RFP 2025HCA5 Exhibit C2 Written P2.docx

EXHIBIT C2 – WRITTEN PROPOSAL - PHASE 2

Bidder must answer all questions in Exhibit C2, Written Proposal Phase 2. This Exhibit must be completed in its entirety in accordance with the page limits identified within the Exhibit (See 2025HCA5 RFP Section 3.2.D). Bidder should respond using Exhibit C2 as its template to ensure compliance with the formatting requirements outlined in Section 3.2.B of the RFP.

Questions in Exhibit C2 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 sections are restated in this Exhibit C2 for Bidder reference.

1. SOW Section 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.

1.1 Bidder Questions - Section 2.2 Eligibility Files and File Systems A. (Please limit response to one (1) page.) Describe the non-social security number-based Member ID that will be assigned. Provide information such as:

a. How many digits will it contain?

b. How will it be assigned?

c. How will you ensure that no Member ID is duplicated?

B. (Please limit response to one (1) page.) Outline (a flowchart will also be accepted) your processes for completing 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 the HCA.

C. (Please limit response to a single sentence.) Briefly state the volume capacity of your system: What is the number of individual records you can receive on a single HIPAA 834 Enrollment file?

2. SOW Section 2.3 - Use of Artificial Intelligence Tools 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.

2.1 Bidder Questions - Section 2.3 Use of Artificial Intelligence Tools A. (Please limit response to one (1) page.) Please explain how you are utilizing Artificial Intelligence (AI) to perform services such as claims processing, prior authorization, customer service phone services, and appeals processing.

B. Including subcontractors, please provide a written list of all AI systems used in connection with the services within this contract.

C. (Please limit response to one (1) page.) Looking forward to the proposed contracting period for this RFP, please detail any new AI system that will process or retain member data.

D. (Please limit response to one (1) page.) How do you intend to guarantee that no Confidential Information, Personal Health Information (PHI), Personally Identifiable Information (PII), or HCA Data will be input into any public, open-source, or unsecured AI system. All AI tools must operate within a secure, sandboxed environment where data is not retained, shared, or used to train third-party AI models without explicit prior written consent.

E. (Please limit response to one (1) page.) HCA requires that any AI tools must be used strictly as supplementary aids to augment, not replace, human labor and professional judgment. All deliverables, outputs, or decisions generated using AI must be reviewed, verified, and approved by a qualified live human professional employed by Contractors before delivery or implementation. Please describe the process of review, verification, and approval that you use for AI deliverables.

F. (Please limit response to one (1) page.) Please describe the measures you take to prevent algorithmic bias, discrimination, or harmful errors in AI-provided services you utilize.

3. SOW Section 2.8.A - Member Engagement Bidder 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 in writing to the final version.)

g. Provide a copy of the final communication(s) to HCA Account Manager; include a distribution/publication date and the quantity sent as applicable.

xvi. Delivering any communications concerning enrollment for the future Plan Year only to Contractor’s current Members. These communications may include all topics reasonably related to Members’ decision-making for reenrollment.

xvii. Maintaining communications aimed at recruiting new members for future Plan Years only on the HCA-specific Microsite, HCA-hosted virtual benefits fair site, social media, and at in-person benefits fairs. No communications with HCA Members not enrolled in the Contractor’s Health Plan are permitted without a request from the member.

xviii. Being responsible for all costs associated with the correction, notification, and distribution if errors are made in Contractor’s branded communications related to benefits, programs, or services. Corrections must be made in the same format as the original communication was sent (for example, if error was in a mailing, the correction should also be mailed).

xix. Thoroughly reviewing all HCA-produced Member communications related to the Contractor’s benefits and services, including, but not limited to, plan summaries and comparison materials, website, enrollment forms, Benefits 24/7 online language, and newsletters.

a. If an error is discovered in HCA materials reviewed by the Contractor after printing, Contractor must cover all costs associated with error correction including, but not limited to, printing and postage (if mailed).

xx. Requirements in this section do not apply to communications aimed at the Contractor’s entire Book-of-Business, including patient communications for treatment, payment, disease management, and health care operations purposes.

