RFP 2025HCA5 Final 10.12.26.pdf

REQUEST FOR PROPOSALS (RFP)

RFP NO. 2025HCA5

NOTE: If you download this RFP from any source other than the Washington Electronic Business Solution (WEBS), you are responsible for registering in WEBS for your organization to receive any RFP amendments, including Bidder questions/agency answers. HCA is not responsible for any failure of your organization to register in WEBS or any other repercussions that may result to your organization because of this failure.

PROJECT TITLE: Fully-Insured Medical Plans

PROPOSAL DUE DATE: January 14, 2027, by 4:00pm Pacific Time, Olympia, Washington, USA.

Only e-mailed bids will be accepted.

ESTIMATED TIME PERIOD FOR CONTRACT: January 1, 2029, to December 31, 2033

The Health Care Authority reserves at its sole discretion the right to extend the contract for up to seven (7) additional one (1)-year periods, dependent on mutual agreement of the contract terms by the parties.

BIDDER ELIGIBILITY: This solicitation is open to those Bidders that satisfy the minimum qualifications stated herein and that are available for work in Washington State.

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TABLE OF CONTENTS

TABLE OF CONTENTS

1. INTRODUCTION

1.1 DEFINITIONS

1.2 ESTIMATED SCHEDULE OF SOLICITATION ACTIVITIES

1.3 PURPOSE AND OBJECTIVES

1.4 BACKGROUND

1.5 SCOPE OF WORK

1.6 MINIMUM QUALIFICATIONS

1.7 FUNDING

1.8 PERIOD OF PERFORMANCE

1.9 ADA

2. GENERAL INFORMATION FOR BIDDERS

2.1 RFP COORDINATOR

2.2 PRE-PROPOSAL CONFERENCE

2.3 FINANCE RATE INSTRUCTION CONFERENCE

2.4 LETTER OF INTENT TO PROPOSE

2.5 INTERESTED SUBCONTRACTOR LIST

2.6 BIDDER QUESTION PERIODS

2.7 SUBMISSION OF PROPOSALS

2.8 PROPRIETARY INFORMATION / PUBLIC DISCLOSURE

2.9 REVISIONS TO THE RFP

2.10 COMPLAINT PROCESS

2.11 RESPONSIVENESS

2.12 MOST FAVORABLE TERMS

2.13 RECEIPT OF INSUFFICIENT NUMBER OF PROPOSALS

2.14 NO OBLIGATION TO CONTRACT

2.15 REJECTION OF PROPOSALS

3. PROPOSAL CONTENTS AND REQUIREMENTS

3.1 PROPOSAL SUBMITTAL CHECKLIST

3.2 PROPOSAL REQUIREMENTS AND GUIDELINES

3.3 EXHIBIT A: BIDDER FORMS AND CERTIFICATIONS

3.4 EXHIBIT B: DRAFT CONTRACT

3.5 EXHIBITS C1.1; C1.2; AND C2

3.6 EXHIBIT D1 AND D2: COST PROPOSALS

3.7 EXHIBIT E: SERVICE AREA

3.8 PERFORMANCE STANDARDS AND PERFORMANCE PAYMENTS ............................................... ERROR! BOOKMARK NOT DEFINED.

3.9 EXHIBIT G: PLAN DESIGN OUTLINE

3.10 EXHIBIT H: BREE COLLABORATIVE FOR COMPLEX DISCHARGE AND HEALTH EQUITY/SDOH

3.11 EXHIBIT I: BIDDER SUBCONTRACTOR LIST

4. EVALUATION AND CONTRACT AWARD

4.1 EVALUATION PROCEDURE

4.2 ADMINISTRATIVE REVIEW

4.3 PHASE 1 EVALUATION

4.4 PHASE 2 EVALUATION

4.5 ANNOUNCEMENT OF APPARENT SUCCESSFUL BIDDER(S)

4.6 BEST AND FINAL OFFER (BAFO)

4.7 NOTIFICATION TO BIDDERS

4.8 DEBRIEFING OF UNSUCCESSFUL BIDDERS

4.9 PROTEST PROCEDURE

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5. RFP EXHIBITS

EXHIBIT A – BIDDER FORMS AND CERTIFICATIONS

EXHIBIT B – DRAFT CONTRACT

EXHIBIT C1.1 – MANDATORY ATTESTATIONS

EXHIBIT C1.2 – WRITTEN PROPOSAL PHASE 1

EXHIBIT C2 – WRITTEN PROPOSAL PHASE 2

EXHIBIT D1 AND D2 – PEBB AND SEBB COST PROPOSAL TEMPLATE

EXHIBIT E – SERVICE AREA

EXHIBIT F – INTENTIONALLY BLANK

EXHIBIT G – PLAN DESIGN OUTLINE

EXHIBIT H – BREE COLLABORATIVE FOR COMPLEX DISCHARGE AND SDOH

EXHIBIT I – BIDDER SUBCONTRACTOR LIST

ATTACHMENT 1 – APM FRAMEWORK

ATTACHMENT 2 – INTENTIONALLY BLANK

ATTACHMENT 3 – MFT USER GUIDE

ATTACHMENT 4 – 834 COMPANION GUIDE

ATTACHMENT 5 – HCA BUSINESS IMPACT ANALYSIS TEMPLATE

ATTACHMENT 6 – INTENTIONALLY BLANK

ATTACHMENT 7 – DISASTER RECOVERY PLAN TEMPLATE

ATTACHMENT 8 – FINANCIAL DETAILS

ATTACHMENT 9 – REQUIRED CLAIMS DATA FIELDS

ATTACHMENT 10 – ASB TECHNICAL REQUIREMENTS

ATTACHMENT 11 – WATECH IT SECURITY CHAPTER

ATTACHMENT 12 – PRE-PROPOSAL CONFERENCE AGENDA

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1. INTRODUCTION

1.1 DEFINITIONS

“Affordable Care Act” or “ACA” means the Patient Protection and Affordable Care Act, the comprehensive health care reform law enacted by the 111th Congress of the United States in March 2010.

