RFP 2025HCA5 Exhibit C1.2 - Written P1.docx

EXHIBIT C1.2 – WRITTEN PROPOSAL PHASE 1

Bidder must answer all questions in this exhibit. This Exhibit must be completed in its entirety in accordance with the page limits identified within this exhibit (See RFP #2025HCA5 Section 3.2.D). Bidder should respond using this exhibit as its template, to ensure compliance with the formatting requirements outlined in RFP #2025HCA5 Section 3.2.D.

Questions in this exhibit are tied directly to specific sections of Exhibit B, Draft Contract, Attachment 3: Statement of Work (also referred throughout this exhibit as SOW). Those Statement of Work (SOW) sections are restated in this exhibit for Bidder reference. Should there be any discrepancy between the SOW sections stated here and those in Exhibit B, Exhibit B will control.

1. SOW Section 1 – Plan Design for Fully Insured Health Plans

1.1 Health Plan Type

This Contract is the result of a solicitation for commercial fully-insured Health Plans (Alternative Payment Model or APM, Exclusive Provider Organization or EPO, Health Management Organization or HMO, or Preferred Provider Organization or PPO) designed by the Contractor. The Contractor must demonstrate the ability to provide all staffing, systems, and procedures required to perform the services described in this RFP, have the ability to customize those systems to meet the needs of HCA’s ERB Division now and during the lifetime of the Contract, and demonstrate a culture of flexibility, innovation, and adaptability in order to develop and administer innovative health care solutions and strategies that align with broader, evolving health care changes.

Fully-insured Health Plan(s) will be offered to non-Medicare Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) Program Subscribers and their Dependents, but will each be separately rated for and provided to the PEBB program and the SEBB program. The total number of Health Plans being procured is up to six (6) per Contractor: up to three (3) for PEBB and up to three (3) for SEBB. However, each of the Health Plans offered to PEBB must be identical in plan design to the Health Plans offered to SEBB.

All Health Plans must be approved by both the PEB Board and the SEB Board and must be open only to PEBB and SEBB Members. HCA, at its sole discretion, will determine the Health Plans to be presented for final approval of the PEB and SEB Boards.

Contractor must have their contract manager(s) attend all public PEB Board meetings and SEB Board meetings virtually or in person during the lifetime of the Contract so that A. PEB and SEB Boards’ discussions and decisions are heard and understood by Contractor;

B. Contractor is aware of PEB and SEB Boards’ directives regarding plans, including Data reporting, benefit coverage, customer service issues, or other items that may be discussed at board meetings;

C. Contract managers may answer questions directly from the PEB and SEB Boards, if the ERB Director or Chief Medical Officer (CMO) approve; and D. Contractor establishes a partnering relationship with the PEB and SEB Boards.

1.2 Health Plan Design Requirements

HCA requires these plans to:

A. Maintain a Federal Actuarial Value of eighty percent (80%) to ninety-two percent (92%).

B. Use standardized Medical Deductible levels and Maximum Out-of-Pockets as outlined in RFP #2025HCA5 Exhibit G - Plan Design Outline.

C. Outline all medical and pharmacy co-pay, co-insurance, visit limits, and deductible accumulators as well as other questions per the instructions on RFP #2025HCA5 Exhibit G - Plan Design Outline.

D. Account for all pharmacy expenses and rebates and report those amounts to HCA (see RFP #2025HCA5 Exhibit D Cost Proposal Template and ATTACHMENT 7: CONTRACTOR REPORTING SCHEDULES AND TEMPLATES).

E. Eliminate any annual vision exam or a hardware/contact lens benefit. These benefits are currently provided by HCA’s contracted fully-insured vision carriers. However, vision care for infections, diseases, and disorders of the eye should continue to be covered under the Contractor’s proposed medical plans; and F. Comply with all requirements contained in other sections of this Contract.

1.3 Additions or Reductions to Number of Health Plans

A. HCA reserves the right to add, at any time, Health Plans to the scope of this Contract (each an “Additional Health Plan”), either in place of or in addition to any existing Health Plans. In the event HCA exercises this right, it must provide Contractor sixty (60) Calendar Days’ notice of such change.

B. HCA reserves the right to remove any Health Plan(s) within the scope of this Contract at any time. In the event HCA exercises this right, it must provide Contractor sixty (60) Calendar Days’ notice of such change. As of the effective date of the removal of a Health Plan, Contractor must no longer charge, and HCA must not be obligated to pay any Monthly Premiums for such Health Plan.

C. Contractor should have adaptable Health Plans and Claims processing systems that allow for realignment should the Legislature, Governor, or other governing entity mandate consolidation of the PEBB and SEBB programs into a single program or entity at some future date. This consolidation could result in a single financial risk pool containing PEBB and SEBB Members including both active employees and Non-Medicare Retirees. The outcomes of future Legislative actions after the execution of this Contract must be accounted for by Contractor.

