RFP26006428 Solicitation Specifications.pdf

2023-1.v2.04222024 RFP – Agency Solicitation Specifications Page 1 of 31 Revised 4/22/2024

RFP26006428

AGENCY SOLICITATION SPECIFICATIONS

MEDICAL PLAN ADMINISTRATION AND PHARMACY BENEFIT MANAGEMENT

FOR STATE EMPLOYEES

Table of Contents

SECTION 1. INTRODUCTION

Data Request Form

SECTION 2: MEDICAL PLAN ADMINISTRATION

2.A. Introduction 2.B. Background 2.C. Scope of Work and Requirements 2.D. Technical Proposal 2.E. Cost Proposal 2.F. Supplemental Bidder Attestation Form 2.G. ISBE Proposal

SECTION 3: PHARMACY BENEFIT MANAGEMENT

3.A. Introduction 3.B. Background 3.C. Scope of Work and Requirements 3.D. Technical Proposal 3.E. Cost Proposal 3.F. Supplemental Bidder Attestation Form 3.G. ISBE Proposal

SECTION 4: EVALUATION AND SELECTION

4.A. Medical Plan Administration Evaluation 4.B. Pharmacy Benefit Management Evaluation 4.C. General Evaluation

SECTION 5: PROPOSAL CONTENTS

APPENDIX A: SUPPLEMENTAL BIDDER ATTESTATION FORM

APPENDIX B: PROPOSER ISBE RESPONSIBILITIES AND MBE, WBE, AND/OR

DISABILITY BUSINESS ENTERPRISE PARTICIPATION FORM

APPENDIX C: LIMITED USE, CONFIDENTIALITY AND NONDISCLOSURE

AGREEMENT

APPENDIX D: DATA REQUEST FORM

APPENDIX E: SUBMISSION CHECKLIST

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APPENDIX F: CENSUS, DETAILED CLAIMS, AND ENROLLMENT DATA

APPENDIX G: PLAN DESIGN INFORMATION & CONFIRMATION

APPENDIX H: MEDICAL QUESTIONNAIRE

APPENDIX I: MEDICAL COST PROPOSAL

APPENDIX J: RX – DETAILED CLAIMS DATA DATABASE

APPENDIX K: RX – TOP 100 UTILIZED BRAND PRESCRIPTIONS SPREADSHEET 31

APPENDIX L: RX – PLAN DESIGN, CLINICAL & OTHER PROGRAMS

APPENDIX M: RX – REQUESTED CONTRACTUAL REQUIREMENTS

APPENDIX N: RX – VENDOR ACCOUNTABILITY AND PERFORMANCE

GUARANTEES

APPENDIX O: PHARMACY QUESTIONNAIRE

APPENDIX P: PHARMACY COST PROPOSAL

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SECTION 1. INTRODUCTION AND PROPOSAL SUBMISSION

The Rhode Island Department of Administration/Division of Purchases, on behalf of the Office of Employee Benefits, is soliciting proposals from qualified firms to provide the administration of medical benefits and/or pharmacy benefits for the State of Rhode Island’s (“State”) approximately 13,400 enrolled employees and non-Medicare retirees (or approximately 29,600 total covered members - employees and dependents) as described in detail in Sections 2 and 3, in accordance with the terms of this Request for Proposals (“RFP”).

This solicitation covers administrative services for two plans: the State’s medical and pharmacy benefits plans. This solicitation therefore has two components and vendors can submit a proposal for both plans or for only one. The vendor must fully respond to and submit: the medical technical proposal if bidding on the medical administration; the pharmacy technical proposal if bidding on the pharmacy administration; or both the medical and pharmacy technical proposals if bidding on both the medical and pharmacy administration. Vendors submitting a response for both the medical and pharmacy plans must submit separate and distinct proposals within the Ocean State Procures system. The proposal (i.e. Medical Plan or Pharmacy Plan) must be clearly indicated on the response within the system as well as all proposal documents submitted therein.

If a vendor submits a proposal for both the medical and pharmacy plans, their initial cost proposals should be based on stand-alone pricing (i.e., being awarded only medical or only pharmacy). As applicable, also clearly indicate any cost proposal modifications that would apply in the event the vendor is awarded both medical and pharmacy components.

Otherwise, proposals submitted by vendors bidding on both benefits plans will be assumed to be identical in the event the vendor is awarded one benefit plan or both benefit plans.

The State reserves the right to award to one or multiple vendors. However, only one vendor will be awarded a contract for medical plan administrative services and only one vendor will be awarded a contract for pharmacy plan administrative services. One vendor may be awarded a contract for combined medical and pharmacy plan administrative services. Also see Section 5, “Proposal Contents,” for additional proposal submission information.

Data Request Form If a vendor intends to submit a proposal for either or both of the requested benefit administration services, they will need to request data from the State that contains non-public information.

Therefore, vendors shall be required to complete and sign the following two documents in the appendices: APPENDIX C: LIMITED USE, CONFIDENTIALITY AND NONDISCLOSURE AGREEMENT and APPENDIX D: DATA REQUEST FORM. The State intends to use the same secure file site for distributing the data and for receiving the electronic version of proposals. As a result, and to limit the number of people with access to the secure file site, the State requests that each vendor assign the same individual for retrieving the data and for submitting its electronic version of their proposal. Details are provided in the Scope of Work included in the Medical (Section 2.C.2) and Pharmacy (Section 3.C.3) sections of this RFP.

