Group Term Life Insurance Attachment 2,3,4 7.pdf

RFP No.: DMS-22/23-174, Attachment A: Draft Contract Attachment 2: Administrative Requirements Page 1 of 11

ATTACHMENT 2: ADMINISTRATIVE REQUIREMENTS

The Contractor shall comply with and provide Services in accordance with the following Administrative Requirements (which have been designated “AR” numbers).

The Contractor agrees to provide documentation evidencing compliance with these Ars.

Should Contractor become aware at any time that they are not in compliance with any AR, the Contractor will notify the Department’s Contract Manager immediately in writing.

The Contractor will also provide a corrective action plan (CAP) as needed detailing the steps Contractor will take to either become in compliance with the AR and/or avoid future non-compliance.

I. Implementation

AR-1 The Contractor shall submit the Final Implementation Plan to the Department for approval no later than ten (10) Business Days following mutual execution of the Contract. If the Final Implementation Plan is not determined by the Department to be sufficient, the Contractor will diligently work to deliver a final Implementation Plan satisfactory to the Department. The Contractor recognizes that time is of the essence in completing a Final Implementation Plan. The Final Implementation Plan shall be based on the proposed plan submitted in Reply Document 3: Final Implementation Plan (see question 5 of the Technical Questions).

a. The Final Implementation Plan shall fully detail all steps necessary to begin full performance of the Contract on January 1, 2024, 12:00 A.M., EST, specify expected dates of completion of all steps and identify the person(s) responsible for each step. The Final Implementation Plan shall include, but is not limited to, the following implementation milestones:

(1) The development and execution of the Final Implementation Plan is subject to PG-1 of Attachment 3: Performance Guarantees and Section 7 (Liquidated Damages) of the Contract for failure to meet the milestones identified therein.

(2) Establishing Department approved website exclusively for State of Florida Participants, toll-free phone line(s) and Department approved communications in advance of the Fall 2023 Open Enrollment period.

(3) Participating in Fall 2023 Open Enrollment benefit fairs and meetings coordinated by the Department or its designee.

(4) Scheduling weekly implementation status meetings with the Department’s Contract Manager. The Contractor shall record detailed meeting minutes and follow-up action items on behalf of all team members during implementation meetings.

(5) Conducting background checks in accordance with Section 4.2.4 of the Contract.

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(6) Prior to Open Enrollment, the mailing of an announcement to all potential enrollees for the first year of the Contract.

(7) Testing eligibility files, reviewing key procedures and program process controls (i.e., approval, design, testing, acceptance, user involvement, segregation of duties and documentation) to the extent required by the Department. The Department must approve and accept the key elements listed prior to the Implementation Date of January 1, 2024.

(8) Designing and presenting to the Department for approval all communication materials to be used for Plan Participants prior to dissemination. Communication materials include, but are not limited to, ID cards, brochures, paper Claims (reimbursement) forms, standard letters, system generated letters, templates, envelopes, posters and any other materials used to communicate with Plan Participants.

(9) Providing evidence of a disaster recovery plan sufficient to meet the requirements of this Contract. The disaster recovery plan information should include how often the systems backup and disaster recovery procedures are tested, when the last tests were and what the results were and should indicate how quickly the services can be replaced in the event of permanent disaster to both the hardware and software.

AR-2 The Contractor shall be one hundred percent (100%) operational prior to the Implementation Date of January 1, 2024,12:00 A.M., EST. The Contractor shall pay liquidated damages as listed in section 7, Liquidated Damages, of the Contract, for failure to meet this milestone.

II. Account Management

AR-3 Account Manager

The Contractor shall designate an Account Manager as the primary contact for the Department.

a. The Account Manager shall participate on the implementation team and coordinate, troubleshoot, advance, and track the State’s interests and requests throughout the organization.

b. If requested by the Department, the account manager shall be replaced with one that the Department approves.

AR-4 Account Management Team

The Contractor shall assign an Account Management Team, as identified in Section 1.1 of the Contract. The Account Management Team shall include an executive sponsor and an Account Manager. The Account Management Team shall meet the following requirements:

a. Devote the time and resources needed to successfully manage the State of Florida account, including but not limited to, being available for virtual, telephonic, email and on-site consultations.

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b. Be thoroughly familiar with the Contractor’s functions and operations related directly or indirectly to the Department and the Plan including, but not limited to, customer service operations, claims and enrollment systems, and systems reporting capabilities.

c. Maintain a current Account Management Team organizational chart.

d. Promptly notify the Department of any changes to the Account Management Team, including provision of an updated organizational chart.

AR-5 Meetings / Conference Calls

Account Management Team meetings shall be conducted as follows:

a. Quarterly Meetings: The Contractor’s Account Management Team (excluding the executive sponsor) shall attend all quarterly meetings in-person at the State offices in Tallahassee, Florida, via web conferencing, or via telephone conference call, as determined by the Department. The Contractor shall not be entitled to additional compensation for meeting preparation or attendance. Quarterly reports are due within forty-five (45) Calendar Days following each quarter’s end and quarterly reviews to be scheduled within sixty (60) Calendar Days following each quarter’s end unless an extension is requested and granted by the Department.