1. Bidder Questions – SOW Section 1 Plan Design for Fully Insured Health Plans

1.1. (Yes = 5 points; No = 0 points) Attest that Bidder understands and agrees to meet all requirements for Plan Design set forth in SOW Sections 1.1 Health Plan Type, 1.2 Health Plan Design Requirements, and 1.3 Additions or Reductions to Number of Health Plans.

☒ Yes ☐ No

1.2. (20 points) Outline the staffing, systems, and procedures the Contractor has in place to perform the required services outlined in this RFP. (Not more than three pages, 10pt, single spaced)

1.3. (30 points) Briefly explain your ability to customize these existing systems to meet the needs of HCA’s ERB Division, and how your organization demonstrates a culture of flexibility, innovation, and adaptability to develop and administer innovative health care solutions and strategies that align with broader, evolving health care changes. (Not more than two pages, 10pt, single spaced)

1.4. (40 points) HCA has outlined in SOW section 1.2 Health Plan Design Requirements, the parameters of the commercial health plans (Alternative Payment Model or APM, Exclusive Provider Organization or EPO Health Management Organization or HMO, Preferred Provider Organization or PPO) to be designed by the Bidder. For each proposed Health Plan (maximum of three (3) for PEBB and maximum of three (3) for SEBB), complete a separate Exhibit G: Plan Design Outline with details of the plan Federal Actuarial Value, service area counties, deductibles, maximum out of pockets, and copays or coinsurance for the listed benefits.

2 SOW Section 2 Plan Administration

2.1 Basic Health Plan Operations

Contractor must:

A. Perform all administrative services within the United States, including clinical decision-making by clinicians licensed in the United States, administrative and clinical Claims processing and adjudication, Data storage, customer service, and Data transfers.

B. Comply and remain in full compliance with all federal and state Data security and privacy requirements, including but not limited to HIPAA, HITECH Act, and WaTech IT Policies.

C. Notify HCA in writing as soon as possible, but no later than thirty (30) Business Days, after Contractor becomes aware of any changes in law or regulation that may require a change to Health Plan benefits, rates, or other terms under this Contract. For federal law or regulation changes, Contractor must notify HCA in writing as soon as possible, but no later than forty-five (45) Business Days, after it becomes aware of any changes that may require a change to health plan benefits, rates, or other terms under this Contract. The scope of this notification is limited to the large group, fully-insured commercial market. Contractor must notify HCA of the topic and source of change, and the date of the statute or regulation was finalized, and its’ effective date. The sources of changes must include applicable statutes or regulations. For federal statutes or regulations, Contractor agrees to collaborate with HCA on making any necessary changes to this Contract.

D. Provide proper banking registration with State of Washington to allow acceptance of premium payments from HCA.

E. Commit at an organizational level to actively support and participate in statewide health transformation efforts.

F. Commit to facilitate conversations between HCA and Contractor’s Participating Providers, if requested by HCA.

G. Demonstrate executive endorsement of community-wide transparency efforts on quality, utilization, pricing, and sharing medical Claims Data, including metrics related to price and quality.

H. Provide HCA with the results of its NCQA accreditation review and maintain accreditation over the term of the Contract.

I. Demonstrate a network contracting and credentialing program for providers of care and services that meets all NCQA accreditation standards and that applies to all providers in all networks available to HCA Members.

J. Provide a fully operational Claims payment service according to the provisions laid out in Section 2.7. Claims Services below, including the ability to pay Claims electronically.

K. Have a documented protocol for processing and paying of out-of-network Claims, when applicable.

L. Have flexible Claims and payment systems that can support and adapt to innovative strategies and new financial reimbursement models.

M. Provide a system for prompt payment of all emergency care, regardless of network restrictions.

N. Issue Members identification cards using unique, permanently assigned, HIPAA compliant, non-Social Security Number (SSN) based Member identification numbers. Contractors must ensure that Participating Providers accept the HCA-issued notice of enrollment as sufficient verification of enrollment to access Covered Services until an official identification card is issued to the Member. Contractor must send each new Subscriber a welcome packet upon initial enrollment into the Contractor’s Health Plan and after subsequent Open Enrollment periods. Contractor must mail the welcome packet and ID cards to Members beginning on or around December 20 each year.

O. Ensure Covered Services received by a Member align to the Member’s coverage effective date.

P. Have protocols for processing of Appeals and Complaints per standards outlined in ATTACHMENT 4: PERFORMANCE STANDARDS AND PERFORMANCE PAYMENTS Q. Accept and process a monthly accumulator file. In certain eligibility situations, PEBB and SEBB Members may move from one (1) HCA program to another within the portfolio during the course of a Plan Year. For example, a scientist from the Department of Ecology might accept a teaching position from a school district in August and disenroll from PEBB benefits to enroll in SEBB benefits. HCA requires that individual Health Plan accumulators—like accumulated visits for services with visit limits, dollars toward deductible and out-of-pocket maximums — transfer from one program’s Health Plan to the other as long as Members stay with the same Contractor. Contractors must participate in this process. Contractor must retrieve a monthly accumulator file from HCA’s MFT site and ensure that Members on the accumulator file have their accumulators applied to their new Health Plan as long as the move is made within the same Plan Year. An example of the accumulator file format is included in ATTACHMENT 19 ACCUMULATOR FILE SPECIFICATION of this Contract.

