MCSB_ASO_RFP_Questionnaire.xlsx
XLSX spreadsheet 66 KB Posted
- Attached to
- Self-Funded Medical Plan ASO
- Solicitation number
- 4115RC
- Issued by
- Florida
About this file
The document is an Administrative Services Only (ASO) Request for Proposal (RFP) #4115RC issued by Marion County Public Schools (MCPS) in Ocala, Florida for a Third-Party Administrator to manage their self-funded medical plan. The RFP seeks a vendor to administer claims processing, provide customer service, and implement cost management strategies for an employee health plan effective January 1, 2026, covering four existing plan designs serving 4,184 subscribers and 5,611 members. Proposals are due by 2:00 PM EST on March 6, 2025, with an anticipated board award date of June 24, 2025. The contract term is initially set for three years (January 1, 2026 through December 31, 2028) with potential renewal options for up to three additional one-year periods.
The current medical administrative services provider is Florida Blue, and a simultaneous Pharmacy Benefit Manager (PBM) procurement is also occurring for the 2026 plan year. The RFP requires vendors to provide detailed per-employee-per-month (PEPM) pricing for medical administration fees, including options for broad and narrow network configurations. Performance guarantees are critical, with potential financial penalties for non-compliance in areas such as claims processing accuracy, financial payment accuracy, turnaround times, and customer service metrics. Three previous vendors have submitted proposals: Aetna Life Insurance Company, Blue Cross and Blue Shield of Florida, Inc., and United HealthCare Services, Inc., with Blue Cross and Blue Shield of Florida, Inc. previously receiving the highest evaluation score of 92.00 points. The district emphasizes a cost-effective solution to manage healthcare spending while providing comprehensive employee health benefits.
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1. Table of Contents Medical ASO RFP Questionnaire for Marion County School Board
| Table of Contents | |
| Tab No. | Description |
| 1 | Medical Cover Page |
| 2 | MCSB Current Suppliers |
| 3 | Plan Design and Enrollment |
| 4 | Questionnaire |
| 5 | Network Access and Disruption |
| 6 | Claims Repricing |
| 7 | Performance Guarantees |
| 8 | Medical Administrative Fees |
| 9 | Supplemental Fee Sheet |
2. LCS Current Suppliers MCSB Current Suppliers
| Item | Supplier | |
| Medical ASO | Florida Blue | Disagree |
| PBM | Current Vendor - Prime PBM RFP Currently Underway for 1/1/26 effective date | |
| Stop Loss | Florida Blue (ISU) | |
| Enrollment and Eligibility | BenefitFocus |
3. Current Plan Des and Enroll.
| BlueOptions | ||
| 05360 | BlueOptions | |
| 03160 / 03161 | BlueOptions | |
| 03359 | BlueOptions |
03559
| In Network Benefits | Deductible | |||||
| (Single/Family) | Calendar Year (CYD) | Calendar Year (CYD) | Calendar Year (CYD) | Calendar Year (CYD) | ||
| $2,000 / $4,000 | $1,650 / $3,300 | $1,500 / $4,500 | $500 / $1,000 | |||
| DED Type | Embedded | Non embedded | Embedded | Embedded | ||
| Coinsurance | 20% | 20% | 20% | 20% | ||
| Max OOP (S/F) | $6,350 / $12,700 | $5,000 | $3,000 / $6,000 | $2,500 / $5,000 | ||
| PCP Visit | $25 | DED then 20% | $25 | $20 | ||
| Specialist | $75 | DED then 20% | $75 | $75 | ||
| Preventive Care | $0 | $0 | $0 | $0 | ||
| Urgent Care | $35 | DED then 20% | $35 | $35 | ||
| Inpatient Hospital | DED then 20% | DED then 20% | DED then 20% | DED then 20% | ||
| Outpatient Surgical | DED then 20% | DED then 20% | DED then 20% | DED then 20% | ||
| Routine Lab & X-Ray | DED then 20% | |||||
| Independent Lab - No Charge | DED then 20% | |||||
| Independent Lab - Ded + $0 | Specialist - DED then 20% |
Independent Lab - No Charge Testing Center - $50 copay Specialist - DED then 20% Independent Lab - No Charge Testing Center - $50 copay
| Complex Imaging | DED then 20% | DED then 20% | DED then 20% | $125 | |
| Emergency Room | DED then 20% | DED then 20% | DED then 20% | $200 | |
| Rx | Deductible | N/A | N/A | Varies | N/A |
| Retail (Generic) | $10 | DED then 20% | 20% | 20% | |
| Retail (Preferred Brand) | $50 | DED then 30% | $500 Brand DED then 40% | 40% | |
| Retail (Non-preferred) | Not Covered | DED then 50% | $500 Brand DED then 50% | 50% | |
| Specialty | Cost Share Based on Tier | Cost Share Based on Tier | 50% | 50% | |
| Mail Order | Not Covered | Not Covered | $20 / $80 / $140 | $20 / $80 / $140 | |
| OON | Deductible | Combined with In Network | $2,500 / $5,000 | Combined with In Network | Combined with In Network |
| Coinsurance | 40% | 40% | 40% | 40% | |
| Maximum OOP | $7,350 / $13,700 | $10,000 | $5,000 / $10,000 | $5,000 / $10,000 | |
