Questions and Answers HMO.pdf

ITN No.: DMS-22/23-072 Questions and Answers Page 1

Questions and Answers to the following Invitation to Negotiate (ITN):

Third Party Administrative Services for

HMO Health Insurance

ITN NO.: DMS-22/23-072

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

Question Number

Document or Attachment

Tab or Section

Q# or Location

Question Answer

1 ITN 3.5.1 During the “Vendors Responding to Electronic Solicitations in MFMP” webinar it was stated that this would be an electronic only submission.

Please confirm 1 bound hard copy and accompanying electronic copy are what will be required of Respondents to submit a Reply to this solicitation

Please see revisions to ITN Section 3.5.1 in Addendum 1.

ITN FORM 5b & FORM 6b

When the Respondent is contracting with a PBM to provide Pharmacy Services as part of the Medical + Pharmacy proposal, should the information on the Pharmacy forms 5b and 6b be specific to both Respondent and contracted PBM or PBM alone?

The information on forms 5b and 6b related to pharmacy management services should be specific to the entity administrating the pharmacy benefits. If Respondent is submitting a reply for their HMO medical services, form 5 and 6 would be specific to that Respondent. If they are responding on behalf of a separate entity for pharmacy services, the information would need to be specific to that entity. Please see Revised Form 5b – Mandatory Responsiveness Requirements and Revised Form 6b – Minimum Qualification – Pharmacy attached to Addendum 1.

3 Attachment A ASO_No Rx_Admin Req.

26 The question seems to be cut off.

Please provide the complete question.

Please see the amended Administrative Requirement #26 in the revised Attachment A

– Administrative Requirements attached to

ITN No.: DMS-22/23-072 Questions and Answers Page 2

Question Number

Document or Attachment

Tab or Section

Q# or Location

Question Answer

4 Attachment C Disruption Per Attachment C instructions, please send the Disruption file in excel format.

Refer to Section 1.10 of the ITN and “Disruption” tab instructions in the “DMS- 22/23-072 Attachment C – Network” downloadable file for the advertisement.

Due to the size of the files, the data is in a text file format. Respondents will be able to convert the text file to an excel file so they can work with the data.

5 Attachment J Pharmacy Carve-In

Please send Attachment J – Pharmacy Carve-In Florida DMS RFP HMO.txt in excel format.

Due to the size of the files, the data is in a text file format. Respondents will be able to convert the text file to an excel file so they can work with the data.

6 Attachment I Coverage codes

Census File What is the difference between Code 9 & 11 since both have the same description “Cobra Individual” ; same for Code 10 & 12 “COBRA Family.”

Code 9 = COBRA Individual Code 10 = COBRA Family Code 11 = COBRA Extension Individual Code 12 = COBRA Extension Family

7 Attachment A ASO_Rx_Admi n Req

Pharmacy Admin Requirement Q’s 1-166

When the Respondent is contracting with a PBM to provide Pharmacy Services as part of the Medical + Pharmacy proposal, should the questions in the Pharmacy Administrative requirements be specific to both Respondent and contracted PBM or PBM alone?

Information provided should be related to the HMO vendor is proposing to provide pharmacy services for that benefit.

8 Attachment A ASO_Rx_Admi n Req

Q’s 4a, 6b, 8a, 8b, 8c, 30

Please provide the State’s definition of the terms “dedicated” and “exclusive.” Additionally, please advise whether this requirement applies regardless of region(s) awarded or membership enrollment.

The claims facility can be dedicated but not necessarily exclusive. Please see the revisions to the Administrative Requirements in the Revised Attachment A – Administrative Requirements attached to Addendum 1.

These administrative requirements would apply regardless of number of regions awarded to a Respondent.

9 Attachment B Tech Q Integration #48 Regarding inbound referrals, please clarify what referral program this is related to?

Inbound referrals pertain to Provider referrals or referrals from other programs.

Please see the revisions to this question in the Revised Attachment B – Technical attached to Addendum 1.

ITN No.: DMS-22/23-072 Questions and Answers Page 3

Document or Attachment

Tab or Section

Q# or Location

Question Answer

10 Attachment I Census File Please confirm that Attachment I – Census is for both medical and pharmacy responses, i.e., Geo Access worksheets.

Confirmed.

11 Attachment A ASO_Rx_Admi n Req

I. Pharmacy Admin requirements Q1.

Please clarify, if it is (14) or (10) calendar days, since both are listed.

Please see the amended Pharmacy Administrative Requirement #1 in the ASO_Rx_Admin Req tab of the revised Attachment A – Administrative Requirements attached to Addendum 1.

