Ext 5.TechProp FA5 (Medical HMO-PPO Plans) 8.8.2025 (AMEND 3) 2025.9.22.docx

FA5 EXHIBIT 5-1: Medical HMO and PPO Plans Technical Proposal Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: Complete each cell with the requested information. Items in the response column with the words "Choose an Item" contain a drop-down list of options. Select a response from those options as applicable.

I. GENERAL PLAN INFORMATION

Response Contractor's Legal Name Click here to enter text.

Plan Name Click here to enter text.

Proposed Plan Type Medical (HMO and PPO) Address Click here to enter text.

City Click here to enter text.

State Click here to enter text.

Zip Click here to enter text.

Web Address Click here to enter text.

Operational Date Click here to enter a date.

Corporate Tax Status Choose an item.

Federal Employer Identification Number Click here to enter text.

Ownership/Controlling Interest Click here to enter text.

NCQA Accreditation Status Choose an item.

JCAHO Accreditation Choose an item.

URAC Accreditation Health Plan Choose an item.

Health Network Choose an item.

Health Utilization Management Choose an item.

Commercial Group Total Membership effective 1/1/2027 Click here to enter text.

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II. PLAN DESIGN

Contractors must adhere to the proposed plan designs shown in "FA5 Exhibit 5-3 Plan Designs" in preparing the quote.

Select Response Confirm that the proposal is issued in accordance with the specifications, assumptions and information included in this Request for Proposals, the accompanying worksheets and standard services addressed in the Information Questionnaire. If "No,” indicate deviations in "FA5 Exhibit 5-2: Explanations and Deviations" worksheet.

Choose an item.

Review and detail deviations from the proposed plan design shown in the worksheet, "FA5 Exhibit 5-3: Plan Designs.”

Choose an item.

Include a concise description of how Contractor covers transitional conditions, such as pregnancy, chemotherapy, etc., if a new Participant is receiving treatment from a non-participating provider. Label as " ResponseFA5.5-1_Transition Care Info.”

Choose an item.

3.

MTA BENEFIT PLAN SERVICES AND ADMINISTRATION FUNCTIONAL AREA 5: MEDICAL

AMENDMENT #3

Solicitation No. AGY-24-026-SR-A FA5 - Exhibit 5

III. MEDICAL DELIVERY SYSTEMS

1.Describe the proposed geographical service area.

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Provide a map of the proposed geographical service area.

Label as " ResponseFA5.5-1_Service Area Map.”

Choose an item.

Provide the website address (URL) for your provider directory and its password, if necessary.

4. Network Participating Physicians Instructions: Provide the total number of participating physician providers by specialty for the proposed networks as of the date of the proposal submission.

MEDICAL HMO

County/ Metro Area Family Practice, General Practice General Internal Medicine

General Pediatrics

Obstetrics/ Gynecology

All Other Specialists

Total Physicians

MEDICAL PPO

County/ Metro Area Family Practice, General Practice General Internal Medicine

General Pediatrics

Obstetrics/ Gynecology

All Other Specialists

Total Physicians

5. Participants' Access to Currently Utilized Providers It is important to MTA that your proposed networks(s) offer In-Network Participating Status for healthcare providers utilized by its enrolled medical plan population. Using FA5 Exhibit 1 Medical HMO and PPO Census, FA5 Exhibit 1 Medical HMO Claim File and FA5 Exhibit 1 Medical PPO Claim File provide detailed network match/disruption report(s) and summarize the findings in the tables below for each plan network you are proposing (HMO, PPO). Prepare the reports using the following: 1. Current HMO claims and enrollment against your proposed HMO network and 2. Current PPO claims and enrollment against your proposed PPO network. Provide the detailed report files containing details supporting these summarized results in unlocked Excel format in the same order of presentation that was provided by MTA for your use in developing these reports. Do not send the data in a read-only file.

The census and claim data needed to perform this reporting is available for download upon execution and return of the RFP Exhibit 3 Non-Disclosure Agreement (Contractor). Label the completed detail report as “FA5 Exhibit 5: Medical HMO and PPO Network Match/Disruption Report.”

MEDICAL HMO NETWORK MATCH/DISRUPTION SUMMARY RESULTS

TOTAL RECORDS EVALUATED

MEDICAL PPO NETWORK MATCH/DISRUPTION SUMMARY RESULTS

TOTAL RECORDS EVALUATED

IV. ADMINISTRATIVE AND OPERATIONAL ISSUESList the location(s) of your service centers (separately identify claims processing centers and customer service centers if in different locations) that would be servicing MTA members and the corresponding geographic areas/regions covered by the respective location. Use the "FA5 Exhibit 2: Explanations and Deviations" worksheet if you need more space.

