PPO_Attachment A - ARs.xlsx
XLSX spreadsheet 299 KB Posted
- Attached to
- TPA Services for PPO
- Solicitation number
- ITN-01869
- Issued by
- Leon County, Florida
About this file
This document is an Invitation to Negotiate (ITN) issued by the State of Florida, Florida Department of Management Services ("Department") for Third Party Administrative (TPA) Services for a Preferred Provider Organization (PPO) medical self-insured plan. The Department is seeking Replies for a contractor to provide claims processing and adjudication, customer service, network access and maintenance, reporting, and integration with the Department's authorized third-party vendors and/or representatives. The contractor will also be responsible for managing any disease and clinical programs the Department has implemented or will implement in the future. Responses are due in accordance with the ITN sections, and the contract term will begin on January 1, 2024.
The ITN outlines the administrative requirements, performance guarantees, and pricing terms the Department expects from the selected contractor. The contractor must provide financial ratings, client references, and supplemental documents as part of the response. The selected contractor will be responsible for all costs associated with the contract, including preparing plan materials, participating in meetings, and providing an account management team to support the Department. The Department reserves the right to conduct audits and performance assessments throughout the contract term.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| DMS-2223-048 PPO ITN.pdf | ||
| PPO_Attachment G - Benefit Document_2023.pdf | ||
| PPO_Attachment B - Technical.xlsx | XLSX spreadsheet | |
| PPO_Attachment D - Cost.xlsx | XLSX spreadsheet | |
| PPO_Attachment H - Data Use Agreement.pdf | ||
| Addendum 1 PPO.pdf | ||
| PPO_Attachment E -Draft Contract.pdf | ||
| PPO_Attachment F - BAA.pdf | ||
| PPO_Attachment C - Network.xlsx | XLSX spreadsheet |
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Read Me First
| YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | |
| Invitation to Negotiate (ITN) for the State of Florida, Florida Department of Management Services ("Department") | ||||||||||||
| PPO Medical Self-Insured | ||||||||||||
| Read Me First |
| Respondent Name: |
| [Insert Respondent Name Here] |
| The State of Florida, Florida Department of Management Services, hereinafter known as "DMS" or "Department". | ||||||||||||
| Statement of Work | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES |
| The State of Florida, Florida Department of Management Services, hereinafter known as "DMS" or "Department," is seeking Replies to this Invitation to Negotiate DMS-22/23-048 for their Self-Insured Medical PPO Services. The Department is committed to offering health care programs which promote the best value and patient-oriented care. |
Department offers eligible Active employees, COBRA participants, Early and Medicare-eligible retirees, and their surviving spouses and eligible dependents the option to enroll in one of two health plan options - "Standard" and "High Deductible Health Plan." Both of these plan options are delivered via a PPO and HMO network model. The PPO options are available to all eligible persons in the State of Florida and out-of-state. The HMO options are available to eligible persons based on where the subscriber lives or works.
All of the above health plans include a global carve-out prescription drug coverage arrangement for Actives, COBRA, Early retirees, and RDS for Medicare-eligible.
Respondents are expected to match, to the extent possible, the PPO Group Health Insurance Plan Booklet and Benefits Document, along with any subsequent Summary of Material Modifications. However, the Department may choose to alter the current plans going forward.
The Respondent that is awarded these services will provide the following, effective January 1, 2024:
• Act as the Third Party Administer for all PPO Medical claims
• Includes claims processing and adjudication
• Provide customer service support to include participant-related customer service via a customer service unit, satisfaction surveys, member website and mobile capabilities
• Maintain network access and keep the Department up to date on any network changes
• The medical Respondent or any entity allowed under Florida Statutes to provide health care plans must offer a network of providers that is sufficiently accessible to the Department's benefit eligible employees, COBRA participants, retirees, and their surviving spouses and eligible dependents, and adequate to service that population.
• Provide various monthly, quarterly, and annual reports, as outlined in the Administrative Requirements
• Integrate with the Department's authorized third-party vendors and/or their authorized representatives
• Manage disease and clinical programs the Department has implemented and/or will implement in the future
• Provide an Account Management Team to support the Department, as outlined in the Admin Requirements
• Prepare plan materials, member communications, and participate in meetings, including but not limited to, utilization meetings and benefit fairs, as outlined in the Administrative Requirements
For a complete and detailed list of services being requested, please see the following Administrative Requirements and Performance Guarantees for each of the options outlined above. By submitting a Reply, the Respondent accepts the Administrative Requirements as written without deviations. 6/29/22: SB updated ITN # to DMS-22/23-048.
| Current Plan Information |
| Department offers eligible Active employees, COBRA participants, Early and Medicare-eligible retirees, and their surviving spouses and eligible dependents, the option to enroll in one of two plan options - "Standard" or "High Deductible Health Plan". Please go to the website link below to obtain copies of the Medical and Pharmacy Plan Descriptions and Documents. |
Both of these plan options are delivered via a PPO and HMO network model. The PPO options are available to ALL eligibles (i.e., FL and out-of-state), whereas eligibility for an HMO option is based on where the subscriber lives or works. See "Map of Options,Carriers" tab for more information. Current carrier partners are listed below:
• Florida Blue PPO
• Aetna HMO
• AvMed HMO
• Capital Health HMO
• UnitedHealthcare HMO
ALL of the above health plans include a global carve-out prescription drug coverage arrangement with CVS Health – a Commercial plan for Actives, COBRA, Early Retirees, and RDS for Medicare-eligibles.