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SECTION 2: MEDICAL PLAN ADMINISTRATION

2.A. Introduction The Medicare-eligible retirees are not part of this RFP.

The State seeks a medical benefit partner that will meet the following objectives:

• Provide nationwide coverage to eligible State employees, non-Medicare retirees, and their dependents (note that the State’s intent is that all participants enrolled in each of the plans offered by the State are enrolled in the same plan/product, regardless of whether they reside within or outside of the Service Area);

• Administer and support a wellness/health program and initiatives for the active population;

• Provide a high level of accountability around the member experience both in terms of quality care and administration;

• Manage the finances of the medical benefit program to optimize the cost/value;

• Improve the health of state employees and their dependents; and

• Contribute to the state’s health policy goals around care transformation and payment reform to improve health care quality and reduce costs.

The State is a non-grandfathered plan under the Patient Protection and Affordable Care Act

(PPACA).

The State currently provides medical benefits to eligible employees, non-Medicare retirees, and their dependents on a self-funded basis through Blue Cross Blue Shield of Rhode Island.

At present, the State offers three plans to active employees:

• Anchor Plan - a Point of Service (POS) plan,

• Anchor Plus Plan - a POS plan, and

• Anchor Choice Plan with HSA (Health Savings Account) - an HSA-qualified plan.

Note that there were active employee plan changes effective January 1, 2025 as noted in Sections 2.B.1. and 2.C.1., which do not apply to unions that have not ratified their contracts as of January 1, 2026.

Non-Medicare eligible retirees also have three medical plan options:

• Retiree Anchor Plan - a Preferred Provider Organization (PPO) plan,

• Retiree Anchor Plus Plan - a PPO plan, and

• Retiree Value Plan - an HSA-qualified plan.

Retired judges, legislators & State Police, as well as certain retirees with disabilities, are also offered a fourth plan:

• Retiree Anchor Choice Plan with HSA (an HSA-qualified plan).

There is a subgroup of approximately 800 enrolled employees and non-Medicare retirees (or approximately 1,850 total covered members - employees and dependents) of the Rhode Island Public Transit Authority (RIPTA) who receive the same benefits as State employees. There may be some additional support services required of the medical administrator for this group (e.g., 2023-1.v2.04222024 RFP – Agency Solicitation Specifications Page 5 of 31 Revised 4/22/2024 direct contact to administrator’s account representative) beyond that of a typical subgroup.

RIPTA participants are not included in the census or medical claims experience provided. The additional support services, if needed, for RIPTA will be negotiated with the winning medical bidder.

The State currently provides and intends to continue to provide (through its medical administrator) the following Medicare group plan options offered to eligible Office of the Postsecondary Commissioner/Board of Governors (OPC/BOG) retirees only:

• Medicare Advantage Plan (BlueChip for Medicare Preferred)—a fully insured Health

Maintenance Organization (HMO) product, including both medical and prescription drug (Rx) benefits (approximately 350 retirees enrolled),

• Medicare Advantage Plan (HealthMate Coast-to-Coast for Medicare Group Plan 14)—a fully insured PPO product with nationwide access, including both medical and prescription drug benefits (approximately 315 retirees enrolled), and

• Medicare Supplement Plan (Plan 65)—a self-funded medical-only plan. Plan 65 is a “Plan C” or “Plan G”, depending on a retiree’s date of birth and type of Medicare supplement plan (approximately 500 retirees enrolled). Plan C has been closed to new enrollees.

There may be some additional support services required of the medical administrator for these plans (e.g., retiree education, marketing materials, etc.) OPC/BOG Medicare retirees are not included in the census or claims experience provided. The logistics for these plans will be negotiated with the winning medical bidder. Vendors do not need to submit proposals for these plans with the medical proposal.

2.B. Background 2.B.1. Population and Historical Information Information was gathered from the current vendor, Blue Cross Blue Shield of Rhode Island, to assist in the preparation of the proposal.

The following files are either available via a secure file site or posted as an attachment with the

RFP:

• Census (Appendix F.1) *

• Detailed Claims Data (Appendices F.2, F.3, F.4) *

• Utilized Providers (Appendix F.5) *

• Claims and Enrollment Data (Appendix F.6) *

• Plan Design Information and Confirmation (Appendix G)

• Cost Proposal Exhibits (Appendix I)

* These files will be provided via a secure file site and Bidder must complete the Confidentiality and Nondisclosure Agreement and the Data Request Form to request this information. See Section 2.C.2 for instructions on how to securely obtain this State data.

Please check the State’s website http://www.employeebenefits.ri.gov for any updated information.

The State makes no representation regarding the data or the format in which the data is prepared.

The following changes to the State’s medical plan were adopted since January 2020:

http://www.employeebenefits.ri.gov/

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• Effective January 1, 2024, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,500/$3,000 to $1,600/$3,200 per individual/family. The State’s HSA contribution for the Active Anchor Choice Plan with HSA also increased effective January 1, 2024 from $1,500/$3,000 to $1,600/$3,200 per individual/family.

• Effective January 1, 2025, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,600/$3,200 to $1,650/$3,300 per individual/family. The State’s HSA contribution for the Active Anchor Choice Plan with HSA also increased effective January 1, 2025 from $1,600/$3,200 to $1,650/$3,300 per individual/family.