Service Center Location(s) Geographic Region(s) Covered Click here to enter text.

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Select Response Attach a copy of your standard report suite, including a plan experience report, and performance metrics that would be provided to MTA at the end of each quarter and the end of each fiscal year at no additional cost. At a minimum, your package should include those outlined in the Reporting section of the Compliance Checklist. Label as " ResponseFA5.5-1_Mgmt Reporting Pkg.”

Contractor agrees to provide at least one fully insured conversion plan option.

Choose an item.

Contractor has disclosed their claims appeals (claims decision or coverage) protocols as well as actual response time statistics for the most recent year. Label these reports "ResponseFA5.5-1_Claims Appeals Protocols" in your proposal.

4.

V. REFERENCES

Complete the following tables with the requested reference information.

Provide three of your employer client references of similar size and industry type (government entities) offering the benefit plan services you are quoting in the area that will be serving most of MTA employees.

Information Reference #1 Reference #2 Reference #3 Organization Name Click here to enter text.

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Contact Person Click here to enter text.

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Title Click here to enter text.

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Telephone # Click here to enter text.

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E-mail Address Click here to enter text.

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Network Name Click here to enter text.

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# Members Enrolled Click here to enter text.

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Effective Date of Contract Click here to enter text.

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Description of Services provided Click here to enter text.

Provide three of your terminated employer clients of similar size that offered the benefit plan services you are quoting in the area that will be serving most of MTA employees.

Information Reference #4 Reference #5 Reference #6 Company Name Click here to enter text.

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Contact Person Click here to enter text.

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Title Click here to enter text.

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Telephone # Click here to enter text.

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E-mail Address Click here to enter text.

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Network Name Click here to enter text.

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# Members Enrolled at Date of Termination Click here to enter text.

Effective Date of Contract Click here to enter text.

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Termination Date of Contract Click here to enter text.

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Reason for Termination Click here to enter text.

VI. CONTRACTOR CONTACT INFORMATION

Primary contact of person authorized to execute this proposal

FA5 EXHIBIT 5-2: Explanations and Deviations Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: All deviations from the specifications of the Request for Proposal (RFP) must be clearly defined using this worksheet. Explanations must be numbered to correspond to the question number and section number to which it pertains. If additional space is required, submit a separate Exhibit labeled “FA5 Exhibit 2a: Explanations and Deviations” using the same table format. Most importantly, keep all explanations brief. In the absence of any identified deviations, your organization will be bound to the terms of the RFP.

"Explanation" or "Deviation" Contractor Response

Indicate if “FA5 Exhibit 2a: Explanations and Deviations” is provided: Choose an item.

MTA BENEFIT PLAN ADMINISTRATION AND SERVICES FUNCTIONAL AREA 5: MEDICAL

FA5 EXHIBIT 5-3: Plan Designs Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: Refer to FA5 Exhibit 9: Medical HMO EOC and FA5 Exhibit 9: Medical PPO EOC for a full description of benefits. Any deviations between the MTA proposed plan design and the proposed plan design of the Contractor must be noted in the space provided below. If there are no deviations in the Contractor's proposed plan design, enter the phrase "No Deviations" in the space provided.

MEDICAL HMO

MAJOR MEDICAL

Annual Deductible

Yearly Maximum Out-of-Pocket Costs

Coinsurance OOP

Copayments

Total Medical OOP

No deviations will be considered.

A. Once enrolled in Medicare Part B, members are required to remain enrolled in order to receive benefits. The plan pays secondary to Medicare, except where prohibited by law.

balance of claim expenses that will reach the published limits of MTA's plan.

No deviations will be considered.

Are referrals required in this plan?

directed by MTA.

No deviations will be considered.

HOSPITAL INPATIENT SERVICES (Preauthorization Required)

MTA BENEFIT PLAN ADMINISTRATION AND SERVICES FUNCTIONAL AREA 5: MEDICAL

Acute Inpatient Rehab for Stroke and Traumatic Brain Injury Patients when Medically Necessary 100% of allowed benefit

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Acute Inpatient Rehab

100% of allowed benefit Hospital Pre-Certification and Review required Click here to enter text.

HOSPITAL OUTPATIENT SERVICES (Preauthorization Required)

$10 PCP/$20 Specialist Click here to enter text.

