S000000107 RFP Medicare Advantage Prescription Drug Services Revised.pdf

STATE OF ARKANSAS

DEPARTMENT OF TRANSFORMATION AND SHARED SERVICES

OFFICE OF STATE PROCUREMENT

501 Woodlane St., Ste. 220

Little Rock, Arkansas 72201-1023

REQUEST FOR PROPOSAL (MAP)

SOLICITATION DOCUMENT

SOLICITATION INFORMATION

Solicitation Number: S000000107 Solicitation

Issued: April 1, 2022

Description: Medicare Advantage Prescription Drug Services

Department: Department of Transformation and Shared Services – Employee Benefits Division

SUBMISSION DEADLINE AND DELIVERY OF RESPONSE DOCUMENTS

Proposal Opening Date: April 25, 2022 Proposal Opening Time: 2:00 PM, Central Time

Proposal submissions for this Request for Proposal must be submitted through ARBuy, the State’s eProcurement system. It can be accessed at https://arbuy.arkansas.gov. Proposals received after the submission deadline may be rejected as untimely. See Section 1.2 for information regarding Live Proposal Openings.

TSS OFFICE OF STATE PROCUREMENT CONTACT INFORMATION

TSS OSP Buyer: Tanya Freeman Buyer’s Direct Phone Number: 501-682-4140

Email Address: Tanya.Freeman@arkansas.gov TSS OSP’s Main Number: 501-324-9316

TSS OSP

Website: https://www.transform.ar.gov/procurement/ https://arbuy.arkansas.gov/ mailto:Tanya.Freeman@arkansas.gov https://www.transform.ar.gov/procurement/

SECTION 1 – GENERAL INFORMATION AND INSTRUCTIONS

• Do not provide responses to items in this section unless specifically and expressly required.

1.1 INTRODUCTION

This Request for Proposal (RFP) is issued by the TSS Office of State Procurement (TSS OSP) for the TSS Employee Benefits Division (“EBD” or “Division”) to obtain pricing and a contract for Medicare Advantage Prescription Drug (MA-PD) services for its Medicare-eligible retirees and Medicare-eligible dependents of retirees.

The contract will be awarded to the Prospective Contractor that is determined to have submitted the most advantageous proposal to the State. Direct all questions, comments, or concerns you may have regarding this solicitation to the TSS OSP, not the Division.

1.2 LIVE PROPOSAL OPENING

Use the information below to view the proposal opening online.

Zoom Meeting Link: https://arkansas-gov.zoom.us/j/83431819757?pwd=N3pOWjVWZHFpZWhxVEJEZkFaZDNYQT09 Meeting ID: 834 3181 9757 Meeting Password: 136719 Dial-In Information: 877 853 5257 US Toll-free 888 475 4499 US Toll-free

1.3 TYPE OF CONTRACT

A. As a result of this RFP, TSS OSP intends to award a contract to a single Contractor for MA-PD services.

B. The anticipated starting date for any resulting contract is July 15, 2022, except that the actual contract start date may be adjusted unilaterally by the State for up to three (3) calendar months. By submitting a signed proposal in response to the RFP, the Prospective Contractor represents and warrants that it will honor its proposal as being held open as irrevocable for this period.

C. The initial term of a resulting contract will be from the date of contract award until December 31, 2025. Upon mutual agreement by the Contractor and Division, the contract may be renewed by TSS OSP for up to three (3) additional one-year terms or portions thereof, not to exceed a total aggregate contract term of seven (7) consecutive years.

1.4 SOLICITATION SCHEDULE

For informational purposes, TSS OSP is providing a Solicitation Schedule; however, dates listed and noted with an asterisk (*) are anticipated dates only and are subject to change at the discretion of the State. All times are listed in Central Time.

TABLE A: TENTATIVE SOLICITATION SCHEDULE

ACTIVITY DATE

RFP Release to Prospective Contractors April 1, 2022 Bidders Conference April 6, 2022, 9:00 am Deadline for Prospective Contractor Questions April 11, 2022, 4:00 pm Answers to Questions Posted to ARBuy* April 15, 2022 Proposal Due Date April 25, 2022, 2:00 pm Initial Proposal Evaluation* April 27 - May 3, 2022 Interviews* May 5 - 6, 2022 Final Proposal Evaluation* May 6, 2022 https://arkansas-gov.zoom.us/j/83431819757?pwd=N3pOWjVWZHFpZWhxVEJEZkFaZDNYQT09 https://arkansas-gov.zoom.us/j/83431819757?pwd=N3pOWjVWZHFpZWhxVEJEZkFaZDNYQT09

Discussions Kick Off Meeting* May 13, 2022 Finalize Discussions* June 1, 2022 Post Anticipation to Award* June 10, 2022 Award Contract* July 15, 2022

1.5 BIDDERS CONFERENCE

A. TSS OSP will host a bidders conference to provide additional information and clarification regarding the RFP.

1. The conference will take place on the date and time listed in Section 1.4 Table A.

2. The conference is important for Prospective Contractors to understand the tasks a Prospective Contractor shall complete when submitting a proposal (“Submission Requirements”).

