QA DMS-2223-073_PPO_10.4.2022.pdf

RFP No.: DMS-22/23-073 Questions and Answers Page 1 of 9

QUESTIONS AND ANSWERS EXHIBIT:

TPA Services for PPO

ITN NO.: DMS-22/23-073

Date: October 4, 2022

The Department’s responses to timely submitted questions are below.

Question Number

Document or

Attachment Tab or Section Q# or Location Question Answer

A Admin Requirements

IV-Customer Service Please confirm intent by dedicated/exclusive claims facility. May the claims facility support other clients yet operate a dedicated and exclusive claims processing/audit team from a shared facility?

Please see the amended Administrative Requirement #8 in the Revised Attachment A – Administrative Requirements attached hereto.

A Admin

Requirements IV-Customer Service Please confirm an overflow customer care team is able to service calls after hours and weekends.

Yes, the overflow care team can service calls after hours and on weekends, provided they are adequately trained.

Attachment E Draft Contract N/A Would the State require two policy numbers if a vendor is awarded both a PPO and HMO contract or is one policy acceptable?

If a Respondent is awarded a contract for both PPO and HMO, policy numbers would need to be separate due to the Department executing two separate contracts for HMO and PPO.

A Performance Guarantees

6a-7c How will the State address PG assessments for GEOs if for example, the required access criteria can not be met for Urban, Suburban or Rural because there are not enough providers in the assessment category to meet criteria?

See Attachment E – Draft Contract, Section 7.3, Failure to meet Performance Guarantees.

A Performance Guarantees

6a-7c Please confirm your definition of Urban, Suburban and Rural (i.e. by density per square mile, etc.) for purposes of the Performance Guarantee Requirements

Please see the Revised Attachment E – Draft Contract, Section 1, Defitions, attached hereto.

ITN No.: DMS-22/23-073 Questions and Answers Page 2 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer

A Performance Guarantees

20 - Claims Processing

Are each of your current PPO vendor meeting this metric today? Is the State willing to consider replacing 100% in 30 days with a metric more representative of accepted industry metrics? Factors that are out of vendors control could impact the ability to meet a 100% goal such as awaiting additional requested claim details or correction to improper billing.

The Negotiation Team reserves the right to negotiate different terms, additional terms, and related price adjustments if the Negotiation Team determines that such changes would provide the best value to the State. A Respondent should assume that the Department will not agree to any caveats, exceptions, conditions, or deviations to such Department created terms contained in Attachment A and should therefore base its pricing on the assumption that the terms will apply as written during any resultant contract term.

A Performance Guarantees

14b - Member Satisfaction Survey

Please confirm member satisfaction level for the current PPO vendor. Also, please confirm State is agreeable to a % of a credible sample size to achieving this metric.

The Negotiation Team reserves the right to negotiate different terms, additional terms, and related price adjustments if the Negotiation Team determines that such changes would provide the best value to the State. A Respondent should assume that the Department will not agree to any caveats, exceptions, conditions, or deviations to such Department created terms contained in Attachment A and should therefore base its pricing on the assumption that the terms will apply as written during any resultant contract term.

A Performance Guarantees

Item 36 - Data Reporting

If the State requires their annual performance report within 45 days from close of the plan year, how much runout does the State expect to be included?

Annual reports typically include 3 months of run-out plus the time to produce the report. Is the State willing to modify this timeframe to allow for more mature and comprehensive claims data?

See Data Reporting Performance Guarantees in Attachment A – Administrative Requirements. The Negotiation Team reserves the right to negotiate different terms, additional terms, and related price adjustments if the Negotiation Team determines that such changes would provide the best value to the State. A Respondent should assume that the Department will not agree to any

ITN No.: DMS-22/23-073 Questions and Answers Page 3 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer caveats, exceptions, conditions, or deviations to such Department created terms contained in Attachment A and should therefore base its pricing on the assumption that the terms will apply as written during any resultant contract term.

B Technical

Questionnaire Tab

Wellness Question 33-Onsite

What on-site & virtual activities have been successful & what has not been?