• Effective January 1, 2025, the following changes to active employee plans resulted from 2024 union negotiations:

o Implementation of Blue Cross Blue Shield of Rhode Island’s virtual musculoskeletal benefit through partnership with Hinge Health.

o Removal of PCP coordination of care. Note that the non-Medicare retiree plans did not have PCP coordination of care.

The changes above did not apply to unions that haven’t ratified their contracts (currently approximately 2,350 subscribers or5,600 total members). Should there still be unions that won’t have their contracts ratified by January 1, 2027, the State’s medical administrator is expected to administer the active plans with and without these changes.

• Effective January 1, 2026, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,650/$3,300 to $1,700/$3,400 per individual/family. The State’s HSA contribution for the Active Anchor Choice Plan with HSA also increased effective January 1, 2026 from $1,650/$3,300 to $1,700/$3,400 per individual/family.

2.B.2. Eligible Populations The following employee and non-Medicare retiree populations are eligible for medical coverage:

• Population I: Actives (approximately 12,750 subscribers and 28,700 members) o Active employees, COBRA and direct pay participants, and their dependents o RI State Police

• Legislative, Judicial, and certain retirees with disabilities

• Population II: Non-Medicare Retirees (approximately 650 subscribers and 900 members) o Retirees under age 65 and their dependents o Retirees over 65 who are not Medicare eligible

State employees are eligible for coverage the first day of employment if they work 20 hours or more per week. Full-time and part-time employees have the same coverage.

Active employee contributions are 15%, 20%, 25%, or 35%, depending on employment status (full-time or part-time), salary band, and coverage tier (individual or family).

For non-Medicare retirees with retirement dates on or after October 1, 2008, the State uses a separately pooled rate and retiree contributions are dependent upon age and years of service. For non-Medicare retirees who retired between July 1, 1989 and September 30, 2008 the State uses the same rates as active employees and contributions are based on a statutory formula taking age and years of service into account.

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There is a subgroup of approximately 800 enrolled RIPTA employees and non-Medicare retirees (or approximately 1,850 total covered members - employees and dependents) who receive the same benefits as State employees. There may be some additional support services required of the medical administrator for this group (e.g., direct contact to administrator’s account representative) beyond that of a typical subgroup. RIPTA participants are not included in the census or claims experience provided.

There are approximately 1,165 Medicare-eligible OPC/BOG retirees on Medicare Advantage and Medicare Supplement plans that will require coverage and some additional support services (e.g., retiree education, marketing materials, etc.). OPC/BOG Medicare retirees are not included in the census or claims experience provided. The logistics for these plans will be negotiated with the winning medical bidder. Vendors do not need to submit proposals for these plans with the medical proposal.

2.B.3. Service Profile The State seeks a vendor to provide medical benefit services including:

• Provision of a comprehensive national provider network with uniform quality;

• Provision of cost-effective contracting arrangements that can be demonstrated to represent direct savings to the State and plan participants;

• Provision of a comprehensive set of medical management services;

• Effective, efficient, and accurate claim processing;

• Payment of claims on a scheduled basis including issuance of reimbursement checks;

• Provision of Explanation of Benefits (EOB) Statements (available online in addition to print copies) to patients;

• Level 1 and 2 internal claims appeals for plan members, as well as willingness to cooperate and provide necessary documentation in the case of an external appeal;

• Provision of best-in-class member services and customer support;

• Accessible current coverage reports;

• An active third-party liability (TPL) coordination of benefits (COB) function encompassing identification of TPL, cost avoidance, and collections;

• HSA accounts administration;

• COBRA administration;

• Superior level of account management and service;

• Sophisticated web-services for plan participants;

• Capability to integrate with the State’s enrollment and open enrollment functionality;

• Assistance in ensuring compliance with new laws and regulations;

• Willingness and ability to provide the communication, tracking, reporting, and administrative services necessary to support the State’s customized current wellness program and calendar, including aggregating data received from the State’s other vendors (i.e., prescription drug, dental, vision, etc.) for the purposes of tracking the State’s Rewards for Wellness Program, as well as to adopt any changes to the program;

• Ability to provide customized communication materials;

• Point solution programs;

• Commitment to successful implementation;

• Demonstrated commitment to supporting and building a strong system of primary care in the state; and

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• Commitment to population health in Rhode Island.

In addition, the vendor will absorb the cost of all types of communications.1

2.C. Scope of Work and Requirements 2.C.1. Plan Design Current Plan Design:

The State currently offers three plans for active employees (Population I) – two POS plans (Anchor Plan and Anchor Plus Plan) with different deductible levels and one HSA-qualified plan (Anchor Choice Plan with HSA).

The State also currently offers three plans for non-Medicare retirees (Population II) – two PPO plans (Retiree Anchor Plan and Retiree Anchor Plus Plan) with different deductible levels and a lower costing HSA qualified plan (Retiree Value Plan). Retired Judges, Legislators & State Police, as well as certain Disabled Retirees, are also offered Retiree Anchor Choice Plan with HSA (an HSA-qualified plan).

All current plan designs are summarized and outlined in detail on the State’s website (see Appendix G).

Please complete and sign in the space provided in Appendix G indicating your ability to duplicate the current benefit plans requested.