3.1 Bidder Questions - Section 2.8.A Member Engagement

A. (Please limit response to three (3) pages.) Attest that Bidder will provide the HCA Account Manager with a single point of contact for Health Plan(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. Additionally, describe your methods to assemble 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 Subscribers and Members enrolled in PEBB & SEBB Health Plans. Scoring will prioritize Bidders who directly employ dedicated writer(s), designer(s), and web developer(s) rather than utilizing temporary or contracted staff for the duration of the resulting Contract.

☐ Yes ☐ No B. (Please limit response to two (2) pages per example.) Provide three examples of cobranded documents that you have produced for another client.

4. SOW Section 2.8.B – Member Engagement B. HCA Plan-Specific Microsite

i. Contractor must host an HCA-specific Microsite for all the Health Plans they offer under this Contract. The Microsite must:

a. Be publicly accessible through most current web browsers and search engines.

b. Be optimized for mobile/tablet access as well as desktop use via commercially available browsers.

c. Be public facing and not require any visitor to create a login or an account so that HCA Members and potential members may research and compare benefits, cost sharing, and health programs.

d. Be cobranded with HCA so that it is readily identified as an HCA Carrier Microsite. HCA will provide needed content, such as HCA logos, to enable this cobranding.

ii. Contractor must have processes and methods in place to:

a. Ensure information on the Microsite is kept up-to-date, accurate, and complies with the ADA and other associated Regulations, such as HIPAA and HITECH.

b. Provide ongoing maintenance of the Microsite.

c. Provide HCA thirty (30) Calendar Days' notice of any proposed material changes of the content of the Microsite (e.g., using a new URL). Submit all content to HCA for review and approval before being posted to the Microsite and before any Microsite redesigns or updates.

d. Provide access to this HCA-specific Microsite, except for scheduled downtime not exceeding ten (10) hours per month, with continuity as provided in section 2.4.C Emergency Response Contract Management.

iii. Contractor must publish Microsite content that:

a. Identifies the Contractor’s Health Plans offered to HCA Members and clearly identifies HCA as the plan sponsor.

b. Provides benefit information, including, but not limited to, Certificates of Coverage (CoCs), Summaries of Benefits and Coverage (SBCs), and other official benefit information.

c. Provides a list of services requiring preauthorization and related standards, coverage criteria, or other information, to be updated monthly in accordance with RCW 41.05.074 (See ATTACHMENT 15 PRIOR AUTHORIZATION REPORTING INSTRUCTIONS (PROCEDURES FOR COMPLIANCE WITH RCW 41.05.074(3)).

d. Includes a searchable up-to-date provider directory with the providers’ locations that is searchable by zip code, and which meets all the provider directory requirements of chapter 284 WAC. This tool must provide Members the support they need to effectively use their Plan and access services.

iv. Contractor must provide links to other Washington State or HCA vendor websites, as requested by HCA, including links to the following websites:

a. Bree Collaborative public website; and

b. HCA’s Employee and Retiree Benefits webpage.

v. Contractor Microsite must prominently display behavioral health immediate intervention links and provide a list of coverage exceptions and service limits.

vi. Contractor Microsite must include a cost transparency tool for both medical and pharmacy benefits, which considers Plan benefit designs relative to copays and cost sharing.

vii. Contractor Microsite must provide downloadable, accessible forms in PDF or Word Format (authorization forms, etc.).

viii. Contractor Microsite must notify Microsite visitors of the availability of:

a. Tobacco cessation services;

b. A 24/7 nurse line;

c. Diabetes Prevention and Management services; and

d. Contractor’s discounts on fitness devices, gym memberships, allergy relief, and other services or items available to Members of the Health Plan(s).

4.1 Bidder Questions - SOW Section 2.8.B Member Engagement

A. (Please limit response to three (3) pages.) Describe the online services that will be provided for Members. Scoring will prioritize Bidders that directly employ dedicated writer(s), designer(s), and web developer(s) rather than utilizing temporary or contracted staff for the duration of the contract. Please include:

a. The structure and makeup of the web team that will be assigned to online services as required by this RFP;

b. The proposed array of web-based tools and information for Members; and

c. The process that will be followed to ensure the tools and information will remain up to date, including frequency of reviews for needed updates.

B. (Please limit response to ten (10) pages.) Please provide screenshots of one of your cobranded Microsites that displays current functionality of a typical Microsite you produce for your clients.

