Health_Plan_Administrative_Services.pdf

Mayor Chief Procurement Officer Buddy Dyer David Billingsley, CPSM, C.P.M.

REQUEST FOR PROPOSAL (RFP)

RFP26-0046

HEALTH PLAN ADMINISTRATIVE SERVICES

The City of Orlando Procurement and Contracts Division has implemented an electronic bidding system to streamline solicitation responses.

CITY OF ORLANDO PROCUREMENT AND CONTRACTS SITE

https://www.orlando.gov/Our-Government/Departments-Offices/OBFS/Procurement

City of Orlando

REQUEST FOR PROPOSAL (RFP)

HEALTH PLAN ADMINISTRATIVE SERVICES

TABLE OF CONTENTS

1. INTRODUCTION

2. REQUEST FOR PROPOSALS INFORMATION

3. TERM OF CONTRACT

4. MANDATORY MINIMUM QUALIFICATIONS

5. SCOPE OF WORK AND TECHNICAL REQUIREMENTS

6. PRE-PROPOSAL CONFERENCE

7. PROPOSAL DUE DATE AND TIME

8. PROPOSAL PREPARATION AND FORMAT

9. REQUIRED PROPOSAL SUBMITTALS

10. DELIVERY OF PROPOSALS

11. CONFORMANCE TO SOLICITATION

12. EVALUATION CRITERIA

13. PROPOSAL ADVISORY COMMITTEE AND EVALUATION PROCESS

14. GENERAL TERMS AND CONDITIONS

15. ADDITIONAL INFORMATION

16. ADDENDUM TO REQUEST FOR PROPOSALS

17. APPLICABLE LAW AND APPEALS

18. CONTRACT

19. EXECUTION OF CONTRACT

20. AFFILIATED AGENCIES

21. EMPLOYMENT ELIGIBILITY; E-VERIFY SYSTEM

22. RIGHT TO AUDIT RECORDS

23. FISCAL YEAR FUNDING APPROPRIATION

24. PUBLIC ENTITY CRIMES

25. PROMPT PAYMENT ACT

26. INVOICES

27. DISPUTE RESOLUTION

28. PROPOSER'S GUARANTEE

29. INSURANCE

30. FLORIDA SALES TAX

31. DRUG-FREE WORKPLACE CERTIFICATION

32. AMERICANS WITH DISABILITIES ACT

33. RECIPROCAL LOCAL PREFERENCE

34. PURCHASING CONTRACTS W/ OTHER GOVERNMENT AGENCIES

35. FOREIGN CORPORATION

36. SUBCONTRACTORS

Health Plan Administrative Services

37. PURCHASING CARD PROGRAM

38. LIVING WAGE POLICY

39. PROHIBITION - CONTRACTING WITH SCRUTINIZED COMPANIES

40. SOFTWARE LICENSES

41. NON-DISCRIMINATION

42. GOVERNING LAW / VENUE

43. RECOVERED MATERIALS

44. PROHIBITION AGAINST CONSIDERING SOCIAL, POLITICAL, OR

IDELOGICAL INTEREST IN GOVERNMENT CONTRACTING

45. VENDOR QUESTIONNAIRE / ATTACHMENTS

Attachments:

A - Exhibit 1 - Summary Plan Descriptions

B - Exhibit 2 - Claims Experience1

C - Exhibit 3 - Census

D - Exhibit 4 - Claims Reporting Fields

E - Exhibit 5 - Stop Loss Information

F - Exhibit 6 - 2026 United Healthcare Summary Booklet

1. INTRODUCTION

1.1. Summary

The City of Orlando (City) is soliciting proposals from qualified organizations to provide administrative services for its self-funded group medical and pharmacy benefit plans, effective January 1, 2027. Proposers may submit responses for one or more of the following service configurations. All proposed configurations must apply across all three plan options (HMO, POS, and Narrow Network), meaning the City will not consider proposals that “slice” administration by plan (e.g., one administrator for HMO/POS and a separate administrator for the Narrow Network).

Service Configuration Options:

A. Option 1: Medical Administrative Services Only (ASO)

B. Option 2: Pharmacy Benefit Manager (PBM) Administration

Each proposer may submit up to two distinct response options. As described in further detail below, one of the City’s three plan options will include a Narrow Network Plan

(which may also be referred to as a High-Performance Network throughout this RFP) beginning in 2027, utilizing a high-performance network anchored by a Clinically

Integrated Network (CIN), as defined by the Centers for Medicare & Medicaid Services

(CMS) and the Federal Trade Commission (FTC) applicable standards, or a network with the underlying systems in place that mirror a CIN. Therefore, proposals must include a high-performance network for this Narrow Network Plan.

Note: The City is not requesting proposals for Medicare-eligible retiree plan options (e.g., fully-insured Part D plans, Medicare Supplement, or Medicare Advantage) or stop-loss insurance as part of this solicitation. These services should not be included in the proposal.

The City of Orlando’s objectives of this solicitation are as follows:

A. Identify a collaborative administrative partner(s) with experience supporting alternative care delivery models, including value-based contracting, clinical data integration, and population health management.