| Emergency Room | DED then 20% | In Network DED then 20% | In-Network DED then 20% | $200 |
| Counts | Subscribers | 4,184 | 764 | 574 | 162 |
| Members | 5,611 | 1,665 | 767 | 188 | |
| *Plan designs are not yet confirmed for the 2026 plan year and may be subject to change | |||||
| *PBM RFP is running simultaneously with ASO RFP - Rx benefits may be carved in or out effective 2026 |
4. Questionnaire Request for Proposal - Medical Benefits
| Firm / Organization Questions | VENDOR RESPONSE | |
| Provide a description of your organization, to include, at a minimum: parent company and location; quoting organization and location, if different; and subcontractors/partners, if any. | ||
| For each organization noted, provide: | ||
| A. Date formed | ||
| B. Ratings of company(s): | ||
| A.M. Best | ||
| Moody’s | ||
| Standard & Poor’s | ||
| C. Number of employees | ||
| D. In force number of groups with 1,000+ employees. | ||
| E. Have you recently been acquired or been involved with any merger/acquisitions? If yes, describe. | ||
| Will you need to hire additional customer service personnel if awarded this business? | ||
| Who will be your primary liaison with MCSB? | ||
| Identify any other members of the client management team, along with their roles. | ||
| Where will the client management team be based? How many other clients will they have? | ||
| Elaborate on future expansion plans and goals within the next 3-5 years, if any. | ||
| References | ||
| Please provide three (3) current client references of public entity employers of similar size to MCSB within the same industry | ||
| A. Client Name | ||
| B. Contact | ||
| C. Address | ||
| D. Telephone number | ||
| E. Email | ||
| F. Approximate number of employees covered by each contract | ||
| Reference # 2 | ||
| A. Client Name | ||
| B. Contact | ||
| C. Address | ||
| D. Telephone number | ||
| E. Email | ||
| F. Approximate number of employees covered by each contract | ||
| Reference # 3 | ||
| A. Client Name | ||
| B. Contact | ||
| C. Address | ||
| D. Telephone number | ||
| E. Email | ||
| F. Approximate number of employees covered by each contract | ||
| Please provide one (1) former client reference of similar size and industry, who may be contacted: | ||
| A. Client Name | ||
| B. Contact | ||
| C. Address | ||
| D. Telephone number | ||
| E. Approximate number of employees covered by each contract | ||
| F. Reason for termination (for former client) | ||
| Network and Provider Reimbursement | ||
| Describe your network offerings nationally and in Central Florida | ||
| Do you have any narrow networks centered around a specific health system? If so, what is difference in reimbursement rate vs. the broader network | ||
| Describe the provider selection process. What are the minimum criteria for providers to be selected as a network provider? | ||
| Will you provide us with the actual contract between the network and the provider illustrating the allowed amounts for services rendered? | ||
| How do you assure the member is not billed for Out Of Network charges for Hospital Based providers not contracted with an in network hospital? (i.e. ER, Radiology, Anesthesia, Pathology) | ||
| VALUE BASED CARE (ANSWER QUESTIONS ON YOUR BROAD NETWORK AND DELINEATE IF THE ANSWER IS DIFFERENT FOR A NARROW NETWORK) | ||
| What percent of your providers will be paid under value based contracting in 2025 and what is your expectation for 2026 and 2027? | ||
| What percent of your claims will be paid under value based contracting in 2025 and what is your expectation for 2026 and 2027? | ||
| How are your value based contracts designed and how is performance measured? | ||
| Describe the payment structure for your value based contracts. Include all types of payments available to providers under your value based arrangements. | ||
| Do your value based contracts include both upside and downside risk? | ||
| What % of providers under value based contracts fail to meet the criteria to receive a payment under the contract? | ||
| UTILIZATION MANAGEMENT | Ranking Weight 5 points | |
| Who provides UM and CM services for your clients? Is it in house or through a third party? | ||
| Answer the following based on vendor's book of business: | ||
| For the below inpatient/outpatient/professional/pharmacy - please breakout your BoB utilization between all commercial business & your high performance network | ||
| Book of business average age of member | ||
| Book of business % Male / Female | ||
| Book of business year-over-year claims trend | ||
| Book of business per member per year cost | ||
| Inpatient | ||