5. SOW Section 2.8.C – Member Engagement A. Secure Access Online Member Portal

i. Contractor must host a secure web-based online Member Portal for enrolled Subscribers and Members of the Health Plans offered under this Contract.

ii. Provide easily located online services including a robust, accurate, and up-to-date array of web-based tools and information that is reviewed frequently for technical errors and updated regularly with the newest information. The Contractor’s online services must at all times meet or exceed the Washington State Technology Standards, or their replacements or successors, found on WaTech’s website.

iii. The Member Portal must include all features required for the HCA Specific Microsite and must:

a. Require Multi Factor Authentication (MFA) for secure log in.

b. Provide services to authorized users allowing them to:

i. View health-related information;

ii. Communicate with practitioners and Contractor staff;

iii. Arrange for clinical and health plan services; and

iv. Access additional selected services.

c. Provide secure email to and from Member Services. Contractor must respond to ninety percent (90%) of Member emails sent to Member Services by the end of the next Business Day after receipt.

d. Advise Members that the information provided on the Member Portal is not a substitute for the advice of a personal physician or other qualified health care professional.

e. Have the ability for an authenticated user to view their use of services and Explanation of Benefits (EOB) in compliance with HIPAA and HITECH privacy laws and requirements.

f. Comply with the privacy provisions of RCW 48.43.505 regarding the protection of a Member’s right to privacy, including a right to privacy from the Subscriber

g. Include deductible and out-of-pocket maximum totals status.

h. Include a list of services, medical and pharmacy prior authorization standards and criteria, to be updated monthly consistent with RCW 41.05.074 and RCW 48.43.016.

i. Include cost transparency tools, including:

i. A cost calculator to search medical costs by treatment code and diagnostic procedure, including office visits, inpatient and outpatient (including provider and facility costs), with filter capability by provider, facility, keyword or category, provider demographics, patient safety scores, clinical quality, measures for hospitals, experience match scores for providers and professionals, and patient satisfaction ratings where available. The cost calculator must include pharmacy benefits.

a. The Contractor must train customer service staff on assisting Members in the use of the cost calculator. Training will include the source(s) of Data used by the calculator, the services reported by the calculator, and the most common scenarios when customer service staff are expected to assist Members with the calculator.

ii. Cost and Outcome comparisons of alternative treatments linked to shared decision-making tools.

5.1 Bidder Questions - SOW Section 2.8.C Member Engagement

A. (Please limit response to ten (10) pages.) Please provide screenshots of your Secure Access Member Portal that displays current functionality.

6. SOW Section 2.9 – Data Reporting and Analytics Eligibility, enrollment, claims, and all other Data is owned by and belongs to HCA. To partner successfully with HCA and comply with Data reporting and Data analytic requirements the Agency supports and promotes, Contractors must:

A. Provide both standard and ad hoc customized reports to HCA on Health Plan quality, cost and utilization performance, Member reported Outcomes, provider performance, and population health measures (including disaggregation by race/ethnicity and Primary Language to identify health disparities).

B. Have robust technology and core systems in place to accept, store, process and validate Data from various sources (e.g., Claims, clinical Data from EHRs, and other HCA vendors).

C. Coordinate with other HCA vendors regarding Member level Claims Data, Member communications, behavioral health outreach, wellness programs and benefits, and other programs. HCA vendors may include but are not limited to the ERB wellness program.

D. Collect and transmit to HCA detailed reporting of Health Plan specific measures from the Washington State Common Measure Set and HEDIS® measures for provider groups, including quality, Claims, Member reported Outcomes, hybrid and ECDS measures. Additionally, the capability to conduct analyses of sub-populations and to identify health disparities so that providers have actionable Data to care effectively for all Members. The measures will be based on standards created at the state and national level, and the Data will be configured in accordance with the applicable specifications.

E. Have experience, knowledge and expertise to provide appropriate Data and routine, standardized reporting on provider performance regarding various clinical and quality metrics, including Patient Reported Outcomes, patient experience, and population health. This reporting must be understandable and accessible to providers and provider groups.