Medicare Advantage HMO and PPO plans, whose pharmacy benefit is administered by the respective HMO or PPO, are NOT a part of this ITN.
For Medical Plan Documents: Please go to https://www.mybenefits.myflorida.com/health/resources to obtain copies of the Plan Descriptions.
For census information (Attachment I) and Medical and Pharmacy claims and network/formulary information (Attachment J), Respondents must submit a fully completed Attachment H - Data Use Agreement in accordance with section 1.10 of the ITN document.
| Instructions Responding to this ITN |
| By submitting a reply to this ITN, Respondent understands they are responding to a PPO Medical Self-Funded plan. A Respondent's Reply should be submitted in accordance with ITN sections 3.5, How to Submit a Reply, 3.7,Contents of Reply, and 3.8, Public Records, Respondent's Confidential Information, and Redacted Replies. Please use the chart below to confirm each Attachment is included in your Reply. |
This Attachment A - Administrative Requirements should be completed by all Respondents, as it includes important acknowledgments and information to assist Respondent in completing their response. Tabs highlighted in yellow are for informational purposes.
Attachment A - Administrative Requirements Attachment B - Technical Attachment C - Network Attachment D - Cost
| Financial Ratings and References | ||||||||||||
| While not a scored factor in the evaluation, it is recommended that the Respondent maintain minimum satisfactory insurance ratings as stated below (or meet alternate criteria specified if not rated): | ||||||||||||
| Rated Companies | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES | YES |
| · A.M. Best Rating: A- | ||||||||||||
| · Standard & Poor's or Fitch rating: BBB, where applicable | ||||||||||||
| · Moody's rating: Baa2, where applicable |
| Companies Not Covered by Rating Agencies | NO | YES | YES | NO | YES | YES | NO | YES | YES | NO | NO | NO | |||||
| · Provide an official document or letter from an accredited credit bureau, verified and dated within the last three (3) months and indicating a satisfactory credit score for the Respondent | NO | YES | YES | NO | YES | YES | NO | YES | YES | NO | NO | NO | |||||
| LAST | LAST | LAST | LAST | LAST | LAST | LAST | LAST | LAST | LAST | LAST | LAST | ||||||
| Ratings | Answer Format | Reply | Explanation | ||||||||||||||
| 1 | For the entity that will be providing this coverage, provide the most recent financial ratings or filings and effective dates of the ratings from each of the following agencies: | ||||||||||||||||
| a. | A.M. Best: Financial Rating Status | drop down box | |||||||||||||||
| Financial Rating (do not report credit rating) | text | ||||||||||||||||
| Financial Rating Modifiers (if applicable) | text | ||||||||||||||||
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | ||||||||||||||||
| b. | Standard & Poor's: Financial Rating Status | drop down box | |||||||||||||||
| Financial Rating (do not report credit rating) | text | ||||||||||||||||
| Financial Rating Modifiers (if applicable) | text | ||||||||||||||||
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | ||||||||||||||||
| c. | Moody's: Financial Rating Status | drop down box | |||||||||||||||
| Financial Rating (do not report credit rating) | text | ||||||||||||||||
| Financial Rating Modifiers (if applicable) | text | ||||||||||||||||
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | ||||||||||||||||
| d. | Fitch: Financial Rating Status | drop down box | |||||||||||||||
| Financial Rating (do not report credit rating) | text | ||||||||||||||||
| Financial Rating Modifiers (if applicable) | text | ||||||||||||||||
| Date Rating Effective (if rated; if not financially rated, leave response cell blank) | date | ||||||||||||||||
| 2 | Respondent's financial rating change within the past 12 months: | ||||||||||||||||
| a. | A.M. Best | text | |||||||||||||||
| b. | Standard & Poor's | text | |||||||||||||||
| c. | Moody's | text | |||||||||||||||
| d. | Fitch | text | |||||||||||||||
| 3 | If Respondent's rating has changed within the past 12 months for any of the rating agencies, discuss any changes. If more space is needed, please use the "Explanation" column. | text | |||||||||||||||
| 4 | Please provide a copy of Respondent's most recent audited financial statement or Annual Report. Name the file: [Respondent's Name]_Audited Financial Statement. | drop down box |
| References | Answer Format | Reply | Explanation | ||
| 5 | Please provide three (3) current client references of like size and industry for whom Respondent provides similar services in the following order of preference: Florida public entities and other public entities. References must be provided with the initial ITN reply. | ||||
| a. | Reference #1 | ||||
| Company Name | text | ||||
| Contact Person | text | ||||
| Title | text | ||||
| Phone Number | text | ||||
| Fax Number | text | ||||
| E-mail Address | text | ||||
| Network Name | text | ||||
| Network Plan Members Enrolled | number | ||||
| b. | Reference #2 | ||||
| Company Name | text | ||||
| Contact Person | text | ||||
| Title | text | ||||
| Phone Number | text | ||||
| Fax Number | text | ||||
| E-mail Address | text | ||||
| Network Name | text | ||||
| Network Plan Members Enrolled | number | ||||
| c. | Reference #3 | ||||
| Company Name | text | ||||
| Contact Person | text | ||||
| Title | text | ||||
| Phone Number | text | ||||
| Fax Number | text | ||||
| E-mail Address | text | ||||
| Network Name | text | ||||
| Network Plan Members Enrolled | number | ||||
| 6 | Please provide one (1) former client reference of like size and industry for whom Respondent provided similar services in the following order of preference: Florida public entities and other public entities. A former client reference must be provided with the initial ITN reply. | ||||
| a. | Reference #1 | ||||
| Company Name | text | ||||
| Contact Person | text | ||||
| Title | text | ||||
| Phone Number | text | ||||
| Fax Number | text | ||||
| E-mail Address | text | ||||
| Network Name | text | ||||
| Network Plan Members Enrolled | number | ||||
| Program Begin Date | text | ||||
| Program Termination Date | text |
| Supplemental Documents |
| Throughout this ITN, various supplemental documents are being requested. Submit these supplemental documents as attachments within your Reply. Please provide attachments in PDF format unless otherwise instructed and include the attachments within the corresponding Tab in your Reply, as described in Section 3.7 of this ITN. |
| Excel Attachment | |||||||
