Exhibit_A_-_Scope_of_Services.docx
DOCX document 37 KB Posted
- Solicitation number
- 26-P-67TF
- Issued by
- Volusia County, Florida
About this file
This Scope of Services document outlines the requirements for Medicare Supplement and Part D Pharmacy Insurance services to be provided by a contractor to Volusia County, Florida, and participating agencies for eligible Medicare retirees and their spouses, effective January 1, 2027. The contractor must provide three Medicare Supplement plan options (Plans F, G, and N) and a comprehensive Medicare Part D Employer Group Waiver Plan (EGWP) with a fully insured group billing structure. Deliverables include assignment of a dedicated client service manager with retiree health experience, telephonic and web-based customer service accessible during regular business hours, monthly eligibility updates with discrepancy reporting to the County or its Third Party Administrator, coordination of claim submissions with Medicare, training and assistance with annual enrollment including attendance at three half-day on-site enrollment meetings, and annual plan experience reports delivered within ninety days of each plan year end. The contractor must verify Medicare eligibility for all members, send enrollment materials directly to retirees' residences, maintain online eligibility access, accept monthly premium payments on a group billing basis, and provide no pre-existing condition limitations with guaranteed issue coverage.
The Medicare Supplement Plan N premiums when combined with the Part D EGWP pharmacy benefit must be lower than the County's current monthly premium of $971. If commissions or administrative fees are included in premiums, the contractor must disclose these on the pricing exhibits along with any agents' or brokers' names and services. The Part D plan must include a comprehensive pharmacy network on state and national bases featuring major chains, classify medications into five tiers with generic drugs at tier 1, and provide comprehensive coverage including one hundred percent Part D coverage plus bonus medications. The contractor may implement pharmacy step therapy and prior authorization programs and must assist in administrating low-income subsidy payments, low-income cost sharing, and catastrophic reinsurance. All plans must comply with Centers for Medicare & Medicaid Services (CMS) and Florida Office of Insurance Regulation requirements, with the contractor maintaining separate eligibility and reporting capabilities for each participating agency to integrate seamlessly with the County's existing Third Party Administrator, WEX.
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26-P-67TF Exhibit A – Scope of Services Medicare Supplement and Part Pharmacy D Insurance
1.0 Scope of Services
The Contractor shall provide the County the services as described herein to the satisfaction of the County.
1.1 General Information and Plan Information
A. The Contractor shall provide fully insured Group or fully insured Individual plans with the ability to group bill Medicare Supplement and Medicare Part D EGWP Plan.
1. Retirees currently covered under the County’s Medicare Supplement and Medicare Part D EGWP shall be automatically enrolled for the 2027 plan year in their current plan selection, if the covered retiree fails to make a timely selection.
B. Active employee services and health plan coverage for non-Medicare eligible retirees and dependents are not included in this Scope of Services.
C. The effective date for the fully insured Medicare plans is January 1, 2027.
D. The plans and premiums being provided by the Contractor will be for 2026 and currently approved by the Centers for Medicare & Medicaid Services (CMS) and the Florida Office of Insurance Regulation, as applicable.
E. A client service manager or Project Manager, with experience in retiree health and pharmacy plans, will be assigned to work with the County or the County’s Third Party Administration (TPA) during the implementation process, during annual enrollment, and through the life of the contract.
F. A telephonic customer service component for specific questions on the Contractor’s plans will be provided and will be accessible to Members and the County during regular business hours.
G. The Contractor shall send all annual and new Retiree enrollment materials, approved by the Centers for Medicare & Medicaid Services (CMS), where applicable, and reviewed by the County, directly to the Retiree’s residence. The Contractor shall be responsible for the enrollment of retirees.
H. The Contractor shall coordinate claim submittals with Medicare, where applicable.
I. Eligibility information will be updated monthly and accessible on-line. Eligibility discrepancy reports shall be provided to the County or the County’s TPA on a monthly basis.
J. Online web-based and telephonic customer service and education tools will be made available to Plan Members.
K. The Contractor shall have the ability to accept monthly premium payments from the County or the County’s TPA on a group billing basis.
L. The Plans will have no pre-existing condition limitations and will be guaranteed, issued for current and future plan Members.
M. The Contractor shall assist the County with annual enrollment by:
1. Training the County staff on the Medicare Supplement Plans, and a Medicare Part D EGWP Plans;
2. Assisting with annual enrollment, eligibility, and premium billing and collection; and
3. Attending at least three (3) half day on-site enrollment meetings at locations designated by the County.
N. The Contractor shall verify Medicare eligibility and enrollment for each Member electing the medical and pharmacy plans.
O. The Contractor shall provide an annual plan experience report to the County within ninety (90) days after the end of each Plan year.
2.1. Medicare Supplement Plan Services
A. Plan Design
1. Medicare Supplement Plans will include the following three options:
a. Plan F
b. Plan G
c. Plan N
B. Cost of Services
1. Premiums will be established on the Age at Issue of the policy.
2. Premiums for Plan N in Volusia County, when added to the Part D EGWP pharmacy benefit, will be lower than the current medical and pharmacy premium charged by the County for coverage, which is currently nine hundred seventy-one dollars ($971) per month.
3. If commissions or administrative fees are included in the premiums, the Contractor shall disclose the applicable commissions or administrative fees that are included in the premiums on Exhibit B.1 - Medicare Supplement Premiums.
a. If agents/brokers are included, the name/names shall be disclosed by the Contractor along with the services that will be provided.
2.2. Pharmacy Plan Services
A. Plan Design, Network and Pharmacy Services
1. The Contractor’s Medicare EGWP Part D plan shall closely match the Plan design and co-pays included in Exhibit B.2 - Medicare Part D Pharmacy Pricing Plan.
2. The Contractor’s Medicare EGWP Part D plan will include a comprehensive Network of pharmacies and have a comprehensive Network on a state and national basis.
3. The Contractor’s Medicare EGWP Part D medication coverage will be comprehensive and closely match the list of drugs contained in Attachment A.3 - Medicare Part D Drug List.
a. All generic drugs, including select generic drugs at reduced co-pay, will be included in tier 1.
b. The Contractor’s Medicare EGWP Part D Plan medication coverage will be comprehensive and include one hundred percent (100%) Part D coverage plus the bonus list of medications for the coverage option.
c. Cost of Services
I. Premiums for plans in Volusia County, when added to the Medicare Supplement Plan N benefit, will be lower than the current medical and pharmacy premium charged by the County for coverage which is currently nine hundred seventy-one dollars ($971) per month.
II. If commissions or administrative fees are included in the premiums, Contractor shall disclose the applicable commissions or administrative fees that are included in the premiums Exhibit B.2 - Medicare Part D Pharmacy Pricing Plan.
a) If agents/brokers are included, the name/names shall be disclosed by the Contractor, along with the services that will be provided.
III. The Contractor shall assist in administrating Medicare EGWP Part D, low-income subsidy payments, low-income cost sharing, and catastrophic reinsurance.
IV. The Contractor is permitted to include pharmacy step therapy and prior authorization programs.
P:\TABATHA\2026 Solicitations\26-P-67TF Medicare Supplement and Part Pharmacy D Insurance\1 SOLICITATION\Exhibit A - Scope of Services.docx
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