F. Submit Data using the NCQA Interactive Data Submission System (IDSS) or other NCQA-approved methods.

G. Report HCA-required HEDIS® measures stratified by race and ethnicity as required by the NCQA.

H. Provide required Claims Data to HCA’s Third Party Actuary in HCA’s required formats, fields, and timelines as detailed in Section 7.1 Paid Claims Data below and ATTACHMENT 9: REQUIRED CLAIMS DATA FIELDS I. Submit primary care expenditures Data for the PEB and SEB Boards’ fully-insured Health Plans using ATTACHMENT 16 PRIMARY CARE EXPENDITURE SURVEY TEMPLATE.

J. Meet the requirement for provider participation in Washington State’s Clinical Data Repository (CDR) and Health Information Exchange (HIE). HCA’s requirement is for ninety-five percent (95%) of ERB Medical Plan Member clinical encounter Data to be submitted to the statewide Clinical Data Repository (CDR).

K. Provide Member-level Data to HCA’s Lead Organization of the CDR for use in clinical quality and health initiatives aimed at HCA’s ERB population.

L. Provide Claims level Data in the format requested upon HCA's request to the HCA data warehouse.

M. Meet the requirements for hospital Claims reimbursement Data reporting in Section 7.2 Hospital Claims Reimbursement Data Reporting below for RCW 41.05.028. See Public employee access and affordability | Washington State Health Care Authority for more information.

N. Provide Data regarding Complaints and Appeals for an annual legislative report that meets HCA specifications by March 30 of each year.

O. Submit Data to HCA’s Washington All Payer Claims Database (WA-APCD) as required by RCW 43.371.

6.1 Bidder Questions - SOW Section 2.9 Data Reporting and Analytics A. (Please limit response to five (5) pages.) Provide an example of a standard report (with PHI redacted) that Bidder produces for a current client on the topics: Health Plan quality, cost and utilization performance, Member reported outcomes, provider performance, and population health measures (including disaggregation by race/ethnicity and primary language to identify health disparities.)

B. (Please limit response to five (5) pages.) Provide an example of an ad hoc report (with PHI redacted) that Bidder has produced for a current client on the topics: Health Plan quality, cost and utilization performance, Member reported outcomes, provider performance, and population health measures (including disaggregation by race/ethnicity and primary language to identify health disparities). Describe in a cover sheet of not more than one page the process and timeline Bidder needs to produce such an ad hoc report.

7. SOW Section 4.1 - HCA Health Care Transformation Requirements Contractor must:

A. Provide a comprehensive health care network and Health Plan(s) that include providers, services, and staff to perform the tasks or provide the services listed in this section.

B. Provide a comprehensive health care network that includes:

i. Geographical coverage across a minimum of two (2) Washington State counties with:

a. A “live or work” enrollment provision that allows Subscribers to enroll in the Contractor’s Health Plans either in the county in which they reside or in the county in which they work.

b. Provisions stating that Members with addresses in the PEBB and SEBB programs’ system of record that reflect residency outside of counties in which the Health Plan is offered cannot enroll in the Health Plan unless they can prove that they work in a county in which the Health Plan is offered.

c. The possible expansion of coverage into additional Washington State counties, which HCA encourages for all Contractors. An amendment merely requires mutual, written agreement of the parties as provided in the appropriate section of this Contract.

C. Maintain a network within each covered county that complies with law and OIC Regulations for network adequacy.

D. Assure high-quality delivery of a broad spectrum of Covered Services, including the health care services or health care items described as Covered Services in the Health Plan(s) COC applicable for that Plan Year.

E. Maintain Data and clinical systems that support the delivery of evidence-based care, as well as provide reporting for HCA-specific Data to produce the required reports identified within this Statement of Work.

F. By January 1, 2028, must offer health plans (or ensure that another carrier in the same insurance holding company system offers health plans) on the Health Benefit Exchange for any county in Bidder’s Service Area for proposed HCA Health Plans, per RCW 41.05.820.