3. Prospective Contractors may attend the conference via Zoom.

Zoom Meeting Link: https://arkansas-gov.zoom.us/j/86141232800?pwd=QlA5LzVvTG1yNFVqdkYyOU5wTnoydz09 Meeting ID: 861 4123 2800 Meeting Password: 266698 Dial-In Information: 877 853 5257 US Toll-free 888 475 4499 US Toll-free

4. The bidders conference presentation will be posted to the Solicitation posting in ARBuy.

1.6 CLARIFICATION OF SOLICITATION

A. Submit any questions requesting clarification of information contained in this Solicitation via the

Solicitation posting in ARBuy by the date and time listed in Section 1.4 Table A.

1. For each question submitted, Prospective Contractor should reference the specific Solicitation item number to which the question refers.

2. Prospective Contractors’ written questions will be consolidated and responded to by the State as deemed appropriate. The State’s consolidated written response is anticipated to be posted to the Solicitation posting in ARBuy by the close of business on the date provided in Section 1.4, Table A. If Prospective Contractor questions are unclear or non-substantive in nature, the State may request clarification of a question(s) or decline to answer.

B. The Prospective Contractor should notify the TSS OSP buyer of any term, condition, etc., that precludes the Prospective Contractor from submitting a compliant, Responsive Proposal. Prospective Contractors should note that it is the responsibility of the Prospective Contractor to seek resolution of all such issues, including those relating to the terms and conditions of the contract, prior to the submission of a proposal.

C. Prospective Contractors may contact the TSS OSP buyer with non-substantive questions at any time prior to the proposal opening.

D. An oral statement by TSS OSP will not be part of any contract resulting from this Solicitation and may not reasonably be relied on by any Prospective Contractor as an aid to interpretation unless it is reduced to writing and expressly adopted by TSS OSP.

1.7 DEFINITION OF TERMS

A. Unless otherwise defined herein, all terms defined in Arkansas Procurement Law have the same meaning herein.

B. “Prospective Contractor” means a responsible offeror who submits a proposal in response to this solicitation.

https://arkansas-gov.zoom.us/j/86141232800?pwd=QlA5LzVvTG1yNFVqdkYyOU5wTnoydz09 https://arkansas-gov.zoom.us/j/86141232800?pwd=QlA5LzVvTG1yNFVqdkYyOU5wTnoydz09

C. The terms “Request for Proposal,” “RFP,” and “Solicitation” are used synonymously in this document.

D. “Requirement” means something required.

E. “Responsive Proposal” means a proposal submitted in response to this solicitation that conforms in all material respects to this RFP.

F. “Shall” and “Must” mean the imperative and are used to identify requirements.

G. “Specification” means any technical or purchase description or other description of the physical or functional characteristics, or of the nature, of a commodity or service. “Specification” may include a description of any requirement for inspecting, testing, or preparing a commodity or service for delivery.

H. “State” means the State of Arkansas. When the term “State” is used herein to reference any obligation of the State under a contract that results from this solicitation, that obligation is limited to the Department/Division using such a contract.

1.8 RESPONSE DOCUMENTS

A. All proposal responses must be submitted through ARBuy, the State’s eProcurement system. The system can be accessed at https://arbuy.arkansas.gov.

B. Technical Proposal Packet

1. Responses within the Information for Evaluation and Exceptions sections must not contain the Prospective Contractor’s name or any other identifiers, including without limitation names of staff members, projects, products, and addresses.

2. Prospective Contractors shall utilize the Technical Proposal Packet to submit their responses.

3. The following items are proposal Submission Requirements and must be submitted as part of a Prospective Contractor’s proposal response.

a. Signed Proposal Signature Page. Signature may be ink or digital. (See Technical Proposal Packet.)

b. Technical Proposal response to the Information for Evaluation section included in the Technical Proposal Packet. Proposal response must be in the English language.

c. Completed Pricing Response. Official Solicitation Price Sheet attached to ARBuy Solicitation posting. Pricing must be proposed in U.S. dollars and cents.

i. Prospective Contractors shall follow instructions as specified on the Instructions tab of the Official Solicitation Price Sheet.

ii. Pricing must be based on EBD’s actual claims data (see RFP Section 1.9 Claims Data Request).

d. Detailed formulary disruption report.

e. Recommended Options Form. The Recommended Options form included in the Technical Proposal Packet allows Prospective Contractors to identify any recommended options or optional service ideas that may benefit the State that were not included in the Requirements and the proposed solution.

f. Proposed Subcontractors Form. The utilization of any proposed subcontractor is subject to approval by the Division.

g. Exceptions Form.

4. The following items, which must be submitted prior to a contract award to the Prospective Contractor, may also be included with the Prospective Contractor’s proposal:

https://arbuy.arkansas.gov/

a. EO 98-04: Contract and Grant Disclosure Form.

b. Copy of Prospective Contractor’s Equal Opportunity Policy.

c. Voluntary Product Accessibility Template (VPAT), if applicable.

5. DO NOT include any other documents or ancillary information, such as a cover letter or promotional/marketing information.

C. Redacted Copy of the Technical Proposal Packet and Completed Pricing Response

1. One (1) redacted (marked “REDACTED”) copy of the Prospective Contractor’s proposal response (see Section 6 of the Solicitation Terms and Conditions referenced in Section 1.10.)

1.9 CLAIMS DATA REQUEST

A. To obtain a copy of the claims data files for the Pricing Submission, the Prospective Contractor shall initiate a request via email to jslutzky@segalco.com.

1. Prospective Contractors shall complete the non-disclosure agreement (NDA) and shall submit as directed prior to receiving claims data files (see Attachment A: Non-Disclosure Agreement).

2. Information and instructions for accessing the claims data files will be provided within twenty-four

(24) hours of receiving the signed NDA.

