Exhibit_B_-_Fees_and_Performance_Guarantees_FINAL.docx

25-P-115TF Exhibit B – Fees and Performance Guarantees

Section 8 - Cost and Performance Guarantees– Complete the section below using the information and instructions found in Section 10.0 (Cost of Services and Performance Guarantees) of Exhibit A – Scope of Services.

The following provides a summary of the current enrollment by plan and paid claims experience.

Plan Membership Based on County provided Census Data – see RFP Exhibit I – Census for enrollment detail the census is the actual census for the January 2025 enrollment eligibility.

Paid Claims Summary – see RFP Exhibit H – Claims Experience for claims and enrollment by month and claims lag report.

1. Guaranteed ASO Fees: Provide Administrative Services Only (ASO) Fees below. Your ASO fees will be inclusive of all administrative and Network management services. Any service not included in the premiums and ASO fee will be disclosed in the response to question 4 below.

A. Self-Funded Administrative Services Only (ASO) Fees

The Plan Administrative Services Only (ASO) fees will be stated and guaranteed for 2027, 2028, and 2029 and quoted on an incurred claim basis. Additional rate guarantees for years four (4) and five (5) (2030 and 2031) are requested and desired, but not mandatory. Claims administration for run-out claims following termination of the Agreement shall be included in the Per Subscriber Per Month (PSPM) fees. Use the “Subscriber” counts provided to calculate the PSPM total costs.

Administrative Services Only (ASO) Fees

Total ASO Monthly Cost

Total ASO Annual Cost

2. Medical Discounts and Trend: Complete the following sections using the claims data found in RFP Exhibit L - Medical Discount Pricing. Only provide Contractor’s aggregate amounts. All amounts, summaries, reports, and discounts listed shall be subject to verification. The verification process will be conducted, at Contractor’s facility, with Contractor’s specific data being kept proprietary to the extent allowed under Florida law. Only the aggregate amounts as verified shall be disclosed.

A. Provider Discount Pricing

Using the utilization and cost information provided in RFP Exhibit K – Medical Claims Pricing File and the RFP Exhibit L - Medical Discount Pricing File, indicate Contractor’s current average percent medical network discounts for the service categories listed below. You must complete the worksheets provided in RFP Exhibit K – Medical Claims Pricing File and the RFP Exhibit L - Medical Discount Pricing File; however, do not submit this detailed information with your proposal. The responses provided below are subject to validation by reviewing the completed worksheets in RFP Exhibit K – Medical Claims Pricing File and the RFP Exhibit L - Medical Discount Pricing File and provider contracts onsite at Contractor’s facility as a part of the evaluation process.

B. Provider Discount Guarantee

Indicate the minimum discounts Contractor shall guarantee for 2027, 2028 and 2029 with no corridor included in the guarantee. Performance Guarantees shall be based on the aggregate medical provider discount guarantee. The provider discount performance guarantees are required for all ASO self-funded plans.

Facility

Ancillary

Professional

Aggregate Medical Provider Discount

Aggregate Medical Provider Discount Guarantee Limitations and Conditions: List any limitations and conditions that will apply to your Contractor’s Performance Guarantee.

3. Medical and Prescription Drug Trend. List Contractor’s medical and prescription drug trends for the Volusia County area in the following calendar years.

(Rx Trend) Overall Cost Increase (Overall Trend)

2026 Anticipated

4. Pharmacy Guarantees. Pharmacy guarantees are required for all ASO self-funded proposals. Contractor’s pharmacy discounts, rebates and dispensing fees shall be guaranteed for at least 2027, 2028, and 2029. Additional guarantees for years four (4) and five (5) (2030 and 2031) are requested and desired but not mandatory. No administrative fees will be charged. Single source generics are generic drugs in the first six (6) month exclusivity period following a brand drug losing its patent. Single source generic discount guarantees will be included in the generic discount/Rx from AWP. Discounts will be applied to zero balance claims, where the Member co-payment equals to total cost of the drug, but are to be excluded from the guarantees. One hundred percent (100%) of the rebates received will be shared with the County. The lesser of Usual and Customary fees, or the guaranteed discounts, will apply. Guarantees will be separated into the following three (3) categories: generic and brand, retail and mail order; specialty pharmacy; and rebate guarantees.