B. Engage administrator(s) with demonstrated success working together to deliver integrated care and comprehensive plan management—even when operating under a carve-out structure.

C. Maintain high-quality medical and pharmacy coverage through continuation of the current open-access Health Maintenance Organization (HMO/Choice) and

Point-of-Service (POS/Choice Plus) plan offerings.

D. Expand access to affordable care through the implementation of a third plan, high-performance Narrow Network plan, which is expected to include reduced premiums and/or cost-sharing.

E. Leverage transparent, data-driven partnerships to support continuous improvement in quality, utilization, and cost control across all plan options.

F. Align the City’s benefits strategy with evidence-based care and emerging value-based healthcare models, while upholding fiscal responsibility to employees, retirees, and taxpayers.

1.2. Background

The City of Orlando currently offers two self-funded medical plan options to eligible full-time employees, retirees, and dependents: an open-access Health Maintenance

Organization (HMO/Choice) and a Point-of-Service (POS/Choice Plus) plan. These plans are administered by UnitedHealthcare (UHC), which has served as the City’s medical and pharmacy benefits administrator since 2001. The City transitioned from fully insured coverage to a self-funded model effective January 1, 2012. The current administrative services agreement with UHC will expire on December 31, 2026.

For the plan year beginning January 1, 2027, the City will continue to offer both the HMO and POS plans, maintaining existing provider access, plan design structure, and cost-sharing arrangements, subject to annual adjustments. While it is acknowledged that future network changes can occur, it is expected that members enrolled in these plans will continue to have similar access to medical providers, including both of the Greater

Orlando region’s major hospital systems (AdventHealth and Orlando Health).

To enhance the value and affordability of its healthcare offerings, the City intends to introduce a third plan option in 2027 built on a high-performance network. The high-performance network must either (1) meet the formal criteria of a CIN, or (2) demonstrate equivalent systems and capabilities. Specifically, the network must show the ability to:

A. Manage population health across covered members

B. Reduce variation in care delivery

C. Implement evidence-based clinical protocols

D. Operate under coordinated governance with supporting infrastructure

The selected Proposer must demonstrate the ability to contract with and support the administration of a high-performance network. The City seeks a flexible, innovative partner capable of supporting evolving delivery models and plan designs. The City desires administrators with demonstrated success working together to deliver integrated medical and pharmaceutical care—even when operating under a carve-out structure. Proposers must have the flexibility to administer client specific strategies, including but not limited to wellness programs and incentives, formulary strategies, and plan design structures that encourage use of cost containment programs and quality providers.

The City currently provides coverage to approximately 9,000 total covered lives, of which includes 5,500 active employee and retiree subscribers. Projected gross annual healthcare claims total $85 million, with an approximate distribution of 65% medical and

35% pharmacy claims.

Regardless of the plan selection, the City currently funds 95% of employee-only premiums and 73% of dependent-tier premiums of the Choice HMO Plan (Employee +

Spouse, Employee + Child(ren), and Employee + Family). Employees who select the

Choice Plus POS Plan pay the additional premium between the Choice and Choice Plus plans. Funding for the Narrow Network Plan is to be determined. Retiree premium contributions are based on years of service and the employee’s retirement date. For

Medicare-eligible retirees, the City provides secondary medical coverage, and enrollment in Medicare Part B is mandatory. The City currently provides primary prescription drug coverage and participates in the CMS Retiree Drug Subsidy (RDS) program. The City maintains individual-specific stop-loss coverage with a $1,000,000 deductible and a

$420,000 aggregating specific corridor. The current stop-loss policy includes an individual laser provision with a $1,600,000 specific deductible.

The City has implemented a comprehensive suite of health and wellness programs and seeks to partner with an administrator that can support these initiatives, track outcomes, and make strategic recommendations to improve employee health and well-being. The

City employs a full-time Wellness Coordinator to oversee program implementation. Key initiatives include the annual multi-day Employee Fitness Challenge and gender-specific health seminars.

UHC currently provides the following integrated wellness and disease management programs:

A. Level 2 Assured Value Diabetes Management Program (implemented 1/1/2025)

B. Chronic Condition Management (Asthma, Diabetes, Coronary Artery Disease, Congestive Heart Failure)

C. Complex Care Programs (Cancer, Transplant, Maternity, Kidney Disease, Neonatal Care)

D. Wellness Platform & Incentive Administration via myUHCRewards (health assessments, coaching, personal health records) including up to $200 for employees completing various wellness activities and preventive screenings

E. Full-time onsite nurse (employed by UHC) supporting education, outreach, and closure of care gaps

F. $25,000 annual communication fund

G. $104,750 annual wellness fund

Additional services such as COBRA administration and retiree direct billing are managed by a third-party vendor.