1.10 ACCEPTANCE OF REQUIREMENTS

A. Unless a Prospective Contractor expressly and conspicuously identifies any exception or exceptions to any of the Requirements in the Requirements Section(s) of this RFP by listing them on the Exceptions Form (see Technical Proposal Packet), Prospective Contractor understands and agrees its submission of a proposal to represent that its proposal meets all such Requirements.

B. A Prospective Contractor’s proposal may be rejected if a Prospective Contractor takes exception to any Requirements in the Requirements Section(s) of this RFP.

1.11 ADDITIONAL TERMS AND CONDITIONS

A. This RFP incorporates all of the Solicitation Terms and Conditions located on the TSS OSP website found at transform.ar.gov.

1. Any special terms and conditions included in this solicitation shall override the Solicitation Terms and Conditions.

B. Unless a Prospective Contractor expressly and conspicuously identifies any exception or exceptions to any of the terms in the Services Contract (SRV-1) Fillable Form (found here) by listing them on the Exceptions Form (see Technical Proposal Packet), Prospective Contractor agrees and shall adhere to all terms if selected as the successful Contractor.

1. Items identified as non-negotiable may only be modified if the legal requirement is satisfied and approved by the State.

C. A Prospective Contractor’s proposal may be rejected if a Prospective Contractor takes exception to any terms or conditions in the documents listed in Sections 1.10.A and 1.10.B.

mailto:jslutzky@segalco.com https://www.transform.ar.gov/wp-content/uploads/2021/12/MASTER-Solicitation-Terms-and-Conditions-11-29-21.pdf https://www.transform.ar.gov/wp-content/uploads/2021/08/Services-Contract-SRV-1-Fillable-Form-V.2.pdf

SECTION 2 – REQUIREMENTS

• Do not provide responses to items in this section unless specifically and expressly required.

2.1 OBJECTIVE AND GOALS

The Employee Benefits Division seeks to provide high quality, cost-effective benefits to its retirees and their families. EBD is soliciting proposals for a fully-insured, national MA-PD passive Preferred Provider Organization (PPO) Plan with the same benefits for services rendered in or out-of-network.

The proposed MA-PD PPO Plan must meet the minimum requirements set by CMS and must mirror EBD’s current benefits design for Medicare-eligible State and Public School retirees (see Attachment B:

Schedule of Benefits). The MA-PD PPO Plan must offer the same benefits for services rendered whether the Medicare-eligible retiree or their Medicare-eligible dependent sees a provider in-network or a provider outside the network that accepts Medicare. Prospective Contractors are encouraged to identify and offer features or enhancements that provide additional value without adding cost to EBD or its members, as well as any creative solutions that will achieve EBD's goals. Of particular interest are programs that focus on wellness, medical management, maximization of CMS funding, and minimization of claims cost.

The following services must be provided under a resulting contract:

• Member Services

• Claims Adjudication

• Data Reporting

• Member Enrollment and Eligibility Maintenance

• Revenue Maximization

• Medical Management

• Network Access and Network Management

• Provider Advocacy and Assistance with Claims Issues

• Formulary and Clinical Program Management

• Medicare Advantage and Part D Administrative Assistance

• Effective Member Communications

• Patient and Family/Caretaker Education and Assistance

2.2 CURRENT ENVIRONMENT

EBD provides medical coverage to retired Arkansas State Employees (ASE) and Public School Employees (PSE) through the Medicare Primary Plan. The plan covers Medicare-eligible retirees and Medicare-eligible dependents of retirees. There are approximately 15,000 Medicare-eligible members in ASE and 15,000 Medicare-eligible members in PSE, respectively. For prescription drug coverage, ASE retirees are offered group coverage as part of the group Medical plan through ARBenefits. PSE retirees are not offered prescription drug coverage post-65 but can choose a Part D plan in the individual market.

If a member or dependent is Medicare-eligible due to age or disability at the time of his or her retirement, Medicare will become the primary payer and the State the secondary payer. The State’s Medicare Primary Plan will supplement the Medicare coverage on a coordination of benefits basis of Medicare integration. The Medicare-eligible retiree’s spouse or other covered dependents who are not Medicare eligible will remain in the State’s (non-Medicare) hospital-medical and prescription drug plans (Premium, Classic, and Basic Plans).

For the upcoming MA-PD PPO Plan effective January 1, 2023, EBD anticipates that all Medicare-eligible retirees and Medicare-eligible dependents of retirees, and qualifying Medicare-eligible primary End Stage

Renal Disease (ESRD) beneficiaries will automatically be enrolled in the MA-PD PPO Plan. If a member beneficiary opts out of the MA-PD PPO Plan, he/she may elect to opt back into the group Medicare Primary plan.

Retirees and covered dependents who age into Medicare will automatically be enrolled into the MA-PD PPO Plan, effective on their Medicare eligibility date. There shall be no gap in coverage for those aging into the MA-PD PPO Plan. The working aged who retire shall be automatically enrolled into the MA-PD PPO Plan. Retirees and covered dependents who age into Medicare will also have the option to opt out of the MA-PD PPO Plan and elect the current group plan. Retirees and their dependents who are enrolled in the MA-PD PPO Plan and subsequently drop, terminate, or otherwise lose their Medicare Part B coverage will lose their State coverage and will not be permitted to re-enroll in MA-PD PPO Plan.

