Ext_5.TechProp_FA6__Vision_Plan__8.8.2025__AMEND_3__2025.9.22.docx

FA6 Exhibit 5-1: Vision Technical Proposal Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: The MTA is requesting proposals for administration of a Self-Funded Vision benefit. Complete FA6 Exhibit 5-6a: Subcontractor Questionnaire for program components that will not be primarily provided by your organization. Please complete each item with the requested information for your proposed Self-Funded Vision Plan. Items in the response column with the words "Choose an item" contain a drop-down list of options. Please select a response from those options as applicable.

I. GENERAL PLAN INFORMATION

Response

1. Offeror's Legal Name Click here to enter text.

2. Plan Name Click here to enter text.

3. Proposed Plan Types Vision Plan

4. Address Click here to enter text.

5. City Click here to enter text.

6. State Click here to enter text.

7. Zip Click here to enter text.

8. Web Address - Vision Click here to enter text.

9. Operational Date Click here to enter a date.

10. Corporate Tax Status Choose an item.

11. Federal Employer Identification Number Click here to enter text.

12. Ownership/Controlling Interest Click here to enter text.

13. Year Vision Network Organized Click here to enter text.

14. Vision Plan Membership total effective 1/1/2023 Click here to enter text.

15. Vision Plan Membership total effective 1/1/2024 Click here to enter text.

MTA PLAN ADMINISTRATION AND SERVICES FUNCTIONAL AREA 6: VISION

AMENDMENT #3

Solicitation No. AGY-24-026-SR-A FA6 Exhibit 6

1.

II.

III.

II.III. PLAN DESIGNS

Confirm that the proposal is issued in accordance with the specifications, assumptions and information included in this Request for Proposals, accompanying Exhibits and standard services addressed in the Information Questionnaire. If "No,” indicate deviations in "FA6 Exhibit 5-2: Explanations and Deviations."

Choose an item.

Review and detail deviations from the proposed plan design shown "FA6 Exhibit 5-3: Vision Plan Design"

Choose an item.

III. VISION PLAN DELIVERY SYSTEMS

1. Describe the proposed Vision Plan geographical service area.

Click here to enter text.

2. Provide a map of the proposed geographical service area.

Label as "ResponseFA6.5-1_Plan Service Area Map.”

Choose an item.

3. Provide the website address (URL) and password if needed for your Vision Plan provider directory.

IV. Network Participating Physicians Instructions: Provide the total number of participating Vision Plan providers by specialty for the proposed networks as of the date of this proposal.

VISION PLAN

V. ADMINISTRATIVE AND OPERATIONAL ISSUES

List the location(s) of your service centers (separately identify Vision Plan claims processing centers and Vision Plan customer service centers if in different locations) that would be servicing MTA’s members and the corresponding geographic areas/regions covered by the respective location. Use "FA6 Exhibit 5-2: Explanations and Deviations" if you need more space.

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

Click here to enter text.

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1.

Select Response Attach a copy of your standard report suite for the Vision Plan, 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 " ResponseFA6.5-1_Vision Plan Mgmt Reporting Pkg”

Choose an item.

Offeror 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 " ResponseFA6.5-1_Vision Plan Claims Appeal Protocol” in your proposal.

2.

3.

VI. REFERENCES

Please complete the following tables with the requested reference information.

1.Provide three employer group client references of similar size and industry type offering Vision Plan services in the area that will be serving most of MTA’s employees. TWO current and ONE terminated.

Information Current Reference #1 Current Reference #2 Termed Reference #3 Company Name Click here to enter text.

Click here to enter text.

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Contact Person Click here to enter text.

Click here to enter text.

Click here to enter text.

Title Click here to enter text.

Click here to enter text.

Click here to enter text.

Telephone # Click here to enter text.

Click here to enter text.

Click here to enter text.

E-mail Address Click here to enter text.

Click here to enter text.

Click here to enter text.

Network Name Click here to enter text.

Click here to enter text.

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# Vision Plan Members enrolled Click here to enter text.

Click here to enter text.

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Effective date of Contract (plus Termination date #3) Click here to enter text.

Click here to enter text.

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Description of services provided Click here to enter text.