Effective January 1, 2025, the following changes to active employee plans resulted from 2024 union negotiations:

• Implementation of Blue Cross Blue Shield of Rhode Island’s virtual musculoskeletal benefit through partnership with Hinge Health.

• Removal of PCP coordination of care. Note that the non-Medicare retiree plans did not have PCP coordination of care.

The changes above did not apply to unions that haven’t ratified their contracts. Should there still be unions that won’t have their contracts ratified by January 1, 2027, the State’s medical administrator is expected to administer the active plans with and without these changes.

The State also reserves the right to make plan design changes during the life of the contract, including offering additional plans. The selected vendor is expected to administer the current and the modified and/or additional plans and to take a significant role in communicating any plan design changes.

2.C.2. Protected Data If a vendor intends to submit a proposal, they will need to request data from the State that contains non-public/confidential information. Therefore, vendors shall be required to complete and sign the attached APPENDIX C: LIMITED USE, CONFIDENTIALITY AND NONDISCLOSURE AGREEMENT and APPENDIX D: DATA REQUEST FORM. The State reserves the right to investigate any requests for the information in order to ensure the data shall be used for its intended purposes.

1 The State uses its third party medical administrator to send customized communication materials to subscribers generally two/three times per month.

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Upon request, your organization will receive access to a secure file site containing the files for the Medical Plan Administration (see Section 2.B.1) and/or Pharmacy Benefit Management (see Section 3.B.1.).

Access to the secure file site will be provided upon receipt of a signed “Limited Use, Confidentiality and Nondisclosure Agreement” and “Data Request Form.” Neither the “Limited Use, Confidentiality and Nondisclosure Agreement” and “Data Request Form” shall be accepted if altered and/or redlined. Terms on the “Limited Use, Confidentiality and Nondisclosure Agreement” and “Data Request Form” must be accepted as presented to receive access to the secure file site.

The State intends to use the same secure file site for distributing the data and for receiving the electronic version of proposals. As a result, and to limit the number of people with access to the secure file site, the State requests that each Vendor assign the same individual for retrieving the data and for submitting its electronic version of their proposal.

Vendors are required to email the executed, unaltered “Limited Use, Confidentiality and Nondisclosure Agreement” and “Data Request Form” to Max Righter at Max.Righter@purchasing.ri.gov, and include the RFP number in the subject line of the email.

Please specify if you are requesting access to the data for the Medical Plan Administration and/or Pharmacy Benefit Management. The accessed State data files are to remain the property of the State and all State files shall be removed from the Vendor’s system(s) by the submission deadline if the Vendor does not submit a proposal. If the Vendor submits a proposal, all State files shall be removed from the Vendor’s system(s) at the conclusion of the RFP process.

2.D. Technical Proposal

General:

This section includes instructions for preparing the technical section of the Medical Plan Administration proposal. Offerors are cautioned to review the instructions carefully.

Failure to comply with these instructions in full may result in disqualification.

Proposal Requirements:

Responses should be in the order as presented in the RFP. Responses to 2.D.1 and 2.D.2 may be included within the RFP document. Responses to 2.D.3 and 2.D.4 should be provided on a separate electronic Microsoft Excel format as referenced in Appendix F.5. Additional pages relevant to your proposal should be placed in an appendix with an organized Table of Contents.

Responses are required for all questions. Failure to respond to any question may result in rejection of the proposal.

The proposal must provide evidence of the offeror’s ability to provide the services described in Section 2.B. of this RFP. The proposal must consist of the following sections outlined in detail below:

Section Title Respond in Appendix 2.D.1. Required Performance Guarantees N/A 2.D.2. Medical Questionnaire Appendix H 2.D.3. Geographic Network Access Appendix F.5 2.D.4. Provider Disruption Appendix F.5

Offerors are advised to be concise and to the point in their responses.

2.D.1. Required Performance Guarantees

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The State requires that each Bidder agree to the following performance standards and guarantees.

As such, the following are minimum performance guarantee requirements and shall be included as part of your proposal. Note that if a subcontractor is used to provide any of the contracted services, the Bidder is accountable for the subcontractors’ performance. Therefore, the Subcontractor’s performance is held to the same performance standards and Subcontractor failure to perform places the Contractor at risk.

Performance guarantees measured on a State-specific basis are preferred. The State recognizes that it may not be practical to measure some guarantees on a State specific basis.

Reconciliation of all performance guarantees shall be completed annually within 180 days of policy year-end.

The performance guarantees may be subject to verification by an outside audit.

Please outline any deviations from the minimum required standards. Deviations will be considered but only granted when in the best interests of the State.

IMPORTANT NOTE: Bids that place less than the minimum required at risk for any of the performance guarantees listed below will receive 0 out of the total points allocated for performance guarantees.

Ref # Category Guarantee At Risk1 S1 Service 85% of member calls resolved on first call $25,000 per year S2 Service Average speed to answer <= 45 seconds $25,000 per year S3 Service Call abandonment rate <= 3% $25,000 per year S4 Service 95% of written inquiries received from plan participants responded to within ten (10) business days $30,000 per year

S5 Service Service outage (website, customer service, etc.) of 24 hours or more, or any outages that exceed 4 hours that occur more frequently than twice per month unless caused by force majeure (ex, acts of God, power outage, cyberattack) other than routine maintenance.