12 Attachment A ASO_Rx_Admi n Req and ASO_No Rx_Admin Req

21 under Support Services

Please advise if the Contractor is required to physically mail SPDs to each new Subscriber within 4 days of enrollment, please consider 14 days for SPD’s and within 4 days for the ID cards.

Please see the amended Administrative Requirements associated with Membership Materials in the revised Attachment A – Administrative Requirements attached to Addendum 1.

13 Attachment E Please confirm, if an Attachment to the Contract is more specific, such as detailing the obligations of the third-party administrator of the Self- Insured HMO, why would that more specific Attachment not govern if there is a conflict between the main Contract and the Attachment?

Additional specificity or requirements does not necessarily create a conflict. DMS cannot evaluate whether a conflict exists as the question does not cite to specific language or obligations. However, if a conflict exists between the contract and an attachment, the contract will control pursuant to section 1 of Attachment E - Draft Contract.

14 Attachment E “Does any portion of Attachment E or any other documents published as part of this IT state or specify the obligations of the third-party administrator and the Department regarding the funding of the self-funded benefits?”

This question is unclear.

ITN No.: DMS-22/23-072 Questions and Answers Page 4

Document or Attachment

Tab or Section

Q# or Location

Question Answer

15 Attachment E Please confirm if in subsection 3.4, based on the use of the term “may,” that, even if the changes to the Contract specifications impact cost or time of performance, the Department reserves the right to not make an equitable adjustment in the Contract price or delivery date? In the event of disagreement, how will it be handled?

Correct that “may” is interpreted to be permissive not mandatory.

Disputes must be resolved pursuant to the Dispute Resolution procedures identified in section 10.7 of Attachment E - Draft Contract.

16 Attachment E Please confirm if In subsection 3.9, when referencing “payment under the Contract,” does that include the funding of claims by the state for payment of the self-funded plan benefits that are administered under the Contract by the third-party?

No. Section 3.9 is in reference to administrative fees and fully-insured premium payments.

17 Attachment E In the event that annual appropriation by the legislature does not occur, is there an alternative method to continue to fund the impacted plans?

No.

18 Attachment E Please confirm if in Section 5, is the intent that the Contractor will be responsible for taxes and liabilities imposed as a result of agency type audit when such a tax or liability is not related to performance by Contractor, as a third-party administrator, of its obligations under the Contract?

Confirmed

19 Attachment G Please confirm if in Section IV Schedule of Benefits, as coverage can be under the self-funded plan as administered by the third-party HMO, should the SPD be clear and state that the summary provides an overview of the Standard and High Deductible Health Plan (HDHP)

This is beyond the purview of the information requested in the ITN.

ITN No.: DMS-22/23-072 Questions and Answers Page 5

Document or Attachment

Tab or Section

Q# or Location

Question Answer

HMO coverage under the Plans administered by AvMed, rather than stating that it is coverage for AvMed?

20 Attachment B Tech Q Credentialing #18

The question asks how the respondent determines quality measures and performance issues with respect to behavioral health. Is this specific to the Network or a more general question? If more general, please provide more detail.

Question 18 in Attachment B – Technical in the Tech Q tab seeks information with respect to Respondent’s proposed network.

21 Attachment B Tech Q Wellness # 36-

Question 36 mentions “wellness dollars” and question 37 mentions “wellness credits”; are these the same thing or are they two separate offerings? Please clarify how the State would like these applied.

Wellness dollars and wellness credits can be used interchangeably. A Respondent’s Reply should indicate how wellness credits are to be applied..

22 Attachment C Does the network need to be in place upon ITN submission date or upon effective date?

A Respondent’s network should be in place before the deadline to submit a reply to DMS.

23 Attachment A ASO Rx Perform G

9 ASA Please provide definitions for the terms "dedicated" and "dedicated and exclusive" to clarify the Department's expectations. Are resources that are "dedicated and exclusive" prohibited from assisting other clients/partners of a Respondent?

The claims facility can be dedicated but not necessarily exclusive. Please see the amended Administrative Requirements in the Revised Attachment A – Administrative Requirements attached to Addendum 1.

24 Attachment A ASO Rx Perform G

9 ASA Will the requirement for the Customer Service Unit to be "dedicated and exclusive" apply regardless of actual enrollment?

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

ITN No.: DMS-22/23-072 Questions and Answers Page 6

Document or Attachment

Tab or Section

Q# or Location

Question Answer assumption that the terms will apply as written during any resultant contract term.

25 Attachment A ASO Rx Perform G

9 ASA Would you consider changing the metric from 99% to 90% “still above the industry standard of 80%”*.

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.

26 Attachment A ASO Rx Perform G

6 ASA-

Pharmacy Performance Guarantees section

The definition of the ASA PG with & with out Rx are different, is that intentional?