“Alternative Payment Model” or “APM” means a plan that places financial responsibility on providers with the goal of improving patient outcomes and decreasing expenditures on low-value care while providing patients with the freedom to select medical service providers.

The APM promotes clinical excellence while simultaneously controlling costs. This cost control depends on the APM’s ability to incentivize hospitals, physicians, post-acute care facilities, and other providers to form partnerships and promote better coordination of care delivery. By increasing Care Coordination, the APM’s goal is to reduce low-value medical care and improve health outcomes. For purposes of this RFP, an APM must comply with at least CMS LAN Category 3 B criteria.

“Annual Open Enrollment” means an annual event set aside for a period of time by HCA when subscribers may make changes to their health plan enrollment and salary reduction elections for the following plan year. During the annual open enrollment, subscribers may transfer from one (1) health plan to another, enroll or remove Dependents from coverage, enroll in coverage, or waive enrollment. Employees (or School Employees for SEBB) eligible to participate in the salary reduction plan may enroll in or change their election under the dependent care assistance program (DCAP), the flexible spending arrangement (FSA), or limited purpose FSA. They may also enroll in or opt out of the premium payment plan.

“Annual Premium” means the total amount of Monthly Premium received by the Contractor for PEBB or SEBB membership during the Plan Year, net of any risk adjustment transfer amount(s) applied for that Plan Year. For example, the Annual Premium amount used to determine a Performance Payment owed to HCA for Measurement Year 2024 includes any premium adjustments applied in calendar year 2025 for Plan Year 2024. Remittance of a Performance Payment to the group policyholder is not a return premium for purposes of RCW 48.14.020 and 48.14.0201.

“Apparent Successful Bidder” or “ASB” means a Bidder selected to perform the anticipated services under this RFP, subject to completion of contract negotiations and execution of a written contract.

“Appeal“ means a written or oral request for reconsideration of a decision to deny, modify, reduce, or terminate payment, coverage, authorization, or provision of health care services, including the admission to, or continued stay in, a health care facility. Appeal means the same as Request for Review of Adverse Benefit Determination as defined in RCW

48.43.005. The word “Appeal” is used in the Washington State Insurance Code (Title 48 RCW and Title 284 WAC) with regard to grandfathered plans (plans which predate and are therefore not subject to the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010)). “Request for Review of Adverse Benefit Determination” is the term used with regard to non-grandfathered plans (plans subject to the Patient Protection and Affordable Care Act.)

An appeal is different from a grievance or complaint. Grievances or complaints do not request that a carrier change an unfavorable decision.

https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf https://app.leg.wa.gov/rcw/default.aspx?cite=48.14.020 https://app.leg.wa.gov/rcw/default.aspx?cite=48.14.0201 https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.005 https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.005 https://app.leg.wa.gov/rcw/default.aspx?Cite=48 https://app.leg.wa.gov/rcw/default.aspx?Cite=48 https://app.leg.wa.gov/wac/default.aspx?cite=284 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https:/www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https:/www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf

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“Authorized Representative” means a person to whom signature authority has been delegated in writing acting within the limits of his/her authority.

“Benefit Cost Ratio” means the ratio of claims to premiums.

“Bid Rate” means the rate that reflects required revenue, by plan, for a risk standardized population assumed to have the average risk score of the applicable risk pool. Bid Rates for the next plan year are final once presented to and authorized by the PEB and SEB Boards.

“Bidder” means individual or company interested in this RFP that submits a proposal to attain a Contract with HCA.

“Book-of-Business” means all commercial business of the Bidder, including any and all fully insured and self-insured products within the Bidder’s accounts.

“Bree Collaborative” means the statewide public-private consortium established in 2011 by the Washington State Legislature in chapter 70.250 RCW, to provide a mechanism through which public and private health care stakeholders can work together to improve quality, health outcomes, and cost effectiveness of care in Washington State. Annually, the Bree Collaborative identifies up to three (3) areas where there is substantial variation in practice patterns and/or high utilization trends that do not produce better care outcomes.

Recommendations from the Bree Collaborative are used by HCA to guide state purchasing for programs such as Medicaid, PEBB and SEBB.

“Business Day” means Monday through Friday, 8 a.m. to 5 p.m., Pacific Time, except for holidays observed by the State of Washington, unless otherwise specified within this RFP.

“Calendar Day” means Monday through Sunday, beginning at 12:00 a.m., Pacific Time, including holidays.

“Care Coordination” means deliberately organizing patient care activities and sharing information among all the participants concerned with a patient's care to achieve safer and more effective care. This means that the patient's needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.

“Carrier” means a disability insurance company regulated under chapter 48.20 or 48.21 RCW, a Health Care Service Contractor as defined in RCW 48.44.010, or a Health Maintenance Organization as defined in RCW 48.46.020.