The ASO agreement with UHC has been in place since January 1, 2012, when the City transitioned to a self-funded health plan. Following RFP16-0077, UHC was re-awarded the contract effective January 1, 2017. ASO fee history is as follows:

A. 2017–2019: $33.43 PSPM (Per Subscriber Per Month)

B. 2020: $34.43 PSPM

C. 2021–2024: $35.79 PSPM

D. 2025: $36.51 PSPM + $13 PSPM Rx Admin Fee**

E. 2026: $37.24 PSPM + $13 PSPM Rx Admin Fee**

**transitioned to 100% pass-through rebate arrangement effective 1/1/2025

For Proposers’ information in preparing their Proposals, Summary Plan Descriptions for the HMO and POS plans are included with this RFP in Exhibit “1”. The City’s Claims

Experience, Census, a Claims File Layout, Stop Loss information, and United Health Plan

Summary Booklet have also been included with this RFP as Exhibits “2”, “3”, “4”, “5”, and

“6” respectively.

The following Attachments are included in this RFP and must be completed and returned with your submission in the format specified based on the self-funded health plan administrative services proposed:

Proposal Option Attachment Description Submittal Format

1 and 2 A Proposed Services and Mandatory Requirements

Worksheet

Microsoft Word

1 and 2 B General Administrative Services Worksheet Microsoft Word

1 C Medical ASO Proposal Worksheet Microsoft Word

1 D Medical Network Disruption Worksheet Microsoft Excel

1 E Medical Claims Repricing File

The City considers medical claims repricing information, including discount information, to be presumptively entitled to protection as a trade secret pursuant to Sections

688.002(4) and 815.045, Florida Statutes. Accordingly, the

City will treat information submitted in Attachment E as confidential and not subject to release in response to a public records request, unless release is required by a valid subpoena or other order of a court of competent jurisdiction, and then only to the limited extent so required.

Microsoft Excel

2 F PBM Worksheet Microsoft Excel

2 G Pharmacy Cost Worksheet Microsoft Excel

1 and 2 H Proposer’s Certification PDF

1 and 2 I Conflict of Interest Disclosure Form PDF

1 and 2 J Confidential and/or Proprietary Information Exemption

Form

PDF

1 and 2 K Human Trafficking Affidavit Form PDF

1.3. Contact Information

Direct inquiries to the following:

Tara Urdininea

CPP, Purchasing Agent III

400 South Orange Avenue

Orlando, FL 32801

Email: tara.urdininea@orlando.gov

Phone: (407) 246-2368

Department:

Human Resources

1.4. Timeline

The following is the scheduled calendar of events with important dates and times. Dates are subject to change by the Chief Procurement Officer (“CPO”) of the Procurement and

Contracts Division or designee, at their sole discretion. If the Procurement and Contracts mailto:tara.urdininea@orlando.gov tel:(407)246-2368

Division determines that it is necessary to change these dates or times prior to the

Proposal due date, the change will be announced via an addendum.

Release Project Date October 31, 2025

Pre-Proposal Meeting (Non-

Mandatory)

November 10, 2025, 10:00am

ALTHOUGH IT IS NON-MANDATORY, IT

IS HIGHLY ENCOURAGED THAT

PROPOSERS ATTEND.

JOIN THE VIRTUAL PRE-PROPOSAL

CONFERENCE.

https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4

NS00YzYxLTkwNDEtZDQyMTA4YzBkZG

Y5%40thread.v2/0?context=%7b%22Tid%

22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%

2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d

Or, call into the virtual meeting by dialing this phone number: +1 321-247-7568

Once dialed-in and prompted, enter the

Meeting ID: 242 352 506 651 2

Passcode: Bh36RD6d

ALTHOUGH IT IS NON-MANDATORY, IT

IS HIGHLY ENCOURAGED THAT

PROPOSERS ATTEND.

Question Submission Deadline November 17, 2025, 5:00pm https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_YTcxODBjODUtNWU4NS00YzYxLTkwNDEtZDQyMTA4YzBkZGY5%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d

Proposal Submission Deadline December 15, 2025, 2:00pm

JOIN THE VIRTUAL PROPOSAL

OPENING.

https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUw

NS00Y2ExLWIyZTUtYWFkODljOTcxZGM

2%40thread.v2/0?context=%7b%22Tid%2

2%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%

2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d

Or, call into the virtual meeting by dialing this phone number: +1 321-247-7568

Once dialed-in and prompted, enter the

Meeting ID: 211 307 648 099 0

Passcode: P8ay7he3

2. REQUEST FOR PROPOSALS INFORMATION

The Procurement and Contracts Division is the official source to obtain information relating to City of Orlando solicitations. It is incumbent on the Proposer to obtain solicitation and current award information prior to and after the scheduled opening date of a Request for Proposals. Information is updated daily as it becomes available. An award, or recommendation of award, may be made at any time after the scheduled opening date of a Request for Proposals. You may obtain award and other solicitation information in a variety of ways:

A. There are currently two Internet sites available to obtain RFP Selection

Committee rankings, Notice of Intended Action for award and other information:

1. The City of Orlando Procurement and Contracts Division’s Website:

http://www.orlando.gov/procurement/solicitations/ If you are interested in obtaining solicitation information, copy and paste the above link into your web browser and click on View Current Bids. Please remember that you must keep your registration information up to date in order to continue to receive notifications of bidding opportunities that meet your commodity code selections.