VII. OFFEROR CONTACT INFORMATION

Primary contact of person authorized to execute this proposal

FA6 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 Proposals (RFP) must be clearly defined below 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 “FA6 Exhibit 5-2: 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 “FA6 Exhibit 5-2: Explanations and Deviations” is provided: Choose an item.

FA6 Exhibit 5-3: Vision Plan Design Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: Refer to FA6 Exhibit 9: Vision Plan EOC for a full description of current benefits. Any deviations between MTA’s current 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, please enter the phrase "No Deviations" in the space provided.

ALL SERVICES SHOWN ALLOW ONE PER 24-MONTH BENEFIT PERIOD

TYPE OF SERVICE

PROVIDED PER BENEFIT PERIOD

CURRENT PLAN MEMBER RESPONSIBILITY

Vision - Routine Exam

Prescription Lenses and Frames*

Frames Selected & Selected Upgrade Display Frames

Contacts

pays $285.00

* Basic prescription lenses (no coverage for “add ons” such as scratch resistant/UV coating, progressive lenses, transitional lenses, etc.) Frames w/lenses or contacts, not both. Plan pays up to noted allowed amounts, remainder is participant responsibility.

FA6 Exhibit 6-4: Compliance Checklist Representations made by the Contractor in this proposal become contractual obligations that must be met during the contract term.

Instructions: Please complete each item with the requested information. Items in the response column with the words "Choose an item,” contain a drop-down list of options. Please select a response from those options as applicable. All "No" responses must be addressed in "FA6 Exhibit 5-2: Explanations and Deviations.”

Response

Yes or No

Customer Service

may be performed offshore.

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pick-up to Member.

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a.) Knowledgeable staff available to answer questions on plan eligibility, plan guidelines, benefit levels, and claims procedures.

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

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c.) A system for providing Explanations of Benefits to eligible Members detailing payments to providers for services rendered and the amounts applicable to each service.

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Solicitation No. AGY-24-026-SR-A

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 an item.

claims.

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"FA6 Exhibit 5-7: Performance Guarantees.”

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Performance Guarantees.”

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Enrollment booklet.

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satisfaction survey and provide results to MTA.

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membership cards, EOBs, etc.

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Network Compliance/Reimbursement

credential questions that Members may have.

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Member services with regard to provider selection.

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notice, in the event that the contract for a Member's network provider terminates for any reason. MTA will review and approve the communications provided to MTA Members for this purpose.

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made available to Members.

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the Maryland Insurance Administration or any other state insurance department.

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provided according to the Plan and reimbursed by that provider at the contract rate previously in effect.

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most cCurrent Procedural Terminology (CPT) CDT code and zip code.

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American Medical Association (AMA) CDT codes on dental procedures and nomenclature when updated by the American Dental Association. Contractor further agrees to confirm these changes, in writing to MTA, no later than 90 days after the effective date of the changes.

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at the same benefit level regardless of (CPT) CDT procedure code changes.

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above the scheduled plan benefit in the event a participating network provider is not paid accurately for services rendered.

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services rendered.

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Audits

audits shall be performed in accordance with audit guidance: Reporting on Controls at a Service Organization Relevant to Security, Availability, Processing Integrity, Confidentiality, or Privacy (SOC 2) as published by the American Institute of Certified Public Accountants (AICPA) and 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”).

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

subpart C, including 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.

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

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d.) In compliance with 45 CFR 164.308(b), the Contractor agrees to ensure through written contract that any agent, including a subcontractor, to whom the Contractor provides electronic PHI agrees to implement reasonable and appropriate safeguards.

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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.

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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.

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and 164, including the following:

a.) The Contractor shall not use or disclose PHI except to fulfill the requirements of this RFP and the contract, or as required by law. In doing so, the Contractor shall use, disclose or request the minimum amount of PHI necessary and act in compliance with §164.502(b) as if a covered entity. Further, the Contractor shall use limited data sets when possible and comply with DHHS guidance in determining minimum necessary standards to accomplish intended use, purpose or disclosure as if a covered entity.

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b.) The Contractor shall implement and use appropriate and reasonable administrative, physical and technical safeguards to prevent Use or Disclosure of Choose an item.