“Cascade Care” means all standardized health plans that are Qualified Health Plans under the Affordable Care Act (ACA) and sold on the Washington Health Benefit Exchange (WAHBE). The Cascade Care program includes Washington's public option plans (called "Cascade Select") as well as state premium assistance (called "Cascade Care Savings").

“Case Management” means the collaborative process of assessment, planning, facilitation, Care Coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective Outcomes.

https://app.leg.wa.gov/rcw/default.aspx?cite=70.250 http://app.leg.wa.gov/RCW/default.aspx?cite=48.20 http://app.leg.wa.gov/RCW/default.aspx?cite=48.21 http://app.leg.wa.gov/RCW/default.aspx?cite=48.44.010 http://app.leg.wa.gov/RCW/default.aspx?cite=48.46.020

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“Centers for Medicare and Medicaid Services” or “CMS” means the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.

“Certificate of Coverage” or “COC” means the document that describes in detail a Member’s health insurance coverage with their Health Plan. The COC explains the health benefits the Subscriber and their Dependents have under their Health Plan. Details include exclusions, conditions, and limitations. Exclusions are services that are not covered under the Health Plan, and conditions are actions needed to receive benefits. Conditions may include deductibles and copays. Limitations include numbers of visits per benefit.

“Certified Veteran Owned Business” means the Bidder is a Certified Veteran-Owned Business as defined in RCW 43.60A.190.

“Charter School” has the same meaning as defined in RCW 28A.710.010 which is a public school that is established in accordance with Chapter 28A.710 RCW, governed by a Charter School board, and operated according to the terms of a Charter School contract executed under chapter 28A.710 RCW.

“Chronic Condition Management” means the oversight and education activities conducted by health care professionals to help Members with chronic diseases and health conditions such as diabetes, high blood pressure, congestive heart failure, and chronic obstructive pulmonary disease learn to understand their condition and live successfully with

it. The work involves motivating Members to persist in necessary therapies and interventions and helping them to achieve an ongoing, reasonable quality of life.

“Claim” means the written (including electronic) request on a form acceptable by the Carrier for reimbursement for any health care service or supply pursuant to the terms of the applicable Certificate of Coverage. Under RCW 41.05.075(6), all Claims Data shall be the property of the state.

“Clinical Data Repository” or “CDR" is a real time database administered by a third-party administrator that consolidates Data from a variety of clinical sources to present a unified view of a single patient. It allows clinicians to retrieve Data for a single patient rather than a population of patients with common characteristics.

“Clinical Management Services” means the use of best practice recommendations (such as the Bree Collaborative recommendations) in the provision of Clinical Management to support optimal health Outcomes, in collaboration with HCA’s clinical team; proactive identification and management of Members who are at risk for health service utilization;

provision of Patient Decision Aids to support appropriate patient self-management;

collaboration and integration with providers and delivery systems; reduction of unnecessary variation in clinical practice; and lower healthcare costs.

“Code of Federal Regulations” or “C.F.R.” means all references in this Contract to C.F.R.

chapters or sections include any successor, amended, or replacement Regulation.

"Collective Bargaining,” means the performance of the mutual obligation of the representatives of the employer and the exclusive bargaining representative to meet at reasonable times and to bargain in good faith in an effort to reach agreement with respect to the subjects of bargaining specified under the collective bargaining statute applicable to that https://app.leg.wa.gov/rcw/default.aspx?cite=43.60A.190 https://app.leg.wa.gov/rcw/default.aspx?cite=28A.710.010 https://app.leg.wa.gov/rcw/default.aspx?cite=28A.710 https://app.leg.wa.gov/rcw/default.aspx?cite=28A.710 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.075 http://www.ecfr.gov/cgi-bin/ECFR?page=browse

HCA RFP #2025HCA5 Page 6 of 75 employer. This definition is intended to be materially identical to RCW 41.56.030(4) and

RCW 41.80.005(2).

“Community Advisory Council” or “CAC” means a group of people from the communities served by the Contractor, especially those from diverse backgrounds. This includes, but is not limited to, individuals of different races, ethnicities, gender identities, sexual orientations, and those with disabilities, as well as people living in rural or underserved areas. The council ensures that the voices and needs of these diverse groups are heard and considered.

“Complaint” means an oral or written expression of dissatisfaction submitted by or on behalf of a Member regarding: issues other than denial of or payment for health care services, including dissatisfaction with health care services, delays in obtaining health care services, conflicts with Carrier staff or providers; or dissatisfaction with Health Plan practices or action unrelated to health care services. This definition is materially identical with the definition of Grievance in RCW 48.43.005.

A Complaint or Grievance is not the same as an Appeal or a Request for Review of an Adverse Determination as defined in RCW 48.43.005(2), WAC 284-43-0160(1), and chapter 284-43 WAC, Subchapter E. An Appeal or Request for Review of an Adverse Determination requests that a carrier change an unfavorable decision; a complaint or grievance does not.

“Confidential Information” means information that is exempt from disclosure to the public or other unauthorized persons under chapter 42.56 RCW or other federal or state laws.

Confidential Information comprises both Category 3 and Category 4 Data as described in EXHIBIT B – DRAFT CONTRACT, Attachment 13: Data Sharing Terms, Section 4 Data Classification, which includes, but is not limited to, Personal Information and Protected Health Information (PHI).

“Continuation Coverage” means the temporary continuation of ERB Health Plan coverage available to Subscribers after a qualifying event occurs as administered under Title XXII of the Public Health Service (PHS) Act, 42 U.S.C. Sections 300bb-1 through 300bb-8 or the PEB or SEB Boards’ policies.