2. Direct link to the City's e-Procurement Portal:

https://procurement.opengov.com/portal/orlando.

https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d https://teams.microsoft.com/l/meetup-join/19%3ameeting_MDk5MjhlOWUtYjUwNS00Y2ExLWIyZTUtYWFkODljOTcxZGM2%40thread.v2/0?context=%7b%22Tid%22%3a%227594da9b-294b-4acf-913b-d159ae921564%22%2c%22Oid%22%3a%2267b536ad-34cb-46e2-afe9-a0f9f437bd65%22%7d http://www.orlando.gov/procurement/solicitations/ https://procurement.opengov.com/portal/orlando

B. You may visit the Procurement and Contracts Division, during normal business hours, to obtain award information, solicitation packages, addendums, and other documents. Our office is located at:

City of Orlando

Procurement and Contracts Division

400 South Orange Avenue, Fourth Floor

Orlando, Florida 32801

You may also call the Procurement and Contracts Division at (407) 246-2291, during normal business hours, to request award and other solicitation related information.

We appreciate your interest in doing business with the City Beautiful and wish you much success with your business ventures.

3. TERM OF CONTRACT

It is the intent of the City is to award a Contract for a three (3) year term to begin upon approval and execution by the City. The Contract may, by mutual assent of the parties, be extended for seven (7) additional twelve (12) month periods or portions thereof, up to a cumulative total of one hundred twenty (120) months.

4. MANDATORY MINIMUM QUALIFICATIONS

The following mandatory minimum requirements have been established. Subject to the

City’s right to waive minor irregularities, Proposers that do not meet these qualifications or do not agree to the technical requirements will be deemed non-responsive and will not be considered for further evaluation. Proposers must complete Attachment A – Proposed

Services & Mandatory Requirements Worksheet and submit it in Microsoft Word format.

Option 1: Medical ASO Proposers

A. The Proposer must have experience providing Medical ASO services to three or more employers each having 2,000 or more subscribers within the past five (5) years.

B. The awarded Proposer must agree to serve as the claims fiduciary and accept fiduciary responsibility for all claims payment decisions, including the defense of claims adjudicated on behalf of the City. The City shall not be involved in claims determination or appeals processes. Participants may not be referred to the City for claims resolution.

C. Proposers must agree to provide a Statement on Standards for Attestation

Engagements (SSAE) No. 18 or equivalent SOC 1 Type II audit report at least annually to the City.

D. Provider networks must meet the following criteria:

1. HMO and POS Plans: Broad Network must include both Orlando Health and

AdventHealth facilities.

2. Narrow Network/High-Performance Network Plan: Proposer must submit at least one network option that is demonstrably anchored to either Orlando

Health or AdventHealth facilities as of the proposal due date. “Anchored” is defined as the hospital system serving as the core inpatient and specialty network around which the plan is designed.

E. Proposers must complete Medical Claims Repricing File (Attachment E) based on the Proposer’s current Broad Network discounts under contract. The City considers medical claims repricing information, including discount information, to be presumptively entitled to protection as a trade secret pursuant to Sections

688.002(4) and 815.045, Florida Statutes. Accordingly, the City will treat information submitted in Attachment E as confidential and not subject to release in response to a public records request, unless release is required by a valid subpoena or other order of a court of competent jurisdiction, and then only to the limited extent so required.

F. The awarded Proposer must permit the City, or a mutually agreed-upon third-party, to conduct one annual audit of claims per plan year.

G. Proposers must agree to provide supporting detail with all medical claims (as applicable) reimbursement requests to assist the City in verifying proper payment.

H. Administrative fees and proposed minimum discount guarantees for the Broad

Network must be guaranteed for the 2027, 2028, and 2029 plan years. In addition, for the High-Performance Network, Proposer must provide guaranteed discount improvements (decrements off of the Broad Network discounts) for each plan year, clearly identifying the basis and methodology used. If a guaranteed percentage or dollar value (as applicable) is not presented for each required year and for each network type (Broad Network and High-

Performance Network), the proposal will be deemed non-responsive. All limitations must be fully disclosed.

Option 2: PBM Proposers

A. The Proposer must have experience providing PBM services to three or more employers each having 2,000 or more subscribers within the past five (5) years.

B. The Proposer must have a registration certificate issued by the Florida Financial

Services Commission Office of Insurance Regulation, pursuant to F.S. §624.490, as of the proposal due date.

C. The awarded Proposer must agree to serve as the claims fiduciary and accept fiduciary responsibility for all claims payment decisions, including the defense of claims adjudicated on behalf of the City. The City shall not be involved in claims determination or appeals processes. Participants may not be referred to the City for claims resolution.

D. Proposers must agree to provide a Statement on Standards for Attestation

Engagements (SSAE) No. 18 or equivalent SOC 1 Type II audit report at least annually to the City.

E. Proposers must agree to provide supporting detail with all pharmacy claims reimbursement requests to assist the City in verifying proper payment.