| Book of business Inpatient - Cost Per Day | ||
| Book of business Inpatient - admits/1000 | ||
| Book of business Inpatient - days/1000 | ||
| Book of business Inpatient - ALOS | ||
| Book of business Inpatient - Per Member Per Year Costs | ||
| Outpatient | ||
| Book of business Outpatient - Services/1000 | ||
| Book of business Outpatient - Cost per service | ||
| Book of business Outpatient - Per Member Per Year Costs | ||
| Book of business ER - Services/1000 | ||
| Book of business ER - Cost per service | ||
| Professional | ||
| Book of business Professional - Services/1000 | ||
| Book of business Professional - Cost per service | ||
| Book of business Professional - Per Member Per Year Costs | ||
| Additional UM Questions | ||
| How does vendor measure client return on investment (ROI)? | ||
| Are you willing to guarantee ROI? If yes, please describe terms and conditions in detail. | ||
| What percentage of your claims are auto adjudicated vs. manual intervention? | ||
| Outline the mandatory programs provided with the medical coverage (i.e. pregnancy program, wellness, disease management) and the additional cost, if any. | ||
| Describe in detail your large case/catastrophic case management program. | ||
| Define an engaged DM/CM member. | ||
| Of your book of business, what percent of targeted DM members are engaged? | ||
| How do you identify potential DM candidates? What sources do you use? | ||
| What DM interventions does your organization propose to provide? (Check ALL that apply.) | ☐ Written communications | |
| ☐ Group education | ||
| ☐ One-on-one interventions | ||
| ☐ Telephone monitoring | ||
| ☐ Clinical interventions | ||
| ☐ Other proposed interventions | ||
| MCSB currently offers robust Diabetic Management Solutions - Please describe your diabetic management approach including costs and qualification metrics | ||
| Do you offer metabolic syndrome programs? If so, please elaborate what you program entails and the standard for participation. | ||
| How will outcomes be reported for each proposed intervention? | ||
| Are your UM services local, national or international? (Check only ONE.) | ☐ Local only | |
| ☐ National, some states | ||
| ☐ National, all states | ||
| ☐ National, all states + international | ||
| Do you have a standard pre-certification requirement? If Yes, check all applicable to your program. | ☐ Hospitalizations | |
| ☐ Outpatient Surgery | ||
| ☐ Specified Diagnostic Procedures | ||
| ☐ Durable Medical Equipment | ||
| ☐ Corrective Appliances / Prosthetics | ||
| ☐ Skilled Nursing Facility | ||
| ☐ Home Health Care | ||
| ☐ Musculoskeletal Services | ||
| ☐ Medical Services (e.g., physical therapy) | ||
| ☐ Inpatient Mental Health / Substance Abuse | ||
| ☐ Outpatient Mental Health/Substance Abuse | ||
| Other _________________ | ||
| Precertification includes the analysis & determination of which of the following (may check more than one). | ☐ Appropriate level of care (e.g., IP vs. OP) | |
| ☐ Reasonable length of stay of IP confinement | ||
| ☐ Actual medical necessity & appropriateness of surgery or service being requested (e.g., does service require performance?) | ||
| ☐ Necessity for the services of an assistant surgeon with each operative procedure analysis | ||
| ☐ Necessity for a proposed preoperative hospital day | ||
| ☐ Necessity for a proposed 23-hour observation stay following OP surgery | ||
| Other _________________ | ||
| ADMINISTRATION - SELF FUNDED | Ranking Weight 10 points | |
| Describe the flexibility MCSB will have with plan design. | ||
| Confirm your ability to administer the existing MCSB plan designs. Plan designs are always subject to change each Plan Year. | ☐ Yes ☐ No | |
| List the PBMs you are willing to integrate with for carve out pharmacy service. The current PBM for Prime however PBM RFP is running for 2026 plan year - vendor TBD | ||
| Vendor agrees to take feeds (weekly or daily) from 3rd party PBM and will mine/integrate the data into the medical management program. | ☐ Yes ☐ No | |
| Describe any requirements, reports, contracts, etc. to coordinate with a 3rd party stop loss carrier. If your firm is also selected as the stop loss carrier, will you agree to provide advanced funding for any approved claims at the specific and or aggregate levels? | ||
| Confirm your ability to provide claims to any stop loss vendor. | ☐ Yes ☐ No | |
| Please confirm that you will agree to the sample vendor contract provided with little variation | ☐ Yes ☐ No | |
| What is your ability to integrate with third party vendors? (i.e.; second opinion, oncology, surgery networks, DM/CM vendors, etc.) Do you have any preferred relationships with third parties? Are there any limitations for integration? Please state all costs associated with integration. | ||