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.

c.) The Contractor shall report to the MTA any Use or Disclosure of PHI that is not permitted within 10 days of when the Contractor becomes aware of such Use and Disclosure.

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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.

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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.

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f.) In compliance with 45 CFR § 164.504(e)(5), the Contractor shall ensure, through written contract, that any agent, including a subcontractor, to whom it provides PHI received from, created by, or received by the Contractor agrees to the same restrictions and conditions that apply to the Contractor with respect to such information. This obligation shall apply in connection with PHI created, retained, used, disclosed, or transmitted in connection with the group plan(s) administered by the Contractor.

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g.) The Contractor shall provide a Notice of Privacy Practices to all individuals enrolled in the plan in compliance with 45 CFR §164.520 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.

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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.

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i.) The Contractor shall accommodate reasonable requests by individuals enrolled in the plan or by the MTA on behalf of such individuals to receive confidential communications in compliance with 45 CFR §164.522(b)(ii) as if the Contractor were the Covered Entity with regard to the plan. The Contractor may condition providing confidential communications as permitted by 45 CFR §164.522(b)(2).

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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.

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k.) The Contractor shall make available for amendment and amend PHI at the request of the MTA or the individual to whom the PHI relates in compliance with 45 CFR §164.526 as if the Contractor were the Covered Entity with regard to the plan.

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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 Vision Dental plan.

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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 the MTA is compliant with the HIPAA Privacy Regulation in the administration of the plan.

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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.

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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.

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p.) The Contractor shall disclose PHI to the 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.

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

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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).

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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.

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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).

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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.

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Response

exchange for PHI on the same terms.

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if it were a covered entity in connection with the Vision and Dental plan.

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a.) A breach shall be treated as discovered in the terms described in 45 CFR §164.410.

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b.) Notice to MTA

(1) The Business Associate shall promptly notify MTA of a breach of unsecured PHI in its possession following the first day on which the Contractor (or Contractor's employee, officer, agent or subcontractor) knows of such breach or following the first day on which Contractor (or Contractor's employee, officer, agent or subcontractor) should have known of such breach. Such notice shall occur without unreasonable delay and in no event more than 30 days following discovery of the breach. Such notice shall occur even if the breach is not of a Member of MTA’s Plan.

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(2) In the event that Contractor determines that there is no risk of an unauthorized access, acquisition, use, or disclosure compromises the security or privacy of the PHI of a Member, Contractor shall promptly notify MTA of the event and the basis for that determination. Such notice shall occur as soon as is reasonable but in no event more than 30 days following discovery of the unauthorized access, acquisition, use or disclosure of PHI of a Member. Such determination shall be in writing and signed by an appropriate officer or employee of Contractor.

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(3) Contractor's notice to MTA pursuant to this section concerning breaches shall include, at a minimum:

(i) the number of individuals overall affected by the breach and the number of Members in MTA’s Plan affected by the breach;

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(ii) if applicable, the identification of each MTA Plan Member whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used, disclosed, or otherwise the subject of the breach;

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(iii) a description of what happened, the date of the breach, if known, and the date of the discovery of the breach;

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(iv) a brief description of the types of unsecured PHI that were involved in the breach (such as name, social security number, date of birth, claims or health care services information, etc.);

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(v) identification of an individual who can provide additional information concerning the breach; and Choose an item.

(vi) a brief description of the steps Contractor is taking to mitigate the breach, investigate the breach, and to protect against further breaches.

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(4) Contractor's notice to MTA pursuant to this section may be provided on a rolling basis, with information provided to the Department as it becomes available.

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c.) Notice to Members.

(1) Business Associate shall provide notice to affected members and to the media in the form, content, manner, method, and timing required to meet the requirements of §§13400-13402 of the HI TECH Act and 45 CFR §§164.404 and 164.406, applied as if Business Associate were a covered entity in connection with the group plan(s) administered by Business Associate pursuant to the Underlying Agreement.

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(2) The notice(s) required by this section may not be issued until MTA has reviewed and approved the notice(s). Such approval may not be unreasonably delayed or withheld.

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d.) Contractor may delay the notice(s) required pursuant to sections 164.404(b) and 164.406(b) only if permitted pursuant to 45 CFR §164.412.