F. Proposals must reflect administrative fees and pricing guarantees based on a retail pharmacy network that excludes Walgreens. Retail, mail-order, and specialty pharmacy arrangements must be compliant with the Florida

Prescription Drug Reform Act (SB 1550). The following amounts and percentages, at minimum, must be guaranteed for calendar years 2027, 2028, and 2029:

1. Administrative Fees

2. Pharmacy guarantees including:

a. Minimum discounts off of Average Wholesale Price

b. Dispensing Fees

c. Rebates for brand drugs

d. Generic fill rates

If a discount guarantee percentage or dollar value (as applicable) is not presented for each year required, your proposals will be considered non- responsive.

5. SCOPE OF WORK AND TECHNICAL REQUIREMENTS

5.1. Proposals Shall Conform to the Scope of Services and Technical Requirements as set Forth in this Section.

The technical specifications listed below describe the scope of services and instructions in completing Attachments “B,” “C,” “D,” “E,” “F”, and “G”, of this RFP.

5.2. General Information and Administrative Services

This section applies to both Options 1 and 2. The technical specifications listed below describe the requested scope of services and contain information and instructions to assist Proposers in completing Attachment B – General Administrative Services

Worksheet.

A. Proposals are being solicited for self-funded health plan administrative services with an effective date of January 1, 2027. The initial contract term will be three

(3) years, with the option to renew for up to seven (7) additional one-year periods, subject to mutual agreement and satisfactory performance.

B. The Proposer shall have accreditation by the National Committee for Quality

Assurance (NCQA) as of the proposal due date (or another nationally recognized accreditation organization as applicable).

C. The City seeks a dedicated, experienced account management team. At minimum, this shall include a Strategic Account Executive, day-to-day Client

Services Representative, Clinical Consultant (RN or equivalent), Claims/Eligibility

Analyst, Implementation Project Manager, and Data Reporting Lead.

D. The awarded Proposer for Option 1 shall provide a full-time onsite Nurse

Liaison/Clinical Coordinator (Registered Nurse or clinical equivalent) to support member health engagement, gap closure, coordination with City wellness initiatives, and high-touch outreach.

1. The individual shall have real-time access to clinical data, eligibility, and claims history to effectively support care coordination and population health management.

2. The selected individual will be subject to City review and approval prior to placement.

3. The selected individual shall be physically present onsite Monday through

Friday, with flexible hours to accommodate employees working early mornings and late evenings. Reasonable time off shall not exceed 160 hours annually.

4. Costs associated with this position must be fully incorporated into the Medical

ASO fee proposal.

E. The awarded Proposer(s) shall be capable of administering an integrated medical and pharmacy self-funded program for active employees, retirees, and eligible dependents. Proposers shall demonstrate successful coordination with medical ASO/PBM vendors and shall provide a list of carriers with whom they have worked in carve-out arrangements. All proposers shall also provide at least three (3) references from employer groups with 2,000 or more covered lives.

F. The awarded Proposer is to provide ADA compliant, web-based informational and educational tools, including online and via mobile app, to Plan participants providing information on issues such as claims status, explanation of benefits

(EOBs), network providers by specialty, health and wellness topics, and provider

/ treatment cost calculators based on specific plan designs of the City.

G. The awarded Proposer shall provide accessible customer service hours and claims administration support with demonstrated service outcomes for administering the City’s comprehensive health plan, including medical and prescription drug benefits for active employees, COBRA participants, retirees, and eligible dependents. All Member-facing customer service shall be performed within the territorial limits of the United States.

H. Proposers shall detail afterhours customer service capabilities, including escalation protocols, member advocacy resources, and, for those proposing under Option 1, access to triage/nurseline support for urgent clinical concerns outside of normal business hours.

I. Proposers shall base proposals on the current Choice and Choice Plus open-access plans, as described in Exhibit “1” – Summary Plan Descriptions.

Proposed network or plan changes shall be clearly documented. Plan design for the new Narrow Network plan (effective 1/1/2027) will be developed in the future. Proposers are expected to collaborate with the City to build a plan design that meets the City’s needs.

J. The awarded Proposer shall attend quarterly stewardship meetings to review plan performance, support monthly operational check-ins, and make medical and pharmacy clinical directors available for strategic consultations and performance improvement planning.

K. The awarded Proposer shall support the City’s annual enrollment by training City benefits staff, preparing educational materials (see Exhibit 6 – United Health Plan

Summary Booklet), attending onsite and virtual enrollment events, annual wellness fairs, and accepting the City’s benefit eligibility files. During the open enrollment in October 2026 for 2027 enrollment, additional meetings and enhanced onsite support will be required to assist with member transition and change management.

L. The awarded Proposer shall support the City’s new hire enrollment by attending on-site bi-weekly new hire enrollment meetings (up to 2x per month).

M. The awarded Proposer shall maintain agreements with accredited Independent

Review Organizations (IROs) and fully manage the external appeals process, including submission of all relevant documentation.

N. The awarded Proposer shall process and adjudicate all claims in accordance with the City's Plan Document and be held liable for payments made in error or outside plan provisions.