$2,500 per day, maximum $25,000 per occurrence

S6 Service Notification of service outage (website, customer service, etc.) at maximum within 4 business hours and notification of outage resolution within 2 business hours

$15,000 per occurrence

O1 Operations 90% of paper claims received from plan participants not requiring clarification processed within 10 business days (These are manual claims submitted by plan participants that do not require additional information from the plan participant or provider in order to process.)

$30,000 per year

O2 Operations Timeliness of non-investigated claims paid (paper and electronic) – minimum of 90% within 14 calendar days (“Non-investigated” means a claim in which all information is present that is required to adjudicate the claim. A “clean” claim would be an appropriate description.)

$70,000 per year

O3 Operations Timeliness of non-investigated1 claims paid (paper and electronic) – minimum of 99% within 30 calendar days

$70,000 per year

O4 Operations Financial accuracy of claims payments 99% (Financial Accuracy is the total paid dollars reviewed minus the sum of overpayments and underpayments, then divided by total paid dollars audited.)

$110,000 per year

O5 Operations Payment accuracy of claims payments 98% (Payment accuracy is the total number of claims processed without a financial variance divided by the total number of claims reviewed.)

$110,000 per year

O6 Operations 100% of all marketing materials not specific to plan enrollees (e.g., general educational materials) must be pre-approved by the State prior to distribution to plan enrollees (Phone outreach messaging or

$25,000 per occurrence

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Ref # Category Guarantee At Risk1 automated messaging via phone specific to plan enrollees do not need to be approved.)

O7 Operations 100% of all plan enrollee communications accurate $5/erroneous document up to $80,000 penalty per contract year

O8 Operations 99% of eligibility updates received from the State processed within forty-eight (48) hours of receipt of a clean and complete eligibility file in an agreed upon format

$60,000 per year

O9 Operations Contractor will respond to all independent auditor requests for clarification, following claims audits within 30 calendar days

$30,000 at risk per audit

O10 Operations Timely and accurate implementation of all programs and program changes required by the State

$5,500 per day, maximum $110,000 per occurrence

O11 Operations Documentation provided to the State of quality control testing prior to implementation of all programs and program changes2

$15,000 per occurrence

R1 Reporting 95% of standard reports within 3 business days $30,000 per year R2 Reporting 90% Ad-hoc reports within 7 business days $30,000 per year R3 Reporting Annual reports showing network performance on core primary care, hospital, and Accountable Care Organization quality measures as specified by the Rhode Island Health Insurance Commissioner.

$30,000 per year

R4 Reporting Prompt delivery of semi-annual reports on the use of alternative payment models and value-based payments for the state employee population. The vendor shall use the report template currently issued by the Health Insurance Commissioner for commercial insurers.

$30,000 per year

1 “At Risk” figures are defined as amounts payable to the State as described for each reference number (Ref #).

2 When programs are implemented or changed, the State expects that these changes will go through a quality control process prior to the effective date. The medical administrator will need to provide documentation that confirms/ explains that this process was completed.

2.D.2. Medical Questionnaire Offerors must answer the questions included in Appendix H: Medical Questionnaire.

Your proposal and the written responses shall be the offer on which the State bases its acceptance decision. The State reserves the right to accept or reject any p roposa l ma te r i a l s o r i n fo rmat ion as stated herein to best meet the needs of the State and its employees.

The questionnaire is organized into the following sections:

A. Administrative, Member, & Claim Paying Services

B. Reporting, IT & Data Integration

C. Health Management Programs

D. Wellness Services

E. Innovative Provider Contracting

F. Experience, Stability, and Contractual

G. References

H. Allowances

2.D.3. Geographic Network Access Introduction

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One of the State’s key objectives is to determine if your organization can provide accessible medical services to its employees. In order to assess your network’s ability to meet the State’s needs, please prepare a network access (GeoAccess® analysis) using residential zip codes and your network of providers.

Results are to be prepared in the following formats:

• GeoNetworks Report (Adobe Acrobat .pdf file)

In order for your organization’s responses to be evaluated, it is critical that you comply with all instructions.

Upon request, your organization will receive a summary database in Microsoft Excel format. The database summarizes unique zip codes and total employees. The database will be made available via a secure file site. See section 2.C.2 for instructions on how to securely obtain this State data.

Summary of Census Information The following fields are included in the file named Appendix F.1 - Census.xlsx and defined as:

• Gender

• Age

• State – residential

• Zip Code – residential

• County – residential

• Relationship (employee, spouse, child, domestic partner)

• Plan (AnchorPlusPlan, AnchorPlan, AnchorHSAPlan, RetAnchorPlusPlan, RetAnchorPlan, RetAnchorHSAPlan, RetValuePlan)

• Plan Detail

• COBRA Flag

• Coverage Tier

• Medicare Primary Flag (Y/N)

Using the census data provided, complete the attached network access spreadsheet included in Appendix F.5 using driving distance as the measurement of distance, not as the crow flies. The parameters of the report must include access to two (2) physicians within an eight (8) mile radius and one (1) hospital within fifteen (15) miles radius.

2.D.4. Provider Disruption Offerors are to complete the provider disruption file accompanying this proposal. Detailed information on this file is referenced in Appendix F.5 - Utilized Providers.

