Exhibit_A_-_Scope_of_Services_FINAL.pdf

25-P-115TF Exhibit A – Scope of Services

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Table of Contents

1.0 Overview

2.0 General Services

3.0 Administrative Services

4.0 Plan Design

5.0 Network Services

6.0 Health Management

7.0 Financial Services, Reporting, and Data Interface

8.0 Pharmacy Services

9.0 Integrated Employee Assistance Program (EAP) Services

10.0 Cost of Services and Performance Guarantees

11.0 County Responsibilities

12.0 Contractor Responsibilities

1.0 Overview

The Contractor shall provide self-funded group health plan services on an Administrative Services Only (ASO) basis. The provision of group health plan benefits for County of Volusia (County) employees, retirees, and COBRA participants, including chiropractic Network, claims administration, an Employee Assistance Program (EAP) program, a national supplemental Network, managed prescription benefits, provider Network(s), and utilization management.

2.0 General Services

2.1 Contractor shall have experience providing Administrative Services Only (ASO) services to four (4) or more employers, each having three thousand (3,000) or more subscribers, within the past five (5) years.

2.2 Contractor is not required to include broker or agent administrative services. If an agent or broker is included for administrative service assistance, Contractor shall identify the standard commissions included, along with the administrative services that will be provided by the agent or broker.

2.3 Contractor providing self-funded ASO services shall include medical, pharmacy, and

Employee Assistance Program (EAP) services; claims administration and customer service; utilization management, regional, state, and national provider Networks; and medical and pharmacy plan management.

2.4 Contractor shall possess accreditation by the National Committee for Quality Assurance

(NCQA), as applicable.

2.5 Contractor shall provide the County with an annual third-party attestation report in accordance with the most current auditing standards for service organizations.

Specifically, the Contractor shall submit a System and Organization Controls (SOC) 1

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Type II report, conducted in accordance with the Statement on Standards for Attestation Engagements (SSAE) No. 18 (or its successor standard). The report must evaluate the design and operational effectiveness of controls relevant to the services provided under this Agreement.

2.6 Contractor shall complete medical claims re-pricing on the sample claims presented in the RFP based on the Contractor’s current Network discounts under contract with the applicable aggregate amounts as requested. The provider specific claims discount information shall be subject to on-site verification of accuracy at the Contractor’s facility as a part of the evaluation process. Specific provider contract discount information will be used for verification and will be treated as confidential and only used to validate the aggregate amounts. THE COUNTY DOES NOT REQUIRE (RE)PRICING FILE DOCUMENTS TO BE SUBMITTED. The (re)pricing file documents are used by the Contractor to complete EXHIBIT B - Fees and Performance Guarantees.

2.7 Contractor shall allow the County, or a mutually agreeable firm selected by the County to conduct annual medical and pharmacy claims audits. Contractor shall provide access to applicable records, files, and documents related to all medical and pharmacy claims, administrative fees and other elements of the Contract in order to conduct the annual audit.

3.0 Administrative Services

3.1 Contractor shall have accessible hours of customer service and claims administration and demonstrated service results to administer the comprehensive health plan, including all medical and prescription drug benefits for active employees, COBRA participants, Transportation Planning Organization (TPO), retirees, and eligible dependents.

3.2 Open Enrollment.

1. Contractor shall attend the County’s annual open enrollment sessions, up to five

(5) full days.

2. Representatives from the following areas shall attend medical, pharmacy, Employee Assistance Program (EAP) services; claims administration and customer service; utilization management, and provider Networks at no cost to the County.

3.3 Contractor shall have an experienced, dedicated account management team assigned to the County to assist with claims, eligibility and day-to-day service issues.

3.4 All customer service support involving interaction with Members will be handled within the territorial limits of the United States of America.

3.5 Contractor shall attend quarterly meetings to review Plan performance; meet monthly to review ongoing administrative, service, and Plan management issues; and make a Medical Director and Pharmacy Director available for ongoing involvement in Plan performance initiatives.

3.6 Secure web-based administrative tools will be available to the County benefits department to manage eligibility on an ongoing basis.

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3.7 Contractor shall make secure web-based informational and educational tools available to Members providing information on issues such as claims status, Network providers by specialty, health and wellness topics, and provider / treatment cost calculators that are based on the specific Plan designs of the County.

3.8 Contractor shall assist in the preparation and maintenance of the Summary Plan

Description (SPD) and Summary of Benefits and Coverage (SBC) annually on behalf of the County and provide these documents electronically for posting on the County’s website.