O. Proposers shall outline their dependent disability verification services. Proposers shall describe their capabilities and protocols for both initial and ongoing verification of disabled dependents. Disclose any fees associated.

P. Web-based administrative tools shall be available to the City’s Benefits staff for real-time eligibility management, reporting, and file reconciliation.

Q. The awarded Proposer shall have the capability to support the City’s engagement with third-party vendors. This includes the ability to integrate with multiple external vendors (e.g., condition-specific management programs, quality care steerage tools, wellness platforms).

R. Proposers shall describe their carve-out capabilities and limitations, including any additional costs, operational constraints, or file integration issues that may arise when administering services alongside external PBM or health management vendors (which are currently offered by UHC). A list of vendors with which the

Proposer currently maintains active integrations—including, but not limited to, condition management programs, point solutions, PBMs, and care navigation tools—shall be included for consideration. Please specify the nature of integration (e.g., eligibility feed, claims data exchange, coordinated outreach, performance reporting).

S. The awarded Proposer is to provide underwriting support to estimate plan projections and impact of various plan design changes.

T. The awarded Proposer is to adhere to standards of care by agreeing to use the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent claims administrator/fiduciary acting in a like capacity, and familiar with such matters, would use under similar circumstances as the standard of care for medical and pharmacy services.

U. The awarded Proposer is to prepare and maintain the Summary Plan Description

(SPD) and annually required Summary of Benefits and Coverage (SBC) on behalf of the City and provide these documents electronically for posting on the

City’s website prior to each annual open enrollment period.

V. The awarded Proposer is to have the ability to identify claims that could be subject to third-party liability such as workers compensation, auto accident, and coordination of benefits, and act on the claims using the same standards in place for the Proposer’s fully insured health plan clients.

W. The awarded Proposer shall demonstrate compliance with all applicable federal and state requirements related to claims processing, transparency, and participant protections, including, but not limited to the Affordable Care Act, Consolidated Appropriations Act of 2021, No Surprises Act, Transparency in

Coverage Rule, Florida Senate Bill 1550, and any future legislation governing price transparency, balance billing, or fiduciary responsibility. The awarded

Proposer shall work with the City to provide all required annual attestations and compliance reporting, including an attestation of compliance with the above requirements and any additional reports mandated by federal or state law.

X. Proposers shall process all runout claims at no additional cost upon contract termination and agree to coordinate transition of care for impacted members.

Similarly, during implementation, Proposers shall work with the prior administrator to ensure continuity of care and minimize disruption for members.

An implementation allowance or credit may also be proposed to offset the City’s transition expenses.

Y. The City reserves the right to terminate the contract after the first year with 90 days’ written notice and without penalty. Financial guarantees remain enforceable mid-year in the event of termination. The City may also terminate without cause if the Proposers is acquired or merged. No penalties or repayment of rebates, credits, or allowances may be imposed upon early termination.

Z. Proposers shall have a comprehensive Fraud, Waste, and Abuse (FWA) detection and prevention program in place. Reporting to the City on FWA activity, recoveries, and provider/member interventions shall be provided on an annual basis.

5.3. Financial Reporting and Data Interface

This section applies to both Options 1 and 2. The technical specifications listed below describe the requested scope of services and contain information and instructions to assist Proposers in completing Attachment B – General Administrative Services

Worksheet.

A. The awarded Proposer shall support banking and financial administration workflows that meet the City’s accounting standards and documentation requirements. This includes daily claims funding reconciliation, weekly claim summaries, and invoicing reports.

B. The City prefers to initiate claims payments via wire transfer, with a transition to

ACH upon successful implementation and validation of the claims funding cycle.

C. Proposers shall be able to integrate biometric screening results and Health Risk

Assessment (HRA) data (regardless of vendor source) into individual member records and provide consolidated reporting for City wellness initiatives and care management tracking.

D. Proposers shall provide a comprehensive list of standard and ad hoc reports available to the City, including frequency (daily, weekly, monthly, quarterly, annually). Sample versions of each report shall be included with the proposal submission.

E. The awarded Proposer shall deliver monthly eligibility, claims, and utilization files to the City and its designated benefits consultant. Eligibility discrepancy reports shall be made available at least weekly through a secure, web-based portal.

F. The awarded Proposer shall support the City’s stop-loss insurance carrier by providing monthly large claimant reports and ad hoc reporting as needed.

Reports shall include diagnosis category, paid and pending claims, detailed claim history, and status of ongoing case management. Timely and complete data submission is required to support reimbursement and policy management.

G. The awarded Proposer is to provide comprehensive medical and/or pharmacy claims and eligibility file downloads (data dumps), in a HIPAA compliant, standard industry format, to the City’s designated Plan Administrator (who has received required HIPAA Privacy and Security training) and its contracted plans vendors including the medical TPA, PBM, and employee benefits consultant monthly. Monthly claims detail is to include, at minimum, all fields listed in Exhibit

“4” – Claims File Layout.