The meeting to review the fourth quarter of a calendar year is considered both a quarterly and year-end meeting. The fourth quarter meeting shall include review of both quarterly and annual calendar year reports and Deliverables.

b. Agenda: At the Department’s request, Contractor shall provide a draft agenda five Business Days in advance of a meeting, allowing changes to the agenda and a reasonable opportunity to prepare for the meeting. The Contractor and Department will discuss issues such as Performance Guarantees, quality assurance, operations, network status and access, benefit and program changes or enhancements, legislative matters, audits, cost trends, utilization patterns, program outcomes, customer service issues, future goals and planning and other issues reasonably related to the Contract. Contractor shall address performance and compare the Plan(s)’s experience to 1) national trends, 2) Contractor’s total book of business, and 3) other governmental clients.

c. Minutes: Minutes shall include a clear and detailed account of the meeting, a list and description of any deliverables, identify the responsible party(ies) and provide projected delivery dates.

d. Other Meetings: Progress meetings, issue meetings and emergency meetings shall be held as needed. Either Party may call such a meeting, subject to reasonable notice. Any meeting held in person shall be at the State offices in Tallahassee, Florida. The Contractor shall not be entitled to additional compensation for meeting preparation or attendance.

III. Support Services

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AR-6 Open Enrollment Benefit Fairs

The Contractor shall participate at all locations of the annual Open Enrollment Benefit Fairs that are sponsored by the Department or its designee. The number of fairs and locations may vary each year or may be held through webinars or other virtual options at the discretion of the Department. Contractor representatives attending the Benefit Fairs shall be adequately trained and knowledgeable about the Plan. In past years, the Department held approximately twenty-four (24) in-person fairs statewide in the Fall; however, the Contractor should be prepared for either format as well as additional locations as required by the Department.

Contractor representatives attending the open enrollment events shall be employees of Contractor (not subcontractors or temporary personnel). Contractor shall educate Participants on Plan benefits, services, and other tips to ensure a positive Participant experience. The Contractor shall be responsible for all costs associated with participating in benefit fairs including, but not limited to, travel and a proportionate share of facility fees.

The Contractor shall not discuss with Participants or prospective Participants or in any manner allude to coverage, products, or materials other than those explicitly related to the Plan without the permission of the Department.

AR-7 Plan Material

The Contractor shall provide all marketing, promotional, educational, or any other materials, or written communication related to the Plan, to the Department for review and written approval prior to its use and dissemination. The Department shall be provided the opportunity to customize all such communications. The final materials used by the Contractor must not differ in form or utility from those approved by the Department. The Contractor shall be responsible for the development of Plan benefit information including but not limited to 1) open enrollment brochures and promotional pieces and 2) other Plan-related printed materials (e.g., Summary Plan Description, ID cards and benefit brochures). The Contractor shall also meet the following requirements:

a. Be responsible for writing, printing, and distributing (electronically or by mail as required) Plan materials.

b. Provide, upon request of the Participant, printed materials in a medium widely accepted for the hearing and/or visually impaired.

c. Provide all printed material in electronic format with final versions submitted to the Department in PDF file format.

AR-8 Public Records Requests and Subpoenas

The Contractor shall, upon request and at no additional cost, provide the Department with any necessary data, documents, etc., to enable the Department to timely (as defined by the Department) respond to Public Record Requests and subpoenas.

The Contractor may receive public records inquiries or subpoenas relating to the Plan. The Contractor shall notify the Department immediately in writing of such inquiries. Any response or material responding to such an inquiry shall be submitted to the Department for approval prior to dissemination by the Contractor.

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AR-9 Responding to Requests

The Contractor shall, upon request of the Department or its attorneys and at no additional cost, make available all necessary resources to assist the Department in responding to any aspect of Services delivered under the Contract, including but not limited to Departmental inquiries or those received by the Department from Participants, providers, or any other persons or entities. Such requests shall 1) be given a priority status, 2) be subject to a method of tracking, 3) result in the delivery of all requested information, documentation, etc., and 4) be overseen by a lead staff person specific to the subject matter area. When the Department is required to provide immediate responses to inquiries, the Contractor shall immediately assist the Department in preparing its reply including providing data and documentation within the timeframes prescribed by the Department at that time.

AR-10 Responding to Requests for Legislative Initiatives

The Contractor shall make available all necessary resources to assist the Department in responding to bill analysis, legislative inquiries and requests related to any aspect of Services delivered under the Contract, at no additional cost. The Contractor shall respond in the timeframe set by the Department, which shall be determined at the time of inquiry depending on the scope and complexity of the request.