| (A, B, C, or D) | Tab Name | Document Name | Name the File | Confirm Included (Yes/No) | |||
| A | Read Me First | Recent Audited Financial Statement or Annual Report | [Respondent's Name]_Audited Financial Statement. | ||||
| A | Read Me First | Credit Bureau Letter (if applicable) | [Respondent's Name]_Credit Bureau Letter | ||||
| B | Tech Q | High Performance Network Market | [Respondent's Name]_High Performance Network Market | ||||
| B | Tech Q | Centers of Excellence | [Respondent's Name]_COE | ||||
| B | Tech Q | Triennial JCAHO survey report | [Respondent's Name]_JCAHO | ||||
| B | Tech Q | Transition of Care | [Respondent's Name]_Transition of Care | ||||
| B | Tech Q | Wellness Plan | [Respondent's Name]_Wellness Plan | ||||
| B | Tech Q | Telemedicine Implementation Schedule | [Respondent's Name]_Telemedicine Implem | ||||
| B | Tech Q | Management Reporting Package (ONLY ELECTRONIC-DO NOT PRINT HARD COPIES) | [Respondent's Name]_MgmtRptgPkg | ||||
| B | Tech Q | ID Card | [Respondent's Name]_IDCard | ||||
| B | Tech Q | Biographies | [Respondent's Name]_Biographies | ||||
| B | Tech Q | Account Management Plan | [Respondent's Name]_Account Management Plan | ||||
| B | Tech Q | ASO/Fully Insured Billing Description | [Respondent's Name]_Billing Descriptions | ||||
| C | GEO Access | GEO Access | [Respondent's Name]_Geo Access Med_Plan Type | ||||
| C | Disruption | Disruption File (please keep in excel format) | [Respondent's Name]_Disruption Med_PPO | ||||
| D | ASO Medical Repricing | Repricing File (please keep in excel format) | Respondent's Name_ Medical Repricing_PPO |
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Admin Req
| Yes | |
| Invitation to Negotiate (ITN) for the State of Florida, Florida Department of Management Services ("Department") | No |
| PPO Medical Self-Insured | |
| Administrative Requirements |
| Respondent Name: | ||
| [Insert Respondent Name Here] | ||
| Instructions: The following are Administrative Requirements (AR) that the Department expects the awarded Respondent to provide. Enter the answer to each question in the space provided. | ||
| I. | Implementation | Respondent Acceptance |
| 1 | Awarded Respondent shall submit the final Implementation Plan to Department for approval no later than ten (10) business days following execution of the Contract. If the Implementation Plan is not determined by Department to be sufficient, Awarded Respondent will diligently work to deliver a final Implementation Plan satisfactory to Department and recognizes that time is of the essence in completing an Implementation Plan. The Implementation Plan shall fully detail all steps necessary to begin full performance of the Contract on January 1, 2024, 12:00:00 A.M., specify expected dates of completion of all such steps, and identify the persons responsible for each step. The Implementation Plan shall include, but is not limited to, the following Implementation Milestones: | |
| a) The Awarded Respondent shall establish an interactive website exclusive for State Participants, exclusive toll-free phone line, and Department approved communications in advance of the Fall 2023 Open Enrollment period. | ||
| b) The Awarded Respondent shall participate in the Fall 2023 Open Enrollment benefit fairs and meetings coordinated by Department. | ||
| c) Regular implementation status meetings with DMS Contract Manager. Awarded Respondent shall be responsible for recording detailed meeting minutes and follow up action items on behalf of all team members during implementation meetings. | ||
| d) The Awarded Respondent shall conduct background checks in accordance with Section 4.2.4 of the Contract. | ||
| e) The Awarded Respondent shall apply the provisions of the Benefits Document as the description of covered services, exclusions, limitations, etc.; establishing and successfully implementing any necessary edits, controls, or other functions to ensure accurate Plan coverage for Participants. | ||
| f) The Awarded Respondent shall test eligibility files, reviewing key procedures and program process controls (i.e. approval, design, testing, acceptance, user involvement, segregation of duties, and documentation). Functional acceptance approval by Department is required. | ||
| g) The Awarded Respondent shall conduct a pre-implementation audit of approximately 200-300 manually created claims. | ||
| h) The Awarded Respondent shall finalize and validate billing procedures, invoice design, and other financial processes that must be approved by Department. | ||
| i) The Awarded Respondent shall design and present to Department for approval all communication materials to be used for Plan Participants. Communication materials include but are not limited to ID Cards, brochures, explanation of benefit statement forms, paper claim (reimbursement) forms, Summary Plan Descriptions (SPDs), Summaries of Benefits and Coverage (SBCs), standard letters, system generated letters, templates, envelopes, clinical program notices and letters, and posters. | ||
| j) The Awarded Respondent shall ensure the mailing of ID Cards and Plan education materials to Participants no later than December 15, 2023 for coverage effective January 1, 2024. | ||
| k) The Awarded Respondent shall detail a plan to educate and enforce Plan benefits, utilization management, and other Plan specifics to all participating providers. | ||
| l) The Awarded Respondent shall participate in all activities related to a readiness assessment prior to the Implementation Date. | ||
| m) The development and execution of the Implementation Plan is subject to PG1 and the liquidated damages of Section 7 of the Contract for failure to meet the milestones identified therein. | ||
| 2 | Awarded Respondent shall be 100% operational prior to the Implementation Date of January 1, 2024, 12:00:00 A.M. Awarded Respondent is subject to the liquidated damages of Section 7 of the Contract for failure to meet this milestone. | |
| 3 | Awarded Respondent shall mail ID Cards (without Social Security Numbers) to all Participants the earlier of December 15, 2023 or ten business days after the receipt of a clean and accurate Open Enrollment eligibility file subject to PG 5. | |
| II. | Account Management | |
| 4 | Account Manager | |
| a.) Awarded Respondent shall assign a dedicated and exclusive Account Manager and a dedicated Account Director/Executive as the a primary contact(s) for Department. | ||
| b.) The Account Manager shall participate full-time on the Implementation Team. | ||
| c.) If requested by Department, the Account Manager shall be replaced with one that Department is allowed to interview and approve. | ||