The State currently does not have any on-site or virtual wellness clinics.

B-Section 2 Wellness Wellness Question

What is the minimum number and locations where the State would like vendor to provide onsite well-care centers/employee clinics?

Please refer to the information requested in wellness question #33 in Attachment B - Technical.

B-Section 2 Wellness Wellness Question 34-Incentives

To clarify, the State is asking vendors to confirm if they can use vendor-funded wellness dollars to purchase programs from another company other than the vendor?

Please refer to the information requested in wellness question #34 in Attachment B - Technical.

B Technical Questionnaire

Tab

Wellness Question 34-Incentives

Please confirm if the State is willing to contribute some funding for incentives for the wellness program or if they are relying completely on the vendors to include in their offer

Please see the response to question 11.

B Technical Questionnaire

Tab

Wellness Question 35 - Resources

What wellness-related resources do you have currently at your disposal: (example ergonomics expert, clinical personnel, etc.)

The state currently does not have any wellness-related resources. The Department has been directed to procure a vendor for weight management services effective January 1, 2024.

B Technical Questionnaire

Tab

Wellness Question 34-Incentives

Please confirm the State's intent to cover biometric screenings and the number and locations of these. Does the State expect vendors to fully fund the biometric screenings or are you able to fund those through your claims?

Please see the response to question 11.

ITN No.: DMS-22/23-073 Questions and Answers Page 4 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer

Attachment J Claims Data N/A Please provide control totals for both the PPO claim files for repricing.

For PPO medical claims, the control totals are as follows:

Claim Count

Total Charges

In-Network 1,945,956 $2,529,504 ,825.87

OON 306,636 $2,689,526

,015.83

Total 2,252,592 $2,689,526 ,015.83

Attachment A Admin Req 2 What are the milestones being measured? Awarded Respondent shall be 100% operational prior to the implementation date of January 1, 2024.

B Technical Questionnaire

Sec 1, #44 Is the intended question: What claims edits, claims limits, systematic procedures and systematic controls are in place prior to claim payment to prevent and detect fraud in-network?

Please see the amended question 44 in the Revised Attachment B – Technical attached hereto

B Technical Questionnaire

Sec 1, #57 The question asks to describe how action and recovery proceed for contracted vs.

non-contracted providers however there is no box to respond, should this box be “Text” and open for responses?

For Technical Question 57 in section I, please respond by answering questions #57 a – 57e. The explanation column may be used to provide additional information.

B Technical

Questionnaire Sec 1, #57 a, b, c, d, e

Do questions a, b, c, d, and e pertain to #57 and are to be responded to as contracted

vs. non-contracted?

Please refer to the answer to question 18.

B Technical

Questionnaire Sec 1, #15 What does the term “provider cases” mean? Is this related to claims?

Please see the amended question 15 in the Revised Attachment B – Technical attached hereto.

ITN No.: DMS-22/23-073 Questions and Answers Page 5 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer

B Technical

Questionnaire Sec 1, #20 J Is this question related to credentialing or is this question asking if this is part of our credentialing process?

Attachment B – Technical, Section 1 Question 20 is related to credentialing

B Technical

Questionnaire Sec 1, #20 K Is this question related to credentialing or is this question asking if this is part of our credentialing process?

Please refer to the answer to question 21.

D Cost Medical Repricing Tab

Upon reviewing “Aon Provider Raw Claim 2022 PPO file”, there are over 2,252,593 rows of data which when converted to excel caps the rows at 1,047,056. Please confirm we are to price all 2,252,593 million lines of claims data in our repricing effort.

Yes, all data lines in “Aon Provider Raw Claim 2022 PPO file” are to be used in the Respondent’s repricing analysis.

C Network Disruption Tab In the “PPO_Attachment C – Network” document we are asked to complete a disruption report. As noted in the disruption tab, we requested Attachment J and received the file “Aon Provider Raw Claim 2022 PPO” which is the claims file. Please confirm this is the correct file that should be used to run a disruption report because a disruption report is usually ran using a provider file and not the claims file which contains millions of records and duplicate provider names which will cause the results to be inaccurate.