R. Have the operational means for processing Disabled Dependent certifications and re-certifications on time so the Dependent does not lose coverage.

S. Have the ability to apply standard Coordination of Benefits rules for all Medicare Members’ Claims (End Stage Renal Disease (ESRD), etc.), consistent with Washington insurance Regulations in chapter 284-51 WAC (Example: A member diagnosed with ESRD has met the 30-month coordination period and Medicare becomes primary payor for ESRD related services). Coordination of Benefits with Medicare using all Medicare crossover Claims, including those paid in full by Medicare, and Claims from Members or their providers for services not covered by Medicare that may be covered by HCA.

T. Have the ability to prepare medical and pharmacy prior authorization standards and criteria, consistent with RCW 41.05.074(3) and Washington insurance Regulations RCW 48.43.016, and to timely provide those prior authorization standards and criteria to HCA in the format set out by HCA in ATTACHMENT 15 PRIOR AUTHORIZATION REPORTING INSTRUCTIONS (PROCEDURES FOR COMPLIANCE WITH RCW 41.05.074(3)), so that HCA may make them publicly available online on the HCA website by no later than the first day of each month.

U. Commit to provide and coordinate customized reporting of fully-insured Health Plan offerings to HCA leadership at least twice per year at Health Plan performance meetings that discuss overall Health Plan performance, including strategies for improving Health Plan efficiency, newly proposed care transformation activities, and other reporting, as requested by HCA. The Contractor will provide an agenda, created in collaboration with HCA, for these meetings no later than three (3) Business Days before the meeting date and will facilitate the Health Plan performance and member experience meetings. The Contractor must be prepared to present and discuss produced deliverables. Contractor attendees must include parties with expertise in the topics on the agenda, including clinicians and other clinical and quality subject matter experts.

V. Consistent with Laws of 2025, Ch. 424, § 210, Contractor will promptly notify the assigned HCA Account Manager and HCA will notify the Washington State Office of the Attorney General upon receipt of a request from or on behalf of a federal agency or a federal, state, or local law enforcement authority for health care information, as defined in RCW 70.02.010, program eligibility information for individuals, information that may identify a health care provider's or facility's delivery of health care services to noncitizens, or the delivery of protected health care services as defined in RCW 7.115.010.

2.2 Eligibility Files and File Systems

HCA is the system of record for all Member eligibility. For purposes of enrollment and eligibility, HCA systems provide final determination. Eligibility, enrollment, Claims, and all other Data is owned and belongs to HCA. Contractors must:

A. Retrieve daily HIPAA Compliant 834 Eligibility Files and other relevant files from a Managed File Transfer (MFT) protocol site hosted by Washington Technology Solutions (WATech), the state’s enterprise IT solution center. Contractors must provide authorized staff to be registered with WATech for accounts and passwords to access the MFT portal. Please review ATTACHMENT 17 MFT USER GUIDE for more details.

B. Accept and ingest daily HIPAA Compliant 834 Eligibility Files according to the process outlined in ATTACHMENT 13: DATA SHARING TERMS in the format detailed in ATTACHMENT 18 834 COMPANION GUIDE.

C. Accept all changes on HIPAA Compliant 834 Eligibility Files as directed by HCA and on HCA’s timelines. HCA has sole discretion to change or add to format, layout, fields and all other elements within the 834 files, with sixty (60) Calendar Days’ notice. Contractor will implement changes within sixty (60) Calendar Days and at no additional cost.

D. Report any issues with HIPAA Compliant 834 Eligibility Files via email to ISPEBBSR@hca.wa.gov to ensure accurate tracking.

E. Complete quarterly full eligibility file matches with HCA (and HCA’s business partners, if applicable), promptly reconciling any discrepancies on those files, and reporting any reconciled differences or unresolved discrepancies to HCA. HCA will schedule standing quarterly meetings for review of file processing and discrepancy reports. Subject matter experts from Contractor will be required to meet with HCA Enterprise Technology Services (ETS) staff and HCA Account Manager to review file processing and repair or reconcile any discrepancies.

F. Accept and store all nonbinary gender indicators on HCA’s HIPAA Compliant 834 Eligibility File. All HCA forms (electronic and paper) include fields for “Sex Assigned at Birth” (“M” or “F”) as mandatory and “Gender Identity” (“M”, “F”, or “X”) as optional. The Contractor must have a solution/system/process by which membership services and clinical staff assure World Professional Association for Transgender Health (WPATH) compliance in avoiding misgendering of Members when they arrive for initial and subsequent visits.

G. Create, maintain, and collect separate and unique Data fields for Member self-reported demographic Data to the Contractor. HCA is focused on addressing Health Equity and the impacts of Social Determinants of Health. Subscribers will be asked during the enrollment process to voluntarily self-report their race, ethnicity, and language (REL), their sexual orientation and gender identity (SOGI), and any disability. Once available, this Data will be provided to the Contractor on the HIPAA 834 Eligibility File transmission. This population Data (except for Medicare Advantage required Data) will not be reported to CMS.

