the official and primary source of all enrollment data.
6	Confirm Offeror agrees to work with the County's Benefits Center to ensure eligibility is updated on a weekly basis and within 48 hours of receipt of data.
7	Confirm that you will provide file discrepancy reports to the County's Benefits Administrator within 3 business days of receiving the file and will work with the County's Benefits Administrator to resolve the discrepancies in a timely manner.
8	Confirm that you will perform a monthly ASO fee reconciliation that identifies discrepancies and provides resolutions.
9	Provide an overview of your data security/PHI protocols, including process for notification to members and plan sponsors in the event of a data breach.
10	Confirm that all eligibility information will be loaded onto the Offeror's system within three (3) business days of data receipt.
11	The County self-bills its current programs. Confirm that Offeror will be able to receive rosters of enrollees for billing purposes and addresses any billing discrepancies with the client.
12	Describe your file feed process as it relates to errors. If there are errors in the file, how will the County and Alight be notified? If there are errors on the file, will the non-errors load or will the entire file fail?
13	Please confirm your organization's ability to perform and document a comprehensive comparative analysis of the design and application of all nonquantitative treatment limits (NQTLs) in the County’s self-funded programs, as required under the Mental Health Parity Addiction and Equity Act (MHPAEA) and all applicable guidance issued thereunder.

Customer Service
Question		Response	Comments
1	Indicate if the following online customer service capabilities are available for employees for medical and pharmacy (add capabilities not listed to Other):
	Claim History and Out-of-Pocket Accumulators
	Provider Search Tool
	Provider Quality
	Health Information/Education
	Member Chat Rooms/Forums
	Benefit Forms
	Temporary ID Cards
	Order Replacement ID Cards
	Email Customer Service
	Plan Benefit Information/Plan Provisions
	Talk to providers or “Ask A Physician”
	Identify any available mobile applications
	Other
2	What mobile technology applications do you currently offer to engage members? Which ones are currently in development?
3	Indicate whether the following services are available via the mobile app for medical and pharmacy:			Need to move this to another page
	ID cards
	Check claim status
	File a claim			Need to move this to another page
	Find a provider			Need to move this to another page
	Contact customer service via email or chat			Need to move this to another page
	Access plan documents and summaries
	Other?			Need to move this to another page
4	Can you develop and maintain a County-specific microsite? If yes, indicate if there would be an additional cost for this in the Comments section.
5	What is the location of the Customer Service Center that would be assigned to County of Orange?
6	What are the days/times that a live customer service representative is available?
6.1	What holidays are live customer service representatives not available?
7	Will there be a dedicated team of member service representatives responsible for the County member calls?
7.1	How many representatives will handle calls?
7.2	What are their average years of service?
8	For the proposed customer service center that will be answering calls for County of Orange, provide the following statistics for the 2022 calendar year:			Need to move this to another page
	Average speed to answer			Need to move this to another page
	Call abandonment rate			Need to move this to another page
	First call resolution			Need to move this to another page
	% of calls not taken
	% of claims received electronically			Need to move this to another page
	% of claims auto-adjudicated			Need to move this to another page
	Financial accuracy %
	Processing accuracy %
9	For the proposed customer service center that will be answering calls for County of Orange, provide the following statistics for the 2023 calendar year:			Need to move this to another page
	Average speed to answer			Need to move this to another page
	Call abandonment rate			Need to move this to another page
	First call resolution			Need to move this to another page
	% of calls not taken
	% of claims received electronically			Need to move this to another page
	% of claims auto-adjudicated			Need to move this to another page
	Financial accuracy %
	Processing accuracy %
10	What customer service model are you proposing for the County? Are enhanced customer service options available? If so, what is the fee?			Need to move this to another page
11	Are all calls recorded?
11.1	If yes, will you allow the County’s Manager of Customer Service functions to listen to calls when researching a complaint?
12	How long are recorded calls archived?
13	Will you provide a dedicated Ombudsman to handle escalated and/or complex issues?
14	Confirm your method for measuring member satisfaction for the required Member Satisfaction Performance Guarantee.
15	Can you support "train the trainer" initiatives? How?
15.1	If there is an additional cost for these initiatives, indicate that here.
16	Describe your member appeals procedures and timelines.
17	How are member complaints handled? How are they documented? Describe quality control processes in place for customer service.
18	What is the coaching/review protocol when there is a complaint regarding customer service?
19	Do you have a disaster recovery program for keeping your member services or other key functions running in the event of a disaster?
19.1	What would be the alternate member services center for the County of Orange?

Pharmacy Vendor Coordination
Question		Response	Comments
1	Is your organization able to transmit Near Real Time accumulator files between your organization and the County's carve out pharmacy vendor, Optum Rx. Please confirm this will be provided at no extra charge to the County.
2	Is your organization willing to allow OptumRx access to your system to view eligibility and accumulators? Please confirm this will be provided at no extra charge to the County.
3	Does your organization to agree to review the County's plan document annually to ensure the Rx MOOP aligns with CMS Guidelines?
4	Confirm that accumulators will be based on the member paid amount, not Medicare allowed amount.

N. Provider Network N. Provider Network

Instructions:

- Please provide succinct responses to the questions below in the respective blue box

Provider Network
Question		Response	Comments

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Apr 27, 2026.