| d.) The Awarded Respondent shall inform the DMS Contract Manager in advance of any planned periods of unavailability of the Account Manager | ||
| e.) The Account Manager shall have the responsibility and authority for the vendor to manage the entire range of services discussed in the resultant Contract and must be able to respond immediately to changes in plan design, changes in claims processing procedures, or general administrative problems identified by Department or Department's third party consultant. | ||
| 5 | Account Director/Executive | |
| a.) Awarded Respondent shall assign a dedicated Account Director/Executive as the primary contact(s) for Department. | ||
| b.) If requested by Department, the Account Director/Executive shall be replaced with one that Department is allowed to interview and approve. | ||
| c.) The Awarded Respondent shall inform the DMS Contract Manager in advance of any planned periods of unavailability of the Account Director/Executive. | ||
| e.) The Account Director/Executive shall have the responsibility and authority for the vendor to manage the entire range of services discussed in the Contract and must be able to respond immediately to changes in plan design, changes in claims processing procedures, or general administrative problems identified by Department or Department's third party consultant. | ||
| Account Management Team | ||
| 6 | a.) Awarded Respondent shall assign a dedicated (but not necessarily exclusive with the exception of the account manager and customer service manager who shall be exclusive) Account Management Team which shall include an executive sponsor, an account director/executive, an account manager, a customer service manager, a data/fiscal analyst, and a medical director. | |
| b.) Awarded Respondent agrees that the Customer Service Manager, as part of the Account Management Team, shall be dedicated and exclusive. | ||
| c.) Awarded Respondent agrees that replacement of personnel to the Account Management Team assigned to this Contract shall be subject to prior written approval by Department. | ||
| d.) The Account Management Team shall act on behalf of the State to advance the best interests of the State through Awarded Respondent's corporate structure. | ||
| e.) The Account Management Team shall devote the time and resources needed to successfully manage the State account, including being available for frequent telephonic, email, and on-site consultations. | ||
| f.) The Account Management Team shall be thoroughly familiar with the Awarded Respondent’s functions and operations that relate directly or indirectly to the Department and the Plan, including, but not limited to, provider networks, customer service operations, claims and eligibility systems, systems reporting capabilities, claims adjudication policies and procedures, standard and nonstandard banking arrangements, and relationships with third parties. | ||
| g.) Awarded Respondent shall maintain a current Account Management Team organizational chart. Awarded Respondent shall promptly notify Department of any change(s) to the organizational chart and/or the Account Management Team and provide detailed information regarding new personnel including name, professional background, mailing and physical address, email address, phone numbers and an updated organizational chart. | ||
| 7 | Awarded Respondent shall assign a dedicated (but not necessarily exclusive) eligibility manager for Department. | |
| 8 | Awarded Respondent shall assign a dedicated (but not necessarily exclusive) billing manager for Department. | |
| a.) Awarded Respondent shall assign a dedicated and exclusive claims supervisor for Department. | ||
| b.) Awarded Respondent shall assign dedicated and exclusive claims processors/adjustors for Department. | ||
| c.) Awarded Respondent shall assign a dedicated and exclusive claims facility for the Department. | ||
| 9 | Background Checks | |
| Awarded Respondent shall comply with the Employee and Subcontractor Security requirements, including the performance of background checks as described in Section 4.2.4 of the Contract. | ||
| 10 | Quarterly Meeting | |
| a.) Quarterly Meetings: The Account Management Team shall attend all quarterly meetings at the State offices in Tallahassee, Florida. Awarded Respondent shall not be entitled to additional compensation for meeting preparation or attendance. The meetings shall be held no later than 45 calendar days following end of the quarter. The meeting to review the fourth quarter of a calendar year shall include quarterly and annual reports and deliverables. Quarterly meetings may be held in-person, telephonically, or virtually throughout the term of the contract, including the 16-month period following the termination of the Contract resulting from this ITN. | ||
| b.) Agenda: Awarded Respondent shall provide for Department approval a draft agenda five (5) business days in advance of a meeting, allowing changes to the agenda and a reasonable opportunity to prepare for the meeting. At a minimum, during the meeting Awarded Respondent and Department will: discuss medical goals, expectations and priorities; review Awarded Respondent’s quarterly reports and other issues such as performance guarantees, quality assurance, operations, network status and access, benefit and program changes or enhancements, legislative issues, audits, cost trends, utilization, program outcomes, customer service issues, future goals and planning, and other issues reasonably related to the Contract. Awarded Respondent shall address past performance and anticipated future performance and compare the Plan’s experience to national trends and the Awarded Respondent’s total book of business, other governmental clients, and the Awarded Respondent's "best in class." | ||
| c.) Minutes: Within five (5) business days after any meeting, Awarded Respondent shall provide Department detailed and well-documented draft meeting minutes. Department will review and revise the draft minutes as appropriate and return to Awarded Respondent. Awarded Respondent shall provide the Department with final minutes within three (3) business days after receipt of the revised minutes. Minutes shall include a list and description of all deliverables, identify the responsible party(ies) and provide projected delivery dates. | ||
| 11 | 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 Awarded Respondent shall not be entitled to additional compensation for meeting preparation or attendance. | |
| III. | Support Services | |
| 12 | Benefit Fairs | |