AR-11 Returned Mail

The Contractor shall hold returned mail for thirty (30) Calendar Days, during which time the Contractor shall search for an updated address within each subsequent enrollment file received from People First. After thirty (30) Calendar days, if no updated address information is provided via the subsequent enrollment file, the Contractor shall store copies on its document imaging system and destroy the returned mail.

AR-12 Grievance Procedures

The Contractor shall develop and maintain formal and informal grievance procedures designed to fairly and expeditiously resolve problems related to the Plan. The procedures shall be made available to the Department, at no additional cost, during Implementation. The Contractor shall maintain a record of all grievances from Participants and shall provide a summary of grievances to the Department via Quarterly Reports, or more frequently upon request.

The Contractor’s system must indicate type or topic of the written correspondence and corresponding dates that individual mailings are provided to specific Participants.

IV. Customer Service

AR-13 Customer Service Operations

The Contractor shall maintain a Customer Service Unit to perform all aspects of customer service to assist Participants, prospective Participants, etc., regarding all aspects of the Plan.

Calls to this unit shall be accepted and answered promptly by a live customer service representative or Interactive Voice Response Unite (IVRU) during the hours of 8:00 A.M. to 5:00 P.M. EST, Monday through Friday, excluding State holidays set forth in section 110.117, F.S., and in accordance with PG-5 and PG-6 of Attachment 3: Performance Guarantees.

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a. The Customer Service Unit shall have the capability to adequately provide service and issue resolution, as well as sufficient numbers of qualified personnel trained in the administration of the Plan to meet or exceed related Performance Guarantees.

b. The Contractor shall maintain an adequate number of incoming toll-free phone lines dedicated to servicing Participant inquiries.

AR-14 Plan Website

The Contractor shall provide and maintain a Plan-specific Participant website, with access twenty-four (24) hours a day, seven (7) days a week, for general information. The design and content of the Plan website shall be approved in advance by the Department. This website shall include links to the Department website, the Contractor (non-Participant) website, and other sites as appropriate to make available a variety of information to Participants. Such web-based access shall include, at a minimum, the ability to access forms and brochures.

Members and non-members must be able to access information regarding the plan.

AR-15 Medical Underwriting

Medical underwriting determinations shall be completed within ten (10) Business Days of receipt of approved enrollment information.

AR-16 Notice of Approved Coverage

The Contractor shall provide Participants with a notice of approved coverage within five (5) business days of receipt of approved enrollment information.

AR-15 Beneficiary Designation

The Contractor shall enable Participants to designate a beneficiary and make changes to a beneficiary designation online. The Contractor shall also enable members to designate beneficiaries via telephone or paper form.

V. Data and Interface

AR-18 The Contractor shall be fully capable of accepting and implementing enrollment and other data files via a secure file transfer protocol (SFTP) on or before October 1, 2023.

AR-19 The Contractor shall not use, or otherwise disseminate, sell, copy, or make available to any person or entity data relating to any aspect of the performance of the Services, without prior written authorization of the Department. This requirement shall survive the termination of the Contract.

AR-20 Enrollment File Transfer from the Department

The Contractor shall maintain an information system capable of electronically receiving and updating Participant eligibility information (e.g., eligibility, name, address, coverage code).

The Contractor shall accurately convert and load the Department’s eligibility files.

The Contractor shall also:

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a. Maintain enrollment records for all Participants based on the Department’s eligibility files submitted to the Contractor.

b. Maintenance enrollment records shall be compliant with the required Gramm- Leach-Billey Act standards.

c. Not overwrite, update or in any way change the enrollment information without express direction from the Department. The Department’s enrollment file shall be the official system of record.

d. Accept the enrollment files in a format and frequency as required by the Department. The current enrollment file format and delivery schedule is in Attachment 5, Interface Files Layouts Life Enrollment Specifications, of the Contract.

e. Accept routine enrollment files and an annual Open Enrollment file (generally provided at the end of November following Open Enrollment). The Open Enrollment file shall not be loaded into production by the Contractor.

f. Process the enrollment files as required in PG-11 of Attachment 3: Performance Guarantees.

AR-21 Disaster Recovery Plan

The Contractor shall develop, implement, and maintain a disaster recovery plan and shall submit a copy of such plan for review by the Department on or before the Implementation Date of the Contract. At a minimum, the Contractor shall maintain backup of State files/data and shall be fully operational within twenty-four (24) hours of a disaster. At a minimum, the disaster recovery plan shall include daily backup of Plan-related files/data, a contingency provision so that critical services are provided within twenty-four (24) hours, and a fully operational provision so that all services are provided within forty-eight (48) hours of activating the disaster recovery plan at the same or better level of service as before the disaster recovery plan was activated. Any changes to the Plan throughout the term of the Contract must be sent to the Department.

VI. Reporting and Deliverables

AR-18 The Contractor shall provide, at no additional cost, ad hoc reports in formats required by the Department. The Contractor shall provide the Department with priority positioning for delivery of ad hoc report requests made by the Department or its designee regarding Plan-specific financial and statistical data, Participant Services, and utilization and claims reports. The Contractor shall acknowledge report requests within one (1) Business Day and shall provide an expected timeline for completion and delivery.