For Part D coverage, the Plan is currently using a Custom Formulary that is customized based on discussions with the Plan's clinical consultants. Currently, the University of Arkansas for Medical Sciences (UAMS) Evidence—Based Prescription Drug Program (EBRx) acts as the Plan’s clinical consultant and maintains the Plan’s custom formulary. For the upcoming MA-PD PPO Plan, Prospective Contractors should propose a formulary to best fit the Plan and the members’ needs.

2.3 PROSPECTIVE CONTRACTOR MINIMUM QUALIFICATIONS

A. The Prospective Contractor shall possess and maintain all licenses, certifications, or registrations required by State and federal laws, rules, and regulations for the services to be provided under any resulting contract.

B. The Prospective Contractor shall be authorized by CMS to provide services as required in this RFP.

C. The Prospective Contractor shall have a total overall CMS Star Rating of four (4) stars or better.

D. The Prospective Contractor shall have experience providing services to public sector group health clients with at least 25,000 public sector group health plan members.

E. The Prospective Contractor shall have experience participating in Medicare with an Employer Group Waiver Plan (EGWP) option for both Part C and Part D benefits.

F. Should Prospective Contractors propose to use subcontractors, the Prospective Contractor’s proposed subcontractors shall meet minimum qualifications listed herein.

2.4 GENERAL REQUIREMENTS

A. The Contractor shall propose, implement, and administer an MA-PD PPO Plan that mirrors the current benefits design for Medicare-eligible State retirees within Centers for Medicare & Medicaid Services (CMS) guidelines.

B. The Contractor shall not require minimum member participation in the MA-PD PPO Plan.

C. The Contractor shall sign and adhere to all requirements contained in the Business Associate Agreement (BAA).

D. The Contractor shall maintain a total CMS Star Rating of four (4) stars or better for the duration of a resulting contract.

E. The Contractor shall provide an MA-PD PPO Plan with same in-network and out-of-network cost sharing for members.

F. The Contractor shall provide an identical MA-PD PPO Plan design to members in all states.

G. The Contractor shall provide the same fully insured rates to members throughout the country.

H. The Contractor shall cover members entering the MA-PD PPO Plan that have been diagnosed with

ESRD.

I. The Contractor shall consider retirees who are disabled and on Medicare, but who are under age 65, eligible for the MA-PD PPO Plan proposed.

J. The Contractor shall participate in the validation of the Medical Loss Ratio (MLR) to be performed by EBD or its designee.

1. The validation must include a review of the Quality Improving Activities (QIA) as defined by CMS.

2. The Contractor shall provide all requested data EBD needs to validate a Medical Loss Ratio

(MLR).

K. The Contractor shall guarantee, at minimum, a ninety percent (90%) annual MLR with a minimum 50% share.

1. The State prefers to maximize gainsharing options.

L. The Contractor shall notify EBD immediately upon identification of significant issues that cause member and/or provider disruption.

M. The Contractor shall maintain, with respect to the services provided under a resulting contract, professional liability (errors and omissions) insurance and general liability insurance in amounts reasonable and customary for the nature and scope of MA-PD services. The Contractor shall provide evidence of such insurance upon EBD’s request.

N. The Contractor shall comply with all relevant CMS, federal and state laws, rules, and regulations, including but not limited to Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Patient Protection and Affordable Care Act (PPACA).

O. The Contractor shall maintain all licenses necessary to do business in the State of Arkansas and to perform the services required under a resulting contract.

P. The Contractor shall accept liability for any mistakes, errors, or omissions it makes in providing services to EBD and its members.

Q. The Contractor shall not render or administer services off-shore, and all work performed under a resulting contract must occur within the contiguous United States.

R. The Contractor shall notify EBD within thirty (30) days after purchase, acquisition, and all other changes in ownership, partners, or control affecting 10% or greater interest; any acquisition by it of 10% or greater interest in any subsidiary; and any new agreement with, by, or between any affiliates that is relevant to the contract.

S. The Contractor shall be responsible for payment of any fines levied against EBD by CMS because of an action or omission by the Contractor that incurred the citation.

T. The Contractor shall maintain fidelity and surety insurance or bond coverage to protect EBD in the event of a loss.

U. The Contractor shall maintain processes to prevent and detect internal and external fraud and fraudulent practices that must include screening for potential fraud and systematically review provider claims.

1. The Contractor shall report all fraud findings and relevant corrective measures to EBD.

V. The Contractor shall keep all EBD information disclosed during the proposal and contract term strictly confidential unless disclosure is required by law.

2.5 IMPLEMENTATION REQUIREMENTS

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Implementation Plan that must address all Requirements specified in this subsection and that must include all components of the proposed plan, including, without limitation, the implementation team, complete implementation and project schedules, testing processes, deliverables, milestones, reporting, which party is responsible for which tasks, and issue escalation processes.

B. The assigned implementation manager shall have at least three (3) years of experience implementing similar plans with at least 25,000 group health members.

C. The Contractor shall ensure the MA-PD PPO Plan is complete and fully implemented by January 1, 2023, unless otherwise specified by EBD.

D. The Contractor shall develop and implement a member communication plan, including development and assistance to EBD, prior to Open Enrollment.

1. Open Enrollment lasts from October 1 to October 31 each year.

2. The Contractor shall bear the cost of printing communications to members as a part of the communication plan.

E. The Contractor shall develop communications for and implement on-site Open Enrollment meetings and district and local retiree meetings.