| a.) Awarded Respondent shall participate in all locations of the annual Open Enrollment Benefit Fairs that are sponsored by Department or its designee. (Number and locations may vary each year, and Open Enrollment Benefit Fairs may be virtual.) Awarded Respondent representatives attending the Benefit Fairs shall be employees of Awarded Respondent (not subcontractors or temporary personnel) and adequately trained and knowledgeable about the Plan. Open Enrollment is held annually in the Fall for enrollment coverage effective the following January 1. Participation in the Open Enrollment Benefit Fairs is subject to PG 5. | ||
| b.) Awarded Respondent shall be responsible for all costs associated with participating in Benefit Fairs including travel, and a proportionate share of facility fees, and the printing and distribution of the Benefits Document. | ||
| c.) Awarded Respondent shall not solicit State Employees for enrollment or otherwise during the Employee's working hours or in the Employee's workplace, except during meetings which may be scheduled by Department. | ||
| 13 | Awarded Respondent shall not discuss with Participants or prospective Participants or in any manner allude to coverages, products, or materials other than those contained in the Plan without the permission of Department. Such prohibition shall also apply to Awarded Respondent's Plan specific website. | |
| 14 | Advertisements and Marketing Materials | |
| a.) Awarded Respondent shall submit copies of any and all Plan materials to the Department for customization and prior written approval, if such material is distributed to Participants for marketing the Plan. All materials shall be approved in writing by Department prior to their use. | ||
| b.) Awarded Respondent shall share in any expenses for the printing and mailing of State Open Enrollment materials distributed by Department, the cost for which shall be shared among all benefit plan providers including medical and prescription drug plans offered by Department. | ||
| 15 | Plan Materials | |
| Subject to Department's customization and prior written approval, Awarded Respondent shall be responsible, at no additional cost, for the development (including, but not limited to, the writing, printing, distributing, and mailing thereof) of all Plan related printed materials including but not limited to: | ||
| a.) Summary Plan Description (Plan Benefits Document) | ||
| b.) Summaries of Material Modifications | ||
| c.) Summaries of Benefits and Coverage (SBCs) | ||
| d.) Member educational materials | ||
| e.) Member Identification Cards | ||
| f.) Benefit brochures (including, but not limited to, Open Enrollment materials) | ||
| g.) Claim forms | ||
| h.) Provider directories, upon request | ||
| i.) Two Benefit Statements (one year-to-date and one in conjunction with Open Enrollment, to be received no later than the first day of Open Enrollment; and one distributed no later than February 15 of each year reflecting the full prior calendar year) for all Participants. Benefit Statements must show complete claim details, including plan and member cost share, deductible, out-of-pocket maximum, etc. for claims incurred during the applicable time period. | ||
| j.) Explanation of Benefits Statements (EOBs) | ||
| k.) Any other materials such as notices, preformatted letters, clinical program notices, other correspondence, and similar material. | ||
| 16 | Awarded Respondent shall assist Department (i.e., review, clarify, edit as necessary, and confirm accuracy) as requested in the development of Department communications regarding the Plan, including, but not limited to, the annual Benefits Guide and Department's benefit website (www.mybenefits.myflorida.com). | |
| 17 | Upon request of the Participant, Awarded Respondent shall provide printed materials in a medium widely accepted for the visually impaired. | |
| 18 | All printed material provided by the Awarded Respondent shall be provided in electronic format with final versions submitted to Department in PDF file format. | |
| 19 | Awarded Respondent shall provide Plan materials in a culturally and linguistically appropriate manner, as defined by section 2719 of the Public Health Service Act (PHSA). | |
| 20 | Provider Directory | |
| a.) Awarded Respondent shall provide an online directory of network providers. The online directory available to members shall be updated and available in real time. The directory shall indicate that the list is subject to change. | ||
| b.) Awarded Respondent shall mail provider directories to Plan Participants upon verbal or written request. | ||
| 21 | Membership Materials | |
| Awarded Respondent shall provide the following materials to new Subscribers within four (4) business days after receipt of the enrollment data file or notice from the Department or its designated agent: | ||
| a.) Summary Plan Description (SPD) (may be provided electronically), and | ||
| b.) Identification Card(s) (ID Card). | ||
| 22 | When Awarded Respondent mails the membership materials, they may include a customized greeting and form letter to new Participants. The greeting and letter are subject to Department customization and approval. This letter may include a summary of information already contained in the SPD or may highlight important Plan information. | |
| 23 | Summary Plan Description (SPD) | |
| The SPD provided by the Awarded Respondent shall include information on all covered services including, but not limited to, benefits, limitations, exclusions, copayments, coinsurance, policies and procedures for utilizing clinical and administrative services, procedures for registering complaints or filing appeals, and procedures for providing continuity of care when a provider's network status is terminated. The document shall be subject to the customization and approval of Department and may be provided electronically. | ||
| 24 | ID Cards | |
| a.) Awarded Respondent shall provide Participants with ID Cards either as a new Participant resulting from Open Enrollment, as an otherwise newly enrolled Participant, or when there are changes in the card's elements. The design of the ID card is subject to approval of Department. | ||
| b.) Awarded Respondent shall mail one (1) ID Card for each individual contract and | ||
| at least one (1) additional ID Card for each family contract. | ||
| c.) Awarded Respondent shall provide additional ID Cards as requested by the Participant. | ||
| d.) Awarded Respondent shall make temporary ID cards available to Participants on its Plan specific Participant website that can be downloaded and printed. | ||