| Implementation, Enrollment, Eligibility and Maintenance Questions | Ranking Weight 5 points | |
| Provide a detailed implementation plan, including action items and due dates. Please provide your plan in the detailed response to the RFP. MCSB's effective date of 1/1 and enrollment generally starts the first week of October. | ||
| Describe the support that will be provided to MCSB during implementation (reoccurring conference calls, onsite meetings, response time, etc.). | ||
| How will you support MCSB during open enrollment? | ||
| Describe the options available to MCSB for submitting eligibility data. | ||
| What mediums do you accept for plan enrollment? | ||
| Do you offer online eligibility maintenance for all clients? | ||
| If so, is there a charge? | ☐ Yes ☐ No |
☐ Yes ☐ No
| How often will MCSB membership be updated? | |
| Explain your billing procedures. | |
| How frequently will MCSB be billed? Provide the frequency for both administrative fees as well as claims invoices. | |
| What charges do the billings encompass? | |
| When are fees due under your policy? | |
| What is the grace period for fee payments by MCSB? | |
| If fees are paid after the grace period, is a penalty and/or interest charge assessed? If yes, explain in detail. | |
| Are there any options available with respect to the grace period? If so, explain. | ☐ Yes ☐ No |
| Can a plan sponsor be issued separate billings for employee subdivisions (e.g., locations, divisions, union/non-union groups, etc.)? | ☐ Yes ☐ No | |
| With respect to ID cards: | ||
| Do you charge a fee for card preparation? If so, state the charge. | ☐ Yes ☐ No | |
| Is there a charge for replacement cards? | ||
| If so, state the charge. | ☐ Yes ☐ No | |
| What triggers an ID card to be mailed to a member? New hire, changes in enrollment tier or plan? | ||
| Can you put the plan sponsor name and logo on the ID cards? | ||
| If there is an additional charge, please state the charge. | ☐ Yes ☐ No | |
| Can you do a combination medical / Rx card (with rx carved out to a 3rd party PBM)? | ||
| If there is an additional charge, please state the charge. | ☐ Yes ☐ No | |
| Customer Service | Ranking Weight 10 points | |
| Describe the member experience: | ||
| Finding a doctor | ||
| Accessing claims EOBs and details | ||
| ID card access - digital - replacement | ||
| Spanish Speaking Capabilities - portal - customer service - materials - member facing | ||
| Out of area care - support - how members access care outside of service areas / internationally | ||
| How does vendor measure member satisfaction? | ||
| What is vendor's book of business member satisfaction result? Provide report if possible. | ||
| Can you track the items outlined below: | ||
| Number of calls received? | ☐ Yes ☐ No | |
| Average speed of answer? | ☐ Yes ☐ No | |
| Call abandonment rates? | ☐ Yes ☐ No | |
| Length of call? | ☐ Yes ☐ No | |
| General reasons for the call? | ☐ Yes ☐ No | |
| Others? | ||
| Describe internal performance standards for the customer service unit. | ||
| Technology Questions | Ranking Weight 5 points | |
| Describe the capabilities your website has for the following items: | ||
| Provider selection – tools that will help members select reputable and effective providers | ||
| Quality comparison – tools that will help members compare quality outcomes of providers and facilities | ||
| Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc. | ||
| Wellness information and tools (i.e. BMI calculator, target heart rate calculator) | ||
| Which of the following tasks can members and plan sponsor representatives perform ONLINE? | Members | |
| Enrollment (New Hires and Open Enrollment) | ☐ Yes ☐ No | |
| Changes in Status | ☐ Yes ☐ No | |
| Billing (Plan Administrators only) | ☐ Yes ☐ No | |
| Claim inquiry | ☐ Yes ☐ No | |
| Provider search | ☐ Yes ☐ No | |
| ID card request | ☐ Yes ☐ No | |
| Electronic EOB | ☐ Yes ☐ No | |
| Terminations | ☐ Yes ☐ No | |
| Reinstatements | ☐ Yes ☐ No | |
| Health Risk Assessments | ☐ Yes ☐ No | |
| Other | ||
| Is there an additional cost for any of these online services? If yes, describe. | ||
| Reporting Questions | Ranking Weight 5 points | |
| Vendor agrees to provide all standard reports to MCSB and GBS. Provide full list of available reports electronically | ☐ Yes ☐ No | |
| Confirm that all reporting is available to export in excel | ☐ Yes ☐ No | |
| Provide your sample reporting package electronically for both monthly financial reports and utilization reports that may be pulled via your data warehouse. | ||