F. The Contractor shall ensure transition of care and prior-authorization data is appropriately transferred from incumbent vendor.

G. The Contractor shall test all systems and process to ensure they are fully functional prior to January 1, 2023.

1. Testing must include testing with an actual retail pharmacy from the Point-of-Sale transaction to a completed transaction where the pharmacy successfully processes the prescription drug claim for a successful fill of the medication.

H. The Contractor shall complete and bear the cost of readiness assessments to the satisfaction of

EBD.

I. At EBD’s request, the Contractor shall allow EBD and its designees full access to test the functionality of all systems and processes during implementation.

J. At EBD’s request, the Contractor shall bear the cost of a third-party auditor selected by EBD to complete all pre-implementation audits required by EBD.

K. The Contractor shall provide, via surface mail, valid, accurate member identification (ID) cards to all members prior to January 1, 2023.

1. Valid, accurate member ID cards (“ID Cards”) must include, at minimum:

a. The member’s name

b. Contract number

c. Contractor’s twenty-four (24) hour, seven (7) day/week toll-free eligibility and pre-certification services telephone number

d. Applicable co-payments for services

e. Rx BIN

2.6 MA-PD PPO PLAN MANAGEMENT

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Management Plan that must address all Requirements specified in this subsection and that must include all components of the proposed plan, including, without limitation, the plan management team, deliverables, milestones, which party is responsible for which tasks, and an issue escalation processes.

B. The Contractor shall assign a single, dedicated account manager for the MA-PD PPO Plan.

C. The Contractor shall provide an account management team to the MA-PD PPO Plan.

D. The account management team shall provide, at minimum, the following duties:

1. Overall account relationship, including strategic planning in relation to plan performance, consultative services, recommendations for benefit design and cost containment opportunities, overseeing contractual services under the contract with EBD, and managing all other Contractor staff

2. Developing EBD’s premiums for MA-PD PPO Plan options and projecting future claims costs and CMS reimbursements

3. Assisting EBD in determining the projected short- and long-term financial impact(s) of prospective programs

4. Evaluating design and clinical effectiveness of medical management and wellness programs to manage the risk of EBD’s membership and therefore control future cost/premium increases

5. Assisting EBD in determining the projected short- and long-term clinical and health impact(s) of current and prospective programs

6. Coordinating with CMS to ensure that all MA-PD PPO Plan filings are structured to properly and fully support EBD’s requirements

7. Developing processes and strategies to maximize CMS funding to minimize premiums

8. Proactively assisting EBD in developing strategic considerations to maximize operational and cost efficiencies

9. Managing the overall pharmacy operation, including all account services directly related to clinical pharmacy including formulary management, clinical plan rules and programs, medication therapy management, and specialty pharmacy

10. Overseeing the file transfer process of eligibility data, interfaces between vendors, reporting, and data sharing

11. Providing all member services and communications

E. The Contractor shall propose an annual account management score card to EBD so that EBD can assess Contractor performance.

F. All employees assigned to work on the EBD account shall be appropriately licensed, certified, and trained to perform their assigned duties.

G. The Contractor shall maintain an escalation process for member satisfaction and complaints.

H. The Contractor shall maintain an escalation process for urgent drug claim issues where claims are rejecting at the pharmacy and members need immediate assistance and resolution, (before the member leaves the pharmacy).

I. The Contractor shall handle all initial internal and external appeals in accordance with CMS requirements and guidelines.

J. The Contractor shall handle all grievances in accordance with CMS requirements and guidelines.

2.7 PLAN ADMINISTRATION

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Administration Plan that must address all Requirements specified in this subsection.

B. The Contractor shall support EBD in handling split-family contracts in which some members are Medicare eligible and some members are not.

C. At minimum, the Contractor shall develop and manage the following processes:

1. Initial enrollment process for January 1, 2023

2. Opt in and opt out processes

3. Age in process

4. The 21-day rule and retro enrollments/cancellations

5. Members with Part A coverage but not Part B coverage

6. Members with Part B coverage only

7. Members who drop Part B after enrollment in the MA-PD PPO Plan

8. Members who enroll in another Part D plan

9. Members who enroll in Medicare late and fail to enroll when he/she turns 65.

10. Applying a member’s Late Enrollment Penalty (LEP)

11. Qualifying life events (QLE) for Medicare-eligible retirees and their Medicare-eligible dependents when the QLE happens after EBD’s Open Enrollment period has ended

12. Low-income subsidies and their impact on copayments, deductibles, and premiums, and calculating amounts owed to EBD

D. The Contractor shall attend and present at (as requested) annual retiree district meetings and local county retiree meetings, including Arkansas State and Public School Retiree Association meetings.

E. The Contractor shall provide, via surface mail, valid, accurate member ID cards to all newly enrolled members within ten (10) Business Days of receiving confirmation from CMS.

F. The Contractor shall re-issue, at no additional cost, via surface mail, valid, accurate ID cards within five (5) Business Days of notice if a member reports a lost card or for any reason that results in a change to the information disclosed on the member ID card.

G. The Contractor shall issue new valid, accurate member ID cards as required by EBD.

2.8 ON-SITE STAFFING REQUIREMENTS

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Staffing Plan that must address all Requirements specified in this subsection.

B. The Contractor shall provide two (2) full-time, dedicated employees to work onsite at the EBD office in Little Rock to serve as member service representatives.