| e.) A unique Participant-identifying number that is not a SSN shall be displayed on the ID Cards. Although never displayed, the SSN shall be the number of record and maintained in Awarded Respondent’s information system. ID Cards shall be compliant with State standards, including section 627.642, Florida Statutes. | ||
| f.) ID Cards, including those mailed in the Fall of 2023 for the 2024 coverage year, annual Open Enrollment periods or otherwise as required due to Plan or law changes, shall be mailed in accordance of provisions of PG 2. | ||
| 25 | Special Post-Office Boxes | |
| Awarded Respondent shall maintain dedicated and exclusive post office boxes which shall be used for the Plan and Plan Participants. | ||
| 26 | Public Records Requests and Subpoenas | |
| Awarded Respondent shall, upon request and at no additional cost, provide the | ||
| Department with any necessary data, documents, etc. to enable Department to timely respond to Public Record Requests and subpoenas related to any aspect of services delivered under the Contract. | ||
| 27 | Responding to Requests for Legislative Initiatives | |
| Awarded Respondent shall make available all necessary resources (including, but not | ||
| limited to, the Account Management Team, analytics and outcomes, research and development, actuarial support, and government relations departments) to assist Department in responding to bill analysis, legislative inquiries and requests related to any aspect of services delivered under the Contract. Awarded Respondent shall respond within the timeframe set by Department, which shall be determined at the time of the inquiry depending upon the scope and complexity of the request. All costing estimates/fiscal impacts shall be made on a PEPM (PEPM to include all Subscribers) basis unless otherwise requested by Department. Support for such legislative initiatives shall be at no additional cost to the Department. | ||
| 28 | Awarded Respondent shall review (and maintain) medical documentation and determine/confirm mental and/or physical disability status for Dependents of eligible Subscribers. Awarded Respondent must re-verify disability status every five years using a process approved by Department. | |
| 29 | Department Inquiries, Account Service and Dispute Support Awarded Respondent shall, upon request of Department or its attorneys and at no additional cost, assist Department in responding to inquiries received by the Department from Participants, providers, or other persons related to any aspect of services delivered under the Contract. |
| 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 handled or overseen by a lead customer service person. When Department is required to provide instant responses, Awarded Respondent shall immediately assist Department in preparing its reply, including providing data and documentation within the timeframes prescribed by Department at that time. | |
| IV. | Customer Service |
| 30 | The Awarded Respondent shall maintain a dedicated and exclusive Customer Service Unit comprised of dedicated and exclusive employees of the Awarded Respondent (not contracted or temporary labor) that shall perform all aspects of customer service for Participants and prospective Participants regarding any and all aspects of the Plan, including, but not limited to, retail, mail, specialty pharmacy, and Medicare secondary drugs and supplies. The Awarded Respondent shall staff this dedicated and exclusive Customer Service Unit with sufficient numbers of personnel to meet or exceed related performance guarantees. the Department expects that in the event of overflow calls, a secondary call center(s) (not dedicated and exclusive) may assist Participants. The dedicated and exclusive Customer Service Unit shall include a state-of-the-art call center. The Customer Service Unite is subject to PGs 9-15. |
| 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. In the case of infrequent and unexpected overflow calls, Participants shall have access to secondary call centers and customer service units. | |
| b. The Customer Service Unit shall have adequately trained customer service representatives to handle calls from Participants and shall be knowledgeable of the State Plan, including but not limited to, medical plans and plan designs. Any customer service deficiencies noted by the Department shall be immediately rectified by the Awarded Respondent to the Department’s satisfaction. | |
| c. The Customer Service Unit shall include multi-lingual staff or service to assist Participants in Spanish and any other language pursuant to the most recent Culturally and Linguistically Appropriate Services county data as defined by Section 2719 of the Public Health Service Act (PHSA). For languages other than English and Spanish, the multi-linguistic customer service function supporting the Department may be provided by personnel outside of the dedicated and exclusive Customer Service Unit (including by an approved Subcontractor). | |
| d. The Customer Service Unit shall have staff with skills, services, and equipment to assist hearing and vision impaired Participants. | |
| e. The Customer Service Unit shall have the ability to assist Participants who contact the unit with only their name and/or SSN. | |
| f. The Customer Service Unit shall have a process or procedure for handling emergency Participant requests in accordance with the Plan. | |
| g. The Customer Service Unit shall maintain an exclusive toll-free telephone number, for use by Participants, accessible from anywhere in the United States. | |
| h. The Awarded Respondent shall maintain an adequate number of incoming telephone lines dedicated to servicing Participants and pharmacy/provider inquiries. | |
| i. The toll-free telephone line shall be supported by live dedicated and exclusive customer service representatives twenty-four (24) hours a day, seven (7) days a week. | |
| j. Any automated voice-response telephone system shall provide an option for the caller to opt-out to a live representative at any time during the call. | |
| k. One hundred percent of all calls to Awarded Respondent’s Customer Service Unit or the Customer Service Centers shall be recorded throughout the term of the Contract and the Awarded Respondent shall have the ability to retrieve and deliver an audio recording to the Department of any calls requested within three (3) Business Days. | |
| l. All complaint types received by the Customer Service Unit related to the Plan shall be documented and reported to the Department on a monthly basis which shall include Awarded Respondent’s corrective action plan to address recurring complaint types. | |