A. Pharmacy Pricing Guarantees

Generic Discount/Rx from AWP

Generic Drug Dispensing Fee/Rx

Brand % Discount from AWP

Brand Drug Dispensing Fee/Rx

Brand Drug Rebate/ Brand Rx

Generic Discount/Rx from AWP

Generic Drug Dispensing Fee/Rx

Brand % Discount from AWP

Brand Drug Dispensing Fee/Rx

Brand Drug Rebate/ Brand Rx

Generic Discount/Rx from AWP

Generic Drug Dispensing Fee/Rx

Brand % Discount from AWP

Brand Drug Dispensing Fee/Rx

Brand Drug Rebate/ Brand Rx

% Discount from AWP

Drug Dispensing Fee/Rx

Drug Rebate/ Specialty Rx

B. Pharmacy Cost Guarantee Worksheet

Confirm that Contractor has completed the Pharmacy Pricing Guarantees Worksheet, Attachment B.1 Pharmacy Pricing Guarantees, and it is included with the response.

C. Generic Fill Rate Guarantee. Indicate the generic fill rate Contractor shall guarantee for the following years. Guarantees shall be factored on a dollar-for-dollar basis for any shortfall.

Amount of Guarantee

5. Pharmacy Administrative Fee. Disclosure any applicable pharmacy administrative fee.

Administrative Fee

6. Services Included and Cost. Indicate whether the following services are included in the self-funded ASO fee:

Current plan design administration

Full time customer service representative on-site at the County

Dedicated account management team to assist with claims, eligibility and day-to-day service issues.

Attendance at quarterly administrative and Plan management meetings

Medical and Pharmacy Clinical Director attendance at annual utilization review meetings

Annual enrollment training and on-site enrollment meeting participation as outlined in Exhibit A – Scope of Services.

Master accumulator for medical and pharmacy deductible and out of pocket maximums

Run-out claims administration following termination of Contract for a minimum of one year

On-line capability for eligibility additions, changes and deletions (prospective and retroactive)

Weekly eligibility discrepancy reports

Eligibility data interface with the County and its contracted vendor for retiree and COBRA participants on an ongoing basis.

Monthly comprehensive eligibility, claims and utilization experience downloads

Retroactive eligibility and claims reprocessing

Printing and distribution of ID cards initially and when Plan deductibles, co-pays, and co-insurance changes are made and when replacement cards are issued

Online access to provider Network directory and link to County’s health plan app.

Development and maintenance of Summary Plan Description (SPD) and Summary of Benefits and Coverage (SBC)

Posting of the Plan Summary Plan Description (SPD) and Summary of Benefits and Coverage (SPC) on your Company website for Member access

Printed Summary Plan Description (SPD) for hard copy requests (approx. fifty (50) per year)

Web-based access to administrative tools for Network providers to access Member coverage details

Web-based administrative tools for Members to view specific Plan information and access claims history and educational tools on provider Network, cost comparisons and wellness issues

Provider Network administration and access to a local and national Network of providers, including Centers of Excellence

Claims adjudication, including review and defense of appealed claims, up to the external claims review

Physician and Pharmacy claims adjudication and benefit appeals

Full claims fiduciary responsibility, including all coverage determinations

External claims administration and selection of review agency for medical and pharmacy appeals

Cost of external claims review

Legal defense of claims appeals involving clinical decisions Contractor made

Fraud, waste and abuse program

Third party liability recovery (subrogation) services

Coordination of benefits recoveries

Overpayment recovery services

Hospital bill audit services

Facility Reasonable and Customary (R&C) charge determination services

Out-of-Network discount negotiation services

Access to records and staff necessary to conduct annual external audits conducted by the County or its designated auditing firm

Monthly full claims detail to County designated representative and County’s benefits consultant in accordance with the fields outlined in Exhibit A.3 - Claims Reporting Fields.