Yes, the provided Attachment J – Scrubbed Claims Data is the correct file to be utilized in running a disruption report.

Provider information is included within the claims file and can be used to provide the disruption report. Duplicate provider names in Attachment J – Scrubbed Claims Data may be filtered out using the Provider NPI numbers.

E Draft Contract Section 4.1 Ownership of Deliverables and Retention of Records, first paragraph, How will data that is both State of Florida and the awarded carrier data be protected?

See Attachment E – Draft Contract, Section 4.2.5, Data Security, for requirements on how state of Florida Data, as defined in the Section 1, Definitions, shall be protected.

E Draft Contract Section 4.2.5.1 Work Locations, No Offshoring of Data, first paragraph, does this mean that NO OFFSHORING is allowed, even at DSGI’s discretion?

Offshoring of data is not allowed pursuant to the terms of Attachment E – Draft Contract, Section 4.2.5.1.

ITN No.: DMS-22/23-073 Questions and Answers Page 6 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer

PPO_Attach ment B -

Technical.xls x

Technical Questionnaire n/a Some questions asked in the technical questionnaire are multiple part and may be difficult to answer in the 400 character limit (one example would be Section III, #8).

Would this State allow us to provide a supplemental document with additional information/explanation for these items?

Per section 3.7 of the ITN, the portions of a response exceeding the 400-character limit will not be evaluated.

DMS-2223-

073 PPO

ITN.pdf n/a 3.5 Can large files (repricing, geos, etc.) be put on USB, rather than printed?

Please see revisions to ITN Section 3.5.1 in Addendum 1 attached hereto..

DMS-2223-

073 PPO

ITN.pdf n/a 1.9 Will there be an online meeting for the public opening and negotiations meetings?

No online access for the public opening meeting will be made available.

Negotiation meetings will be conducted in Tallahassee, Florida, if conducted in-person, or using technology-based solutions, if conducted remotely.

DMS-2223-

073 PPO

ITN.pdf n/a 3.3 and 3.5 Can you confirm no uploads and/or submissions via "my Florida market place" are required? i.e. only the hard copy requirements in Section 3.5 apply

Replies are to be submitted in accordance with ITN Section 3.5 which does not include a requirement to upload any documents via MyFloridaMarketplace.

PPO_Attach ment C -

Network.xlsx and

PPO_Attach ment I-

Census file

GEO Access n/a Can you confirm we should just run the Geo access reports only on the lines in the census with the "E" indicator in the "Relation To Employee (Elig)" column?

Confirmed

PPO_Attach ment A-AR

Admin Req n/a Please confirm that no Behavioral Health program fees, capitation, contingency fees, shared savings fees, radiology program fees and the like can be charged through the claim wire?

Please refer to Attachment A - Administrative Requirements.

DMS-2223-

073 PPO

ITN.pdf n/a 1.3 Can you outline all current administrative fees / rates?

The current vendor’s rate information is set forth in the current PPO contract which can be viewed at the following DMS website:

ITN No.: DMS-22/23-073 Questions and Answers Page 7 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer https://www.dms.myflorida.com/workforce _operations/state_group_insurance/ legislative_and_policy_resources/vendor_ contracts..

DMS-2223-

073 PPO

ITN.pdf n/a 1.3 Does the Medicare Eligible population have current disease management or case management programs or are they in a standard Medicare Direct PPO plan?

The plans within this ITN include Medicare-Eligible retirees and any disease management or case management programs would be consistent across the entire active and retired enrolled population.

This ITN does not include the separate Medicare Advantage HMO and PPO plans.

PPO_Attach ment A-AR

Admin Req n/a Are there any current TPA's who are charging for services through the claims wire? E.g., Capitated Behavioral Health or Disease Management.

Please refer to Attachment A - Administrative Requirements.

Attachment J

– Scrubbed Claims Data

(Aon Provider Raw Claim

2022 PPO.txt

PPO_Attach ment D - Cost.xlsx

Medical Repricing n/a Repricing- do we need to return the full Scrubbed claims file for the repricing/disruption? If so, what fields do you want populated?