| m. The Awarded Respondent shall make available to Department staff the ability to listen to and monitor calls to and from the dedicated and exclusive Customer Service Unit. | |
| n. The Customer Service Unit shall document Participant calls (all issues, concerns of the Participant, all responses, and feedback of the Awarded Respondent) in complete detail such that Department staff with online access to Plan data can fully understand the contents of the call. | |
| 31 | Awarded Respondent shall maintain a written service disruption plan or procedure to continue customer service activities when existing service is temporarily unavailable due to either scheduled or unforeseen events (e.g., relocating offices, repairing/restoring utility or power supply, upgrading phone systems, and other events). Department shall be notified as soon as possible for scheduled disruptions and other events. |
| 32 | Plan Website/Mobile Device |
| Awarded Respondent shall provide and maintain a Plan specific Participant website, with 24/7 access, for medical and general health information. Design and content shall be approved in advance by Department. This website shall include links to Department website, the PBM website and other state, federal, and medical condition specific/general health websites as appropriate to make available a variety of information to participants. Such web-based access shall include the ability to, at a minimum: | |
| a.) access forms and brochures; | |
| b.) order ID Cards; | |
| c.) download and print ID Cards; | |
| d.) access preventive educational information; | |
| e.) access general health and chronic disease information; | |
| f.) track accumulator information including separate tracking for both individual and family coverage (annual deductible and annual out-of-pocket coinsurance maximum); | |
| g.) locate network physicians and hours of operation; | |
| h.) locate network facilities and hours of operation; | |
| i.) view claim history (3 years minimum); | |
| j.) communicate with a customer service representative via web chat, text messaging, and/or email; | |
| k.) access general plan coverage information | |
| l.) access SPD and SBC | |
| m) link to medical policy guidelines | |
| 33 | Awarded Respondent shall maintain a process for Participants, their authorized representative, or their provider to contact customer service to receive a written predetermination of benefits. |
| 34 | Subscriber Satisfaction Surveys |
| In addition to the annual Subscriber Satisfaction Survey, the Department may conduct its own Member Satisfaction survey. Department may conduct or have it conducted by an independent third party. If the survey results in unsatisfactory performance, the Awarded Respondent shall implement a corrective action plan and/or changes to processes as approved by Department. | |
| 35 | Awarded Respondent shall respond to and resolve all Participant inquiries (i.e. written, including email or member website, telephonic) within the timeframes specified in PG 10-11. |
| 36 | Awarded Respondent 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 Awarded Respondent creates, receives, maintains or transmits in the Awarded Respondent's administration of the Plan, as required by the HIPAA 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. Prior to the destruction of any such claim records, Awarded Respondent shall consult with and obtain the prior written approval of Department. |
| 37 | All calls to the customer service unit shall be recorded in their entirety and easily retrieved throughout the entire term of the Contract. |
| V. | Network Requirements |
| 38 | Awarded Respondent shall provide and maintain a national comprehensive health care provider network of sufficient numbers and types of providers to provide adequate access to members. Network access shall be consistent with the minimum access standards in PGs 6 and 7. |
| 39 | Awarded Respondent shall notify Department immediately if the Awarded Respondent or provider network (owned, rented or leased) loses any accreditation, licenses or liability insurance coverage. |
| 40 | If the Awarded Respondent uses any rented or leased networks, the network(s) shall be |
| transparent to the membership (e.g. single ID card, single provider directory, single | |
| point of contact for network inquiries, etc.). | |
| 41 | Continuity of Care |
| a.) If a major provider's (facility, laboratory, imaging center or other large provider group) network status ends, the Awarded Respondent shall notify impacted Participants 30 calendar days prior to the date of the network status change or as soon as administratively possible. | |
| b.) The Awarded Respondent shall provide Continuity of Care as described in the Benefits Document. | |
| 42 | The Awarded Respondent shall provide Department with at least 30 days prior notification and a statement of justification in the event of a major loss of network providers or disruption to the network (i.e. loss of a facility, large provider group, etc.). The statement shall include the following: |
| a.) a description of how the contract action impacts the Plan participants; and | |
| b.) the facility or provider group's utilization by Plan members; and | |
| c.) a confirmation that the Awarded Respondent shall continue to maintain minimum access standards, as described in PGs 6 and 7. Awarded Respondent shall keep Department up-to-date on any contract negotiations/efforts to maintain the network status of the provider. | |
| 43 | The Awarded Respondent shall solicit the top 100 non-network providers utilized in the prior year |
| VI. | Data Processing and Interface Requirements |
| 44 | Eligibility File Transfers from Department |
| The Awarded Respondent shall maintain an information system capable of electronically | |
| receiving and updating Participant eligibility information. The Awarded Respondent shall | |
| accurately convert and load Department's eligibility files. | |
| a.) The Awarded Respondent shall maintain eligibility records for all Participants based on Department's eligibility file. | |
| b.) The Awarded Respondent agrees that Department's eligibility file shall be the official system of record. Awarded Respondent shall not overwrite, update or in any way change the eligibility information without express direction from Department or People First. | |
| c.) The Awarded Respondent shall accept the eligibility files in a format required by Department. | |