“Contract” means a written agreement, resulting from this procurement, between an ASB and HCA, including all exhibits, schedules, attachments, and other terms or documents referred to, incorporated by reference, or attached hereto. HCA’s draft Contract is included as EXHIBIT B – DRAFT CONTRACT.

“Contract Year” means the calendar years beginning from the initial effective date of the Contract. For example, 2029 is expected to be Contract Year one.

“Contractor” means an entity performing services under a Contract resulting from this RFP.

Contractor includes any firm, provider, organization, individual or other entity performing services under this Contract. It also includes any Subcontractor retained by Contractor as permitted under the terms of this Contract.

“Data” means information produced, furnished, acquired, or used by Contractor in meeting requirements under the Contract. Confidential Information, Personal Information, and Protected Health Information are all considered Data for the purposes of the Contract. For EXHIBIT B – DRAFT CONTRACT, Attachment 13 Data Sharing Terms, Data specifically refers to the information that is disclosed or exchanged as described in the Attachment.

https://app.leg.wa.gov/rcw/default.aspx?cite=41.56.030 https://app.leg.wa.gov/rcw/default.aspx?cite=41.80.005 https://app.leg.wa.gov/RCW/default.aspx?cite=48.43.005 https://app.leg.wa.gov/rcw/default.aspx?cite=48.43.005 https://app.leg.wa.gov/wac/default.aspx?cite=284-43-0160 https://app.leg.wa.gov/wac/default.aspx?cite=284-43 https://app.leg.wa.gov/wac/default.aspx?cite=284-43 https://apps.leg.wa.gov/rcw/default.aspx?cite=42.56 https://www.law.cornell.edu/uscode/text/42/chapter-6A/subchapter-XX

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“Deliverables” means all tangible objects, reports, work product, program or tool documentation, designs, formulas, methods, or other documents and materials provided or delivered by Contractor to HCA pursuant to the terms of the Contract. Deliverables will consist of Customized Materials and/or Non-Customized Materials.

“Dependent” means an eligible spouse, state-registered domestic partner, and/or child, who meets the PEBB and/or SEBB program eligibility requirements as described in WAC 182-12-250, WAC 182-12-260, and WAC 182-31-140.

“Diversity, Equity, Inclusion, and Belonging” or “DEIB” means practicing values that respect and create a culture where people are empowered to be their complete, authentic selves, by building and sustaining a high performing workforce, delivering services with cultural humility, and perpetuating a culture of respect, caring, and inclusion.

“Educational Service District” or “ESD” means a regional education unit in Washington State. There are nine (9) ESDs; each ESD serves multiple school districts. ESDs are established under RCW 28A.310.020 to provide cooperative and information services to local school districts, assist superintendents in the performance of their duties, and provide services to the school districts and the Washington State Center for Childhood Deafness and Hearing Loss and the School for the Blind to assure equal education opportunities.

“Electronic Protected Health Information” or “ePHI” means Protected Health Information that is transmitted by electronic media or maintained in any medium described in the definition of electronic media at 45 C.F.R. § 160.103.

“Employer Group” has the same meaning as set forth in RCW 41.05.011(9). An Employer Group is a group that has contracted with HCA to obtain employee benefits through benefit plans developed by the PEBB or SEBB program. Employer Groups eligible to obtain PEBB benefits include counties, municipalities, political subdivisions, the Washington health benefit exchange, tribal governments, and employee organizations representing state civil service employees. Employer Groups eligible to obtain SEBB benefits include employee organizations representing school employees and tribal schools as defined in RCW 28A.715.010

“Employer Medical Contribution (EMC)” means the collectively bargained mechanism used to calculate the employer contribution toward employee medical benefits. The EMC is currently calculated as eighty-five percent (85%) of the single subscriber Bid Rate for the self-insured UMP Classic (PEBB) and UMP Achieve 2 (SEBB). It is the amount subtracted from each plan’s Bid Rate to determine the single subscriber employee contribution amount for each plan. The EMC and the employee’s contribution are both multiplied by one of several pre-determined tier factors if the employee elects to enroll Dependents (self plus spouse/partner, self plus child(ren), or full family).

“Formulary” means a list of covered drugs that specifies how prescription drugs are covered by the Contractor, and whether the Contractor has any limitations about how the drug is covered.

“Grievance” has the same meaning as “Complaint”

“Health Care Authority” or “HCA” means the Washington State Health Care Authority, any division, section, office, unit or other entity of HCA, or any of the officers or other officials lawfully representing HCA.

https://apps.leg.wa.gov/wac/default.aspx?cite=182-12-250 https://apps.leg.wa.gov/wac/default.aspx?cite=182-12-250 https://app.leg.wa.gov/WAC/default.aspx?cite=182-12-260 https://apps.leg.wa.gov/wac/default.aspx?cite=182-31-140 https://app.leg.wa.gov/rcw/default.aspx?cite=28A.310.020 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160/subpart-A/section-160.103 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.011 http://app.leg.wa.gov/RCW/default.aspx?cite=28A.715.010 http://app.leg.wa.gov/RCW/default.aspx?cite=28A.715.010

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“Health Care Quality” means the degree to which health care services for individuals and populations increase the likelihood of desired health Outcomes and are consistent with current professional knowledge.

“Health Equity” means the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, Preferred Language, or other factors that affect access to care and health Outcomes.