3.9 Contractor shall assist the County with annual enrollment by training the benefits staff on plans; creating County specific enrollment and educational materials; providing secure web portal assistance for annual enrollment; and agreeing to accept the County’s benefits enrollment files electronically on an ongoing basis.

3.10 Contractor shall have contractual arrangements in place with external claims review companies that will be made available to the County’s members. Contractor shall be responsible for facilitating all aspects of the external review process and shall provide the external review company with the claims and information needed for an appropriate decision to be made.

3.11 Contractor shall be the claims fiduciary and accept fiduciary responsibility for claims payment decisions and for defense of actions taken for claims adjudicated and related appeals, including legal defense of claims and medical and pharmacy claims decisions.

1. The County will be responsible for the legal defense of claims for which the County made the choice as to the determination of coverage.

2. The Contractor shall be responsible for the legal defense of claims that involve the claim determination based on the Contractor’s medical, pharmacy, and authorization standards for Level 1, Level 2, and external appeals. The County will be informed of all levels of appeals and Contractor’s decisions on appeals but will not be responsible for any claim’s determination matters or appeals.

3.12 Contractor shall process and adjudicate all medical and prescription drug claims in accordance with the Plan document. Contractor shall be held liable for claims adjudicated outside the health plan document.

3.13 Contractor shall have the ability to identify claims that could potentially be subject to third party liability such as workers compensation, auto accident, and coordination of benefits, and seek reimbursements for such services.

3.14 Contractor shall agree to use the care, skill, prudence and diligence under the circumstances then prevailing that a prudent claims administrator/fiduciary acting in a like capacity, and familiar with such matters, would use under similar circumstances as the standard of care for medical and pharmacy services.

4.0 Plan Design

4.1 Contractor’s medical plans will include an open-access (non- Gatekeeper) model option

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4.2 Contractor shall have discount arrangements for Complementary and Alternative

Medicine Services for Members.

4.3 Contractor shall have the ability to separately accumulate medical and pharmacy Member costs toward the medical deductible and medical and pharmacy out-of-pocket maximums.

4.4 The Contractor shall assist Members with End Stage Renal Disease in applying for

Medicare benefits.

5.0 Network Services

5.1 Contractor’s local hospital network will include access to in-Network benefits, at a minimum, at both Halifax and Advent Health hospitals.

5.1.1 Note: It is acknowledged that future Network changes may occur.

5.1.2 Contractor may provide client specific networks to meet this requirement.

5.2 Plans may include two levels of copayments with lower copayments for Network physicians in a high-performance limited network.

5.3 The Networks should have 85% of providers Board Certified/Board Eligible, and an annual turnover rate of less than 3%.

5.4 Contractor shall include a comprehensive network of hospitals, outpatient facilities, physicians, other healthcare providers, including chiropractic, and pharmacies specifically in Volusia, Flagler, Lake, Orange, Seminole, and Osceola Counties.

5.5 In addition to a network of retail pharmacies, Contractor shall include mail order and specialty pharmacy services.

5.6 Network gaps where in-Network providers are not available in Volusia and Flagler County will be disclosed.

5.7 Contractor Network will include state and national access for non-emergency and emergency care, including services provided at Centers of Excellence.

5.8 Contractor shall specify contracted services where capitation is applied. Contractor shall provide encounter data for services covered under capitated arrangements.

5.9 Members will be held harmless from balance billing when using in-Network providers, when being referred for specialty services by an in-Network provider, and for services provided by an in-Network provider that is not approved by the Contractor.

5.10 Contractor shall monitor Network performance based on nationally recognized quality

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5.11 Contractor shall include a telemedicine service for Members.

6.0 Health Management

6.1 Contractor shall include an online Health Risk Assessment (HRA) tool, accessible to Members, capable of having biometric screening results loaded into an individual’s HRA, and shall provide an aggregate report on the responses, including the changes in risk factors.

6.2 Contractor shall provide on-site biometric screenings at convenient times and locations, for Members.

6.3 Contractor shall demonstrate its ability to increase preventive care utilization.

6.4 Contractor shall demonstrate its ability to identify high risk Members, and its ability to assist them in managing their health.

6.5 The County desires to have a dedicated case management team assigned to the County to address the specific needs of seriously ill Members.

6.6 The Contractor shall include a full-time on-site clinical care coordinator (Registered Nurse or clinical equivalent) within forty-five (45) days at no additional cost other than the established ASO fees. The clinical care coordinator shall assist Members in achieving optimal health through identification of risks, closing gaps in care, assisting with County wellness initiatives, conducting educational sessions at various locations, and developing health improvement strategies. County will provide network access, internet access, and workspace ad detailed in Section 10.0.