AR-19 Reports shall be provided in a format subject to customization and approval of the Department that provides utilization and claims reporting by Plan and by subgroup. The subgroups at a minimum are Active (includes all active employees including OPS/Variable hour employees), Vested Legislators, retirees, spouses, and dependent children. Reports shall contain all such data/details as required by the Department. Reports shall be delivered electronically to the Department and/or its designee, and in hard copy by request. Reports

Attachment 2: Administrative Requirements Page 8 of 11 that contain proprietary, trade secret and/or confidential information shall also be delivered in a redacted format at the same time as the non-redacted format.

a. Complete and detailed backup/supporting documentation must be provided with submission of each report. Backup/supporting documentation must identify the source of the material.

b. Each report and/or deliverable shall be subject to PG -14 of Attachment 3:

Performance Guarantees.

AR-20 Monthly Reports

Enrollment Discrepancy Reports. Contractor shall deliver enrollment discrepancy reports to People First based on the monthly enrollment file, indicating (where applicable) (i) duplicate records, (ii) reject records and (iii) address errors.

AR-21 Quarterly Reports

a. Claims Experience Report. The Contractor shall provide a summary by month of enrollment, premium collected, claims paid in the month, claims incurred in the month and incurred loss ratio. The report shall provide subtotals for the reporting period(s) and the Plan Year.

b. Benchmark Utilization Report. The Contractor shall provide benchmark utilization data for clients of similar size and complexity.

c. Performance Guarantees Summary Report. Contractor shall deliver the Performance Guarantee Summary Report (PG Report) as developed and provided by the Department (or as developed by the Contractor if one (1) cannot be provided by the Department) at least three (3) Business Days prior to each quarterly meeting.

d. Audit Report. Based on the results of the Contractor’s audits, the Contractor shall provide a report detailing the audit, its findings and financial impact on the Plan and Participants.

AR-22 Annual Reports

a. Participant Satisfaction Survey Report. The Contractor shall annually survey a sample of Participants using Plan services to verify satisfaction levels relating to the Contractor’s customer service unit and other related services and to gauge satisfaction with the Plan. The Contractor will provide a copy of the survey instrument and results to the Department. The survey instrument and results reporting format shall be prescribed or otherwise approved in advance by the Department.

b. Performance Bond and Insurance Report. Within thirty (30) Calendar Days of executing the Contract, the Contractor shall provide the Department with verification that a sufficient bond and insurance policies are valid and will

Attachment 2: Administrative Requirements Page 9 of 11 remain in force for the calendar year as prescribed in Section 8.2 of the Contract.

c. Warranty of Security Affidavit. By the Implementation Date and by December 31st of each Plan Year, the Contractor shall provide the Department with an executed Affidavit of Warranty of Security from an authorized representative.

d. Annual Plan Report. Contractor shall submit to the Department plan experience documentation including, at a minimum, the overall loss ratio and the loss ratios for each group coverage type (i.e., basic life, optional life, dependent child, spouse, etc.), claims data, annual cause of death report, and a participation summary. This report is due within 60 Calendar Days of the end of the reporting year.

VII. Renewal Report

AR-23 By May 1, 2027, and annually thereafter if the Contract is renewed pursuant to section 3.1.2 of the Contract, the Contractor shall submit to the Department a rate renewal report prepared and signed by an actuary with a Fellow of the Society of Actuaries (FSA) designation, subject to the Department’s approval, to validate premiums for the renewal term. The report shall include at least the following information:

i. Projection of incurred claim costs, a description of the methodology used to project incurred claims costs and justification of the use of any data not specific to the State of Florida.

ii. Detailed description of the methodology used to estimate claims trend.

iii. Disclosure of the targeted loss ratio used in the renewal calculation; and

iv. Disclosure of supporting data used in calculations, including enrollment, large claim analysis, trend analysis, demographic analysis, etc.

Upon the Department’s approval of the renewal report, an appropriate premium rate adjustment may be made via Contract amendment. The premium rates shall not exceed those specified in Contactor’s Price Sheet.

VIII. Claims Processing

AR-24 The Contractor shall establish and perform all aspects of claims processing, adjudication, and payment in accordance with the Plan design.

AR-25 Accounting System

The Contractor shall maintain an accounting system and employ accounting procedures and practices conforming to generally accepted accounting principles and standards. The Contractor’s accounting records and procedures shall be open to inspection by the Department, or its authorized representatives, at any time during the Contract period and for so long thereafter as the Contractor is required to maintain records and such inspections shall be subject to confidentiality protocol requirements. All charges, fees, costs, expenses, etc., applicable to the Contract shall be readily ascertainable from such records. Supporting

Attachment 2: Administrative Requirements Page 10 of 11 documentation for all charges, fees, expenses, etc., shall be readily ascertainable from such records.