Upon request, your organization will receive a Microsoft Excel file needed to complete the provider disruption analysis. The file will be made available via a secure file site. See section 2.C.2 for instructions on how to securely obtain this State data.

Summary of Provider Utilization Information The following fields are included in the file named Appendix F.5 - Utilized Providers.xlsx:

• National Provider Identification Number (if available)

• Provider Tax Identification Number (if available)

• Provider Name

• Provider Address (if available) o Street Address

2023-1.v2.04222024 RFP – Agency Solicitation Specifications Page 13 of 31 Revised 4/22/2024 o City o Zip Code o State

• Provider Specialty Offerors must indicate whether each provider is in your medical network by placing a “Y” or “N” in the designated columns. Please complete the medical provider disruption request using your PPO network.

Do not change the file format, re-sort the list provided, or delete any columns from the file. In addition, do not rename any of the worksheets.

2.E. Cost Proposal Important Note: Bidders are requested to provide their most competitive proposal in their response to this RFP.

General This section must be completed in full. Bidders must propose fees for all the requested services.

Your fee proposal needs to indicate the separate and distinct fees for each of the services requested. Offerors are cautioned that failure to respond in full, or in part, to all questions may negatively affect the evaluation of the offeror’s proposal, up to and including disqualification.

You must complete each of the charts located in the “Appendix I.1 - Medical Cost Proposal.xlsx” file.

Responses are due in the electronic Excel format provided.

Proposal Requirements Potential offerors are cautioned that proposals must conform to the specification of this RFP. Each offeror must submit proposals for the current medical plans for the entire eligible population based on self-funded financial arrangement. Offerors are required to submit proposals for each of the first three (3) plan years of the initial 36-month contract. At the end of the 36-month contract, the State may seek to renew the contract with up to two one-year renewal periods.

2.E.1. Administrative Fees, Network Access Charges, and Wellness Administrative & Program Fees (Appendix I.1) Complete the Administrative Fees and Wellness Charts in the attached Excel spreadsheet assuming a January 1, 2027 effective date. Fees should be on a per subscriber (contract) per month basis. Please provide answers only as applicable for quote. Fees must be provided in the format provided. [See the “Administrative Fee – Medical” and “Administrative Fee – Wellness” Tabs in “Appendix I.1 - Medical Cost Proposal.xlsx”] All fees to be included in monthly billing are to be broken out in detail for each service proposed or provided, i.e. specific for disease management; case management, utilization review, etc.

Additionally, provide detail on any service fees that may be charged on per claim basis, i.e.

subrogation, MRI review services, etc.

Important Notes

• While bidders are requested to provide detailed breakouts of fees, it is the State’s intent to receive as much of an all-encompassing fee as possible. The State relies on its medical administrator to provide the full suite of services outlined in this RFP (including, but not limited to, the services in section 2.B.3) and to provide significant support and resources to

2023-1.v2.04222024 RFP – Agency Solicitation Specifications Page 14 of 31 Revised 4/22/2024 the State’s Health Plan. The State does not expect to pay supplemental fees for these services and, the proposed all-encompassing fees should reflect that supplemental fees will be considered only as rare exceptions.

• The State relies on its medical administrator to take a leadership role in partnership with and approval by the State team to manage its wellness program. Again, the State’s intent is to receive an all-encompassing wellness fee (including, but not limited to, member communications) and does not expect to be charged supplemental fees.

Please complete separate charts for the following: plans without an HSA and the plan with an HSA. If only one administration chart is completed, it will be assumed the same fees apply for all requested plans and there are no plan specific fees (e.g., HSA administration fee).

Administrative fees must assume the full value of your provider discounts will be passed through to the State on each and every claim and that no portion of the provider discounts are retained to offset the administrative fees.

• Confirm that your proposal is consistent with the arrangement indicated above.

• Confirm that the contract (if awarded) with the State would include consistent language.

• Confirm the State will have the right to perform an audit if desired.

If a vendor submits a proposal for both the medical and pharmacy plans, their initial cost proposals should be based on stand-alone pricing (i.e., being awarded only medical or only pharmacy). As applicable, also clearly indicate any cost proposal modifications that would apply in the event the vendor were awarded both medical and pharmacy components.

Otherwise, proposals submitted by vendors bidding on both benefits plans will be assumed to be identical in the event the vendor is awarded one benefit plan or both benefit plans.

2.E.2. Provider Reimbursement & Discounts This section refers to spreadsheets that must be completed based on your current network provider contracts and experience. Worksheets should be completed separately for the indicated locations.

Claims Repricing Analysis (Appendix I.1) Please reprice the claims provided in detailed claims experience files referenced in Appendices F.2, F.3, and F.4. The repricing should be based on eligible charges (column “Eligible_Billed_Amt” on the repricing claims files) and your current (as of January 1, 2026) network provider contractual fee arrangements. The claims repricing amounts shall be based on actual data and shall not include any assumptions regarding projected discounts or assumed increases in billed charges. In the event the volume of claims is inadequate to support the calculation of credible discounts, the bidder may expand the experience period to achieve credible discounts. The intent is to provide pricing that is as close to January 2026 as possible.

The Bidder must note the methodology used in their response.