“Health Plan” means one of the fully-insured or self-insured medical plans offered by HCA Employee and Retiree Benefits Division (ERB). Each Health Plan includes a Certificate of Coverage for services relating to medical, behavioral health, and pharmacy Claims. If not capitalized, health plan refers to the more general definition of health plan used in statute and rules and by Washington State Office of the Insurance Commissioner (OIC), National Committee for Quality Assurance (NCQA), WHA, and other health insurance industry sources.

“Health Plan Challenge” means the Washington Health Alliance’s (WHA) Health Plan Challenge (or similar initiative) which provides a forum for purchasers and health plans to interact and share health plan performance. The WHA invites purchasers and health plans to come together to discuss and answer questions in five topic areas: mental and behavioral health, diversity and equity, advanced primary care, high-cost claims, and innovation and action specific to Washington.

“Healthcare Effectiveness Data and Information Set" or “HEDIS®” means a widely used tool created by the National Committee for Quality Assurance (NCQA) to measure the performance of health plans in delivering quality care. It's a standardized set of performance measures developed by NCQA to help objectively measure, report, and compare quality across different plans.

“HIPAA” means the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic and Clinical Health Act of 2009 (42 U.S.C. 1320d-1329d-9), and its implementing Regulations, including the Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164, Subparts A and E), the Security Standards for the Protection of Electronic Protected Health Information (45 C.F.R. Parts 160 and 164, Subparts A and C), and Breach Notification for Unsecured Protected Health Information Rules (45 C.F.R. Part 164, Subpart D).

“Independent Review Organization” or “IRO” means an organization as defined in WAC 284-43A-010(14).

“LAN” or “HCP-LAN” means the Health Care Payment Learning and Action Network, a collaborative effort between CMS and its private, public, and non-profit partners to transform the nation’s health system to emphasize value of care over volume.

“Measurement Period” means the period of the Contractor’s performance under the Contract for which Performance Results are to be reported. A list of Measurement Periods is outlined in Table 1 “Summary of Performance Standard” below.

“Measurement Year” or “MY” means the Plan Year in which care occurs and for which performance is used to calculate Performance Results.

https://uscode.house.gov/view.xhtml?req=granuleid%3AUSC-prelim-title42-chapter7&saved=%7CKHRpdGxlOjQyIHNlY3Rpb246MTMyMGQtOSBlZGl0aW9uOnByZWxpbSk%3D%7C%7C%7C0%7Cfalse%7Cprelim&edition=prelim https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160?toc=1 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164?toc=1 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160?toc=1 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164?toc=1 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164?toc=1 https://app.leg.wa.gov/wac/default.aspx?cite=284-43A-010 https://app.leg.wa.gov/wac/default.aspx?cite=284-43A-010

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“Member” means Subscribers and their Dependents who are enrolled in either a PEBB or SEBB program medical plan.

“Member Portal” means a web interface requiring sign-up that can act as a central hub to access features such as self-service account management and member services and benefits.

“Microsite” means an auxiliary website with independent links and address that is accessed mainly from a larger site. Microsites allow brands to deliver highly targeted content to specific segments of their audience.

“Monthly Premium” as used in this RFP, means the total monthly payment made by HCA to Contractor as payment for the insurance coverage and services for the underlying enrolled populations in each program. Monthly Premiums are equal to the plan Payment Rate multiplied by Subscriber enrollment tier factor for all plan enrollees.

“Multi Factor Authentication” or “MFA” means an electronic authentication method in which a user is granted access to a website or application only after successfully presenting two or more pieces of evidence (or factors) to an authentication mechanism.

“National Committee for Quality Assurance” or “NCQA” means the private 501(c)(3) not-for-profit organization dedicated to improving Health Care Quality. NCQA is the accrediting body for health plans in the United States. NCQA uses the Healthcare Effectiveness Data and Information Set (HEDIS) to measure health plan performance on important dimensions of care and service.

“Non-Medicare Retiree(s)” means a Subscriber who has retired or separated from service, is eligible for PEBB program benefits, and not yet Medicare-eligible.

“Outcomes” means changes in Member health, functional status, satisfaction or goal achievement that result from health care and/or supportive services.

“Participating Provider” means healthcare institutions and practitioners who have contracted with health insurance companies. They are known as Participating Providers or “in-network” providers.

“Patient-Centered Medical Home” or “PCMH” means practices that have earned recognition for making a commitment to continuous Quality Improvement and a patient-centered approach to care.

“Patient Decision Aid” means a tool that can help people engage in shared health decisions with their health care provider. Research shows that use of Patient Decision Aids leads to increased knowledge, more accurate risk perception, and fewer patients remaining passive or undecided about their care.

“Patient-Reported Outcome Measures” or “PROMS” means tools used to evaluate patients’ perception of their health care Outcomes including symptoms, physical and emotional well-being, and overall quality of life. PROMs are a type of measure that can help clinicians better understand the patient perspective and tailor treatment plans to improve Outcomes over time.

https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/ https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh/ https://stateofwa.sharepoint.com/sites/HCA-erbcontractsteam/Shared%20Documents/Contract%20Documents/RFP%202025HCA5/hca.wa.gov/about-hca/programs-and-initiatives/making-informed-health-care-decisions/patient-decision-aids-pdas

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“Patient Reported Outcome-Based Performance Measures” or “PRO-PM” are a way to aggregate the information from patients into a reliable and valid measure of performance.