IX. Audits

AR-26 The Contractor shall give the Department full access rights to perform audits, or have audits performed by a third party, as determined necessary or required to ensure and validate that premiums are being expended timely, efficiently and within compliance of all governing Florida statutes and the contract between Contactor and the Department. The Department’s audit rights are further specified in the Contract.

AR-27 The Contractor shall make a designated, internal audit representative available to the Department or its designee throughout the entire audit process.

AR-28 The Contractor shall research discrepancies identified during the audit and report the results of this research within ten (10) Business Days of the identification of the discrepancies.

AR-29 The Contractor shall review draft audit reports and provide written replies within ten (10) Business Days of receipt. Contractor’s reply will be included in final report.

AR-30 The Contractor shall provide one non-redacted Reply to the audit and one redacted Reply to the audit in the event confidential or proprietary information is contained within the report. Only confidential or proprietary information should be redacted.

AR-31 The Contractor shall provide a corrective action plan to address all audit findings in the manner and timeframe designated by the Department. All audit findings are to be completely remediated (system corrections, financial impact analyses and reimbursement, where applicable) within 60 Calendar Days of the issuance of the audit report.

AR-32 The Contractor shall reimburse impacted Participants for any financial findings identified during the audit within 20 Business Days of notification from the Department as to the final amount due.

AR-33 The Contractor shall perform, no less than quarterly, internal or external audits on a statistically valid sample of claims and shall report results to the Department quarterly. At a minimum, the quarterly audits must provide the Department with sufficient information to apply the measurement methodologies of PG-12 and PG-13 of Attachment 3: Performance Guarantees, of the Contract.

AR-34 Before commencing any audit, inspection, or copying of records, the State, the auditor, and the Contractor shall agree to the audit process, including but not limited to the scope of the audit, inspection, or copying and any additional confidentiality and privacy provisions pertaining to the information obtained or disclosed during the audit, inspection or copying, including any provisions required by law. Contractor shall unconditionally submit to the Terms and Conditions of the audit as are established by the State and auditor.

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X. Payment Specifications

AR-35 Direct Deposit EFT

The Contractor shall accept payments from the Department processed through the Department’s standard transmittal process (i.e., electronic funds transfer (EFT)) to the Contractor and by the Department determined due dates. The Contractor must complete a direct deposit authorization form (currently form number DFS-A1-26E rev 6/2014).

AR-36 The Contractor shall provide any payments to the Department through the normal transmittal process (i.e., EFT transfer from the Contractor) and by the Department determined due dates.

AR-37 All payments to the Department shall be made separately by EFT from any payment balances due from the Department. The netting of payments related to the Plan is prohibited.

XI. Special Provisions

AR-38 Notify the Department

The Contractor shall notify the Department within twenty-four (24) hours of occurrence, if the Contractor loses any accreditation, licenses, liability insurance coverage, or breach of AR-50 below.

AR-39 Protected Health Information

The Contractor agrees to adhere to leading industry practices in the development, implementation, and application of administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the protected health information that the Contractor creates, receives, maintains or transmits in the Contractor’s administration of the Plan, as required by the Gramm-Leach-Billey Act security standards. Records shall be retained for ten (10) years after the later of (i) the final disposition of a claim, (ii) the expiration of this Contract, (iii) the conclusion of any judicial or administrative proceedings or audits or other action. Records may be retained in a digital imaging format.

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Attachment 3: Performance Guarantees Page 1 of 7

ATTACHMENT 3: PERFORMANCE GUARANTEES

It is critical to the success of the State’s benefits plans that Services be maintained in a timely manner and that the Contractor operates in a reliable manner. It would be impracticable and difficult to repair the actual damage sustained by the State in the event of certain delays or failures in scheduled Services and the provision of Services to Members served by this Contract. The Department and Contractor, therefore, agree that in the event of certain delays and failures, the amount of damage that will be sustained will be the amounts set forth in this Attachment.

Further, Contractor agrees that in the event of any such failure of performance, Contractor shall pay such amount as liquidated damages and not as a penalty. At its option, the Department may, for any amount due to the State as liquidated damages, deduct such amount from any money payable to Contractor or may bill Contractor as a separate item.

All references to Ars are to the Administrative Requirements of Attachment 2.

PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology

I. Implementation 1 Final

Implementation Plan

AR-1

The Contractor shall provide the Final Implementation Plan, as described in Reply Document 3:

Final Implementation Plan of Attachment E, to the Department for approval no later than the date specified.

Delivery no later than ten (10) Business Days following the Effective Date of the Contract

One (1) time measurement

$5,000 per Calendar Day past the due date that the Final Implementation Plan, inclusive of all details, if not received and approved by the Department.

Department will confirm receipt and provide approval of Contractor’s final Implementation Plan within ten (10) Business Days following the Effective Date of the Contract. If the final Implementation Plan is submitted, but is not subsequently approved by the Department, the Contractor will have a timeframe designated by the Department to submit a revised Implementation Plan.