G. Attend meetings with HCA on a regular cadence as described in this Statement of Work.

i. The Contractor must actively participate in in-person and/or virtual quarterly quality meetings with HCA’s ERB Clinical Quality and Care Transformation (CQCT) team, no less than four (4) times per year at times agreed to by HCA and the Contractor. The Contractor will prepare an agenda in collaboration with HCA. The agenda will be reviewed and approved by HCA before being finalized. The Contractor will facilitate these quarterly quality meetings and be prepared to present and discuss produced deliverables, including but not limited to Bree care transformation projects, timely access to care objectives, Member experience, ongoing quality initiatives and quality performance specific to PEBB and SEBB Members.

ii. Attend annual Bree care transformation meetings H. Each year after the first year and for each Bree care transformation project, Report annually (per ATTACHMENT 7: CONTRACTOR REPORTING SCHEDULES AND TEMPLATES) on the work that has occurred throughout the year, using a template provided by HCA (see ATTACHMENT 14 BREE COLLABORATIVE MASTER). This report will include, but is not limited to:

i. Progress toward each of the SMART Goals. For those targets not achieved, the report must provide details on the barriers that prevented the Health Plan(s) from achieving the targets and discuss how these barriers will be mitigated going forward.

ii. New or revised targets for SMART Goals as appropriate.

iii. An overall narrative discussion of lessons learned in the prior year, best practices, notable achievements, and anticipated and actual challenges identified as well as how they were addressed, highlights of specific population impacts, and a discussion of how best practices identified will be disseminated across the Health Plan(s).

I. Possess an organizational structure, processes, and staff to manage the delivery of the Health Plan(s) to both PEBB and SEBB Members. This includes proactively monitoring Members that navigate within and outside their network to ensure all covered services are appropriate, evidence-based, and delivered in ways that are culturally and linguistically appropriate for the patient. Any Contractor must provide timely review and approval of any out-of-network covered services that are not available in network. Contractor must provide communication plan and implementation plan to HCA within fifteen (15) Calendar Days upon request for covered services being offered outside of the network.

J. Maintain adaptable systems that allow for realignment should the Legislature, Governor, or other governing entity mandate change to the PEBB and SEBB programs or merger of the two programs at some future date.

K. Employ or contract with Participating Providers to deliver healthcare services with the following requirements:

i. Credentialing - Contractor will have in place credentialing requirements for its Participating Providers sufficient to maintain its accreditation by the NCQA. Further, Contractor will have an ongoing review process to ensure that its Participating Providers remain in compliance with the representations and warranties set forth in this Contract. A copy of these requirements will be submitted to HCA immediately upon request.

ii. Provider Licenses - All of Contractor’s Participating Providers will be duly licensed or certified, as required by the laws of the state in which the Participating Provider is practicing. Contractor will routinely monitor its Participating Providers’ licenses to ensure they are current. Contractor’s Participating Providers must not have any Washington State Department of Health (DOH), Washington Medical Commission, and any of the other Washington Quality Assurance Commissions, or National Practitioner Data Bank Provider restrictions.

iii. Provider Insurance - Contractor will ensure that its Participating Providers are insured for malpractice, either independently or through Contractor, in a dollar amount sufficient for their practice and as may be required by law or accrediting entities. Contractor’s Participating Providers will also have other liability insurance in a dollar amount appropriate for their business practice.

iv. Providers and Staff Turnover - Contractor will maintain records of the turnover of its Participating Providers, healthcare professional staff, and customer service staff. Contractor must routinely monitor this turnover to ensure that it does not disrupt the delivery of quality care and customer service.

v. Notice Regarding Participating Provider Network Changes - Contractor will notify HCA in writing of any pending material change in the composition of its Participating Provider network, or its Participating Provider network contracts, at least sixty (60) Days prior to the implementation of such change or as soon as reasonably possible upon learning of a material change.

7.1 Bidder Questions - SOW Section 4.1 HCA Health Care Transformation Requirements A. Attest that Bidder understands and agrees to meet the Commitment to Health Care Transformation requirements of the SOW.

☐ Yes ☐ No B. (Please limit response to one(1) page or less.) Outline the staffing, systems, and procedures the Bidder has in place to perform the Commitment to Health Care Transformation requirements as outlined in this section of the SOW.

8. SOW Section 6.2 – Timely Access to Care / Time to Appointment Bidder will:

A. Provide Members with timely access to care to ensure that health problems are addressed before they progress, and that care is provided in efficient settings such as primary care clinics rather than the emergency room (ER) or other less efficient sites, when appropriate.

B. Provide alternatives to traditional in-person office visits such as telehealth, email, or text-based care.

C. Provide sites for acute and Urgent Care access.

D. Keep abreast of industry trends such as hospital-at-home and in-home Urgent Care.

E. Provide access to routine and Urgent Care appointments outside regular business hours, specifically including routine primary care.