H. Ingest and maintain Member accounts for “split accounts” where the Subscriber may be on a separate HCA Health Plan (usually a Medicare plan) while the Dependents are on the Contractor’s Health Plan.

I. Participate in file-mapping and file testing processes during implementation of Health Plans and at any necessary occasion during the life of this Contract.

J. Generate unique, permanently assigned, HIPAA compliant, non-Social Security Number (SSN) based Member identification numbers for eligible Members. Any subsequent changes to the Member record will be sent over daily on the HIPAA Compliant 834 Eligibility File to the Contractor.

K. Maintain accurate information and share such information with other contractors working with the HCA (i.e., HCA’s actuary, wellness program vendor, etc.). This process may involve transmission of daily and weekly eligibility files within HCA required timelines.

L. Integrate information from other HCA vendors to achieve effective and efficient coordination of services. Contractor also will be required to transfer Member SSNs to other HCA vendors via secure files and audit those files for Data reconciliation on a quarterly basis.

M. Accept invoicing files for electronic transfer of funds in HCA’s proprietary format and at HCA’s sole discretion to align with Washington State Office of Financial Management’s Automated Clearinghouse (ACH) system AFRS. This file format does not at present conform to 820 File standards.

2.3 Use of Artificial Intelligence

A. All AI Systems used by Contractor or its authorized agents in performance of this Contract that access, process, transmit, or retain HCA Data shall operate within a secure sandbox environment that complies with Contractor’s Data security, confidentiality, privacy, and other obligations set forth in this Contract. The Contractor shall ensure that any HCA Data it receives is not retained, disclosed, or shared with any unauthorized third-party, or used to train, fine-tune, or otherwise improve an AI system or third-party AI model, except as expressly authorized in writing by HCA prior to such action and to the extent such action is permitted by applicable law. For avoidance of doubt, the term “AI System” is defined as that term is used in National Institute of Standards and Technology Artificial Intelligence Risk Management Framework (NIST-AI-100-1).

B. All AI Systems used by Contractor or its authorized agents in performance of this Contract shall be used as supplementary tools to augment, not replace, human professional judgement, oversight, and accountability. Except where approved in writing by HCA prior to such action, all material outputs, recommendations, determinations, or decisions generated or informed by an AI System shall be reviewed, verified, and approved by a qualified human professional who is (i) an employee or (ii) an authorized agent of Contractor before such outputs, recommendations, determinations, and/or decisions are provided to HCA, an Enrollee, a Provider, or otherwise implemented under this Contract.

C. The Contractor and its authorized agents (including Subcontractors or vendors) shall ensure that the development, acquisition, implementation, use, and output of any AI system used by Contractor or its authorized agents in the performance of this Contract complies with applicable local, state, and federal laws and regulations, including but not limited to, privacy laws and AI-specific transparency or disclosure mandates.

D. The Contractor shall utilize a standardized risk assessment framework at least as stringent as the National Institute of Standards and Technology Artificial Intelligence Risk Management Framework (NIST-AI-100-1), or equivalent framework approved in writing by HCA, to clearly identify and designate its “high risk” uses of AI in performance of this Contract. HCA considers uses that impact client access to benefits and care to be high-risk, such as including but not limited to use for claims processing, prior authorization, customer service phone services, fraud, waste, and abuse activities, clinical decisions, and grievance and appeals processing. The Contractor shall maintain written documentation of the risk assessment and designation for each AI System used in performance of this Contract and shall provide such written documentation to HCA promptly upon request.

E. The Contractor shall obtain HCA’s written prior approval,, before any “high risk” implementation or use of AI Systems to perform services under this Contract, including but not limited to, claims processing, prior authorization, customer service phone services, fraud, waste, and abuse activities, clinical decisions, and grievance and appeals processing.

F. The Contractor shall provide HCA with at least ninety (90) calendar days’ advance written notice prior to implementing any (i) new AI System or (ii) materially modifying an existing AI System, that will process or retain HCA Data. HCA may require additional information regarding the proposed AI System, including the purpose, data elements to be accessed or processed, security controls, risk assessment, validation methodology, and applicable third-party entities involved with the underlying implementation.

G. The Contractor shall take reasonable measures to identify, prevent, monitor, and mitigate algorithmic bias, discrimination, inaccurate or unreliable outputs, and other harmful errors associated with its use of AI Systems in performance of this Contract. Such measures shall include appropriate testing and validation based on the intended use and potential impact of the AI System.

H. The Contractor and its authorized agents (including from its Subcontractors or vendors) shall provide HCA with a written inventory of all AI systems used in performance of this Contract, including by its Subcontractors or authorized agents, on a bi-annual basis. The Contractor shall submit the report to HCA no later than January 1 and July 1 of each calendar year.