• Provide the sum of all repriced claims by category (Hospital Inpatient, Hospital Outpatient, Professional) and by in-network and out-of-network based on the eligible charges in the column “Eligible_Billed_Amt”. [See the “Claims Repricing” Tab in “Appendix I.1 - Medical Cost Proposal.xlsx”] Responses are due in the electronic Excel format provided.

• Provide responses to the questions in Appendix I.1 Claims Repricing.

Physician Reimbursement (Appendix I.1)

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• Physician Discount Analysis. Complete this spreadsheet for network physicians only.

Provide your current (as of January 1, 2026) average physician discounts negotiated in the 3-digit zip codes 027, 028, 029 as well as your average physician negotiated discounts in the State of Massachusetts. These discount percentages shall be based on actual achieved discounts and shall not be based on projected or expected discounts. Physician discounts should assume Non-Facility reimbursements only. Any claims paid with Facility site of service should be reflected in the hospital discounts chart. [See “Physician Discount” Tab in “Appendix I.1 - Medical Cost Proposal.xlsx”] Responses are due in the electronic Excel format provided.

• Provide responses to the questions in Appendix I.1 Physician Discount.

Hospital and Outpatient Facility Charges (Appendix I.1) Hospital Discount Analysis. Complete this spreadsheet for network hospitals only. Provide your current (as of January 1, 2026) average inpatient and outpatient hospital discounts negotiated for the entire State of Rhode Island, for each of the five State of Rhode Island counties, and for the City of Boston, Massachusetts. These discount percentages shall be based on actual achieved discounts and shall not be based on projected or expected discounts. [See “Hospital Discount” Tab in “Appendix I.1 – Medical Cost Proposal.xlsx”] Responses are due in the electronic Excel format provided.

Contracted Future Discounts with Dollar-for-Dollar Guarantees (Appendix I.1) Reflect your contracted future discounts for calendar year 2027 by completing the spreadsheet.

Include the annual dollar amount that you are willing to put at risk on a dollar-for-dollar basis for not achieving your contracted future discount. [See the “Future Discount” Tab in “Appendix I.1 - Medical Cost Proposal.xlsx”]

Bidders’ contracted future discounts should only reflect contracts with providers that have already been executed at the time of their proposal submission. Bidders should not reflect expected contracts that have not been executed as of the date of their proposal submission.

A bidder’s current average discount (as of January 1, 2026) will be adjusted to reflect expected future average discount improvements up to the amount the bidder is willing to put at risk for calendar year 2027. Please see the following examples of the future discount adjustment assuming aggregate billed charges of $100 million:

Example #1 Example #2 Percent Off of

Billed Charges

Discounted Claims

(in millions)

Percent Off of Billed

Charges

Discounted Claims

(in millions) Repricing Analysis Current Discount (As of 1/1/2026) 40% $60 40% $60

Bidder’s Expected Discount Improvement (from spreadsheet in Excel file)

2% -$2 2% -$2

Expected Contracted Future Discount (As of 1/1/2027) 42% $58 42% $58

Proposed Amount at Risk Dollar-for-Dollar up to $2 million at Risk

Dollar-for-Dollar up to $1 million at Risk

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Example #1 Example #2 Percent Off of

Billed Charges

Discounted Claims

(in millions)

Percent Off of Billed

Charges

Discounted Claims

(in millions)

Example Calculation $60 - $2 = $58 1 - $58 / $100 = 42%

$60 - $1 = $59 1 - $59 / $100 = 41%

Estimated and Guaranteed Discount for CY 2027 42% 41%

Self-Funded Claims Pick (Appendix I.1) Reflect your mature medical claim pick for calendar year 2027, 2028 and 2029 based on the 13,400 subscribers by completing the spreadsheet. If you are willing to guarantee the PEPM claim picks, include the fees that you are willing to put at risk. Also include your expected medical trend for each of the calendar years. [See the “Self-Funded Claims Pick” Tab in “Appendix I.1 - Medical Cost Proposal.xlsx”]

Claims Trend Guarantee (Appendix I.2) Provide the non-Medicare participant (active and retiree plans) claims trend your organization is willing to guarantee for each year of the contract by completing the table in Appendix I.2. Your guarantee should state the percentage of your administration fee that will be at risk.

Trend guarantee will be based on the following methodology:

• The trend guarantee will apply to all claims incurred through all medical plans administered by the selected carrier for all non-Medicare participants (active and retiree plans).

• The actual 2027 incurred claims number will be measured using medical claims that were incurred during the 2027 calendar year and paid during that calendar year and a six-month run-out period through June 2028, removing claims in excess of $250,000. This total will be divided by the actual enrollment during the policy year. (Same methodology applies for CY 2028 and 2029.)

• The actual 2026 incurred claims number will be measured using medical claims that were incurred during the 2026 calendar year and paid during that calendar year through June 2027 removing claims in excess of $250,000. This total will be divided by the actual enrollment during the policy year. All the necessary supporting claims and enrollment data for the 2026 calendar year will be obtained by the State from its current medical administrator and provided to the Contractor.

• Claims will include the amounts that are the responsibility of both the member and the employer to mitigate distortions created by plan design changes. The actual 2027 trend will be calculated by dividing the adjusted 2027 incurred claims per member per month (calculated as described above) by the adjusted 2026 incurred claims per member per month (calculated as described above) less 1. (Same methodology applies for CY 2028 over CY 2027 and for CY 2029 over CY 2028.)