Diagnostic Lab and X-ray and Radiology

$10 PCP/$20 Specialist Click here to enter text.

THERAPIES (Preauthorization required)

$10 PCP/$20 Specialist Click here to enter text.

Physical Therapy (PT), and Occupational Therapy (OT) and Speech Therapy 90 visits per illness or injury per Benefit Period combined for PT/OT/Speech Therapy $20 copay Click here to enter text.

COMMON AND PREVENTIVE SERVICES

Physician Office Visits - Primary Care

Physician Office Visits – Specialist

Preventive Health Office Visit and Associated Lab (Adult and Child)

Routine annual GYN Exam (including PAP test)

Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention with respect to the individual involved.

Click here to enter text.

No age or frequency limitation on diagnostic mammograms.

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STD Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benefit Counseling and screening for sexually active women as mandated by PPACA.

Click here to enter text.

$10 copay PCP; $20 copay Specialist Click here to enter text.

EMERGENCY TREATMENT

Ambulance Services (Emergency and Non- Emergency transport)

$50 Copay, waived if admitted.

Click here to enter text.

MATERNITY BENEFITS

OTHER SERVICES AND SUPPLIES

Limited to 20 days per Benefit Period for Medically Necessary treatment Click here to enter text.

Diabetic Nutritional Counseling, as mandated by Maryland Law

Durable Medical Equipment Must be medically necessary as determined by the attending physician

75% of allowed benefit

Skilled Nursing Facility 100% of allowed benefit Skilled nursing care and extended care facility benefits require Hospital Pre-Certification and Review

Click here to enter text.

Contraception and Contraceptive Counseling

Family Planning and Fertility Testing

Requires an approved Plan of Treatment Click here to enter text.

Requires an approved Plan of Treatment Click here to enter text.

In-Vitro Fertilization (IVF) Artificial Insemination(AI) Intrauterine Insemination (IUI) 50% of allowed benefit IVF limited to 3 attempts per live birth with a $100,000 lifetime maximum benefit.

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Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines.

Diabetes equipment and diabetic supplies are covered at 100% of allowed benefit.

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES

Partial Hospitalization Services

Outpatient Services

MEDICAL PPO

NETWORK

MAJOR MEDICAL

Annual Deductible

Yearly Maximum Out-of-Pocket Costs

Medical Coinsurance OOP (combined in and out of network)

NETWORK

Lifetime Benefit Maximum

No deviations will be considered.

Medicare except where prohibited by law.

plan.

No deviations will be considered.

Are Referrals Required?

directed by MTA.

No deviations will be considered.

HOSPITAL INPATIENT SERVICES (Preauthorization Required) *

benefit after deducible

deductible

deductible

deducible

deductible

HOSPITAL OUTPATIENT SERVICES

benefit after deductible

Benefit, no deductible

Specialist 80% of allowed benefit after deductible

NETWORK

benefit after deductible

THERAPIES (Preauthorization required)

benefit after deductible

up to 90 visits per Benefit Period combined PT/ST/OT

COMMON AND PREVENTIVE SERVICES

deductible

benefit after deductible

Preventive Health Office Visit and Associated Lab (Adult and Child)

Routine annual GYN Exam (including PAP test)

benefit after deductible

No deviations will be considered.

deductible

deductible No deviations will be considered.

Mammography Preventive

100% of allowed benefit

80% of allowed benefit after deductible

NETWORK

benefit after deductible

benefit after deductible

STD Screening and Counseling (Including HPV DNA and HIV) And related screenings as mandated by PPACA

benefit after deductible

EMERGENCY TREATMENT

copay

benefit after $50 copay 100% of allowed benefit after $50 copay

MATERNITY BENEFITS

deductible

benefit after deductible

benefit after deductible

deductible

NETWORK

OTHER SERVICES AND SUPPLIES

Chiropractic Services for Spinal Manipulation when Medically Necessary

benefit after deductible

deductible

federal law.

No deviations will be considered.

Diabetic Nutritional Counseling, as mandated by Maryland Law

Durable Medical Equipment

deductible

Must be medically necessary as determined by the attending physician No deviations will be considered.

benefit after deductible

Skilled nursing care for medically necessary care. Hospital Pre-Certification and Review required.

deductible

Contraception and Contraceptive Counseling

deductible

In-Vitro Fertilization (IVF) Artificial Insemination(AI) Intrauterine Insemination (IUI)

Hospice Care 100% of allowed Benefit after $10 PCP/$20 Specialist Copay AI/IUI limited to 6 attempts per live birth; IVF limited to 3 attempts per live birth and $100,000 lifetime maximum.