6.7 The Contractor shall include a full-time on-site health engagement senior analyst within forty-five (45) days based on established ASO fees. The analyst’s primary responsibilities are to support and develop health promotion strategies that influence the organization’s overall wellbeing and drive engagement and adoption of healthy behaviors. County will provide, network access, internet access, and workspace ad detailed in Section 10.0.

6.8 Disease management programs will have demonstrated success in participation, care outcomes, and include condition specific online health coaching for Members.

6.9 Contractor shall track and manage health and wellness activities, and report performance to the County,

6.10 Contractor shall possess the ability to assist the County with customized, targeted initiatives to improve the health of the population. Comprehensive initiatives may include optional programs such as:

1. Weight management for overweight, obese and morbidly obese Members;

2. Diabetes control and prevention;

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3. Tobacco cessation;

4. Comprehensive cardiology program, including hypertension control and prevention;

5. Chronic Obstructive Pulmonary Disease (COPD);

6. Healthy pregnancy; and

7. Compliance with preventive screening guidelines.

6.11 Contractor shall possess the capability to administer co-payment incentives specifically for Members participating in and adhering to the qualifications of health and wellness activities and targeted initiative programs.

6.12 Contractor shall have a Fraud, Waste and Abuse (FWA) policy that results in demonstrated success.

7.0 Financial Services, Reporting, and Data Interface

7.1 The finance and banking arrangements for the self-funded health plan will include documentation for claims reimbursement and will meet the accounting needs of the County, as determined by the County.

7.2 Contractor shall accept self-billing by the County for administrative fees which is based on payment of the invoice as presented and retroactive adjustments made by the County in the following month.

7.3 Contractor shall establish a mutually agreeable funding mechanism for claims payment that includes regular reporting and notification to the County regarding required funding amounts. Contractor shall implement a claims payment system that allows for timely processing of provider and member payments while providing the County with appropriate controls and visibility. The County will fund claims payments on a check clearing basis (not on an issued check or accounting basis), meaning the County will reimburse only for payments that have actually cleared the bank account. The County will fund claims payments on a regular basis according to a mutually agreed upon schedule and mechanism that maintains adequate funding levels while minimizing excess cash balances.

7.4 Preference for claims payments made by the County for the self-funded health plan will be on a check clearing the bank basis. The County will transfer money into Contractor’s bank account for the reimbursement of claims at least one (1) time per week.

7.5 Contractor shall have the capability to integrate any biometric screening results, specific to each Member and performed by the Contractor or by an independent screening company, into the claims history of each Member.

7.6 Contractor shall provide a list of the standard reports that will be available to the County on a daily, weekly, monthly, quarterly or annual basis. Sample reports will be provided to the County upon request.

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7.7 Contractor shall provide eligibility, claims and utilization data on a monthly basis; and eligibility discrepancy reporting on a weekly basis via secure web-based employer portal.

7.8 Comprehensive medical and pharmacy claims and eligibility in secure file downloads

(data dumps), preferably provided via SFTP, will be provided to the County and its benefits consultant on a monthly basis. Monthly claims detail will include, at minimum, all fields listed in Exhibit A.3 – Claims Reporting Fields.

7.9 Contractor shall provide the applicable reports necessary for the County to comply with any requirements of the Affordable Care Act and other related health plan requirements.

8.0 Pharmacy Services

8.1 Contractor shall confirm the following as it relates to the pharmacy program pricing and guarantees:

1. Contractor shall utilize a broad network of pharmacies for pricing guarantees that will include the major chain pharmacies as In Network.

2. Single-Source generic prescriptions, multiple-source generic prescriptions, Maximum Allowable Cost (MAC) and Non-MAC prescriptions will be included in the generic medication category for discount and fill rate guarantee calculations.

3. Single-source generics will be identified as having two (2) or less manufacturers for discount and fill rate guarantee calculations.

4. Brand drug. The term brand drug will mean the following: The multisource code field in Medi-Span that contains an “M” (co-branded product), “O” (originator brand), or an “N” (single source brand); however, if the Multisource Code is “O” and there is a DAW Code of 3, 4, 5, 6, or 9, the drug will be considered a generic drug.

5. Usual and Customary (U&C) claims, zero balance claims, compounds and over-the-counter claims will be excluded for discount and fill rate guarantee calculations.

6. “Ingredient Cost” will mean the lesser of MAC price, discounted Average Wholesale Price (AWP) or the dispensing pharmacy’s U & C.