• A member continuously enrolled 12-months would count as 12-member months.

Capitation and Other Risk Sharing Arrangements (Appendix I.3)

• Provide responses to the questions in Appendix I.3.

2.E.3. Financial Questions

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Provide responses to the questions in Appendix I.4.

2.F. Supplemental Bidder Attestation Form

See Appendix A on the “Overview” tab in Ocean State Procures™ for information. Vendors are required to complete, sign and submit this form with their overall proposal.

2.G. ISBE Proposal See Appendix B on the “Overview” tab in Ocean State Procures™ for information and the MBE, WBE and/or Disability Business Enterprise Participation Plan form(s). Vendors are required to complete, sign and submit these forms with their overall proposal. Please complete separate forms for each MBE, WBE, and/or Disability Business Enterprise subcontractor to be utilized on the solicitation.

SECTION 3: PHARMACY BENEFIT MANAGEMENT

3.A. Introduction The Medicare eligible retirees are not part of this RFP.

The State seeks a pharmacy benefit management (PBM) partner to administer the current prescription drug benefit plan designs and management programs that will meet the following objectives:

• Provide PBM services to eligible State employees, non-Medicare retirees, and their dependents;

• Provide a high level of accountability around the member experience both in terms of quality of care and administration; and

• Manage the pharmacy benefit program to optimize the cost/value.

The State is a non-grandfathered plan under the Patient Protection and Affordable Care Act

(PPACA).

The State currently provides pharmacy benefits to eligible employees, non-Medicare retirees, and their dependents on a self-funded basis through CVS Caremark.

At present, the State offers three plans to active employees:

• Anchor Plan (a POS plan),

• Anchor Plus Plan (a POS plan), and

• Anchor Choice Plan with HSA (an HSA-qualified plan).

Note that there was an active employee plan change effective January 1, 2025 as noted in Sections 3.B.1. and 3.C.1. which does not apply to unions that have not ratified their contracts as of January 1, 2026.

Non-Medicare eligible retirees also have three medical plan options:

• Retiree Anchor Plan (a PPO plan),

• Retiree Anchor Plus Plan (a PPO plan,) and

• Retiree Value Plan (an HSA-qualified plan).

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Retired judges, legislators & State Police, as well as certain retirees with disabilities, are also offered a fourth plan:

• Retiree Anchor Choice Plan with HSA (an HSA-qualified plan).

There is a subgroup of approximately 800 enrolled employees and non-Medicare retirees (or approximately 1,850 total covered members - employees and dependents) of the Rhode Island Public Transit Authority (RIPTA) who receive the same benefits as State employees. There may be some additional support services required of the PBM for this group (e.g., direct contact to administrator’s account representative) beyond that of a typical subgroup. RIPTA participants are not included in the census but included in the pharmacy claims experience provided. The additional support services, if needed, for RIPTA will be negotiated with the winning pharmacy bidder.

3.B. Background 3.B.1. Plan Design and Historical Information Information was gathered from the current pharmacy benefits vendor, CVS Caremark, to assist in the preparation of the proposal.

The following files are either available via a secure file site or posted as an attachment with the

RFP:

• Detailed Claims Data Database (Appendix J)*

• Top 100 Utilized Brand Prescriptions Spreadsheet (Appendix K)*

• Plan Design Summary (Appendix L.1)

• Preventive Therapy Drug List (Appendix L.2)

• Maintenance Drug List (Appendix L.3)

• Clinical Programs Summary (Appendix L.4)

• Specialty Guideline Management Drug List (Appendix L.5)

* These files will be provided via a secure file site and Bidder must complete the Confidentiality and Nondisclosure Agreement and the Data Request Form to request this information. See section 3.C.3 for instructions on how to securely obtain this State data.

Please check the State’s website http://www.employeebenefits.ri.gov for any updated information.

The State makes no representation regarding the data or the format in which the data is prepared.

The following changes to the State’s prescription drug plan were adopted since January 2020:

• Effective January 1, 2023, the State added coverage of anti-obesity drugs with a prior authorization requirement.

• Effective January 1, 2024, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,500/$3,000 to $1,600/$3,200 per individual/family. The State’s HSA contribution for the Active Anchor Choice Plan with HSA also increased effective January 1, 2024 from $1,500/$3,000 to $1,600/$3,200 per individual/family.

http://www.employeebenefits.ri.gov/

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• Effective January 1, 2025, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,600/$3,200 to $1,650/$3,300 per individual/family. The State’s HSA contribution for the Active Anchor Choice Plan with HSA also increased effective January 1, 2025 from $1,600/$3,200 to $1,650/$3,300 per individual/family.

• Effective January 1, 2025, the following change to active employee plans resulted from 2024 union negotiations:

o Change in the specialty Rx copay structure to adopt CVS’s PrudentRx program with a

$0/30% cost sharing for specialty drugs on the PrudentRx list.

The change above did not apply to unions that haven’t ratified their contracts. Should there still be unions that won’t have their contracts ratified by January 1, 2027, the State’s PBM is expected to administer the active plans with and without this change.

• Effective January 1, 2026, the Active Anchor Choice Plan with HSA and Retiree Anchor Choice Plan in-network deductibles (medical and Rx combined) increased from $1,650/$3,300 to $1,700/$3,400 per individual/family.