| Provide electronic sample detailed claims invoice, including breakouts for large claims, etc. We want to see the level of detail available for the actual claim of a member. | ||
| Describe the level of service you provide for reporting related to the CAA. Do you handle this or does MCSB? Is there a charge for this service? | ||
| Vendor agrees to provide a dedicated reporting contact for MCSB. This person would be responsible for running ad hoc reports at MCSB and/or its Consultant’s discretion, at no additional cost. | ☐ Yes ☐ No | |
| Vendor agrees to permit MCSB to have access to all files on request (e.g., a claims audit). | ☐ Yes ☐ No | |
| Vendor agrees to provide claims experience at least monthly, including each renewal. | ☐ Yes ☐ No | |
| Are special or ad hoc reports available to MCSB? If there are additional fees, are the fees generated on a fixed cost per report or billed on an hourly basis? | ☐ Yes ☐ No | |
| Does MCSB have the ability to access your database in real time for purposes of: | ||
| Adds / deletes | ☐ Yes ☐ No | |
| Tracking plan experience | ☐ Yes ☐ No | |
| Utilization patterns | ☐ Yes ☐ No | |
| Other available plan information | ||
| Is there an additional charge to MCSB? If so, clarify. | ☐ Yes ☐ No | |
| What DM/CM reporting will be available and at what frequency? | ||
| Are you willing to provide a raw claims file to GBS and/or a third party data warehousing vendor? If so, detail all costs associated with monthly file feeds for both eligibility and claims and confirm vendor agrees to waive any such fees for the length of the contract. | ☐ Yes ☐ No | |
| How do you measure the cost-effectiveness of your program? Please elaborate. | ||
| Indicate your standard method of reporting savings from the review of IP hospitalization. (Check only ONE.) | ☐ IP hospital savings reports not available | |
| ☐ The difference between days requested and days approved / certified. | ||
| ☐ A comparison of days or LOS utilized vs. normative or case mix adjusted days or LOS. | ||
| Indicate your standard method of reporting savings from the review of OP surgery. (Check only ONE.) | ☐ OP surgical review not available | |
| ☐ OP surgical available but specific reporting not delineated | ||
| ☐ $ value times the # of cases determined not to be medically necessary | ||
| ☐ Other (describe) | ||
| Wellness Questions | Ranking Weight 5 points | |
| Provide dollar amount of wellness fund that will be available to MCSB annually and ongoing each plan year. | ||
| Define options for use of wellness funds to include any exclusions and limitations. | ||
| Will vendor provide a on-site wellness coordinator to MCSB? | ☐ Yes ☐ No | |
| If yes, what types of services will this coordinate provide? | ||
| If no, will vendor provide additional wellness funds to support the district hiring an on-site wellness coordinator? | ☐ Yes ☐ No | |
| If yes, what additional funding will be provided? |
5. Case Studies Case Studies
| Question | VENDOR RESPONSE REQUIRED |
| LCS currently has a traditional network structure with Florida Blue. While this network is "turn key" its limited in its ability to drive provider steerage and an ultimate lower total cost of care. Please provide two case studies for the committee to review where you have helped a similar sized organization right size their healthcare spend while navigating employees through change management. Please make sure your case studies include the following: |
A. Client size and Industry B. Client Problem C. Your Solution D. Results after implementing your solution
| E. Lessons learned along the way, i.e. what speed bumps existed and disruption that occurred. | Disagree | |
| Case Study # 1 Answer | ||
| Case Study # 2 Answer |
5.Network Access and Disruption
| NETWORK ACCESS ANALYSIS | Ranking Weight 10 points |
| Using the census provided, conduct a geo-access (based on driving distance not "as the crow flies" analysis with the following assumptions: | |
| Primary Care Physicians (PCPs)*: 2 within 10 miles | |
| Specialists: 1 within 10 miles | |
| Hospitals: 1 within 15 miles | |
| Dialysis Centers: 1 within 30 miles | |
| *PCPs include: (1) Internists, (2) Family Practitioners, (3), OB/GYNs, (4) Pediatricians, (5) Generalists | |
| NETWORK DISRUPTION ANALYSIS | Ranking Weight 10 points |
| MCSB is providing a file of all claims (in and out of network) for the past 12 months. You are required to indicate whether or not a claim would be PAR or Non Par under your network. |
If you have a network centered around any specific healthcare system you should complete the disruption report on your broader network and a separate report on your narrow network for review.