“Payment Rate” means the Health Plan single Subscriber Bid Rate multiplied by the Contractor’s projected plan Risk Score and is used to calculate Monthly Premiums paid to Contractor.

“PEBB Employee” has the same meaning as in RCW 41.05.011(6)(a), which includes employees such as employees of state agencies and higher education institutions, superior court and appellate judges, members of the state legislature; and may also include employees of political subdivisions (counties, municipalities, etc.) and employees of employee organizations representing state civil service employees.

“Performance Metric” means the specific result the Contractor must achieve on a given Performance Standard to avoid owing a Performance Payment. For example, “Average Answer Time for ninety-five (95%) of all calls into Contractor’s Plan customer service line is thirty (30) seconds or less.”

“Performance Payment” means the financial consequence associated with failure to meet the applicable Performance Standard as explained in RCW 48.30.360. Performance Payments can be either a specified dollar amount or calculated as a percentage of Annual Premium. Performance Payments may be paid in the form of premium credits to HCA.

Remittance of a Performance Payment to the group policyholder is not a return of premium for purposes of RCW 48.14.020 and 48.14.0201.

“Performance Result” means the Contractor’s actual result on a given Performance Standard for a given Measurement Period.

“Performance Standard” has the same meaning as in RCW 48.30.360: a contractual provision in a group insurance contract that establishes a specific standard for the insurer's or health carrier's performance of an obligation in the contract, and under which the insurer or health carrier is required to remit a penalty payment, based on a percentage of the premium or a set dollar amount, to the group policyholder for the next policy term if the insurer or health carrier fails to comply with the standard. Group policyholders and insurers or health carriers may calculate the amount of the penalty based on a percentage of the overall premium owed to the insurer or health carrier by the policyholder.

“Performance Standard Verification and Validation” means the document that sets forth in detail the mechanics of measuring, calculating, and reporting the Contractor’s result under a Performance Standard, including:

• The Performance Standard (which includes the Performance Metric);

• The Measurement Period (e.g., monthly, quarterly, annually);

• Required documentation Contractor must submit to show the Performance Standard has been met;

• How the result will be calculated;

• Any definitions necessary to ensure clarity;

• Performance Penalty;

• Subject Matter Experts;

• Approvals; and

• Any other information deemed necessary by HCA and the Contractor to ensure clarity of expectations.

https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.011 https://app.leg.wa.gov/RCW/default.aspx?cite=48.30.360 https://app.leg.wa.gov/rcw/default.aspx?cite=48.14.020 https://app.leg.wa.gov/rcw/default.aspx?cite=48.14.0201 https://app.leg.wa.gov/RCW/default.aspx?cite=48.30.360

HCA RFP #2025HCA5 Page 11 of 75

All Performance Standard Verification and Validations are agreed to between HCA and the Contractor. They become part of the Operations Manual and are incorporated by reference into the Contract.

“Plan Year” means the 12-month time period beginning on January 1 of each year and ending December 31 of the same year.

"Preferred Drug List" has the same meaning as Formulary.

“Preferred Language” has the same meaning as Primary Language.

“Primary Language” means the language a Member or potential Member identifies as the language in which they wish to communicate verbally or in writing with HCA.

“Proposal” means a formal offer submitted in response to this solicitation. To be responsive, a Proposal must include all items outlined in section 3 Proposal Contents and Requirements.

“Proprietary Information” refers to any information that has commercial value and is either:

(1) technical information, including patent, copyright, trade secret, and other Proprietary Information, techniques, sketches, drawings, models, inventions, know-how, processes, apparatus, equipment, algorithms, software programs, software source documents, and formulae related to the current, future, and proposed products and services; or (2) non-technical information relating to products, including without limitation pricing, margins, merchandising plans and strategies, finances, financial and accounting data and information, suppliers, customers, customer lists, purchasing data, sales and marketing plans, future business plans, and any other information which is proprietary and confidential.

Bidder’s Proprietary Information is information owned by Bidder to which Bidder claims a protectable interest under law.

“Protected Health Information” or “PHI” has the same meaning as defined in 45 C.F.R. § 160.103.

“Public Employee” has the same meaning as in RCW 41.05.011(18), which includes employees of state agencies and higher education institutions, employees of employer groups with contracts to participate in the PEBB program, and school employees as defined in RCW 41.05.011(6)(b).

“Public Employees Benefits Board” or “PEBB” or “PEB Board” means the Public Employees Benefits Board, which is authorized to design benefits and determine the terms and conditions for participation in health insurance benefits for eligible Public Employees and Retirees under chapter 41.05 RCW.

“Qualified Health Plan” or “QHP” means an insurance plan that’s certified by the Health Insurance Marketplace®, provides essential health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out-of-pocket maximum amounts), and meets other requirements under the ACA. All Qualified Health Plans meet the ACA requirement for having health coverage, known as “minimum essential coverage”.

“Quality Improvement” means a systematic and continuous set of actions that lead to measurable improvement in health care services and the health status of targeted patient groups.

https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160?toc=1 https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-160?toc=1 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.011 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.011 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05

HCA RFP #2025HCA5 Page 12 of 75

“Quality of Care” means the degree to which a Bidder increases the likelihood of desired health Outcomes of its Members through its structural and operational characteristics, and through the provision of health services that are consistent with current professional knowledge.