| d.) In addition to the file schedule above, the Awarded Respondent shall accept an Open Enrollment eligibility file (generally provided at the end of November following Open Enrollment) for the purpose of generating ID cards for distribution prior to the coverage effective date. | |
| e.) The eligibility files, excluding the Open Enrollment eligibility file, shall be processed as required in PG 30-32. | |
| f.) Eligibility file transfers and subsequent discrepancy reports between the Awarded Respondent and Department shall be exchanged using a method required by Department. | |
| g.) Eligibility updates (including manual reinstatements and terminations) from People First shall be processed, at no additional cost to Department. | |
| 45 | Paid Claims File to Department |
| The Awarded Respondent shall provide all claim data related to the Plan, including all data deemed trade secret, proprietary of confidential (including, but not limited to, all claim related financial information: charged amount, allowed amount, discount, member paid amounts, plan payment amounts, other insurance amounts; industry standard procedure codes and diagnosis codes; denied claims; and provider information including location and National Provider Identifier or TIN) to Department and/or a third-party designated by Department, in the timeframe and in the industry standard format and layout specified by Department. Failure to timely submit complete, properly formatted data shall be considered a material breach of the contract and shall be subject to PG 26. | |
| 46 | Use of Plan Data |
| The Awarded Respondent shall not sell or share the Plan’s data without the prior written authorization of Department. | |
| 47 | The Awarded Respondent agrees that the only compensation to be received by or on behalf of its organization in connection with this Plan shall be that which is paid directly by the State. |
| 48 | System Upgrades, Enhancements and Problems |
| a.) The Awarded Respondent shall provide at least six (6) months prior notice of any significant planned system upgrades or changes, including but not limited to claims, customer service, eligibility, operating systems and any other changes that may materially affect the administration of the Plan. Changes shall be subject to prior written approval by Department. | |
| b.) The Awarded Respondent shall immediately notify Department upon the discovery of problems or issues impacting claims processing related to the Plan. Failure to timely notify Department shall be considered a material breach of the Contract resulting from this ITN. | |
| c.) The Awarded Respondent shall not take any corrective action related to systemic problems or issues impacting claims processing related to the Plan without the written approval of Department. | |
| 49 | Accumulator Exchange with PBM |
| On a daily basis (or more frequently as mutually agreed) the Awarded Respondent shall: | |
| a.) Provide a file of all Participant accumulator information to the PBM and/or other required third parties. This file shall be formatted as agreed upon by the parties and approved by Department and is subject to PG 28. | |
| b.) Accept a file of all Member accumulator information from the PBM and other required third-parties. | |
| c.) Function as the "keeper" of the Member medical and drug spend accumulator information and update the applicable Member cost shares (i.e. remaining deductible, out-of-pocket maximum, etc.) using all pertinent information as appropriate and consistent with the Plan Designs. | |
| 50 | Paid Claims Exchange with PBM |
| On a monthly basis (or more frequently as mutually agreed) the Awarded Respondent shall: | |
| a.) Provide a file of all paid claim activity to the PBM and/or other required third parties. This file shall be formatted as agreed upon by the parties and approved by Department and is subject to PG 27. | |
| b.) Accept a paid claim file from the PBM and/or other required third parties. | |
| 51 | Health Insurance Management Information System (HIMIS) |
| The Awarded Respondent shall provide all claim related data related to the Plan, including all data deemed trade secret, proprietary of confidential (including, but not limited to, all claim related financial information: charged amount, allowed amount, discount, member paid amounts, plan payment amounts, other insurance amounts; industry standard procedure codes and diagnosis codes; denied claims; and provider information including location and National Provider Identifier or TIN) to Department and/or a third-party designated by Department, in the timeframe and in the industry standard format and layout specified by Department. Failure to timely submit complete, properly formatted data shall be considered a material breach of the contract and shall be subject to PG 29. | |
| 52 | Other Data Transfers as Required |
| File transfers between the Awarded Respondent and Department and/or authorized third parties shall be exchanged using a method, format and frequency required by Department. | |
| VII. | Claims Processing |
| 53 | Claims Processing and Adjudication |
| The Awarded Respondent shall establish and perform all aspects of claims processing, coordination of benefits, claims reimbursement, point-of-sale transactions, claim adjudication and payment in accordance with the Benefits Document. The Awarded Respondent shall verify benefits and eligibility before authorizing services. | |
| 54 | Standard Claims Administration Practices |
| The Awarded Respondent shall receive, process and adjudicate claims in accordance with best industry practices using nationally recognized standards. | |
| 55 | The Awarded Respondent shall accommodate both a standard PPO plan and an HSA qualified High Deductible Health Plan design, as described in Department’s Plan Benefits Documents. |
| 56 | The benefits to be provided are approved by the Florida Legislature and/or the General Appropriations Act. The Awarded Respondent shall strictly adhere to the coverage provisions of the Plan Benefit Document, as amended and modified by law. |
| 57 | The Awarded Respondent agrees to make available a post-COBRA fully insured conversion policy to all terminated Participants. |
| 58 | The Awarded Respondent shall process claims in accordance with PGs 19-21. |
| 59 | The Awarded Respondent shall prohibit network providers who render covered services to Plan Participants from billing such Participants for amounts in excess of the allowed amounts established by the Awarded Respondent. Network providers may bill for applicable deductibles, copayments, coinsurance, per visit/administration fees, and non-covered services. |
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