80% of allowed benefit after deductible AI/IUI limited to 6 attempts per live birth; IVF limited to 3 attempts per live birth and $100,000 lifetime maximum.

benefit after deductible

deductible

NETWORK

deductible

Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law.

MENTAL HEALTH AND SUBSTANCE USE DISORDERS

(Preauthorization required)

deductible No deviations will be considered.

deductible No deviations will be considered.

FA5 EXHIBIT 5-4: Compliance Checklist Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: Complete each item with the requested information. Items in the response column with the words "Choose” contain a drop down list of options. Select a response from those options as applicable.

NOTE: If a Response/Explanation/Deviation is being provided, a "No" response must be selected and addressed in "FA5 Exhibit 5-2: Explanations and Deviations.”

Response

CUSTOMER SERVICE

health insurance benefits for themselves and their eligible Dependents.

Choose

performed offshore.

Choose

out-of state) 24/7, staffed by live customer service representatives during the core hours, 7 am – 11 pm Eastern Time, seven days a week at no additional charge.

Choose

representative at any time during the call.

Choose

up to Participant.

Choose

customer service line.

Choose

b.) The ability to maintain an eligibility file that identifies eligible Participants as well as certain other pertinent information regarding Participants.

Choose c.) A system for providing Explanations Of Benefits to eligible Participants detailing payments to facilities and providers for services rendered and the amounts applicable to each service.

Choose

e.) An integrated claims and customer service system enabling both claims and service team members to view all screens.

Choose f.) Adequate access to the customer service system for individuals with disabilities. (TTY and online access for deaf, full-service phone access for blind) Choose

Response

Enrollment booklet.

Choose

survey and provide results to MTA.

Choose

etc.

Choose

MTA’s logo for claims submission.

Choose

replied to by noon of the following business day.

Choose

approval by MTA.

Choose

Supervisor, Claim Processor and claim facility for any reason at any time.

Choose

and customer service issues.

Choose

“FA5 Exhibit 13: Performance Guarantees.”

Choose

NETWORK COMPLIANCE/REIMBURSEMENT

that Participants may have.

Choose

claims.

Choose

Participants.

Choose

event the contract for a practice group or physician terminates for any reason.

Choose

provider until 90 days after discharge.

Choose

to determine the maximum allowance for a specific procedure in advance of having the procedure performed.

Choose

bill participants and/or the plan sponsor any amount in excess of the network allowance.

Choose

patients above the network allowance.

Choose

accurately for services rendered.

Choose

the member’s liability (coinsurance, etc.), if applicable, for in-network services rendered.

Choose

national network.

Choose

AUDITS

Relevant to Security, Availability, Processing Integrity, Confidentiality, or Privacy (SOC 2) as published by the American Institute of Certified Public Accountants (AICPA), as updated from time to time, or according to the most current audit guidance promulgated by the AICPA or similarly-recognized professional organization, as agreed to by the Department, to assess the security of outsourced client functions or data (collectively, the “Guidance”). Copies of such audits will be provided to MTA annually.

Choose

Response

end.

Choose

MTA eligibility files.

Choose

HIPAA (Terms herein shall have meaning provided in 45 CFR, Parts 160, 162 and 164.)

subpart C, including all updates that result from future rulemaking and the following:

a.) The Contractor agrees to develop and implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic protected health information that the Contractor creates, receives, maintains or transmits in the Contractor’s administration of the plan, as required by the HIPAA security standards.

Choose

c.) The Contractor agrees to maintain documentation of the policies and procedures and safeguards implemented to comply with the HIPAA security standards.

Choose

e.) The Contractor agrees to report to MTA within 10 days any security incident of which the Contractor becomes aware during the term of the Contract and any mitigation or remedial plans to address such security incidents.

Choose f.) The Contractor agrees to make the Contractor’s policies and procedures, and its documentation required by the HIPAA security standards, available to MTA and the Department of Health and Human Services for purposes of determining if the plan complies with the HIPAA security standards.

Choose

164, including all updates that result from future rulemaking and the following:

b.) The Contractor shall implement and use appropriate and reasonable administrative, physical and technical safeguards to prevent Use or Disclosure of PHI other than (1) as provided in this RFP and the contract, (2) permitted by the HIPAA Privacy Regulation for a Covered Entity, and (3) permitted by the Medical Records Act. In the event that the HIPAA Privacy Regulation and the Medical Records Act conflict regarding the degree of protection provided for PHI, the Contractor shall comply with the more restrictive protection requirements.