H. COBRA and retiree billing are currently managed by Chard Snyder. While not in scope for this RFP, the awarded Proposer shall interface effectively with the current or future COBRA/retiree billing vendor and accept electronic eligibility files without disruption.

I. The City requires the ability to make retroactive eligibility changes, including claims reprocessing, at no additional cost.

J. The awarded Proposer shall provide full access to records, files, and documentation related to medical and pharmacy claims, administrative fees, discounts, rebates, and any financial elements necessary for audit. Records shall be electronically accessible and exportable in standard formats.

K. A detailed description of the audit adjustment process shall be provided, including how erroneous payments are refunded (even if not systemically reprocessed), and how the Proposer identifies and remediates similar issues across the population and over past periods of time.

L. The awarded Proposer shall accept self-bill administrative fee arrangements based on City-issued payment schedules. Retroactive eligibility changes or payment corrections shall be applied to the following month’s invoice.

M. The awarded Proposer shall support integration with the City’s HRIS platforms, currently Workday (for active employee eligibility management) and Pension

Gold (for retiree eligibility management). Proposers shall demonstrate the ability to receive, interpret, and process eligibility data from both systems with appropriate reconciliation and reporting protocols in place. Implementation funds or technology credits are requested to assist the City with establishing the electronic data interfaces. Proposers shall describe their eligibility data management capabilities in the event of a carve-out/external PBM is selected.

5.4. Plan Design Flexibility and Value-Based Innovation

This section applies to Option 1. The technical specifications listed below describe the requested scope of services and contain information and instructions to assist Proposers in completing Attachment C – Medical ASO Proposal Worksheet.

A. Proposals shall demonstrate the ability to administer health plans that match or improve upon the plan designs provided in Exhibit “1” – Summary Plan

Descriptions. Any deviations from existing plan design shall be clearly described.

B. Proposers shall demonstrate the ability to administer member cost-share differentials based on facility location, preferred provider arrangements, in order to encourage utilization of cost-effective settings of care (e.g. free-standing/ambulatory surgery centers vs. hospital-based outpatient facilities).

C. Proposers shall identify discount arrangements for Complementary and

Alternative Medicine (CAM) services not covered under the Plan, if available.

D. Proposers shall demonstrate the ability to integrate medical and pharmacy claims data for accurate tracking of accumulators (e.g., out-of-pocket maximums), including cross-accumulation between benefit types where applicable. Member overpayments shall be automatically reconciled and refunded within 30 days of adjudication.

E. The City currently contracts with a third-party vendor for Employee Assistance

Program (EAP) services. Proposers shall describe how they would coordinate care with the City’s EAP provider, currently Aetna Resources For Living, and outline any supplemental mental health and behavioral health support resources available to members, including programs, tools, or services designed to enhance access to care and continuity of support. Proposers may outline any integrated or stand-alone EAP solutions they can offer for the City’s consideration.

F. Proposers shall confirm the ability to coordinate benefits with Medicare on a secondary payer basis for retirees or their dependents who are eligible but not enrolled in Medicare Part B. Proposers shall also assist members with End Stage

Renal Disease (ESRD) in applying for Medicare when applicable and tracking coordination with Medicare during the 30-month coordination of benefits period.

5.5. Network Strength and Performance

This section applies to Option 1. The technical specifications listed below describe the requested scope of services and contain information and instructions to assist Proposers in completing Attachment C – Medical ASO Proposal Worksheet, Attachment D – Medical

Network Disruption Worksheet, and Attachment E – Medical Claims Repricing File.

A. Proposers shall complete the Medical Network Disruption Worksheet

(Attachment “D”) and indicate the participation status of each listed provider.

Where applicable, proposers shall also identify whether the provider participates in a high-performance network or is designated as a quality-tier provider. In addition, proposers shall provide a comprehensive network directory for each network proposed, along with a geo-access report demonstrating provider availability and member access by ZIP code.

B. Proposer shall complete the Medical Claims Repricing File (Attachment “E”) .

The awarded Proposer’s medical claims discounts will be subject to verification at the City’s discretion as a part of the evaluation process. The Proposer will be responsible for all costs associated with such verification, including providing system access, reports, and supporting documentation. The City considers medical claims repricing information, including discount information, to be presumptively entitled to protection as a trade secret pursuant to Sections

688.002(4) and 815.045, Florida Statutes. Accordingly, the City will treat information submitted in Attachment E as confidential and not subject to release in response to a public records request, unless release is required by a valid subpoena or other order of a court of competent jurisdiction, and then only to the limited extent so required.

C. The awarded Proposer shall permit the City, or a mutually agreed-upon third-party, to conduct annual audits of network provider contracts to verify discount arrangements. The City will cover the fees of the third party auditor; however, proposers may propose the use of an audit fund to offset the City’s costs.