Please see the amended Average Speed to Answer Performance Guarantees in the revised Attachment A – Administrative Requirements attached to Addendum 1.

27 Attachment A ASO_Rx_Admi n Req

10 -Quarterly Meetings

AR indicates quarterly meeting to be held 45 days following end of quarter. Would the Department consider changing the language to specify “quarterly meeting to be scheduled within 45 days following end of quarter.”

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.

28 Attachment A ASO_Rx_Admi n Req

8c Is the State’s requirement that all claims be handled in one specific physical/geographical location? How does the State view hybrid work environment where employees are

The claims facility can be dedicated but not necessarily exclusive. Please see the amended Administrative Requirements in the Revised Attachment A – Administrative Requirements attached to Addendum 1.

ITN No.: DMS-22/23-072 Questions and Answers Page 7

Document or Attachment

Tab or Section

Q# or Location

Question Answer working partially remotely and from the office, in the context of this requirement?

29 Attachment B Disease Management

3 Drop down selections for target age range of members for pediatric program does not reflect the age range our program manages and unable to free text response. Please advise how to properly respond to that question.

Select the age range which most closely resembles the target age range of the Respondent’s program.

30 Attachment A ASO_No RX_Admin Req.

85 Please provide clarification for the below requirement: “Awarded Respondent shall reimburse Department for any and all overpayments regardless of whether the overpayment is recovered from the Plan member or provider or how the error was discovered.”

Are there different rules for par vs.

non par providers?

Are we allowed to recoup from the member if an error is made impacting the member responsibility?

The overpayment process should follow Florida Prompt Pay regulations, correct?

When should the Department be reimbursed after conclusion of Florida Prompt Pay timeframe?

Please refer to the ITN for instructions on this item

ITN No.: DMS-22/23-072 Questions and Answers Page 8

Document or Attachment

Tab or Section

Q# or Location

Question Answer

31 ITN 4.6.1 At the end of the evaluation phase, when the department determines the one or more respondents who are determined to be within the competitive range of Replies reasonably susceptible of award, will the vendors selected to be advanced to the negotiation phase be posted or will there be a public meeting to announce the selected vendors?

See ITN Section 1.9 for a list of all currently scheduled public meetings and anticipated postings.

32 ITN Cover Please clarify the bond requirement.

What is the basis for the amount?

Please clarify how DMS will determine the amount (i.e., based on annual ASO fees only? For what period of time? Does it consider changes in enrollment over time?)

Please see revisions to ITN Section 3.2 in Addendum 1.

33 Attachment A ASO_Rx_Admi n Req

Pharmacy Admin Requirement Q’s 2-4

Please clarify if DSGI is requiring a separate Pharmacy Account management team when proposing Rx administration, or if the Account Management team severs both the medical & Pharmacy benefits.

The account management team will be the same for both HMO and PBM services.

34 Attachment A ASO_Rx_Admi n Req

Pharmacy Admin Requirement Q’s 5 a

Would the Department consider changing the language in AR 10 from “held” no later than 50 days following end of quarter to ”scheduled” no later than 50 days following end of quarter.

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.

ITN No.: DMS-22/23-072 Questions and Answers Page 9

Document or Attachment

Tab or Section

Q# or Location

Question Answer

35 Attachment A ASO_No RX_Admin Req.

49-50 Accumulator Exchange with PBM/ Paid Claims Exchange with PBM:

Please clarify if this applies for a “No Rx” Bid. If it does, please clarify what type of accumulator data needs to be submitted to PBM.

Please refer to information requested in Attachment A – Administrative Requirements.

Attachment A ASO_No RX_Admin Req.

70 Prescription Drug rebates.

For a “No Rx” bid please clarify if this applies.

Medical pharmacy rebates apply for an HMO Self-Insured Carve-Out offering.

37 Attachment A ASO_Rx_Admi n Req

Is there a reason that ITN DMS- 22/23-072 (TPA Services for HMO) contemplates options both with and without Rx, and ITN DMS-22/23- 073 (TPA Services for PPO) is only carve out?

The State is not considering a carve-in option on the PPO plan.

38 The only material change we noticed from the previous solicitation (ITN DMS - 22/23-046) is in the timeline. Is there an explanation as to why the previous solicitation was withdrawn?

This question is not relevant.

39 Attachment J Medical Please send Attachment J – Medical

– Aon Provider Raw claim 2022 HMO.txt in excel format.

Due to the size of this file, the Department is unable to send Attachment J – Scrubbed Claims Data as an excel document.

40 Attachment B Disease Mgmt. 4 m The cells only allows for “yes or no”, please advise how to provide you with our description for each, since the question indicates to “Describe onsite services provided”

Please see the revisions to the “Other” column for this question in the Revised Attachment B – Technical attached to Addendum 1. .