6. Claims Repricing Network Discounts
| CLAIMS REPRICING | Ranking Weight 15 points |
| Complete the attached claims worksheet with your 2024 reimbursements for the claims. Explain if you are excluding any claims and the reason for such exclusion. |
Proprietary and/or Leased Network - If providing a proprietary and/or leased network provide the allowed amounts for the claims that already happened in that network. If there is an out of network provider for your network, provide your average pricing and include for each claim if the provider is excluded, OON or In network.
Narrow Network: If you have a narrow network to offer you should complete the repricing with both your broad network and narrow network (two repricing analysis).
7. Performance Guarantees Performance Guarantees
| Question | Answer | ||||
| PERFORMANCE GUARANTEE | YES | NO | EXCEPTIONS OR QUALIFICATIONS | ||
| CONFIRMED: WE ACCEPT AT A MINIMUM THE FOLLOWING PERFORMANCE GUARANTEES | |||||
| If YES, above, please explain any additional performance guarantees you would suggest to enhance your value proposition | |||||
| If NO, above, please confirm YES/NO on each item below individually, noting any qualifiers/exceptions to the right | |||||
| l | Claims processing accuracy - 97% - Penalty 1% of fees - Quarterly assessment | ||||
| l | Financial payment accuracy - 99% - Penalty 1% of fees - Quarterly assessment | ||||
| l | Turn-around time - 97% of clean claims processed and paid within 21 calendar days - Penalty 1% of fees - Quarterly assessment | ||||
| l | Turn-around time - 99% of investigated claims processed and paid within 45 calendar days - Penalty .5% of fees - Quarterly assessment | ||||
| l | Telephone response time - Answered within 30 seconds - Penalty .5% - Quarterly assessment | ||||
| l | Telephone abandonment rate - 5% or less - Penalty 1% - Quarterly assessment | ||||
| l | Appeals and grievance response time - 90% within 5 working days of receipt for UM cases - Penalty 1% of fees - Quarterly assessment | ||||
| l | Appeals and grievance response time - 98% within 15 working days of receipt for non-UM cases - Penalty 1% of fees - Quarterly assessment | ||||
| l | ID Card delivery - 10 working days from receipt of eligibility data - Penalty 1% of fees - Quarterly assessment | ||||
| NET COST OF CARE GUARANTEE | |||||
| Guarantee | YES | NO | PERCENTAGE AT RISK | ||
| Given the persistent increases in healthcare prices and the financial strain placed on the plan and employees, Client is looking for a committed administrator that will stand by proposed solutions. There will be emphasis placed on the Net Cost of Care guarantee that is provided. Please illustrate your guarantee and associated fees at risk. | |||||
| IMPLEMENTATION GUARANTEE | |||||
| Guarantee | YES | NO | PERCENTAGE AT RISK | ||
| It is the intention of this marketing exercise to move forward with the best possible administrative partner. If awarded the business, are you willing to put a percentage of administration fees at risk on the sole (subjective) perception of Client in performance implementing the contents of this request for proposal? | |||||
| ACCOUNT MANAGEMENT GUARANTEE | |||||
| Guarantee | YES | NO | PERCENTAGE AT RISK | ||
| Penalty and Measurement Criteria: CLIENT agrees to make VENDOR aware of possible sources of dissatisfaction throughout the guarantee period and will allow VENDOR fair opportunity to address any problems brought to its attention. CLIENT'S responses to the attached evaluation criteria will evaluate account management services in the following categories: technical knowledge, accessibility of personnel, responsiveness of personnel, interpersonal skills, communication skills (written and oral) and overall assessment of the services provided to the client. If CLIENT is still dissatisfied after VENDOR has been given fair opportunity to address such problems, CLIENT will simply inform VENDOR’s Senior Management regarding their dissatisfaction and VENDOR will make a mutually agreeable reduction in its compensation, on the following basis: | |||||