D. For the current HMO/POS plans, Proposers shall demonstrate the breadth and stability of their provider networks, including:

1. Network Coverage & Composition

a. Statewide and national access, including Centers of Excellence for transplants and complex care.

b. A comprehensive network of hospitals, outpatient facilities, physician offices, and behavioral health providers shall meet industry-standard geo-access by member ZIP codes (e.g., primary care within 10 miles, specialists within 20 miles, and hospitals within 30 miles). Network coverage shall include Orange, Seminole, Osceola, Lake, Brevard, and

Volusia counties.

c. At least 85% of physicians shall be Board Certified or Board Eligible, with an annual in-network provider turnover rate of less than 3%.

2. Network Access & Stability

a. Disclosure of any known access gaps, including in-network specialists, hospital-based physicians (e.g., anesthesiologists, radiologists), and behavioral health services

b. Disclosure of any network facilities or large physician group contracts scheduled to expire within the next twelve (12) months

E. For the High-Performance/Narrow Network plan, Proposers shall describe their capabilities for supporting value-based provider contracting models including

Clinically Integrated Networks (CINs), Patient-Centered Medical Homes (PCMH), Accountable Care Organizations (ACOs), and narrow/high-performance networks, including:

1. Network Design & Structure

a. Geographic coverage and provider composition

b. Tiered or incentivized access structures

c. Clinical and cost performance criteria

d. Impact on claims costs and member out-of-pocket costs

2. Network Access & Stability

a. Disclosure of any known access gaps, including in-network specialists, hospital-based physicians (e.g., anesthesiologists, radiologists), and behavioral health services

b. Disclosure of any network facilities or large physician group contracts scheduled to expire within the next twelve (12) months

3. Evidence of Effectiveness

a. Case studies or documented outcomes demonstrating success in reducing cost, improving quality, and enhancing member experience in value-based or narrow network arrangements

b. Sample performance reports (e.g., clinical quality metrics, cost-trend analyses, patient satisfaction/experience measures) that the City could expect to receive on an ongoing basis

F. The awarded Proposer shall monitor network performance using nationally recognized quality metrics (e.g., HEDIS, CAHPS, Leapfrog), and take corrective action when providers fall below acceptable performance thresholds. Reporting to the City shall be made available upon request.

G. The City expects the awarded Proposer to facilitate regular engagement with network decision makers and/or chief medical officers to review care delivery strategies, utilization trends, and network performance and access.

H. Proposers shall describe available telehealth services (medical, behavioral health, and other modalities), integration with care management programs, and coordination with Member customer service to ensure seamless access to virtual care options. Proposers shall also clearly disclose any associated administrative fees or claim-related costs tied to the provision or utilization of telehealth services.

I. Proposers shall identify any capitated service arrangements in their network and provide encounter data related to such services upon request. Transparency of utilization and pricing under capitated contracts is required.

J. Members shall be held harmless from balance billing for all in-network services, including services rendered by an in-network provider that were referred or arranged through another in-network provider, or that occur at in-network facilities.

K. The City reserves the right to implement or expand alternative delivery and payment models—including but not limited to CIN-based plans, PCMH, ACO arrangements, and narrow networks—during the contract term. The awarded

Proposer shall demonstrate flexibility to integrate and administer these models through aligned contracts, claims processing, eligibility tracking, and outcome reporting, subject to mutual agreement and operational feasibility. The City further reserves the right to modify or discontinue the narrow network plan offering at any time during the contract term.

L. Proposers shall agree to indemnify and hold the City harmless to the extent permitted under Section 768.28, Florida Statutes, for any losses, damages, or expenses arising from your gross negligence, willful misconduct, or that of your employees, agents, or subcontractors, and that nothing in your proposal limits or waives the City’s sovereign immunity.

5.6. Health and Wellness Management Integration

This section applies to Option 1. The technical specifications listed below describe the requested scope of services and contain information and instructions to assist Proposers in completing Attachment C – Medical ASO Proposal Worksheet.

A. Proposers shall demonstrate the ability to increase preventive care utilization across all lines of coverage, with a focus on closing HEDIS-defined gaps in care and improving population health metrics. Describe your preventive outreach model and results achieved in similar-sized public sector groups.

B. Proposers shall outline capabilities to identify high-risk and rising-risk members using predictive analytics, integrated medical and pharmacy claims (including those under carve-out arrangements), and engagement scoring. Describe methodology, stratification logic, and any AI-enabled tools used.

C. The City requires a dedicated case manager (in addition to the onsite clinical coordinator) to work collaboratively with the City’s HR and benefits staff to manage seriously ill members, coordinate complex cases, and facilitate navigation through the healthcare system.

D. Disease management programs shall demonstrate evidence-based protocols, ROI measurement, and proven results in reducing ER and inpatient utilization.

Proposers shall list all core and optional disease management programs and provide outcome metrics.

E. Proposers shall offer comprehensive wellness tracking and incentive program capabilities. This includes tracking participation in biometric screenings, health assessments, health activities, and wellness challenges. Proposers shall provide quarterly reporting and year-end summaries, including participation rates, incentive fulfillment, and outcomes.

F. Clinical engagement tools shall support biometric screenings, Health Risk

Assessments (HRAs), care gap alerts, and health coaching. Programs shall be accessible online, telephonically, and via mobile application.

G. Proposers shall describe any available targeted programs designed to…