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PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology

II. Account Management 2 Quarterly

Performance Review Meetings

AR-5

The Account Management Team shall attend and participate in all required quarterly performance review meetings in-person, via web conferencing, or via telephone and in accordance with AR- 5 of this Contract.

One hundred percent (100%) attendance

Quarterly $500 per meeting in which each member of the Account Management Team is not in attendance unless an absence is pre-approved by the Department.

Department will confirm Account Management Team attendance at each meeting.

3 Corrective Action Plan

AR-4

When requested by the Department and within ten (10) Calendar Days of that request, Contractor shall develop and submit a corrective action plan (CAP) to be approved by the Department.

Contractors shall submit such CAP(s) to the Department for approval, and if approved, implement within ten (10) Calendar Days. If the Department does not approve the CAP(s),

a) Contractor shall revise, to incorporate Department feedback, and resubmit within five (5) Business Days.

As requested by the

Department

$2,500 per Calendar Day late beyond the ten (10) Calendar Days.

Measurement from date of delivery of the Plan Performance Review in Calendar Days.

b) Contractor shall complete implementation of the approved CAP within thirty (30) Calendar Days.

$5,000 per Calendar Day beyond the thirty

(30) Calendar Days.

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PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology

III. Support Services 4 Open Enrollment

Benefit Fairs

AR-6

The Contractor shall guarantee trained and knowledgeable staffing at each annual Open Enrollment Benefit Fair sponsored by the Department or its designee, in accordance with AR- 6 of this Contract.

One hundred percent (100%) of Open Enrollment Benefit Fairs shall be staffed by trained and knowledgeable personnel.

Annually $5,000 per Open Enrollment Benefit Fair not staffed as specified.

Department will confirm attendance at each event.

IV. Customer Service 5 Average Speed to

Answer

AR-13

The Customer Service Unit phone line shall answer within an average of thirty (30) seconds.

Measurement shall be from the initial time the call is placed in queue.

Ninety-nine percent (99%) of calls shall be answered within an average of thirty (30) seconds or less.

Quarterly $1,000 per percentage point, or fraction thereof, less than ninety-nine percent (99%).

“Average Speed to Answer” means (i) the total number of seconds from the time a caller is queued, and the call is answered for all calls queued to a live customer service representative or Interactive Voice Response Unit (IVRU), divided by (ii) the total calls handled by a live customer service representative or IVRU of the member service telephone line.

6 Call Abandonment Rate

AR-13

The call abandonment rate of the dedicated toll-free customer service phone line shall not exceed the specified rate.

Less than or equal to three percent (3%).

Quarterly $2,500 per percentage point, or fraction thereof, greater than three percent (3%).

The call abandonment rate percentage represents the number of calls in queue in which the caller has hung up the phone before the live customer service representative has answered

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PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology the call divided by the total calls offered.

7 Participant Satisfaction Survey

AR-27

The level of overall Participant satisfaction with Services provided by the Contractor, as measured one (1) time by a Department-approved satisfaction survey instrument, will be greater than or equal to ninety percent (90%).

The Contractor will conduct a Department-approved Participant Satisfaction Survey containing a Department designed overall satisfaction question.

Approval of the survey includes approval of survey methodology and the methodology in obtaining the result as a percentage.

Annually

(Reported during the 4th quarter of the Plan Year.)

$2,500 per percentage point, or fraction thereof, below ninety percent (90%).

Measurement of the difference between overall satisfaction (measured by survey as a percent of Participants satisfied) and ninety percent (90%) satisfaction.

Written Inquiry Response Time

AR-13

Ninety-nine percent (99%) of written inquiries related to the Plan will be acknowledged and resolved in twenty-one (21) Calendar Days. Written inquires includes communication via mail, email, and fax from Participants.

Audit performed on written inquiries from Plan Participants. The audit shall be conducted by Contractor or Contractor’s Subcontractor on a statistically valid sample. The Contractor shall submit the audit reports to the Department quarterly.

Quarterly $2,000 per each full percentage point, or fraction thereof, below ninety-nine percent (99%).

Number of written inquiries, received from Plan Participants, resolved within twenty-one (21) Calendar Days divided by the total number of written inquires received from Plan Participants.

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PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology

9 Medical Underwriting Timeliness

AR-15

Ninety-nine percent (99%) of medical underwriting determinations shall be completed within ten (10) Business Days.

Measured from the date the evidence of insurability form (form) is received in the office (day 1) to the date it reaches final action determination or is returned for additional information.

The measurement refers to “clean” form only and the required timeframe is paused while the form is pending additional information from the applicant.

Quarterly $2,000 per each percentage point, or fraction thereof, below ninety-nine percent (99%).

Total number of forms processed within ten (10) business days / total number of forms received within the quarter.

Pended forms will be measured as the total number of Business Days prior to being pended and the number of Business Days from removal of pending status to completed processing. Turn-around time for pended forms will be applied to the quarter the form was either approved or denied.