C. The member service representatives shall provide, at minimum, the following services:

1. Answer member service calls (consistent with the responsibilities of other member service representatives not on-site)

2. Respond to member walk-in inquiries

3. Work with EBD staff to resolve claim and member issues

D. The member service representatives shall have detailed knowledge of the plan benefits and shall have expertise in timely resolving complex pharmacy and medical claims issues.

E. On-site staff shall be subject to a background check at EBD’s discretion and shall pass the background check prior to performing services under a resulting contract.

2.9 MEMBER SERVICES

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Staffing Plan that must address all Requirements specified in this subsection.

B. The Contractor shall provide an Arkansas-specific website and mobile application for members to access plan specific information.

1. The website must include provider and pharmacy directories (or look-up functions) and the drug formulary, as well as plan documents sent to all members such as Evidence of Coverage documents and Annual Notice of Change documents.

2. The website must comply with all state, federal, HIPAA, and CMS laws, rules, and regulations.

C. At minimum, the Contractor shall provide dedicated information support via email, toll-free telephone help line, and direct chat to members from 8:00 am to 5:00 pm, Central Time.

1. Member service staff shall be English-speaking and fully trained to answer questions from EBD’s members.

2. Toll-free telephone help line must provide features for the hearing impaired and resources to assist non-English speaking callers.

D. The Contractor shall provide a twenty-four (24) hour, seven (7) day/week toll-free eligibility and pre-certification services telephone number.

1. Member service staff shall be English-speaking and fully trained to answer questions from EBD’s members.

2. Toll-free telephone help line must provide features for the hearing impaired and resources to assist non-English speaking callers.

E. The Contractor shall provide a warm or soft transfer members to other service areas, including EBD, as needed. Members must be able to opt out of the Interactive Voice Response (IVR) to speak with a live member service representative.

F. The Contractor shall provide designated clinical managers to EBD for both medical and pharmacy programs, who shall have full knowledge of all clinical programs in effect as well as all clinical programs offered by the Contractor.

2.10 COMMUNICATIONS AND OUTREACH REQUIREMENTS

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Communications and

Outreach Plan that must address all Requirements specified in this subsection.

B. The Contractor shall develop and implement communication plans and materials for the MA-PD PPO Plan that must include, at minimum:

1. Open Enrollment campaigns to assist members in learning about their benefit options

2. Notification letters to members and their prescribing physicians of drug formulary changes or other changes where there is a negative impact on the member at no additional fee.

a. Letters must be sent at least sixty (60) days prior to effective date of change

3. On-site, Statewide educational sessions for EBD's Medicare-eligible retirees and Medicare-eligible dependents of retirees prior to and throughout Open Enrollment

4. All other items required by CMS

C. The Contractor shall provide an opportunity for EBD to review and approve all communication materials (including letters, brochures, electronic, website, etc.) prior to being sent to members and providers. Communication materials includes all CMS-related communications, even if edits are not allowed by CMS.

D. The Contractor shall effectively communicate with and educate EBD’s retirees about programs and services available to them.

2.11 DATA SECURITY & DISASTER RECOVERY

A. During Discussions, the Contractor shall provide a proposed Data Security and Disaster Recovery

Plan to address all Requirements specified in this subsection that must, at minimum, include the following components:

1. Privacy policies, terms of use protections and any other terms related to cyber security protection, that applies to how the Contractor uses and transfers data, including via websites and online portals.

2. Information security policies and procedures related to the systems, processes, and personnel directly related to the work included in this contract.

3. Operational and system redundancy and disaster recovery procedures to ensure disruption-free services under a resulting contract.

2.12 TRANSITION REQUIREMENTS

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Transition of Services

Plan that must address all Requirements specified in this subsection.

B. Upon contract termination, cancellation, and/or expiration, the Contractor shall assist EBD and the new Contractor, to the extent EBD determines necessary, to ensure an orderly transfer of responsibility and the continuity of those services required under the terms of the contract to another organization designated by EBD.

1. The Contractor shall ensure that no covered Medicare-eligible retirees and covered Medicare-eligible dependents of a retiree lose or gain coverage as a result of transfer of responsibility.

a. All transition-of-care-related issues and non-confinement provisions must be expressly waived for the initial enrollment for covered retirees and covered dependents that have already satisfied the limitations under the existing plan, unless otherwise specified in the eligibility rules established by EBD and/or CMS.

C. The Contractor shall provide at no charge to EBD, all records, documentation, reports, data, recommendations, and/or printing elements, etc., produced under a resulting contract to EBD or to EBD’s designee, within ninety (90) days of EBD’s request, contract termination, or contract cancellation.

1. The Contractor shall follow the method of delivery determined by EBD.

2. This Requirement does not refer to the Contractor’s intellectual property.

3. Data must include all raw, primary data from all research and analysis completed under a resulting contract.

D. The Contractor shall provide all services to execute the successful transition of services data.

E. All data, records, files, and other information relating to the EBD account must remain the property of EBD and must be returned to EBD in the event the contract is ended.

F. The Contractor shall not share, release, or otherwise use EBD’s data without the prior and express written consent from EBD.

G. The Contractor shall allow EBD, or an entity chosen by EBD, to review and audit Contractor operations, including the internal control procedures and records, at any point during the life of the resulting contract.

1. The Contractor shall cooperate with an outside audit firm EBD selects to perform the audit.

2. The Contractor shall allow EBD or its designated agent to annually audit Contractor’s performance under the contract, at no cost to EBD, including, but not limited to, claims processing and payment, customer service, and banking and billing records to assure that claims subject to

MA-PD coverage are evaluated in accordance with the plan provision.