“Race, Ethnicity, and Language” – Race refers to the social construction and categorization of people based on perceived shared physical traits that result in the maintenance of a sociopolitical hierarchy. The term is also loosely applied to geographic, cultural, religious, or national groups. Self-reported race frequently varies owing to changing social contexts and an individual’s possible identification with more than one race.

Ethnicity is a characterization of people based on having a shared culture (e.g., language, food, music, dress, values, and beliefs) related to common ancestry and shared history.

Language is the specific communicative system used by a particular group of speakers, with its distinctive vocabulary, grammar, and phonological system.

“Race, Ethnicity, and Language Data” means information about demographic factors of an individual or population.

“Rebates” means retrospective payments or discounts, including promotional or volume-related refunds, incentives or other credits, however characterized, pre-arranged with pharmaceutical companies on certain prescription drugs, which are paid to or on behalf of a Carrier, and are directly attributable to the utilization of certain drugs by Members, including administrative fees and software or data fees paid by pharmaceutical companies. “Rebate” includes all rebates, discounts, payments or benefits, however characterized, generated by medical drug claims, or derived from any other payment or benefit for the dispensing or administration of prescription drugs or classes or brands of drugs within HCA’s programs or arising out of any relationships the Carrier has with pharmaceutical companies, including but not limited to Rebate sharing, market share allowances, educational allowances, gifts, promotions, or any other form of revenue whatsoever.

“Reference-based Pricing” or “RBP” is a concept in health care where a standard reimbursement level is established for payment of certain services, such as hospital (inpatient) care. The reference point, or price, is tied to an already defined pricing level, such as Medicare Fee-for-Service (FFS) reimbursement rates.

“Regulation” means any federal, state, or local regulation, rule, or ordinance.

“Request for Proposals” or “RFP” means this formal solicitation document that identifies a service or need but no specific method to achieve it has been chosen.

"Request for Renewal" or "RFR" is a formal proposal that HCA releases each year for the PEBB and SEBB program health plans. Through the RFR process, the PEB and SEB Boards adjust employee benefits annually because of (a) new requirements under the ACA; (b) changes requested by PEB or SEB Board members, the public, HCA’s Chief Medical Officer, or other internal policy drivers; (c) benefit design strategies promulgated by HCA; and/or (d) legislative mandates and other changes. Both parties may propose possible benefit changes and other potential changes to any of the Health Plans for the following Plan Year. Benefit changes may have cost impacts to the Bid Rate, but benefit changes proposed in the RFR process cannot affect the structure of the Health Plans being offered, the clinical goals and

HCA RFP #2025HCA5 Page 13 of 75 expectations, or the financial structure of a Contract resulting from this procurement between an ASB and HCA. A secondary purpose of the RFR is to renew the Contract based on annual budget approval by the Legislature, and it is not to be used to re-negotiate any other aspects of the Contract.

“Revised Code of Washington” or “RCW” means the laws of the State of Washington, as enacted by the Legislature. Any references to specific titles, chapters, or sections of the RCW include any substitute, successor, or replacement title, chapter, or section.

“Risk Score” means a health status factor calculated by HCA’s contracted actuary via the Milliman Advanced Risk Adjuster (MARA) model and applied as described in EXHIBIT B –

DRAFT CONTRACT.

“School Employee” has the same meaning as in RCW 41.05.011(6)(b), which includes employees of school districts, charter schools, and educational school districts, employees of employee organizations representing school districts, and employees of tribal schools.

“School Employees Benefits Board” or “SEBB” or “SEB Board” means the board authorized to design benefits and determine the terms and conditions for participation in health insurance benefits for eligible School Employees under RCW 41.05.740.

“Service Area” means the designated geographical area within which a Member must reside or currently work to be eligible for enrollment. This area is comprised of the counties and zip codes listed in any Contract resulting from this RFP.

“Sexual Orientation and Gender Identity” or “SOGI” – Sexual orientation is an often-enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both. It also refers to an individual’s sense of personal and social identity based on those attractions, related behaviors, and membership in a community of others who share those attractions and behaviors.

Gender identity refers to a person’s innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves.

These two related, but distinct, characteristics are often discussed together.

“Shared Decision Making” means the process that allows Members and their providers to make health care decisions together, considering the best scientific evidence available as well as the patient’s values and preferences.

“SMART Goals” means goals which are specific, measurable, achievable, relevant, and time bound.

“Social Determinants of Health” or “SDOH” means the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Examples include housing, education, transportation, access to nutritious food, opportunities for employment, and social support.

“Statement of Work” means a detailed description of the work activities the Bidder is required to perform under the terms and conditions of a Contract resulting from this RFP, including the http://apps.leg.wa.gov/rcw/ https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.011 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05.740

HCA RFP #2025HCA5 Page 14 of 75

Deliverables and timeline. See EXHIBIT B: DRAFT CONTRACT, Attachment 3: Statement of Work.

“Subcontract” means any separate agreement or contract between the Contractor and a person, partnership, or entity not employed or owned by the Bidder (“Subcontractor”) to perform any activities of the Contract under a separate contract with (or on behalf of) the Bidder. Subcontracts may give rise to a business requirement to access the Data that is the subject of the Contract resulting from this RFP.

“Subcontractor” means a person, partnership, or entity not employed or owned by the Bidder, who would be performing all or part of the business activities of this RFP under a separate contract with (or on behalf of) the Bidder. The term “Subcontractor” means those who directly or indirectly contract with the Bidder, and includes Healthcare Benefit Managers as defined by RCW 48.200.020.