Monthly reporting of large dollar claims to independent stop loss insurance carrier and submission of all data necessary for claims recovery to the County

Predictive modeling and ongoing outreach and management of members at risk

Case management with a dedicated case management nurse working closely with the County

Disease management programs

Healthy pregnancy program

Assistance with comprehensive health management program design and implementation

Annual health fair participation

Wellness educational materials – electronic and printed

Telemedicine service administration

Online health risk assessments

Biometric screening administration onsite at various County locations as part of the annual wellness program

Ability to upload biometric screening results from a third party vendor to the individual Member health record and ability to auto-populate the Member’s health risk assessment

Activity tracking for wellness and health management activities and administration/tracking of incentives

Administration of value based benefit design for participation in health management programs

Pharmacy clinical prior authorization program and review

Pharmacy step therapy program and review

Pharmacy retrospective utilization review

Pharmacy clinical review for medical necessity

Formulary disruption letters to impacted Members when changes occur

Targeted letters to Members on pharmacy-related issues (any additional costs should be quoted on a per letter basis)

Pharmacy patient safety audits at point of sale

Claims data requests for GASB and other state and federal reporting requirements

Online report access with query capabilities including detailed eligibility, claims and utilization data

Direct Member claims reimbursement (paper claims)

Open file transfers to new Contractor using industry standard formats at termination

Provide data necessary to complete the requirements for Medicare RDS subsidy.

Provide all required notifications and data necessary to comply with any out-of-state requirements, e.g. New York Surcharge.

Annual satisfaction survey specific to County Members

List any additional services Contractor shall perform that have not been previously disclosed that will result in additional administrative charges to the County or any additional fees for Contractor

Other services not included in premiums or ASO Fees

Cost of biometric screenings per Member

Cost of a full-time on-site clinical care coordinator (Registered Nurse or clinical equivalent). 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.

Other services

7. EAP Services Cost

The EAP Services fees will be stated and guaranteed for 2027, 2028, and 2029. Additional rate guarantees for years four (4) and five (5) (2030 and 2031) are requested and desired but not mandatory. Use the “Subscriber” counts provided to calculate the PSPM total costs.

EAP Fees

Total EAP Monthly Cost

Total EAP Annual Cost

Ten (10) face to face counseling sessions per incident

Minimum of twenty (20) hours of on-site EAP seminars for County employees annually

Behavioral health fitness for duty exams for employees, as needed.

Substance Abuse Professional (SAP) services following U.S. Department of Labor, Commercial Driver License and Florida Drug-Free workplace regulations.

On-site intervention incidents (e.g., Critical Incident Stress Debriefing or Emotional Incidence Stress Debriefing).

List other services where and additional cost may apply

8. List any implementation funds that Contractor shall allocate to the County to offset transition costs associated with Contractor’s program. Please specify the total dollar amount and specify any limitations in how the County can utilize these funds.

9. If an agent or broker is included for administrative services assistance, identify below the standard commissions included, along with the administrative services that will be provided by the agent or broker.

10. Confirm that Contractor agrees with the County Responsibilities found in Exhibit A - Scope of Services, Section 11.0. List any limitations, if applicable.

11. Confirm that Contractor agrees with the Contractor Responsibilities found in Exhibit A – Scope of Services, Section 12.0. List any limitations, if applicable.

12. Performance Guarantees: List performance guarantees, including a description of the guarantee and measurement and dollar amount at risk for each of the categories listed below. Guarantees will be for a minimum of three (3) years.

Implementation

Plan Implementation (plans loaded, tested; staff trained; eligibility accurate and ID cards issued before 1/1/2027)

Plan document, Contract, and banking arrangement Agreement completion

Administration

Claims Financial Accuracy

Claims Processing Accuracy

Clean Claims Turnaround Time

Timely Reporting

Timely Data Transfer

Telephone Responsiveness

Average speed of answer

Percent of issues answered on initial call

Call abandonment Rate

Medical and Pharmacy

Minimum Aggregate Network provider percentage guarantee

Network will include a minimum of eighty-five percent (85%) of providers being Board Certified or eligible

Provider turnover rate of less than three percent (3%) annually

Generic discounts, brand discounts, and dispensing fee guarantee for retail and mail order

Specialty discount guarantees

Rebates on all brand and specialty drugs generic fill rate guarantee

Satisfaction

Account management satisfaction survey scores

Employee satisfaction survey scores

Other performance guarantees you will provide

By completing this document, the Contractor certifies that the information contained herein is accurate and that the Contractor shall be bound by the contents of this Exhibit B - Fees and Performance Guarantees.

Please return this Word document with your answers and a separate PDF file.

Contractor Legal Name: ___________________________________________ Page 1 of 26