I. The Contractor shall submit quarterly reports to HCA regarding the monitoring and oversight of AI Systems used in performance of this Contract. At a minimum the reports shall include the AI System’s accuracy, repeatability, reproducibility, bias testing, bias mitigation efforts, material changes to the AI Systems, inaccurate or harmful outputs, security incidents, privacy incidents, and any reported incidences of discrimination or errors connected with the use of such AI Systems. The quarterly reports are due with information from the preceding quarter no later than the first day in the second month of the new quarter (e.g., by February 1, for 2026, by May 1 for Q1 2027, by August 1 for Q2, and by November 1, each reporting year).

J. The Contractor shall not input, transmit, disclose, or otherwise provide confidential information, protected health information, personally identifiable information, HCA Data, or other information protected under this contract into any publicly accessible, unsecured, or otherwise HCA unapproved AI System.

K. Upon HCA’s written request, the Contactor shall provide HCA with documentation sufficient to evaluate any AI System used in Contractor’s performance under the Contract, including as applicable, documentation regarding the AI System’s intended purpose and functionality, risk assessment and classification, material limitations, sources and general characteristics of training, testing data, validation and testing methodology and results, measures used to identify and mitigate bias, security and privacy controls, data retention and use practices, and other information reasonably necessary for HCA to evaluate compliance with applicable laws and Contract requirements.

L. The Contractor must require its authorized agents (including Subcontractors or vendors) to comply with the requirements of this Section 2.3, Use of Artificial Intelligence, as applicable for any use of AI systems as The Contractor remains responsible to HCA for the acts and omissions of its Subcontractors and vendors relating to compliance with this Contract.

M. In case of failure by Contractor, its Subcontractors or vendors to comply with this Section, HCA shall provide written notice of noncompliance to Contractor. Contractor shall have 15 calendar days from the date of the notice of noncompliance to provide to HCA evidence of compliance by the Contractor, its Subcontractors or vendors.

N. Failure by the Contractor, its Subcontractors or vendors to comply with this Section may result in the suspension of AI systems or AI use. Notwithstanding HCA’s existing termination rights under this Contract, including the termination procedures set forth in Section 4.38 Termination, HCA reserves the right to terminate the Contract for cause in the event of Contractor, its Subcontractors or vendors’ noncompliance, including but not limited to a security breach or violation of law.

2.4 Enrollment Provisions

A. Eligibility for Enrollment Eligibility of Subscribers and their Dependents and the terms of their coverage must be as set forth in the COCs, subject to amendment in accordance with current and future provisions of Chapter 41.05 RCW and Title 182 WAC.

B. Concerning Eligibility and Enrollment HCA, as the employer sponsor of the plan, will determine the enrollment and eligibility criteria. HCA will annually provide updated eligibility and enrollment language to be used in Contractor’s COC. The eligibility and enrollment language in the Contractor’s COC will be the language provided by HCA or substantially similar language. “Substantially similar” means that the meaning of the language is not changed from the language provided by HCA, and any change in the language has been approved in writing by HCA.

C. Annual Open Enrollment Periods Contractor must support HCA’s designated Annual Open Enrollment activities each fall, including, but not limited to, developing and delivering communications, attending benefit fairs, and processing enrollment change files.

D. Special Open Enrollments HCA may, at its discretion, authorize special open enrollment periods for Subscribers. Contractor agrees to accept new Members during these special open enrollment periods at the existing Monthly Premiums as set forth in this Contract.

Contractor also must comply with RCW 48.43.517 and RCW 48.43.008, which require special enrollment rights when HCA determines that it is cost-effective to enroll an eligible person participating in a medical assistance program in an employer-sponsored health plan.

E. Retroactive Enrollment To the extent permitted by federal and state law, at the direction of HCA, Contractor must enroll any person for whom HCA pays such person’s Monthly Premium on a retroactive basis, even though the person may not have complied with the prescribed time limits for obtaining coverage. When a person has been retroactively enrolled, services covered during that retroactive period may be limited to those provided by Participating Providers (except if otherwise required by COB provisions included in section 2.1.S above), and emergency care services. In addition, regarding services that require preauthorization, retroactive coverage may be limited to services that would have been preauthorized (except if otherwise required by COB provisions included in section 2.1.S above) had the Member been actively enrolled at the time services were provided.

To the extent authorized by federal and state law, HCA may retroactively disenroll a Member who is not eligible for enrollment in Contractor’s Health Plan(s) or who has not fully paid premiums when due and recoup premium payments paid after the effective date of termination. In the case that HCA disenrolls a Member, any incurred charges whether paid or unpaid, pertaining to the Member will become the responsibility of the Member effective on the date of the disenrollment.

2.5 Account Management

A. Account Management Structure

i. HCA will designate an HCA Account Manager and other Account Management team members as needed for the Contract and send written notice informing the Contractor of these designated personnel at the beginning of each Plan Year. HCA may designate a different HCA Account Manager or other HCA Account Management team member at any time by written notice to Contractor's designated Contract manager(s).

ii. Contractor will designate a Contract management team that is experienced and knowledgeable regarding the Washington State health insurance system, Regulations, and market, as well as readily accessible and responsive to the HCA Health Plan Sponsor(s) and/or HCA Account Manager. This Contractor’s Contract management team will include designated primary and secondary Contract managers as points of contact for Contract management functions. The Contractor will identify the Contractor’s Contract management team, including primary and secondary Contract managers, in writing to HCA at the beginning of each Plan Year. If the Contractor Contract management team changes, the Contractor will notify HCA in writing within thirty (30) Business Days of the change.

iii. Contractor must adjust the number of staff assigned by Contractor to manage the HCA Health Plans dependent on increases and decreases in the number of Members enrolled in the Health Plans, using the guidelines in the chart below. The term “Designated” means such Contractor employee is not dedicated to HCA but will be identified and available as needed.