| * | Knowledge |
- Understands the service expectations
- Is knowledgeable about products and services
- Understands Client's organization, culture and challenges
- Understands Client's benefit plan design and administrative processes
* Communication
- Proactive communicates industry and vendor news, including network changes
- Communicates in an organized, professional manner
- Actively listens and acknowledges client concerns
- Provides appropriate written communication
* Proactive Management
- Acts as an advocate for me and appropriately escalates issues on my behalf
- Demonstrates flexibility in evaluating issues and resolving problems. Is open minded and provides viable alternative solutions to meet our needs
- Acts with a sense of urgency and achieves results
- Proactively identifies potential issues and opportunities to improve plan performance
* Responsiveness
- Responds to issues in a timely manner
- Provides thorough responses
- Effectively solicits assistance from internal resources to respond to issues
* Overall Satisfaction
8. Medical Admin Fees Medical Administration Fees / Costs Ranking Weight 20 points
| Effective: January 1, 2026 | |||
| Medical Administration (PEPM) | Broad Network Pricing | Narrow Network Pricing (if different) | |
| Medical Plan Administration with PBM carved in | |||
| Medical Plan Administration with PBM carved out | |||
| Network Access Fee | |||
| Telemedicine Fee | |||
| Disease/Case Management | |||
| UM/CM + Nurse line | |||
| Maternity Management | |||
| Disease Management | |||
| Radiology Benefit Management | |||
| Reinsurance Carve-Out Fee | |||
| PBM Interface Fee | ` | ||
| Integrated Ded/OOP for RX | |||
| Claim Fiduciary | |||
| Outside Vendor Eligibility | |||
| Total Medical Administration |
| Additional Items |
| Communications/Implementation Budget |
| Wellness Fund |
| Eligibility Feed Set-Up |
| ID Cards/Logo/Mail to Home |
| Reporting |
| OON "Shared Savings" |
| Run Out Claims Admin Fee |
| Run Out Claims Duration |
| 3-Year Admin Fee Guarantee 2026 - 2028 |
| Additional One Year Fee Guarantee (3 additional years) |
| Prescription Drug Carve-Out Fee if applicable |
| Total Monthly Administrative Costs |
| Material Translation Fees if any - Spanish |
| One-Time Fee Costs - list any not detailed above |
| Total Annual Administrative Costs |
Communication/Implementation Fund (to be paid by TPA)
9. Supplemental Fee Sheet
| Additional Fees - Through Admin or Claims | ||||||
| Program | Fee | |||||
| (30% of Savings, $3 PEPM, etc.) or Included | How are Fees Billed? | |||||
| (In claims or in admin invoice) | Estimated Fee | Will you guarantee a cap to these fees? if so, what? | Are you the sole service provider or is an additional vendor utilized? | Can Program be Removed? | If yes, provide the admin fee impact for removal? | |
| 2026 | 2027 | 2028 | ||||
| OON Claims Shared Savings | ||||||
| Supplemental Network (List each by Name) | ||||||
| Subrogation | ||||||
| Capitation (Indicate what is included in capitation) | ||||||
| Coordination of Benefits Program | ||||||
| Secondary Vendor Recovery Program | ||||||
| Provider Credit Balance Recovery | ||||||
| Class Action Recoveries | ||||||
| Care Management/Cost Containment Program Fees | ||||||
| Retro Termination Recoveries | ||||||
| Medical Bill and Hospital Bill Audit |
Program
| Bill audit |
| DRG Validation/Audit |
| Inpatient Admission Retrospective Review |
| Eligibility Overpayment Recovery Fees |
| Nurse Line |
| DM |
| CM |
| List Any Other Sources of Revenue |
| Other 1 |
| Other 2 |
| Other 3 |
| Other 4 |
| Other 5 |
| Other 6 |
| Other 7 |
File details come from the government source that posted it. Updated .