10 Notice of Approved Coverage

AR-16

A notice of approved coverage will be distributed to one hundred percent (100%) of Participants within five (5) business days of receipt of approved enrollment information.

Measured in business days as the amount of time from receipt of approved enrollment information and when the notices are distributed.

Quarterly $2,000 per percentage point, or fraction thereof, below (one hundred percent) 100%.

Measured from the date of receipt of approved enrollment information to the date the notification is provided to the Participant.

V. Data and Interface 11 Enrollment

Updates

AR-21

Routine Updates:

Enrollment files as described in AR-19, shall be accurately and timely loaded

One hundred percent (100%) within two (2) Business Days of receipt.

Quarterly $2,000 for each Business Day past the deadline, per incident.

Measured from the date/time of receipt of a processable enrollment file until the file is loaded.

Attachment 3: Performance Guarantees Page 6 of 7

PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology within the time frame specified.

VI. Reporting and Deliverables 12 Claims Timeliness

AR-28

Timely process claims by ensuring a final action determination within twenty (20) Calendar Days from the date the claim is received in the office.

Average turn-around time for claims processing for a final action determination will not exceed twenty

(20) Calendar Days for ninety-five percent (95%) of all claims submitted by Participants.

Measured from the date the claim is received by Contractor (Day 1) to the date the processed claim reaches final action determination (includes weekends and holidays).

The measurement refers to “clean” claims only and the required timeframe is paused while the claim is pending additional information from the claimant.

Quarterly $2,000 per percentage point, or fraction thereof, below ninety-five percent (95%)

Total number of original claims processed within twenty (20) days / total number of original claims processed during the quarter.

For electronically submitted claims, Day 1 is the date the claim was received by the Contractor, irrespective of time of day and including weekends and holidays. For Paper claims, Day 1 is the date the claim was time stamped upon receipt.

Pended claims will be measured as the total amount of time prior to being pended and the time from removal of pending status to completed processing. Turn-around time for pended claims will be applied to the quarter the claim was either paid or denied.

Attachment 3: Performance Guarantees Page 7 of 7

PG # Performance Indicator Standard/Goal Measurement Criteria Frequency of

Measurement Liquidated Damages Measurement Methodology

13 Claims Payment Accuracy

AR-36, 37

Claims shall be processed without financial payment error.

Average payment accuracy of ninety-seven percent (97%) or more.

Quarterly $5,000 per percentage point, or fraction thereof, below ninety-seven percent (97%).

Claims payment accuracy measured by (Number of claims in sample paid accurately / number of claims in sample).

14 Timeliness of the Delivery of Reports and Deliverables

AR-22, 23

Reports and Deliverables shall be delivered to the Department and/or its designee within the time specified.

a) Due monthly: Within ten (10) Calendar Days of end of the reporting month.

Monthly $250 for each Calendar Day past the due date that a report or Deliverable is not submitted.

Measured as the difference between the date a report is delivered to the Department and the due date

b) Due quarterly:

Within forty-five (45) Calendar Days of end of the reporting quarter.

Quarterly $250 for each Calendar Day past the due date that a report or Deliverable is not received.

c) Due annually:

December 31st of each Plan Year.

Annually $250 for each Calendar Day past the due date that a report or Deliverable is not received.

Attachment 4: Plan Benefit Design Page 1 of 7

ATTACHMENT 4: PLAN BENEFIT DESIGN

Standard Plan Design provisions used to provide Services to Members that are not included in this attachment, or otherwise included in this Contract, and that do not conflict with the same may be used in relation to the Plan. If such provisions are normally set out in the insurance policy or certificate of coverage, the Contractor must include them in the policy and/or certificate documents provided to the Department and Plan Members. If such provisions are technical in nature or generally relate to the Contractor’s internal practices or systems and are not typically found in the policy or certificate of coverage documentation, the Contractor is not required to include these provisions in those documents but must be able to explain and document any decisions resulting from such processes upon request from the Department.

The insurance policy that is issued to the Department for this Plan must be offered by a business entity domiciled in the State of Florida.

i. Basic Group Life Coverage for Eligible Employees Initial Term & Renewal Term Rate per $1,000 per month

ii. Group Term Life Coverage for Vested Legislators

Rate per $1,000 per month

iii. Group Term Life Coverage for Spouses:

Rate per spouse per month ($15,000 and $20,000 Coverage Level)

iv. Group Term Life Coverage for Dependent Children

Rate per $1,000 month (covers all children in a family)

v. Group Term Life Coverage for Retired Employees

Rate per $1,000 per month ($10,000 and $25,000 Coverage Level)

vi. Group Term Optional Life Coverage Premium rates are based on the insured’s annual salary rounded to the nearest dollar.

Rate per $1,000 month by age band

I. Basic Group Term Life Insurance for Eligible Employees

Basic Group Term Life insurance is a guaranteed issue for all eligible employees.