B. The Contractor’s Contract manager(s) must:

i. Participate in activities to analyze the Health Plan(s), identify improvement opportunities, design interventions, and coordinate implementation with HCA.

ii. Provide proficient coordination of resources and services to meet all requirements and Performance Standards identified in this Contract.

iii. Monitor and report on the requirements to be met by the Contractor as identified in this Contract.

iv. Provide timely support to requests, questions, and concerns from HCA by responding within two (2) Business Days, unless the matter is designated urgent by HCA. The Contract manager will: (A) provide a substantive answer to the request, question, or concern; (B) outline the additional information needed from HCA to answer the request; or (C) indicate the time in which a full substantive answer will be provided.

v. Provide expedited answers to HCA requests for Carrier analysis on proposed legislation and potential impacts to finances within the requested timeframes (usually 24 – 48 hours) during Legislative Session.

vi. Notify HCA of any disruption of normal Contract or Health Plan administration or operational duties without delay, but in no case more than one (1) Business Day after discovery by the Contractor (whether discovered by the Contract manager or anyone else employed by or reporting to the Contractor). Contractor will investigate the issue and provide reasonable cooperation with HCA. At HCA’s discretion, the response may include but not be limited to development of risk assessment, root cause analysis and entering into a corrective action plan, including mitigation and remediation activities. Contractor must provide, at least annually, a detailed review on progress toward meeting previously established goals to the HCA leadership team.

vii. Prioritize succession planning for critical positions on the Contractor’s Contract management team to ensure seamless transitions, accurate Data capture, and documented policies and procedures.

viii. Collaborate with HCA to develop an Operations Manual for the account. HCA and Contractor will begin using an initial version of the Operations Manual by an agreed-upon date. Thereafter, HCA and Contractor will collaboratively work on revisions to the Operations Manual and agree to the effective date of any revisions in writing. The Operations Manual is incorporated by reference into this Contract, and all revisions will become effective when agreed to in writing by both parties. HCA and Contractor will follow the procedures and requirements written in the most recently agreed upon Operations Manual.

ix. Support HCA efforts during Annual Open Enrollment events by having Contractor’s Contract manager(s) and other representatives attend all HCA-sponsored benefits fairs throughout the state in the fall of each contracted year. Representatives must attend the entire benefit fair hours as directed by HCA. The representatives must be able to cover topics such as benefits and cost-sharing, network providers, Claims procedures, Member services, and information tools and resources.

x. Attend other benefit and health fairs sponsored by PEBB agencies or employer groups, and SEBB Educational Service Districts and school districts at Contractor’s own choice and discretion.

xi. Collaborate each Annual Open Enrollment season with HCA on single point of truth document(s) to capture benefit details like copays and cost shares, visit limits, etc. for creation of HCA benefit comparison materials.

xii. Coordinate timely review of HCA’s Member documents for Annual Open Enrollment.

xiii. Provide well in advance all Contractor Annual Open Enrollment Member documents for review by HCA Communications. HCA and Contractor will mutually agree on deadlines for these documents.

C. Emergency Response Contract Management

i. The Contractor must make all reasonable efforts to maintain specific core business functions during natural disasters, severe weather, an extended closure, or emergency, system or power outages, or other abnormal events which, for the purposes of this section, will be considered an “Event.” Contractor must be compliant with HCA Policies included in ATTACHMENT 21 HCA’S DISASTER RECOVERY POLICY. Contractor will:

a. Provide an initial Disaster Recovery Plan (DRP) during implementation that maintains uninterrupted core business operations for Contractor’s Health Plan during an Event.; ATTACHMENT 10: DISASTER RECOVERY PLAN provides an illustrative template for the DRP.

b. By January 1 of each year, for the term of the Contract, Contractor must provide a current DRP specific to Health Plan operations.

c. Within ten (10) Business Days of a written request from HCA, provide the current DRP specific to Health Plan operations.

d. Make all reasonable efforts to maintain specific core business operations during an Event and provide HCA specific information that clearly relates the emergency response to the contracted Health Plans during an Event no less frequently than once per 24 hours.

e. Maintain in an uninterrupted manner specific core business operations listed below during an Event:

i. Account Management section 2.5;

ii. Claims Services section 2.7;

iii. Member Services section 2.8.D;

iv. Access to Care section 6.3;

v. Clinical Programs section 6.4;

vi. Clinical Management Programs section 6.5;

vii. Prior Authorization Standards section 6.6;

viii. Utilization Management Clinical Services section 6.9;

ix. Alternative Contracting Arrangements for Clinical Requirements Section 6.10;

x. Prescription Drug Benefit Section 6.15;

xi. Medical Benefit Drug Benefit Section 6.16; and

xii. Contractor must be compliant with HCA policies included in ATTACHMENT 21 DISASTER RECOVERY POLICY. during any Events.