7. Contractor shall utilize the most expansive and cost-effective MAC list of behalf of the County.

8. Members will always be charged the lesser of their Plan copayment, the PBM’s contracted price, the pharmacy U&C, or the cash price.

9. Contractor shall base AWP on date sensitive, eleven (11) digit National Drug Code (NDC) of the actual product dispensed as supplied by Medi-Span for retail, mail order, and specialty adjudicated claims.

10. Discount guarantees and other guarantees will be the minimum guarantees (not fixed) regardless of whether the County implements any additional specific

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11. Rebate revenue that is earned by the County during the term of the Agreement with the Contractor will be paid to the County at least quarterly and shall be paid following termination of the Contract, as long as claims reimbursements remain current.

12. Auditing of all claims will be permitted versus a claims sample.

13. Each distinct pricing guarantee will be measured and reconciled on a component basis (i.e. generic and brand; specialty; rebates; and generic fill rate) with no surpluses in one component offsetting deficits in another component.

14. Guarantee shortfalls will be guaranteed on a dollar-for-dollar basis with 100% of any shortfall in any component recouped by the County.

15. Contractor shall use the Centers for Medicare and Medicaid Services (CMS) definition of a specialty medication.

8.2 Contractor shall commit to minimum guarantees on retail and mail order generic and brand pharmacy discounts and costs on an annual aggregate basis for a minimum of three (3) years.

8.3 Contractor shall commit to retail ninety (90) day fill program.

8.4 Contractor shall commit to minimum guarantees on specialty pharmacy discounts and costs on an annual aggregate basis for a minimum of three (3) years. While specialty drug type and dispensing channel may be on a drug-by-drug basis, the minimum guarantee will apply.

8.5 Contractor shall commit to minimum rebate guarantees on all brand and specialty drugs dispensed for a minimum of three (3) years.

8.6 Contractor shall commit to minimum generic dispensing fill rate guarantees for a minimum of three (3) years.

8.7 Contractor shall notify impacted Members of negative formulary changes that may occur throughout the Plan year.

8.8 Contractor shall assist the County with Medicare Part D administration, including necessary reports to qualify for Retiree Drug Subsidy (RDS), and interfacing with RDS directly for eligibility and claims submission.

8.9 Contractor shall include any programs available to impact pharmacy utilization such as step therapy and clinical prior authorizations for consideration by the County. Include return on investment guarantees.

9.0 Integrated Employee Assistance Program (EAP) Services

9.1 Provide EAP services to Members for up to ten (10) face to face counseling sessions per incident for conditions such as: marital and family relationships; stress management;

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9.2 Provide work/life balance assistance for conditions such as financial and budgeting concerns; legal services; day care and nursing facility selection assistance; and life coaching services.

9.3 Provide Member tools and online services for obtaining EAP clinical and non-clinical information.

9.4 Provide EAP telephonic customer service and urgent / crisis response counseling functions, which will be available 24 hours 7 days a week.

9.5 Provide timely assistance to Members in scheduling counseling sessions.

9.6 Provide referrals that integrate with the behavioral health benefits offered through the

County’s health plan.

9.7 Record and maintain information regarding service-related or other complaints reported by Members.

9.8 Provide communication materials during the year to educate Members and bring awareness to the EAP and work/life services available.

9.9 Provide an assigned account manager who shall be available to meet on a quarterly basis with the County and its administrative staff, or more frequently as deemed necessary by the County.

9.10 Provide quarterly management reports and observations on methods to enhance the behavioral health and EAP benefits for Members.

9.11 May provide an annual training session for all County supervisors and managers regarding behavioral drug free workplace.

9.12 Provide a minimum of 20 hours of on-site EAP seminars for County employees annually.

9.13 Provide licensed, professional EAP counselors of varying degrees of professional licensing (e.g., certified psychologist, family, and marriage counselors) and experience in providing EAP services.

9.14 Provide comprehensive EAP National and Statewide provider Networks.

9.15 Provide access to quality licensed providers specifically in Volusia, Flagler, Lake, Orange, Seminole, and Osceola Counties.

9.16 Include the ability for self-referral and supervisor referrals.

9.17 Provide consultation to supervisors to assist them in resolving workplace issues and in making necessary referrals.

9.18 Include eight (8) fitness for duty (FFD) exams per calendar year for employees at no additional cost. If additional FFD exams are needed within the calendar year they will be

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9.19 Include Substance Abuse Professional (SAP) services following U.S. Department of

Labor, Commercial Driver License and Florida Drug-Free workplace regulations.

9.20 Provide on-site intervention incidents (e.g., Critical Incident Stress Debriefing or Emotional

Incidence Stress Debriefing).