3. If an audit identifies performance guarantees are not being met, the Contractor shall pay for follow-up audits to confirm resolution of any problem(s) uncovered during the initial audit.

4. The Contractor shall allow EBD the right to audit for the duration of the agreement and for a period of three (3) years following expiration or termination thereof.

2.13 CLAIMS PROCESSING REQUIREMENTS

A. During Discussions, the Prospective Contractor shall propose an MA-PD PPO Claims Processing

Plan that must address all Requirements specified in this subsection.

B. The Contractor shall provide claims processing in accordance with EBD and CMS policies.

C. The Contractor’s claims processing system must fully integrate with the eligibility and member services system.

D. The Contractor shall provide claims processing from date of receipt to full adjudication of checks to providers or patients.

E. The Contractor shall ensure that medical and prescription drug benefits or program changes that have the potential to create member disruption and provider payment issues are made timely and accurately. Such changes include mandated CMS updates of service codes, fee schedules, etc.

F. The Contractor shall provide proper quality control testing for medical and prescription drug benefit and/or program changes (e.g. codes and/or fee schedule updates) prior to live release.

G. The Contractor shall provide medical Prior Authorization (PA) and medical pre-certification processes, including appeals process for denied PAs and medical pre-certifications.

H. The Contractor shall honor existing medical PAs and pre-certifications and shall ensure member care is not disrupted.

I. The Contractor shall provide results of internal claims audit to EBD.

2.14 REPORTING REQUIREMENTS

A. During Discussions, the Prospective Contractor shall provide a MA-PD PPO Reporting Plan that must address, at minimum, each of the Requirements in this subsection.

B. The Contractor shall create and generate standard utilization and cost reports through secure file transfer protocols approved by EBD. The Contractor shall propose a comprehensive standard utilization and cost reporting package.

C. The Contractor shall provide claim line detail for all claims—medical and pharmacy—including, but not limited to, financial and diagnoses information. All required fields can be found in Attachment C:

Claims File Layouts. Note this list may be subject to change depending on data that may be needed for analysis.

D. The Contractor shall provide reporting in a mutually agreed upon format by the 15th day of the month following the subject month.

E. The Contractor shall submit the Part C and Part D Medicare Membership Reports (MMR) monthly, including all fields as received from CMS. The monthly MMR must be submitted by the end of the corresponding month.

F. The Contractor shall submit the Part C and Part D Model Output Reports (MOR) upon request, no more often than annually, including all fields as received from CMS. The latest MOR will be submitted within thirty (30) calendar days of EBD request.

G. The Contractor shall submit a weekly Transaction Reply Report (TRR) file.

H. The Contractor shall work with EBD daily to resolve any discrepancies that may arise from the nightly 834 file.

I. The Contractor shall submit denied claims reports, including number of denials by reason, within timeframes approved by EBD.

J. The Contractor shall submit monthly, quarterly, and annual appeals reports to EBD.

K. The Contractor shall provide ad hoc reports as requested by EBD.

L. The Contractor shall submit web portal and member services utilization reports (i.e., number of hits and calls and the nature of the members' inquiries) to EBD.

M. The Contractor shall submit quarterly report rebates received associated with the reimbursement of Medicare Part B drugs to EBD and its designated health care consultant.

N. The Contractor shall ensure all required data is sent to CMS for each data collection period.

O. The Contractor shall improve encounter data and maintain controls to identify duplicate transactions that are ineligible from a CMS perspective.

P. The Contractor shall submit data elements and additional documentation as requested by EBD prior to contract renewal.

2.15 ELIGIBILITY REQUIREMENTS

A. During Discussions, the Prospective Contractor shall provide a MA-PD PPO Eligibility Plan that must address, at minimum, each of the Requirements in this subsection.

B. The Contractor shall provide a comprehensive online enrollment system that must consider the following components:

1. Ability to handle more than one (1) 834 eligibility file each day

2. Member data repository

3. Accommodate confidential mailing addresses as required by Title II of HIPAA

4. Maintain historical eligibility information on an individual's file, including accessible online, real time and archived information

C. The Contractor shall update eligibility data within 24 hours from receipt of data.

D. The Contractor shall electronically daily accept and process the 834 eligibility file sent by EBD.

E. The Contractor shall not enroll or cancel EBD members without EBD’s approval unless there is a conflict from CMS.

1. If a conflict from CMS is found, the Contractor shall confirm conflict information will be reported back to EBD within twenty-four (24) hours so EBD can correct and retransmit records.

F. The Contractor shall validate participant eligibility through CMS.

G. The Contractor shall generate a monthly reconciliation file that must contain, at a minimum, the member's social security number, the contract number, demographics, enrollment date, and cancel date.

H. The Contractor shall implement processes for working error reports generated from file loads.

I. The Contractor shall confirm member physical address and other necessary enrollment information if the information is not initially provided on an enrollment file.

J. The Contractor shall handle CMS eligibility issues for members that only have a P.O. Box address.

K. The Contractor shall manage and coordinate with EBD regarding CMS eligibility issues.

2.16 COORDINATION OF BENEFITS (COB)

A. The Contractor shall, at a minimum, accept and use the Coordination of Benefits (COB) data provided by EBD to process claims.