f. The Contractor DRP is the responsibility of the Contractor. The Contractor’s DRP is included as a key component in building HCA’s internal Business Impact Analysis (BIA). The BIA also may be used to support the development of other contingency plans associated with the system, including, but not limited to the Continuity of Operations Plan (COOP).

g. The BIA establishes the three (3) following imperatives:

i. Determine mission/business processes and recovery criticality;

ii. Identify resource requirements; and

iii. Identify recovery priorities for system resources.

2.6 Certificates of Coverage (COCs)

A. Unless otherwise stated, the benefits and services described in the COCs are hereby incorporated by reference as if fully set forth herein. The parties understand the terms of coverage under this Contract are fully set forth in the COCs in effect for the Plan Year in which services were received.

B. Upon notification by HCA, or Office of Insurance Commissioner (OIC), that any COC contains provisions that are in conflict with this Contract or non-compliant with state or federal regulation or law, Contractor must amend the COC and provide notice of the changes to Subscribers as directed by HCA or OIC.

C. Contractor must update the COCs for each Plan Year after the RFR process is concluded. Contractor must assume responsibility to write, design, print, and distribute the COCs for the Contractor's Health Plan(s) annually and in accordance with the timeline(s) provided by HCA, ensuring their compatibility with Contractor’s administration of the Health Plan(s) and HCA’s responsibility for defining eligibility and benefits. HCA will create a COC review schedule during the annual RFR process for Contractor to review and comment on. HCA has final approval of the COCs.

D. After HCA review and approval, Contractor must deliver a .pdf formatted copy of its COCs to HCA no later than September 15 each year, and a total of 25 printed copies must be delivered to HCA as soon as possible, but in no event later than January 15 of the Contract Plan Year.

E. Contractor must make a Summary of Benefits for each Health Plan available to Health Plan Members, and prospective members, no later than the PEBB scheduled Annual Open Enrollment Benefits fairs each fall.

F. Contractor must make available, upon request, a printed copy of the COCs to Health Plan Members and prospective Health Plan Members.

2.7 Claims Services

Claims processing must be located and performed within the United States. Contractor will:

A. Administer the Health Plan benefits as outlined in the most current Certificate of Coverage (COC) and as described in this Contract. HCA will approve all CoCs for all Health Plans every calendar year.

B. Provide a structured, dedicated, and adequately staffed, United States-based Claims office that delivers a consistently high degree of Claims payment accuracy and timeliness as measured by the Performance Standards.

C. Provide internal audit, training, and performance management programs to ensure consistency and accuracy of Claims processing, coverage decisions, customer service, and administrative performance.

D. Use only clinicians licensed and located in a state or territory of the United States to consult during any part of the Claims administration process. Use only Participating Providers licensed and located in a state or territory of the United States when the need for physician consultations arises during any part of the Claims administration process.

E. Provide services for Claim adjudication, Appeals and Complaint/Grievance management, reports, and customer service for all Claims for dates-of-service during the Term and for all run-out Claims for sixty (60) months after termination of this Contract, with no additional fees or payment.

F. When requested by HCA, provide corrective action plan(s) for resolution of Claims adjudication issues, including administration in accordance with Health Plan benefits, Member eligibility, referral, authorization, COB, third-party liability, subrogation, fraud, overpayments, or workers’ compensation information, within fifteen (15) Calendar Days of being notified of any such issue.

G. Include all Claims and provider networks in one resource enabling Members to receive EOBs, access Claims information (electronic and paper based), and search for providers.

H. Adjudicate all Claims in accordance with Health Plan benefits and Service Area/non-Service Areas in the applicable CoC.

I. Resolve issues with Claims requiring additional information for proper adjudication, including:

i. Member eligibility;

ii. Referral;

iii. Authorization;

iv. Coordination of Benefits;

v. Third-party liability; and

vi. Workers’ Compensation information.

J. Track and resolve incomplete or pending Claims using an automated process and within designated timeframes.

K. Perform other Claims-related functions necessary to provide a complete administration of Claims service.

L. Provide a credit balance recovery service.

M. Provide fraud, waste, and abuse (collectively called program integrity) awareness, detection, and recovery services.

N. Make mutually agreed-upon benefit revisions and update the Claims system to pay accordingly on sixty (60) Calendar Days’ advance notice from HCA.

O. Collect information from Members via mail, or other methods approved by HCA, annually about other health insurance coverage the Member has for administration of COB.

P. Administer Member deductible credit incentives identified by HCA for Member completion or participation in HCA-sponsored wellness or disease management activities. HCA will inform Contractor via the eligibility file which Subscribers receive a deductible credit or Health Savings Account deposit as an incentive for participation in such programs.