“Subscriber” means the account holder for PEBB or SEBB program benefits.

“Summary of Benefits and Coverage” or “SBC” means a document, required by law under the ACA, that insurance companies and group health plans provide to consumers comparing benefits and coverage for different plans. The information provided must be concise, use plain language, and be consistent with the health plan’s benefits and coverage information for consumers to easily compare different coverage options to select their health plan.

“U.S.C.” means the United States Code. All references in this Contract to U.S.C. chapters or sections will include any successor, amended, or replacement statute.

“Uniform Medical Plan” or “UMP” means a collection of the state’s self-insured, preferred provider Health Plans administered by third-party administrators, currently Regence BlueShield and ArrayRx, to PEBB and SEBB program Members. The UMP plans for PEBB program Members include UMP Classic, UMP Select, UMP CDHP, and UMP Classic Medicare with Part D (PDP). The UMP plans for SEBB program Members include UMP Achieve 1, UMP Achieve 2, and UMP High Deductible.

“Urgent Care” means a visit for an illness or injury that will not likely cause further disability or death if not treated immediately but could become worse without treatment. Examples include minor lacerations, urinary infections, earaches, migraine headaches and rising fever.

“Utilization Management” or “UM” means the evaluation of medical necessity appropriateness, and efficient use of health care services, procedures, and facilities under the provisions of the applicable Health Plan. Utilization Management is sometimes called utilization review.

“Value-Based Payment” or “VBP” is a form of reimbursement that ties payments for care delivery to the Quality of Care provided and rewards providers for both efficiency and effectiveness. HCA defines Value-Based Payments as payment arrangements in the CMS Health Care Learning & Action Network Categories 2c – 4b (See Appendix 1 – CMS Framework for Value-Based Payments or Alternative Payment Models (CMS LAN APM)).

VBP refers to arrangements between the Contractor awarded through this RFP and providers.

https://app.leg.wa.gov/RCW/default.aspx?cite=48.200.020 http://uscode.house.gov/

HCA RFP #2025HCA5 Page 15 of 75

“Value-Based Purchasing” refers to arrangements between HCA and the Contractor and describes a range of health care payment strategies intended to contain costs while improving Outcomes through tying payment to performance expectations. Value-Based Purchasing includes contractual arrangements between a purchaser (e.g., HCA) and its Contractors to meet specified value-based targets which may include quality, cost, access, patient and provider experience, and other value-based metrics.

“Washington Administrative Code” or “WAC” means the code of regulations (rules) promulgated by agencies of the State of Washington. All references to WAC chapters or sections will include any substitute, successor, amended, or replacement regulation.

“Washington All Payer Claims Database” or “WA-APCD” means Washington’s statewide all-payer health care claims database to support transparent public reporting of health care information as described in RCW 43.371.020.

“Washington Health Alliance” or “WHA” means a nonprofit, nonpartisan organization that reports Data on Health Care Quality and value through the collection and analysis of Claims and clinical Data from providers, health plans, health trusts, and employers. WHA focuses on evidence-based practices and provides information to providers, patients, employers, and union trusts to help them make better decisions about how to reduce waste and cost while focusing on quality.

“Washington Health Benefit Exchange” or “WAHBE” means Washington’s marketplace for qualified health and dental insurance coverage for individuals and families.

“Washington Small Business” means the Bidder is a Washington Small Business as defined in RCW 39.26.010(22).

“Washington State Common Measure Set” means a set of quality performance measures for Washington State that provides the foundation for health care accountability and measuring performance. The development and ongoing evolution and implementation of a set of measures is not only mandated by RCW 41.05.690, but necessary to ensuring our ability to measure progress toward achieving healthier Outcomes for all residents in Washington. To learn more go to Washington State Common Measure Set.

“Washington’s Electronic Business Solution” or “WEBS” means an internet-based bid notification system that HCA uses to post competitive solicitations. Individuals and firms interested in state contracting opportunities with any Washington state agency should register for competitive solicitation notices on WEBS. There is no cost to register on WEBS.

1.2 ESTIMATED SCHEDULE OF SOLICITATION ACTIVITIES

Issue Request for Proposals October 12, 2026

Pre-Proposal Conference

Microsoft Teams meeting

Join:

https://teams.microsoft.com/meet/229427348778832?p=Xc2zEyv Grodj6CilXE

October 20, 2026

11:00am – 12:00pm Pacific Time http://app.leg.wa.gov/wac/ https://app.leg.wa.gov/rcw/default.aspx?cite=43.371.020 https://app.leg.wa.gov/rcw/default.aspx?cite=39.26.010 https://app.leg.wa.gov/rcw/default.aspx?cite=41.05&full=true#41.05.690 https://www.hca.wa.gov/about-hca/who-we-are/washington-state-common-measure-set https://teams.microsoft.com/meet/229427348778832?p=Xc2zEyvGrodj6CilXE https://teams.microsoft.com/meet/229427348778832?p=Xc2zEyvGrodj6CilXE

HCA RFP #2025HCA5 Page 16 of 75

Meeting ID: 229 427 348 778 832

Passcode: Ea6Zs9Li

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Phone conference ID: 284 006 060#

Letter of Intent to Propose Due October 23, 2026, at 4:00pm Pacific

Finance Rate Instruction Conference October 29, 2026

Bidder Round 1 Questions Due November 6, 2026

HCA Answers Posted* November 13, 2026

Bidder Round 2 Questions Due December 4, 2026

HCA…