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e.) In the event of an unauthorized use or disclosure of PHI or a breach of Unsecured PHI, Contractor shall use reasonable efforts to mitigate any harmful effects of said disclosure that are known to it.

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f.) Notices to DHHS.

(1) In the event of a breach described in 45 CFR §164.408(b), Contractor shall provide to MTA all information required by that subsection to be submitted to the Secretary of DHHS. The information shall be provided without unreasonable delay and in no event more than 30 days following discovery of the breach. Upon request, Contractor shall submit the required breach notice to the Secretary of DHHS on behalf of the MTA, the group plan(s), and the Program.

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(2) Contractor shall maintain a log of breaches described in 45 CFR §164.408(c) and that affect members and the group plan(s) administered by Business Associate pursuant to the Underlying Agreement.

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g.) In fulfilling its obligations pursuant under this Contract in connection with 45 CFR §164.530, Business Associate shall address the provisions of 45 CFR Part 164, subpart D in the manner provided in 45 CFR §164.414, as if Contractor were a covered entity in connection with the benefits plan administered by the Contractor pursuant to this Contract and RFP.

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h.) Business Associate agrees to review any guidance from DHHS specifying the technologies and methodologies that render PHI unusable, unreadable, or indecipherable to unauthorized individuals. BA further agrees, to the extent practical, appropriate and reasonable, to incorporate such guidance into its administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of PHI.

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i.) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides PHI received from, or created or received by the Contractor, agrees to provide notice of a breach and the information necessary for the Contractor to comply with its notice requirements in sections (a) through (h) above.

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b.) As of the applicable effective date identified in HITECH §13405(c )(4), when complying with the obligations to respond to requests for an accounting under 45 CFR §164.528, Contractor shall respond to requests for an accounting of disclosures of PHI, in compliance with the requirements of §13405( c)(1) and (3) of the HITECH Act and any regulations promulgated by the Secretary of DHHS pursuant to §13405( c)(2) of the HITECH Act. The requirements of this section shall apply if Contractor uses or maintains an electronic health record with respect to

PHI.

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c.) When complying with the obligation to provide access to PHI under 45 CFR §164.524, Contractor shall respond to requests for access to PHI in compliance with the requirements of §13405(e) of the HITECH Act. The requirements of this section shall apply if Contractor uses or maintains an electronic health record with respect to PHI.

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Special Provisions

existing conditions applied to any eligible Members under the plan.

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Response

Claim Processing

payor in a COB situation.

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included in the contract.

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process.

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weekly.

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adjudication and defense of "utilization review" decisions.

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storage and retrieval.

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eligible periods and initiate overpayment recovery efforts.

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available to provide specific services.

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evidence of such processing during quarterly vendor meetings.

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evidence of such processing during quarterly vendor meetings.

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Response

during quarterly vendor meetings.

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Reporting

administrative services data by subgroup to the MTA.

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following the end of the accounting period to MTA.

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Quarterly reports include:

Performance Guarantees."

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new patients. This report should separate data based specialty type.

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network development plan for the upcoming quarter.

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the vision plan.

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Annual reports include:

Guarantees,” including, but not limited to:

b.) Complete documentation of the methodology and assumptions used to develop the projected costs, including a break out of all expenses;

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c.) Disclosure of supporting data used in calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc.;

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d.) Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees;

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year and areas of focus for the upcoming plan year.

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Other reporting requirements include:

annually, at no additional charge.

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Implementation

RFP Section 2.9.20, Contract Implementation Milestones and Due Dates.

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Payment Specifications

payment procedures described in Sections 2.9.14 – Billing and Claims Payment and 3.3 – Invoicing, 4.23 – Payments by Electronic Funds Transfer and 4.24. Prompt Payment policy of the RFP.

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process.

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MTA.

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Account Management/Customer Service

manager, claim supervisor, claim processor and/or claim facility for any reason at any time.

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team.

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from the claim processing unit.

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MTA.

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items CC-86 through CC-96 above.

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Response

MTA’s Open Enrollment booklet each year, upon request by MTA, and at no extra cost.

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Provider Contracting/ Relations

meetings, as needed.

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based on MTA’s needs and agreed to by the MTA.

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