Choose

d.) The Contractor shall use reasonable efforts to mitigate the effect of any Use or Disclosure of PHI known to Contractor that is not permitted.

Choose e.) The Contractor shall comply with the administrative requirements of 45 CFR §

164.530 as if the Contractor were the Covered Entity in relation to the plan.

Choose

g.) The Contractor shall provide a Notice of Privacy Practices to all individuals enrolled in the plan as if the Contractor were the Covered Entity with regard to the plan.

(1) This Notice of Privacy Practices shall comply with the requirements of 45 CFR §164.520 as if the Contractor were the Covered Entity with regard to the plan.

(2) A copy of this Notice of Privacy Practices shall be provided to MTA with certification that the notice has been provided to the Members.

Choose h.) The Contractor shall permit an individual enrolled in the plan to request restricted Uses and Disclosures of PHI related to that individual in accordance with 45 CFR §164.522(a)(1)(i). The Contractor shall comply with 45 CFR §164.522(a)(1)(iii)-(iv) and HITECH §13.405(a) in the event that a request for restricted Uses and Disclosures is granted as if the Contractor were the Covered Entity with regard to the plan. The Contractor may refuse such request to restrict Uses and Disclosures or terminate a restriction on Uses and Disclosures provided that the Contractor complies with the provisions of 45 CFR §164.122(a)(1)(ii), §164.522(a)(2)-(3) and HITECH §13.405(a) as if the Contractor were the Covered Entity with regard to the plan.

Choose

j.) The Contractor shall maintain PHI in a Designated Record Set and make available to an individual the PHI relating to that individual in compliance with 45 CFR §164.524 and the HITECH Act as if the Contractor were the Covered Entity with regard to the plan.

Choose k.) The Contractor shall make available for amendment and amend PHI at the request of MTA or the individual to whom the PHI relates as if the Contractor were the Covered Entity with regard to the plan.

Choose l.) Contractor shall document and track Disclosures and provide an accounting of Disclosures of PHI to the individual about whom it relates in compliance with 45 CFR §165.528 and the HITECH Act as if the Contractor were the Covered Entity with regard to the Medical plan.

Choose m.) The Contractor shall make the Contractor’s internal practices, books and records, including privacy and confidentiality policies and procedures and PHI, available to MTA and the Federal Department of Health and Human Services, for purposes of determining whether MTA is compliant with the HIPAA Privacy Regulation in the administration of the plan.

Choose

n.) Upon termination of the Contract, for any reason, the Contractor shall maintain all records created under the Contract as required by the Contract and shall extend the protections of the HIPAA privacy standards to the PHI contained in those records for so long as the Contractor maintains the PHI. All such records containing PHI shall be destroyed at the expiration of the record retention period required by the Contract or, if retained by the Contractor, protected, used and disclosed only in accordance with this RFP and the Contract.

Choose o.) The Contractor shall provide a certification to MTA that the Contractor’s HIPAA Privacy Standards obligations have been met, to occur no more frequently than quarterly, upon MTA’s request for certification.

Choose p.) The Contractor shall disclose PHI to MTA and to MTA’s agents for MTA’s use in treatment, payment and health care operations related to the plan, and MTA’s other related plans.

Choose q.) The Contractor may Disclose PHI as required by law in compliance with 45 CFR §164.512.

Choose r.) The Contractor may Use and Disclose PHI to conduct data aggregation services as permitted by 45 CFR §164.501 and §164.504(e)(2)(i)(B).

Choose s.) The Contractor may Use and Disclose PHI for the proper management and administration of the Contractor or to carry out its legal responsibilities as permitted by 45 CFR §164.504(e)(4), provided that: (a) such Uses and Disclosures would be permitted by the HIPAA Privacy Regulation if the Contractor were a Covered Entity regulated by the HIPAA Privacy Regulation and (b) the Contractor obtains reasonable written assurances from the person, agency, or entity to which such Disclosures are made that all PHI will remain confidential and be Used or Disclosed further only as required by law, for the purposes of Disclosure by the Contractor, and the person, agent or entity notifies the Contractor of any instances in which the confidentiality of the PHI has been breached.

Choose t.) The Contractor may Use or Disclose PHI to report violations of the law to appropriate State and Federal authorities consistent with 45 CFR §164.502(j).

Choose u.) The Contractor may Disclose PHI in response to an authorization executed by the individual who is the subject of the PHI or that individual's personal representative in accordance with 45 CFR §502(g) and 45 CFR §164.508.

Choose