Attachment B Disease Mgmt. 4 n The cells only allows for “yes or no”, please advise how to provide you with our description or comment for each, since the question indicates to “Describe” our other interventions/resources/ tools.

Please see the revisions to the “Other” column for this question in the Revised Attachment B – Technical attached to Addendum 1.

42 Attachment B Disease Mgmt. 3 The cells under “Asthma & Diabetes” columns do not display the correct age ranges when selected (it displays a date) Also, advise how to provide you

Select the age range which most closely resembles the target age range of the Respondent’s program.

ITN No.: DMS-22/23-072 Questions and Answers Page 10

Document or Attachment

Tab or Section

Q# or Location

Question Answer our age ranges should those differ from the ones on the selection list.

43 Attachment J After receiving the link to the ITN No:

DMS-22/23-072 HMO information, the following message was received while trying to download the AON Provider Raw Claim document:

Aon Provider Raw Claim 2022 HMO(1).txt file is too large for Notepad.

Use another editor to edit the file.

Is there another option for downloading this file?

Due to the size of the files, the data in Attachment J – Scrubbed Claims Data was provided in a text file format and the Department is unable to send in another format.

HMO_Attachme nt B - Technical.xlsx

Tech Q 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.

45 DMS-2223-072

HMO 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

DMS-2223-072

HMO 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.

47 DMS-2223-072

HMO 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.

48 HMO_Attachme nt C - Network.xlsx and HMO_Attachme nt 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?

Yes

ITN No.: DMS-22/23-072 Questions and Answers Page 11

Document or Attachment

Tab or Section

Q# or Location

Question Answer

49 HMO_

Attachment A-

AR

ASO_No Rx_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.

50 DMS-2223-072

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

No, this question seeks information that the vendor considers trade secret, confidential and proprietary information. It also undermines the purpose of a competitive solicitation.

51 DMS-2223-072

HMO 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.

52 HMO_

Attachment A-

AR

Admin Req AND ASO_No Rx_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.

53 Attachment J – Scrubbed Claims Data (Aon Provider Raw Claim 2022 HMO.txt) & HMO_Attachme nt D - Cost.xlsx

ASO 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.

54 Attachment J – Scrubbed Claims Data (Aon Provider Raw Claim 2022 HMO.txt) & HMO_Attachme nt D - Cost.xlsx

ASO 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. Per these instructions, a Respondent submitting for more than one service area should submit a different file for each Region for the disruption report and repricing data.

55 HMO_Attachme nt A - Administrative

ASO_No Rx_Admin Req.

#88 Can you confirm that providing the industry standard 3/31 period-end report and a subsequent bridge letter to

The Negotiation Team reserves the right to negotiate different terms, additional terms, and related price adjustments if the

ITN No.: DMS-22/23-072 Questions and Answers Page 12

Document or Attachment

Tab or Section

Q# or Location

Question Answer

Requirements_0 7.27.2022 address 4/01 – 6/30 meets Administrative Requirement #88 SSAE Reporting Timing?

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.

56 HMO_Attachme nt B - Technical.xlsx

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 revisions to the “Other” column for this question in the Revised Attachment B – Technical attached to Addendum 1. .

57 DMS-2223-072

HMO ITN.pdf n/a Form 5 and Form 6

Confirm on HMO that the "b" forms of 5 and/or 6 are not required, if we do not bid on the pharmacy portion

Respondents not submitting a Reply for the HMO Pharmacy Carve-In option are not required to submit Forms 5b and 6bcre.

58 HMO_Attachme nt D Cost

ASO HMO #7 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 Respondent is willing to provide. See Attachment A – Performance Guarantees which speaks to discount guarantees.

ITN No.: DMS-22/23-072 Questions and Answers Page 13

Document or Attachment

Tab or Section

Q# or Location

Question Answer

59 HMO_Attachme nt D Cost

ASO HMO #8 Trend Guarantee please confirm you would like the trend guarantee by region and penalty would be based upon the aggregate results of the region awarded?

A Respondent’s submitted trend should be an aggregate of the trends for the Respondent’s proposed regions.

60 HMO_Attachme nt A - Administrative Requirements_0 7.27.2022

ASO_No Rx_Admin Req.

26 Administrative Requirements item # 26 looks like it may be cut off. Can you provide the full text if so?

Please see the revisions to the Administrative Requirements in the Revised Attachment A – Administrative Requirements attached to Addendum 1

61 Attachment J – Scrubbed Claims Data (Aon Provider Raw Claim 2022 HMO.txt)

ASO Medical Repricing n/a HMO repricing- you want broken out by Region- can you provide instructions on which indicator in the file to use?