B. The Contractor shall identify and recover overpayments and pass 100% of all overpayment to EBD.

C. The Contractor shall provide COB and subrogation reporting to EBD, which, at a minimum, should track savings.

2.17 REVENUE MAXIMIZATION

A. The Contractor shall maintain revenue maximization and risk adjustment strategies that benefit the

MA-PD PPO Plan.

B. The Contractor shall utilize innovative programs to improve the accuracy of risk scores and increase scores whenever possible.

C. The Contractor shall reconcile member risk scores with risk scores on file with CMS, track member risk scores, and track the financial impact of risk-adjusted scores.

D. The Contractor shall educate and incent providers on the importance of complete medical record documentation, including documentation of known chronic conditions.

E. The Contractor shall maintain risk adjustment strategies to impact the pharmacy risk score.

F. The Contractor shall audit the quality and completeness of provider claims data.

G. The Contractor shall maintain controls to ensure that claims data that is submitted to CMS includes only valid risk adjustment codes.

2.18 MEDICAL MANAGEMENT

A. During Discussions, the Prospective Contractor shall provide a MA-PD PPO Medical Management

Plan that must address, at minimum, each of the Requirements in this subsection.

B. The Contractor shall maintain program design that enhances quality of care, including engaging targeted individuals and improving health status and clinical outcomes.

C. The Contractor shall provide members access to behavioral health services in a primary care setting, during chronic condition case management, during an acute inpatient episode, and during post-discharge follow up.

D. The Contractor shall provide after-hours behavioral health and crisis call support.

E. The Contractor shall educate members and medical providers and facilities of available behavioral health services.

F. The Contractor shall give medical providers access to clinical documentation of behavioral health case management notes.

G. The Contractor shall offer case management that should include, at minimum, the following components:

1. Pre-admission review/Pre-determination

2. In-patient admission/concurrent review

3. Discharge planning

4. High-risk post-discharge outreach

5. Retrospective review

6. Outpatient review

7. Catastrophic/long-term case management

8. Episodic/short-term case management

9. End-of-life program identification and transition

H. The Contractor shall provide disease management that should include, at minimum, the following programs:

1. Asthma

2. Diabetes

3. Chronic Obstructive Pulmonary Disease

4. Heart conditions, including coronary artery disease and congestive heart failure

5. Low back pain and musculoskeletal pain

6. Weight complications

7. Hepatitis C

8. Fibromyalgia

9. Irritable bowel syndrome

I. The Contractor shall minimize member disruption during the discharge or transition of care processes. EBD expects on-site (in facility) and remote case managers to be available for members at facilities statewide.

J. The Contractor shall ensure provider advocates are available via telephone and physically in Arkansas.

K. The Contractor shall review medical management and utilization management.

L. The Contractor shall implement medical necessity guidelines that align with EBD’s benefit intent and shall evaluate and update/revise guidelines as needed.

M. The Contractor shall implement a referral process that includes communication between all parties (PCP, specialist, and medical management) prior to the issuance of a referral, timelines for communication, and after-hours processes.

N. The Contractor shall provide training for providers regarding utilization management issues and shall identify, educate, and/or sanction non-compliant providers.

O. The Contractor shall utilize value-based contracting practices both nationally and in Arkansas (to the extent permitted by CMS) whenever possible.

P. The Contractor shall utilize “total cost of care” reduction programs whenever possible.

Q. The Contractor shall provide criteria and processes for case management referrals to the Medical Director, specialty programs, and community resources including addressing social determinates of health.

R. The Contractor shall provide support to members that reside in lower income zip codes to access/link to community-based services, including tools to help members access and use virtual health care services.

S. The Contractor shall support senior membership with respect to issues such as anxiety/depression, substance use disorder, social isolation, food insecurity, etc. that came to light or were exacerbated as a result of the COVID-19 pandemic.

T. The Contractor shall provide a senior gym benefit such as Silver Sneakers at no additional cost.

2.19 NETWORK ACCESS AND MANAGEMENT

A. The Contractor shall maintain and expand adequate network capacity to meet the demand of MA-PD

Plan members, including actively recruiting providers and pharmacies to participate in MA-PD networks.

1. Medical Provider Directory can be found online at healthadvantage-hmo.com

2. Pharmacy Locator can be found online at medimpact.com

B. The Contractor shall accommodate pharmaceutical needs of members who live in areas where pharmacy access is inadequate.

C. The Contractor shall actively recruit providers currently utilized by EBD members, including conducting outreach to providers and building and maintaining relationships.

D. The Contractor shall target and educate providers that are considered out-of-network.

E. The Contractor shall ensure retail pharmacy in the proposed pharmacy retail network will dispense covered prescriptions regardless of days’ supply (e.g., 0-90 days’ supply).

F. The Contractor shall provide the name of its proposed pharmacy retail network.

G. Should EBD wish to add a retail pharmacy to the network, the Contractor shall contact the pharmacy and offer the contract for network inclusion within two (2) business days following EBD’s request.

H. The Contractor shall provide a customized network without re-contracting.

I. The Contractor shall provide specialty pharmacy network and services.

J. The Contractor shall provide transition of members engaged in treatment and shall ensure continuity of care when a member changes carriers.

K. The Contractor shall offer a comprehensive behavioral health network that includes a variation of providers such as Psychiatrists (MDs), Psychologists, Therapists, Counselors, Social Workers, DEA waiver providers, etc.

L. The Contractor shall ensure some network providers are certified in medication assisted treatment

(MAT).

M. The Contractor shall offer telemedicine benefits that…