F. Show evidence of good faith efforts to increase Member access to in-network, routine primary care services outside of regular business hours, including:

i. approaches to existing providers seeking to begin or expand primary care outside business hours (including offers to contract);

ii. efforts to contract with new providers who offer expanded hours; and

iii. other efforts toward this goal.

G. Communicate to Members about using primary care appropriately and the availability of after-hours primary care locations.

H. Have 24/7 consulting nurse services available (Subcontracting with United States-based vendor permitted).

I. An adequate provider network that is cost effective and delivers high-quality services to Members.

J. A network contracting and credentialing program consistent with NCQA accreditation standards.

8.1 Bidder Questions – SOW Section 6.2 Timely Access to Care / Time to Appointment A. Attest that Bidder understands and agrees to the Timely Access to Care / Time to Appointment requirements of the SOW.

☐ Yes ☐ No B. (Please limit response to one(1) page or less.) Outline the staffing, systems, and procedures the Contractor has in place to perform Timely Access to Care / Time to Appointment requirements as outlined in this section of the SOW.

9. SOW Section 6.3 – Access to Care A. Specialty Care

i. Contractor will provide availability of medically necessary covered specialty care for Members with acute or urgent problems, available within the Contractor’s Participating Provider network, within three (3) Business Days.

ii. If a Member needs medically necessary specialty care that cannot be obtained (for any reason) from a specialist within Contractor’s Participating Provider network, within the timelines for specialty care provided within WAC 284-170-200, Contractor must provide the necessary services through a qualified specialist outside Contractor’s Participating Provider network with no financial liability to the Member other than what would have been incurred at a Participating Provider.

B. Preventive Care

i. Preventive care services will be provided in accordance with the ACA.

ii. If any federal or state laws regarding preventive care services are repealed, Contractor will continue to cover said preventive care services, unless otherwise directed by the HCA.

iii. Contractor will provide Members with a description and recommended schedule of preventive care benefits in the COC.

iv. Contractor will administer a preventive services program that ensures appropriate wellness and preventive services by providing targeted reminders for Members when Data indicates a Member may be due for certain services.

C. Certification of Disabled Dependents

i. Contractor will follow the Disabled Dependent process outlined in the current Operations Manual.

D. Gender Affirming Care

i. Washington State law requires that health insurers generally must cover medically necessary gender affirming treatment, when qualifying criteria are met. Medically necessary and legally required gender affirming care must be provided at the in-network benefit rate.

ii. Gender affirming care includes all medically necessary treatment for gender dysphoria/gender incongruence.

E. Vision Exams and Hardware Benefit

i. Contractor will not be required to provide comprehensive annual vision exams or hardware or lens benefits to Members. Fully-insured vision care carriers currently provide annual exams and hardware benefits. However, coverage for diseases of the eye, infection, glaucoma, and injury to the eye must continue to be part of the clinical services that a Contractor provides. Similarly, Contractors must provide medically necessary eye treatment.

9.1 Bidder Questions – SOW Section 6.3 Access to Care

A. Attest that Bidder understands and agrees to the Access to Care requirements of the SOW.

☐ Yes ☐ No B. (Please limit response to one (1) page or less.) Outline the staffing, systems, and procedures the Contractor has in place to perform Referrals and what type of services require Referrals.

C. (Please limit response to one (1) page or less.) Outline the staffing, systems, and procedures the Contractor has in place to perform the Access to Care requirements as outlined in this section of the SOW.

10. SOW Section 6.4 – Clinical Programs A. Tobacco Use Interventions

i. Contractor will cover, without cost-sharing or the need for prior authorization, preventive services consistent with the ACA requirements and the U.S. Preventive Services Task Force (USPSTF) A and B recommendations for tobacco screening and use interventions.

a. In providing such coverage, Contractor acknowledges the current applicability of the 2014 federal guidance (as may be modified in the future) provided within the FAQs About Affordable Care Act Implementation (Part XIX) | CMS .

b. Contractor will provide monthly tobacco use intervention participation reports for PEBB and SEBB to HCA.

c. The Contractor will promote the Contractor’s tobacco cessation program on their website for PEBB and SEBB Members. In addition, the Contractor must provide additional Washington State tobacco cessation resources such as the: Washington State Quitline | Washington State Department of Health B. Diabetes Prevention Program

i.…