Should bidders provide just the lines with these indicators in the response file for each region?

Repricing data should be provided pursuant to the instructions in Attachment D - Cost in the “Medical Repricing” tab. Per this instruction, a Respondent submitting for more than one service area should submit a different file for each Region for the repricing data.

Region assignment is provided in the column labeled “Region Map.” The Regions are defined within Attachment A – Administrative Requirements, in the Map of Options, Carriers tab.

62 Attachment J – Scrubbed Claims Data (Aon Provider Raw Claim 2022 HMO.txt) AND HMO_Attachme nt C - Network.xlsx

Disruption n/a HMO Disruption- you would like this run by each region. Can you provide instructions on which indicators to use?

Should bidders provide just the lines with these indicators in the response file for each region?

Use the Regions Map column within the Attachment J – Scrubbed Claims Data to determine the providers for each Region. The Regions are defined within Attachment A– Administrative Requirements, in the Map of Options, Carriers tab.

63 HMO_Attachme nt A - Administrative Requirements_0 7.27.2022.xlsx

ASO_No Rx_Admin Req

VII. Claims Processing, #55

"Please confirm ""PPO plan"" is meant to be ""HMO plan"" instead here: ""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.""

Please see the amended Standard Claims Administration Practices administrative requirements in the revised Attachment A – Administrative Requirements attached to Addendum 1.

64 HMO_Attachme nt B - Technical.xlsx

Tech Q, Disease Mgmt, Clinical Programs, Fully- Ins. HMO Plans

N/A At the top of the Tech Q, Disease Management, Clinical Programs and Fully-Ins. HMO Plans tabs, there are drop downs where carriers can indicate Carve-in / Carve-out. Please clarify if these drop downs in each tab are

Correct. This is to help determine which option the Respondent is proposing.

ITN No.: DMS-22/23-072 Questions and Answers Page 14

Document or Attachment

Tab or Section

Q# or Location

Question Answer always referring to whether pharmacy is carved in or carved out of the HMO medical plan.

65 Attachment J – Scrubbed Claims Data (Aon Provider Raw Claim 2022 HMO.txt)

ASO Medical Repricing n/a Can you confirm bidders do not need to reprice the Out of Area claims for the HMO repricing exercise

Confirm.

66 Attachment H:

Data Use Agreement

N/A Please confirm that the Access List on page 4 of Attachment H can include employees of the Respondent’s PBM.

Existing and prospective subcontractors are recognized under the ITN and presumed to be acting on behalf of the vendor with whom they contract. (See ITN 1.8, 3.2 subsection 7, 3.9 and Form 4.) In order to respond to the ITN, Attachment H: Data Use Agreement, states that the Department is providing vendors access to protected health information (“PHI”) contained in Attachment I: Census File and Attachment J: Scrubbed Claims Data.

Vendors are required to maintain a list of all persons granted access (“Access List,” Attachment H, pg. 4). Please confirm that the Access List can include employees of the Respondent’s PBM whose access is necessary for the vendor to respond to the ITN and who agree to abide by the terms specified in Attachment H.

Please see the applicable revisions to the ITN issued through Addendum 1 and the Attachment H2 – Data Use Agreement attached thereto.

67 Attachment D FI HMO Premium

Respondents are requested to submit proposed fully insured ‘Monthly Premium Rates for Medical with same Pharmacy Carve-in as Actives for Medicare Retirees (EGWP)’. However, the accompanying instructions for these rates [cell C16] state "Submit rates for Medicare retirees on a RDS basis.", which is not pertinent to a fully-insured product option for Employer Groups and

Please see the applicable revisions in the Revised Attachment D – Cost attached to

ITN No.: DMS-22/23-072 Questions and Answers Page 15

Document or Attachment

Tab or Section

Q# or Location

Question Answer is not available for Medicare Retirees in the current offering of a Fully-Insured MAPD EGWP. Please confirm the Department is requesting Fully-Insured HMO with Pharmacy Carve-In rates on an EGWP basis consistent with the current Fully-Insured MAPD EGWP offering.

68 Attachment D FI HMO Premium

Respondents are requested to submit rates for the following 2 coverage tiers:

‘Employee/Retiree Only’, which is currently described as the ‘MCR I’ coverage tier ; Employee/Retiree + Family’, which is currently described as the ‘MCR II’ coverage tier. This requested tier structure precludes the ability to submit rates for a family plan for only two people where both are eligible for coverage for Medicare Parts A and B due to age 65 or disability, which is currently described as the ‘MCR III’ coverage tier. How/where can a Respondent provide proposed rates for this existing coverage tier?

To calculate Medicare III where two people are both eligible for Medicare, the monthly premium rate listed for “Employee/Retiree Only” in Attachment D

– Cost FL HMO Premium tab will be doubled.