A. Eligibility

Attachment 4: Plan Benefits Design Page 2 of 7

i. Full-time active employees. Coverage begins on the date of hire. Premium is employer paid. Enrollment in basic group term life insurance is automatic for new full-time employees. These employees may elect to opt out of coverage.

ii. Part-time active employees. Coverage begins the first day of the month after a full month’s premium has been paid. Premium is paid by the employer and the employee—prorated based on the employee’s full-time equivalency. Enrollment in basic group term life insurance must be elected by part-time active employees.

iii. OPS/Variable hour employees. Coverage begins the first day of the month after a full month’s premium has been paid. Premium is paid by the employee.

Enrollment in basic group term life insurance must be elected by OPS/Variable hour employees.

iv. Layoff Employees. Layoff employees may elect to continue coverage and pay the full premium amount while in layoff status for the duration specified in Chapter 60-P, Florida Administrative Code.

B. Life Benefit

The life insurance benefit for basic group term life insurance is $25,000.

C. Additional Life Benefits

i. Repatriation Benefit. If an insured dies at least 75 miles from the insured’s principal address and is eligible for the life benefit, a benefit shall be paid for the preparation and transportation of the body to a mortuary. The benefit shall be either the actual cost of the preparation and transportation or $5,000, whichever is less. This benefit will be paid to the person incurring the cost, whether that person is the beneficiary for the life benefit, or to the facility providing the preparation and transportation.

ii. Waiver of Premium. If Participant becomes totally disabled and remains continuously totally disabled for at least nine months, his life insurance may remain in force without payment of premium for the continuous duration of the total disability. If Participant becomes totally disabled at age 60 or older, the Participant ‘s insurance will continue one year from the date of onset of the total disability.

iii. Accelerated Death Benefit. This benefit is an amount equal to the life benefit. This benefit is payable when the insured is expected to live less than twelve months as certified by his physician and verified and accepted by Contractor, as appropriate. Payment of this benefit terminates the insured’s premium payments and eligibility.

D. Portability

If Participant terminates employment for reasons other than retirement or is no longer in an eligible class, the Participant may request to port coverage within 31 days of becoming ineligible for the coverage. This coverage is guaranteed issue. The amount of insurance will reduce to 65% when the Participant turns age 65. Ported insurance terminates when the Participant turns age 70.

Attachment 4: Plan Benefits Design Page 3 of 7

II. Group Term Life Insurance for Vested Legislators

Group term life insurance for vested legislators is guaranteed issue.

A. Eligibility

Vested legislators. Coverage begins the first day of the month after a full month’s premium has been paid. Premium is paid by the vested legislator. Enrollment in group term life insurance for vested legislators must be elected by the vested legislator. Vested legislators are not required to continue coverage. They always remain eligible for coverage, even if they have elected not to enroll or have terminated coverage in the past.

B. Life Benefit

The life insurance benefit for group term life insurance for vested legislators is $150,000.

C. Additional Life Benefits

AR-16 Repatriation Benefit. If an insured dies at least 75 miles from the insured’s principal address, and is eligible for the life benefit, a benefit shall be paid for the preparation and transportation of the body to a mortuary. The benefit shall be either the actual cost of the preparation and transportation or $5,000, whichever is less. This benefit will be paid to the person incurring the cost, whether that person is the beneficiary for the life benefit, or to the facility providing the preparation and transportation.

AR-17 Accelerated Death Benefit. This benefit is an amount equal to the life benefit. This benefit is payable when the insured is expected to live less than twelve months as certified by his physician and verified and accepted by Contractor, as appropriate. Payment of this benefit terminates the insured’s premium payments and eligibility.

D. Portability

a. If Participant terminates employment for reasons other than retirement or is no longer in an eligible class, the Participant may request to port coverage within 31 days of becoming ineligible for the coverage. This coverage is guaranteed issue.

The amount of insurance will reduce to 65% when the Participant turns age 65.

Ported insurance terminates when the Participant turns 70 years of age.

b. Group Term Life Insurance for Spouses

Group term life insurance for spouses is guaranteed issue during the spouse’s initial eligibility period.

A. Eligibility

i. Legal spouses, as defined by subsection 741.212(3), Florida Statutes, of full-time, part-time, OPS/Variable hour employees or vested legislators enrolled in coverage for basic group term life insurance or group term life insurance for

Attachment 4: Plan Benefits Design Page 4 of 7 vested legislators. Legal spouses of State employees who are also State employees or retirees may not have spouse coverage and employee or retiree coverage simultaneously. Coverage begins the first day of the month after a full month’s premium has been paid. Premium is paid by the Participant. Enrollment in group term life insurance for spouses must be elected by the Participant.

ii. Layoff Employees. Layoff employees may elect to continue coverage and pay the full premium amount while in layoff status for the duration specified in Chapter 60-P, Florida Administrative Code.

B. Life Benefit

Participants may choose from either a $15,000 benefit or a $20,000 benefit for group term life insurance for spouses.

C. Additional Life Benefits

i. Repatriation Benefit. If an insured dies at least 75 miles from the insured’s principal address, and is eligible for the…