Repricing is to be submitted pursuant to the instructions in Attachment D - Cost in the “Medical Repricing” tab.

Attachment J

– Scrubbed Claims Data

(Aon Provider Raw Claim

2022 PPO.txt

PPO_Attach

Medical Repricing n/a Should the repricing and disruption should be combined into one file (i.e. both the repriced amount and the network indicator would be in the same file)?

Disruption report should be submitted separately from the repriced claims pursuant to the instructions in Attachment C – Network in the “Disruption” tab.

Repricing data should be provided pursuant to the instructions in Attachment D - Cost in the “Medical Repricing” tab.

ITN No.: DMS-22/23-073 Questions and Answers Page 8 of 9

Number

Document or

Attachment Tab or Section Q# or Location Question Answer ment D - Cost.xlsx

PPO_Attach ment A -

Administrativ e

Requirement s

07.27.2022.xl sx

Admin Req #88 Can you confirm that providing the industry standard 3/31 period-end report and a subsequent bridge letter to address 4/01 – 6/30 meets Administrative Requirement #88 SSAE Reporting Timing?

The Negotiation Team reserves the right to negotiate different terms, additional terms, and related price adjustments if the Negotiation Team determines that such changes would provide the best value to the State. A Respondent should assume that the Department will not agree to any caveats, exceptions, conditions, or deviations to such Department created terms contained in Attachment A and should therefore base its pricing on the assumption that the terms will apply as written during any resultant contract term.

PPO_Attach ment A -

Administrativ e

Requirement s

07.27.2022.xl sx

Admin Req I. Implementation, #3 Please confirm that the reference to PG 5 is instead supposed to be PG 2. PG 5 discusses Open Enrollment Meetings and PG 2 discusses ID cards turnaround time that question 3 in section I. Implementation addresses.

Please see the amended Administrative Requirement #3 in the Revised Attachment A – Administrative Requirements attached hereto.

PPO_Attach ment A -

Administrativ e

Requirement s

07.27.2022.xl sx

Admin Req X. Audits, #88 Question # 88 in Section X. Audits references that "the SSAE 18 Report shall be subject to the provisions of PG 43", however there is no PG 43 in the Performance Guarantees tab. The last PG referenced in Performance Guarantee tab is PG 42. Please provide the Performance Indicator, Standard/Goal, Measurement Criteria, Measurement Frequency and Amount at Risk requested for PG 43 for the PPO plan.

Please refer to PG 43 in the Revised Attachment A – Administrative Requirements attached hereto.

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END OF QUESTIONS AND ANSWERS

Number

Document or

Attachment Tab or Section Q# or Location Question Answer

PPO_Attach ment B -

Technical.xls x

Disease Mgmt Program Component #4

"Question #4 in the Program Component section asks carriers to specify whether any components 4 a. through 4 n. are provided only for certain risk levels.

However, the restrictions of the Excel sheet only allows carriers to choose Yes or No and does not allow us to write in a response. The instructions also state to enter the answer to each question in the space provided and to not change the formatting of this worksheet including adding or deleting rows and/or columns.

If there are program components that are provided differently for certain risk levels, please clarify where you would like carriers to indicate this in the response given the restrictions in this worksheet do not allow us to specify as requested.

Please see the Revised Attachment B – Technical attached hereto..

PPO_Attach ment D-Cost

ASO PPO #6 Discount Guarantee - Please Confirm that the State would be ok with carriers setting the discount guarantee based upon the 3 digit zip code and the penalty would be based upon the membership in the 3 digit zip code service area and penalty would be based upon aggregate results?

Respondents are to indicate the discount guarantee the Resopndent is willing to provide. See Attachment A – Performance Guarantee 25 which speaks to discount guarantees.

PPO_Attach ment D Cost

Wellness ASO

PPO

ALL Are we able to put the wellness programs as confirmed if we included it as a buy up option in the ASO PPO tab under Additional Programs Not Identified Above?

Yes. Additional buy up costs associated with wellness are to be identified in Attachment D – Cost in the ASO PPO tab in the “Additional Programs Not Identified Above” section.