2.8 Member Engagement

Contractor must support Member engagement through:

A. Paper and Electronic Communications with Members

i. Providing accurate, timely communications to Members and potential Members to enable them to make informed decisions in selecting Contractor’s Health Plan, appropriately utilize available benefits, and actively engage in managing their health.

ii. Assembling a professional, experienced, and effective communications team (including writers, web team, and graphic designers) to work directly with HCA Account Manager and communications staff on multiple annual, semi-annual, and ad-hoc multi-modal communication campaigns and products for Members.

iii. Providing the HCA Account Manager with a single point of contact for Contractor’s communications at the beginning of each year or if there are changes to Health Plan contact staff. This contact will be responsible for review, triage, and approval of HCA-produced communications related to the Health Plan(s) to ensure consistency, clarity, and accuracy.

iv. Adhering to requirements stated in WAC 182-08-220 (PEBB) and WAC 182-30-120 (SEBB). This excludes patient communications as described in provision A.xx below.

v. Dual branding all communications related to Contractor’s Health Plans or any successor name and branding per HCA’s design standards, unless HCA requests single branding.

vi. Agreeing not to communicate with Members using communications that are branded as being solely from the Contractor except with advance written approval of HCA, except for patient communications described in provision A.xx below.

vii. Assuring that all communications to Members relate directly to the Health Plan(s) and not any other products or services provided by the Contractor that HCA has not contracted to provide to Members, except for communications described in provision A.xx below.

viii. Refraining from directly distributing any communications related to the HCA Health Plan(s) to Members who are not enrolled in the Contractor’s Health Plan(s). These prohibited communications include, but are not limited to, mailings, emails, etc. This prohibition does not include Health Plan materials distributed at a benefits fair or worksite at the invitation of a Benefits Administrator (see provision A.xx below), public social media postings, public advertising or Contractor’s website.

ix. Preventing any other entity (Subcontractors or associated entities) from sending communications to Members except those communications relating directly to the Contractor’s Health Plan(s) or patient care, unless authorized in writing in advance by HCA.

x. Agreeing not to directly distribute any communications related to the Health Plan(s) to Benefits Administrators. These communications include, but are not limited to, mailings, emails, etc. HCA allows exceptions for a Benefits Administrator who directly contacts the Contractor to request participation in an onsite benefits fair at the Benefits Administrator’s worksite. If the Contractor chooses to participate, the Contractor may distribute Health Plan materials relevant to enrollment or reenrollment in the Health Plan(s).

xi. Ensuring and attesting that all communications from the Contractor, and Contractor’s subcontractors, including websites, emails, digital documents, mobile applications, and all printed materials, comply with the Americans with Disabilities Act (ADA), all subsequent amendments to the ADA, and implementing Regulations of ADA; Section 508 of the Rehabilitation Act; Governor’s Executive Order 23-02 (Plain Language), and all other relevant federal and Washington State laws pertaining to equal access to information. Contractor’s communications must:

a. Meet or exceed the requirements of the WCAG 2.2 AA standard for all websites, emails, and mobile applications;

b. Meet or exceed the requirements of the PDF/UA (ISO 14289) standard for all digital documents;

c. Adhere to industry best practices for accessibility, including but not limited to using accessible fonts, colors and color contrast, and physical formats with all printed communication, such as letters, postcards, advertisements, and guides;

d. Use images that include an appropriate diverse representation of the intended audience in all designed communications.

xii. Providing communication materials in other accessible formats (e.g., large print, braille, etc.) at no extra cost, upon request from Members or HCA.

xiii. Providing electronic and printed materials translated into HCA’s identified most requested languages at no extra cost. HCA lists language access requirements online at Language Access. At present, the most requested languages are Spanish, Russian, Vietnamese, and Ukrainian.

xiv. Communicating directly with Members only if approved by HCA and only as reasonably necessary to carry out the Health Plan's obligations to HCA, except for communications as described in provision A.xx below.

xv. Abiding by the procedure below to obtain HCA’s approval of the Contractor’s communications content:

a. Provide the initial draft for all Contractor Health Plan-specific Member communications to the appropriate HCA Account Manager for review. The HCA Account Manager will forward the draft to the appropriate HCA Communications reviewer. Contractor must provide at least ten (10) Business Days for review, or more time as needed for long documents, multiple documents, or campaign strategies that include multiple messages and/or tactics.

b. Identify which audience the communications are intended for (employees, retirees, etc.).

c. Note which sections of the communication cannot be edited due to state or federal Regulations, or Health Plan brand or style standards.

d. Ensure all communications are accurate, readable, and clear, co-branded according to HCA’s standards, to the appropriate program, and sent timely. These communications should align with language used in Member communications as much as possible to avoid Member confusion and decrease Member appeals and calls to HCA and the Contractor’s Customer Service. (An example could include using the Glossary of Terms in the federal Summaries of Benefits and Coverage document.)

e. Include document numbers and version dates on all Contractor-produced HCA Member communications.

f. Reconcile HCA edits. (This may involve an iterative process if a Contractor objects to HCA’s edits, but the communication may not be issued until HCA has agreed…