69 Attachment D FI HMO Premium

4 "The structure of this tab does not enable a respondent to submit rates independently of, or in addition to, the requested scenarios of: ‘Medical with Pharmacy Carve-In [for] Actives, COBRA, & Early Retirees’ coupled with ‘Medical with same Pharmacy Carve-In as Actives for Medicare Retirees (EGWP)’; or, ‘Medical Only with Pharmacy Carve-Out [for] Actives, COBRA, & Early Retirees’ coupled with ‘Medical Only with Pharmacy Carve-Out Medicare Retirees’.

Specifically, in addition to submitting rates in the requested scenarios provided in the template, a respondent is unable to submit proposed rates for the scenario ‘Medical Only with Pharmacy Carve-Out [for] Actives, When responding to Attachment D – Cost, please provide rates for the Actives, COBRA, and Early Retirees on a carved-in and carved-out basis and also provide rates for Medicare-eligible retirees in the column to the right of the “Actives, COBRA, and Early Retirees” column on a carved-in and carved-out basis.

Please see the applicable revisions in the Revised Attachment D – Cost attached to

ITN No.: DMS-22/23-072 Questions and Answers Page 16

Document or Attachment

Tab or Section

Q# or Location

Question Answer

COBRA & Early Retirees’ coupled with ‘Medical with Same Pharmacy as Actives for Medicare Retirees (EGWP), which matches the current benefit offering provided to Medicare Eligible Retirees in the Tallahassee market.

Please provide instructions of how/where can a Respondent submit proposed rates for this existing benefit coverage offering?

70 Attachment D "Rx Pricing Factors Rx Admin Fees Comm Rx Pricing Trans Comm Rx Pricing MFP Comm Rx Pricing Spec Comm Rx Alt Pricing FI HMO Premium"

The requested detail information and associated guarantees in tabs ‘Rx Pricing Factors’, ‘Rx Admin Fees Comm’, ‘Rx Pricing Trans Comm’, ‘Rx Pricing MFP Comm’, ‘Rx Pricing Spec Comm’ and Rx Alt Pricing’ are all pertinent to a self-insured contract but not to a fully-insured contract, where the Department is provided a total cost guarantee via the Fully-Insured Monthly Premium Amount.

ITN Sections 4.4.1 and 4.6.1 explicitly state that, for a Reply that includes Pharmacy Carve-In Services, the Consultant will project self-insured gross plan expenses for medical and pharmacy based, in part and with respect to pharmacy, upon Aon’s market trend assumptions adjusted for expected differences based on Respondents information contained in these tabs.

In contrast the Consultant will project fully-insured gross plan expenses for medical and pharmacy based upon the premiums for fully-insured, as reflected in the ‘FI HMO Premium’ tab.

Consequently, please confirm that a Respondent that is submitting a Reply that includes HMO Pharmacy Carve-In

A Respondent submitting a Reply that includes HMO Pharmacy Carve-In services on a fully insured basis is not required to provide the information requested in tabs ‘Rx Pricing Factors’, ‘Rx Admin Fees Comm’, ‘Rx Pricing Trans Comm’, ‘Rx Pricing MFP Comm’, ‘Rx Pricing Spec Comm’ and Rx Alt Pricing’ in Attachment D – Cost.

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Question Answer services on a fully insured basis, is not required to provide the information in the aforementioned tabs.

71 Attachment I Census_05.26.2

"The field ""Dummy Member ID"" in the file “Florida DMS RFP – HMO.txt” from Attachment J – Scrubbed Claims Data does not appear to match the field ""BI Member ID (Elig)"" from the ”Census_05.26.2022” tab in the file “Census_05.26.2022 (to send).xlsx” from Attachment I – Census File, precluding the ability to identify pharmacy utilization of members within a specific geographic region of eligibility, for use in developing proposed FI HMO premium rates.

Attachment J – Scrubbed Claims Data is supplemented with HMO_Attachment J – Rx Claims Data_09.07.2022 which includes an updated pharmacy claims file that now includes a column to show Regions. Vendors who previously submitted a timely Attachment H: Data Use Agreement will be sent a OneDrive link from the Procurement Officer to download HMO_Attachment J – Rx Claims Data_09.07.2022, which will remain subject to the terms in Vendor’s Attachment H: Data Use Agreement.

72 DMS-2223-072

HMO ITN

Section 3.3 -

MFMP

Registration and Florida Substitute Form W-9 Process

N/A ITN Section 3.3 states: “The awarded Respondent, if any, will be required to pay the required MFMP transaction fee(s)... unless an exemption has been requested and approved in accordance with Rule 60A-1.031, F.A.C.”