10.0 Cost of Services and Performance Guarantees

10.1 The Administrative Services Only (ASO) fees will be deemed to be inclusive of all services unless otherwise expressly stated. Other services not included in the ASO fees will be specified in detail.

10.2 The following WILL BE guaranteed for self-funded health plans for calendar years 2027, 2028 and 2029:

1. Administrative fees;

2. Minimum medical discount guarantees;

3. Pharmacy pricing guarantees; and

4. Generic fill rate guarantees.

10.3 Contractor shall clearly disclose any retained fees (shared savings) for all programs such as subrogation, out-of-Network fee negotiations, overpayment recoveries, etc.

10.4 Contractor shall include an implementation fund to offset any costs associated with a potential transition for issues such as file transfers, data interface fees, employee education, etc. The total allocated funds will be included in the services and any limitations associated with the use of the funds shall be disclosed.

10.5 Contractor shall include minimum Network discount guarantees for a minimum of three

(3) years.

10.6 Performance Guarantees and associated penalties may include, but not be limited to, the following categories:

1. Implementation

a. Plans loaded and tested; staff trained; eligibility accurate and ID cards issued before 1/1/2027.

b. Contract negotiations completed by June 20, 2026.

c. Banking arrangements completed by November 1, 2026.

d. Plan documents completed by September 1, 2026.

2. Plan documents completed by September 1st of each year.

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3. Network stability will include an annual turnover of 3% or less in Volusia and

Flagler County.

4. Network will maintain 85% of provider Board Certified/Board Eligible physicians.

5. Administration standards, specific to the County, will include:

a. Financial Accuracy to be calculated by using total claims dollars processed, compared to the combined over and under payment errors, with a minimum of 99% accuracy.

b. Processing Accuracy of at least 99% of the total number of correct claims divided by the total claims processed.

c. Turnaround time minimum of 94% clean claims in fourteen (14) calendar days and 100% all clean claims in thirty (30) days.

6. Accurate and timely reporting with monthly, quarterly, and annual reporting due by the twentieth (20th) of the following month and reports to be error free.

7. Account management standards that demonstrate the Contractor’s commitment to maintain experienced, dedicated account service contacts that provide ongoing and timely service to the County’s administrative staff, conduct service meetings with the County to review the status of the account and deliverable services, and issue resolution as needed.

8. Customer service standards that will include average speed to answer, and call abandonment rates.

11.0 County Responsibilities

11.1 Within ten (10) business days of the agreed upon start date, the following work environment will be available for up to two (2) of Contractor’s team members.

11.2 County will supply workspace for up to two (2) of the Contractor’s team members, including desks, phones, fax facilities, and adequate filing space.

11.3 County will supply wireless connection for two (2) of Contractor’s team members.

11.4 County will supply access to the Internet.

11.5 County will supply ability to utilize Contractor’s VPN for continuous access to Contractor’s databases at Contractor’s home office.

11.6 If necessary, the County will provide facilities, workstation(s), and Internet connectivity to support training.

12.0 Contractor Responsibilities

12.1 Personnel Requirements

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12.2 Physical security and safety of County employees, clients, and support personnel is

County’s number one priority. Therefore the following requirements are intended to provide and promote this priority.

1. Contractor personnel shall conduct themselves in a professional and friendly manner at all times.

2. Contractor personnel entering a County facility shall be clean and attired in business casual clothing with a professional appearance.

3. Contractor personnel entering a County facility shall carry and display a Contractor identification badge.

4. The County reserves the right to refuse facility access to any Contractor personnel.

5. The Contractor shall immediately remove and replace any personnel, agent or subcontractor at the request of the County.

6. The Contractor shall recover all inactive Contractor identification badges immediately and report such personnel removal from active service to the Human Resources Director or designee.

7. The Contractor shall abide by all the County rules and regulations regarding Contractor access to County property and facilities.

8. The Contractor’s personnel and subcontractors shall have reasonable access to the County to facilitate the performance of their duties.

9. The Contractor shall conform and abide by all additional security/safety policies, rules, regulations, etc., that may be dictated by the County over the life of this Contract.

10. Contractor agrees to the Exhibit G - County Computing Security Procedures.

12.3 Space Requirements

1. All additional Contractor space requirement requests to the County shall be made in writing.

2. The Contractor shall not erect, install, or operate signage or other advertising devices in or upon any County property, without first having obtained the written consent of the Human Resources Director or designee.

12.4 Electrical Power Requirements

1. The use of electrical power by the Contractor to operate any equipment will comply with the County’s and all other appropriate industry codes, rules, and regulations.