Questionnaire No. 1 - ASO Provider.pdf

City of Miami  Questionnaire for

RFP No.2130386

Questionnaire 1 Group Health Plan – ASO Provider

Completion of this questionnaire is not mandatory, but it is strongly encouraged as failure to do so could negatively impact the overall evaluation score of the Proposal. Responses will strengthen your technical evaluation and may contribute to your overall proposal score.

Please answer in the order presented. Incomplete responses may affect scoring.

I. Organizational Overview & Experience

1. Provide a summary of healthcare services and outcomes-based strategies used to improve member health.

2. Highlight differentiators from competitors and benefits to the City.

3. Describe consulting specialties, ACA compliance support and the location of the service office.

4. Provide public sector client metrics: size, retention, and growth in Florida.

5. Disclose any mergers, litigation, audits, bankruptcies, or regulatory action within the last 7 years.

6. Include ratings with A.M. Best, Moody’s, Fitch, and/or Standard & Poor’s and the complaint resolution process.

7. Describe a business continuity plan for pandemics.

II. Adequacy of Network and Qualifications of Providers

1. Provide a GeoAccess report and disruption analysis.

2. Complete network and location count tables by county.

3. Describe:

a. Network contract renewal and notification process;

b. Credentialing and turnover rates;

c. Reimbursement methods by percentage;

d. Transition of care and provider nomination;

e. Balance billing protections

4. Submit:

a. Provider reimbursement models (RBRVS, DRG, etc.) ;

b. CPT code negotiated fee chart;

c. Ancillary network facilities data;

d. Centers of Excellence, mobile App access, and audit schedule.

5. If a provider leaves the Proposer’s network and does not notify the participant, who is responsible for the claim payment?

6. Are the Proposer’s network providers prohibited from balance billing the patient for any excess of the contracted amount, except for deductibles and coinsurance?

7. If obstetricians are not PCPs, can a woman access an Obstetrician-Gynecologist (“OB/GYN”) without a PCP referral?

8. What percentage of participating physicians have limited their practice to current enrollment?

9. Are all PCPs required to have admitting privileges to network hospitals? If no, what percentage of the Proposer’s physicians have privileges at participating hospitals?\

10. What happens if a network provider refers a member to a nonparticipating provider?

Who is at risk?

III. Claims Administration & Member Services

1. Describe claim adjudication systems, turnaround standards, and audit processes.

2. Confirm:

a. Auto-adjudication rates;

b. R&C data source and percentile used;

c. Coordination of Benefits and subrogation approach;

d. Dedicated claims team for City;

e. Multilingual capabilities. (English, Spanish and Creole)

3. Provide data retention duration and override protocols.

4. Submit performance metrics for past twelve (12) months.

IV. Medical & Case Management

4. Detail pre-certification, concurrent review and appeals processes.

5. Describe case and disease management programs, maternity and nurse line services.

6. Confirm in-house vs vendor usage.

7. Submit HEDIS scores for past two (2) years.

8. Describe internet-based tools for:

a. Claims and benefits access;

b. Pre-authorization triggers;

c. Large claim threshold alerts

V. COBRA, HIPAA & Compliance

1. Provide COBRA and HIPAA administration processes and fees.

2. Submit sample notices, protocols, and certifications.

3. Outline additional compliance services included or offered at cost (ACA, GINA, MHPP, WHCRA, etc.).

VI. Plan Design & Administration

1. Confirm ability to administer proposed plans.

2. Detail deviations and justifications.

3. List network access fees and clarify inclusions.

4. Provide:

a. Administrative fees chart (2025–2028);

b. Fee for run-in/run-out, ID cards, stop-loss interfaces.

5. Confirm advance notice for fee changes (120 days).

VII. Account Management

1. Complete account team matrix, title, location, and percent commitment.

2. Submit resumes or biographies of the proposed team.

3. Describe service structure, satisfaction standards, and escalation points.

VIII. Banking & Invoicing

1. Provide:

a. Premium billing/payment procedures;

b. Bank reconciliation process;

c. Funding requirements;

d. Principal banking relationship for reference.

2. Submit a sample financial report package.

IX. Reporting & Analytics

1. Complete report matrix: type, frequency, and cost.

2. Confirm:

a. Online access (real-time or lag);

b. Consultant access and credential limits;

c. Monthly claim detail feeds;

d. Stop-loss carrier data support.

3. Submit report samples for:

a. Claims,

b. pharmacy,

c. finance,

d. stop-loss,

e. wellness.

X. Communication and Member Engagement

1. Describe enrollment and communication support (EDI, online, paper).

2. Confirm City logo branding, and available languages.

3. Submit sample communications on:

a. Enrollment,

b. Disease management,

c. Wellness,

d. ID cards.

4. Describe mobile app features and update frequency.

5. The City requires that the Successful Proposer provide all Benefit Summary booklets, product materials, and Standard Communications for all services in electronic format, and provide these materials in paper format when necessary. This includes, but is not limited to, health plan-related brochures, flyers, posters, and other materials typically distributed to City worksite locations. The Successful Proposer is responsible for the costs of developing, producing, and distributing these materials.

XI. Performance Guarantees

1. Provide performance guarantees in:

• Implementation (including ID card production and distribution).

• Claim turnaround time.

• Claims accuracy.

• Average speed of answer.

• Overall customer satisfaction.

• Account management (including management reports and renewal information delivery).;

• Telephone response time (including abandonment rate and average speed of answer).

2. Provide the Proposer’s performance results in the above categories for Calendar Year 2024.

3. Is the Proposer proposing any financial incentives or penalties with your Performance

Guarantees?

XII. Transition & Termination Process

1. Describe standard termination/data transfer processes.

2. Confirm claims run-out procedures and fees.

3. Identify transition protocols to ensure continuity.

XIII. Ability to Administer Requested Plan Designs

1. Confirm the Proposer can administer the health plan designs as designated in this RFP.

2. If not, please indicate the deviations per plan. All deviations must be indicated in your response.

XIV. Administrative Services Only (“ASO”) fees

1. Insert instructions for the chart below:

Administration and access fees

Fees 1/1/2025-12/31/2028

Medical Claims Administration

Network Access Fee

Telemedicine

Utilization Management (“UM”)

Case management (“CM”)

24 Hour Nurse Line (“NL”)

Disease management (“DM”)

Maternity management (“MM”)

Medical and pharmacy integration

Stop Loss interface fee

External vendor interface fee

ID Card (Fees)

COBRA

Other programs not mentioned (please add)

Cost reduction and savings program - shared savings/large bill review/fee negotiation and secondary/travel network - % of savings

Subtotal

Wellness Credit - $250,000 Requested

Technology Credit - $30,000 Requested

XV. Qualifications

1. Confirm whether the City will be considered a Key or National Account?

2. Provide a sample service plan by the Proposer for a client similar in size to City.

3. Does the Proposer anticipate utilizing external companies or consultants in servicing City? If so, please provide:

• List of companies

• Services provided

• Length of relationship

• Established service standards

• Quality control measures.