Please confirm that this transaction fee will not be applied to a fully-insured contract.

Such confirmation would be wholly consistent with prior ITN’s, as more fully described, below:

ITN NO: DMS 04/05-082, Health Maintenance Organization (HMO) Services, expressly exempted the MFMP transaction fee from the solicitation. (ITN NO,: DMS 04/05-082, Section 5 Special General Conditions,

5.08 Exceptions.)

Likewise, ITN NO: DMS 10/11-010, Pharmacy Benefits Plan Management

The MFMP transaction fee is assessed in accordance with section 287.042(1)(h), F.S. and Rule 60A-1.031, F.A.C.

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Services, provided that the MFMP transaction fee did not apply to payments made under that contract. In response to questions received, the Department issued Amendment 5 which included the following question and answer:

Question #8 Would the State please outline the details expected for the MyFloridaMarketPlace?

Answer #8 The 1% MFMP transaction fee does not apply to payments made under this contract and the invoices will not be processed through the MFMP system.

(ITN NO: DMS 10/11-10, Amendment 5.)

ITN No. DMS 16/17-018, Fully-Insured Health Maintenance Organization Benefits and Self-Insured Health Plan Services, specifically provided that the transaction fee would only apply to awarded vendor(s) providing self-insured health plan services.

2.6 MFMP Registration

The awarded vendor(s) providing self-insured health plan services shall pay the required MFMP transaction fee(s) as specified by statute, unless an exemption has been requested and approved prior to the award of the contract pursuant to Rule 60A-1.032 of the Florida Administrative Code.

The transaction fee that third party vendors providing self-insured health plan services were required to pay was applied only on the Administrative

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Services Only (“ASO”) fee. Not applying the transaction fee to vendors providing fully-insured health plan services recognized the factual reality that those vendors would be disproportionally impacted if required to pay the transaction fee on the entire premium amount of a fully-insured contract.

ITN NO. DMS-22/23-072, Third Party Administrative Services for HMO Health Insurance, states “The awarded Respondent, if any, will be required to pay the required MFMP transaction fee(s) as specified in Section 14 of the PUR 1000, unless an exemption has been requested and approved in accordance with Rule 60A-1.031, F.A.C.”

Please confirm that, similar to past ITNs, the transaction fee will not be required of Respondents providing fully insured HMO benefits.

73 Attachment I Census_05.26.2

"The field ""Dummy Member ID"" in the file “Florida DMS RFP – HMO.txt” from Attachment J – Scrubbed Claims Data does not appear to match the field ""BI Member ID (Elig)"" from the ”Census_05.26.2022” tab in the file “Census_05.26.2022 (to send).xlsx” from Attachment I – Census File, precluding the ability to identify pharmacy utilization of members within a specific geographic region of eligibility, for use in developing proposed FI HMO premium rates.

Can the Department provide a cross-walk, or some other data element(s) or methodology, to enable a Respondent to link these data fields, or otherwise identify pharmacy utilization of each

Please see response to #71

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Question Answer member by their specific geographic region of eligibility?

74 Attachment J N/A Pharmacy Can you send claims data for Pharmacy by Region (similar to the Medical claims file).

Please see response to #71

75 N/A N/A N/A Please describe how the ASO with Rx proposal will be evaluated when considering the stand alone PMB will cover the entire state vs awarded regions.

See Section 4.6.1 of the HMO ITN document.

76 Attachment B Tech Q Banking Section Q34 a & b (lines 346-348)

Please provide clarification on question 34 a & b. Define what is being requested under a. Percent & b.

calculation description.

Question 34a is asking for the Respondent’s variance percentage when a client is self-billed.

Question 34b is asking for Respondent to describe the calculation used to determine the self-billed amount.

77 A-AR Read Me Scope of Work Please confirm a Respondent can submit both a Carved-In and a Carved- Out Pharmacy response for the HMO response. Our understanding is the Carved-In Pharmacy solution will only be evaluated in the Negotiation Phase if Respondent is selected for this Phase.

Please also confirm if Respondent is selected for the Negotiation Phase that both their Carved In-Pharmacy and Carved-Out Pharmacy responses will be reviewed to determine which proposal option provides best value to the State.

A Respondent can submit a Reply which proposes both Carve-In and Carved-Out services. A Respondent should, in submitting Attachment A – Administrative Requirements, in a Reply indicate in the Read Me First tab all coverage line options included in the Reply.

A Respondent’s HMO Pharmacy Carve-In option will only be considered by the Negotiation Team if the Respondent is selected to negotiate with the Department in the negotiation process. r

78 ITN Overview 4.6.1 - Negotiations page 27 "The ITN indicates that the department selects one or more Respondents within ""competitive range"". Would the State please quantify what

The competitive range will be determined by the Department in accordance with section 4.2 of the ITN.

79 ITN Overview 1.5 Page 6 Will the State consider a statewide contract with a vendor if they provide best in class aggregated value across the 9 regions? If so, would a regional

Please see ITN sections 1.5 and 5.1.

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Question Answer vendor be a offered as well where the statewide offering may not be best in class for that region?

80 A-AR ASO-No RX Admin

6 Please provide sample of report card tied to PGs 4-6

The Department will discuss the content of the report card with Respondent(s) selected to negotiate with the Department.

81 A-AR ASO-No RX Admin

8c Please clarify intent for a dedicated and exclusive claims facility. May the claims facility support other clients yet operate a dedicated and exclusive claims processing/audit team for the State from this shared facility?

The claims facility can be dedicated but not necessarily exclusive. Please see the amended Administrative Requirements in the Revised Attachment A – Administrative Requirements attached to Addendum 1.

82 A-AR ASO-No RX Admin

30i Please confirm an overflow customer care team is able to service calls after hours and on weekends.

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

83 A-AR ASO-No RX Admin

38 Confirm how national provider counts outside of Florida/GA/AL will be assed for access and disruption? Also, please confirm weighting, if any, for company owned provider network versus a network comprised of subcontractor networks. The requirements indicate 80% of the network must be owned by the vendor, correct?

For this HMO ITN, a Respondent’s proposed network and disruption will only be assessed based on each region and the national network will not be assessed.

A Respondent must own 80% of the Respondent’s proposed network within the State.

84 A-AR ASO-No RX Admin

38 It appears in PGs that network access criteria will be based on the vendor's Florida network yet the State also references reporting of national networks. How will national network value be assessed in addition to regional or statewide value and how does PG criteria apply outside of FL?

For this HMO ITN, a Respondent’s proposed network will be assessed based on each region and a national network will not be assessed. Performance Guarantees related to network access are assessed based on the awarded or aggregated region(s).

85 A-AR ASO-No RX Admin

55 The requirement refers to the PPO.

Please confirm the requirement was intended to refer to the HMO plan.

Please see the amended Standard Claims Administration Practices administrative requirements in the revised Attachment A – Administrative Requirements attached to Addendum 1.

86 A-AR ASO-No RX Admin

113 - Special Provisions

Does the State allow a PCP election requirement on the HMO plan for either the broad or narrow network program?

If so, confirm the State's willingness to allow a PCP, referral driven model

The HMO plan will be an open access model where a referral is not required.

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(gatekeeper model) versus a PCP open referral model (no referral required to see specialty but PCP designation required).

87 A ASO-No RX Performance Guarantees

7a-8c - Network 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.

88 A ASO-No RX Performance Guarantees

7a-8c Network 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, Definitions attached to Addendum 1.

89 A ASO-No RX Performance Guarantees

21 - Claims Processing

Are each of your current HMO vendors 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 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.

90 A ASO-No RX Performance Guarantees

15b - Member Satisfaction Survey

Please confirm current member satisfaction level for each HMO vendor or aggregated across HMO vendors.

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.

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91 A ASO-No RX Performance Guarantees

37 - 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 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.

92 Attachment A ASO_Rx_Perfor m G

(Pharmacy Performance Guarantees) 31 Desktop Audits

Please clarify/confirm the Standard/Goal and Measurement Criteria. 10.0% of scripts seems like an usually high number of scripts (~400K) to perform desktop audits on and it also doesn’t match the Amount at Risk description.

Please see the amended performance guarantee in the Revised Attachment A – Administrative Requirements, attached to Addendum 1.

93 Attachment A ASO_RX_ Admin Req

152 d. iii and 152 e. iv

The phrase “shall not apply only exclude to” is confusing. Can you please clarify the meaning?

Please see the amended Attachment A – Administrative Requirements, attached to Addendum 1.

94 Attachment A ASO_Rx_Perfor m G

(Pharmacy Performance Guarantees) 5 Open Enrollment Benefit Fairs

Confirm estimated number of locations and benefit fairs the vendors will attend for Open Enrollment

Number and locations may vary each year, and Open Enrollment Benefit Fairs may be virtual. For the 2022 open enrollment (2023 Plan Year), there are 30 scheduled benefit fairs throughout the state. Attendance is only required at locations in regions for which a vendor is awarded.

95 Attachment B Rx Tech Q Question 6 We were looking to clarify if the request for “specific” refers to 5 client requested (client directed) on-site audits or if it was intended to be 5 percent of participating pharmacies.

Question 6 in the Rx Tech Q tab in Attachment B – Technical is stated correctly

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96 B-Section 2 Wellness Wellness Question 33

What is the minimum number…