S000000375 Third Party Administrator~3.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

SOLICITATION DOCUMENT

SOLICITATION INFORMATION

Solicitation Number: S000000375 Solicitation Issued: January 10, 2025

Description: Third Party Administrator

Department: Transformation and Shared Services – Employee Benefit Division

SUBMISSION DEADLINE AND DELIVERY OF RESPONSE DOCUMENTS

Proposal Opening Date: February 10, 2025 Proposal Opening Time: 10:00 AM, Central Time

Proposal submissions for this Request for Proposal must be submitted through ARBuy, the State’s eProcurement system. It can be accessed at arbuy.arkansas.gov. Proposals received after the submission deadline may be rejected as untimely.

LIVE PROPOSAL OPENING INFORMATION

Teams Meeting Link: Join the meeting now

Meeting ID: 212 934 153 407

Passcode: HF2Ry2N5

Call in (audio only):

Phone Conference ID:

501.244.3310 or find a local number 491 447 971#

TSS OFFICE OF STATE PROCUREMENT CONTACT INFORMATION

TSS OSP Procurement Specialist:

Julie Robnolt Procurement Specialist’s Direct Phone Number:

(501) 371-6070

Email Address: julie.robnolt@arkansas.gov TSS OSP’s Main Number: (501) 324-9316

TSS OSP Website: transform.ar.gov/procurement/ https://arbuy.arkansas.gov/ https://teams.microsoft.com/l/meetup-join/19%3ameeting_NDViZTIxNjQtZWM1ZS00ZDczLWFiODYtNzJiM2Y1MDhiOWMx%40thread.v2/0?context=%7b%22Tid%22%3a%225ec1d8f0-cb62-4000-b327-8e63b0547048%22%2c%22Oid%22%3a%22a5e9cf20-c478-4e36-8fed-351f1ae086e2%22%7d https://dialin.teams.microsoft.com/6b6513dc-a034-48d2-8d06-7e711c4ecc0b?id=719036839 mailto:julie.robnolt@arkansas.gov https://www.transform.ar.gov/procurement/

SECTION 1 – GENERAL INFORMATION AND INSTRUCTIONS

1.1 INTRODUCTION

This Request for Proposal (RFP) is issued by the Department of Transformation and Shared Services (TSS) Office of State Procurement (TSS OSP) for the TSS Employee Benefits Division (“EBD” or “Division”) to obtain pricing and a contract(s) from Third Party Administrators (TPAs) for the administration and management of two (2) Major Service Components for the eligible Arkansas recipients. The two (2) Major Service Components are defined as: (1) Health Insurance and (2) Medical Management Program (MMP).

Employee Assistance Program (EAP) information is requested in this RFP but does not constitute a Major Service Component. Prescription Drug benefits are not included in this RFP.

A Prospective Contractor’s proposal must provide for the overall administration and management of the Major Service Components. Proposals offering administration and management for less than two (2) Major Service Components will be rejected.

Contract(s) will be awarded to the Prospective Contractor(s) determined to have submitted the proposal(s) that is the most advantageous to the State. Direct all questions, comments, or concerns regarding this solicitation to the TSS OSP, not the Division.

1.2 TYPE OF CONTRACT

A. As a result of this RFP, TSS OSP intends to award contract(s) for the two (2) Major Service

Components (and potentially EAP services) with the goal of successful cost containment and integration of the services. However, if it is in the best interest of the State, the State reserves the right to award one (1) or more of the Major Service Components to multiple Contractors.

B. The State may make an award to a single Contractor covering all ARBenefits members or may make contract awards to multiple Contractors with either overlapping or distinct geographic service areas defined by zip code.

C. The anticipated starting date for any resulting contract is immediately upon award, except that the actual contract start date may be adjusted forward 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.

D. The initial term of a resulting contract will be for three (3) years. Upon mutual agreement by the Contractor and Department, the contract may be renewed by TSS OSP for up to four (4) additional one-year terms or portions thereof, not to exceed a total aggregate contract term of seven (7) consecutive years.

1.3 DEFINITION OF TERMS

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

B. “Any Willing Provider” refers to a legal concept where a health insurance plan is required to contract with any healthcare provider who is willing to meet the plan’s terms and conditions, essentially meaning that no provider can be excluded from a network solely based on their identity if they agree to the plan’s rules and reimbursement rates; it gives patients more choice in selecting their healthcare providers within the network.

C. “ARBenefits.org” is an interactive platform that is the primary means of communication with Recipients and various vendors and contractors working with EBD.

D. “AR Employees” means all active Arkansas State Employees (ASE) and Arkansas Public-School Employees (PSE) and their household dependents as referenced for EAP eligibility.

E. “Benefit Coordinator” is any employee of the Contractor or subcontractors who interacts with the Recipients and/or EBD staff.

F. “Care Coordination” is the deliberate organization of patient care activities between the providers, community resources, specialist and the patients that facilitate the most effective delivery of health care services.

G. “Enrollment” means receipt of referral followed by contact with enrollee based on Participant’s agreement to participate in any module of services outlined within the Medical Management Program.

H. “Greater Little Rock Area” is defined as the following counties which comprise Central Arkansas:

Cleveland, Faulkner, Grant, Jefferson, Lincoln, Lonoke, Perry, Pulaski, Saline, and White; or, alternatively, within 50 miles of the EBD office at 501 Woodlane Street, Little Rock, AR 72201.

I. “High Dollar Claim” is a claim that exceeds $50,000 that requires additional documentation to support medical necessity and confirms that submitted services correctly reflect the services documented in the medical record.

J. “Implementation Period” means the period of time beginning on the starting date of the contract, anticipated to be April 2025, during which the Contractor shall perform all start up and implementation activities required to achieve full implementation by the Administrative Services Start Date.

K. “Member” means any ASE/PSE or dependent enrolled in one of the Plans of the Health Insurance Program.

L. “Open Enrollment” means an annual time period, facilitated by EBD, which allows all ASEs and PSEs the opportunity to make changes, additions, or deletions to their current health insurance and for ASE/PSE employees not currently enrolled in any of the available Plans, the ability to enroll.

M. “Participant” means any Member who is enrolled in any module of services outlined within the Medical Management Program.

N. “Plan” means the ASE and PSE and retirees health insurance benefit coverage, designed, and administered by EBD.

O. “Plan Year” means the benefit year for ASE, PSE and retirees health insurance and runs from January 1 to December 31 of each year.

P. “Program” means one (1) or all of the individual units within the Major Service Components.

Q. “Proposal Submission Requirement” means a task a Prospective Contractor shall complete when submitting a proposal response. These requirements will be distinguished by using the term “shall” or “must” in the requirement.

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

S. “Recipients” means any person eligible for any of the Major Service Components.

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

U. “Requirement” means a term, condition, provision, deliverable, Specification, or a combination thereof, that is obligated under the Solicitation, resulting contract, or both.

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

W. “Service” means an individual service module of a Program.

X. “Shall” and “must” mean the imperative and are used to identify Requirements.

Y. “Small Dollar Claim” is a claim with a billed amount between $25,000 - $49,999 that requires additional documentation to support medical necessity and confirms submitted services correctly reflect the services documented in the medical record.

Z. “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.

AA. “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 using such a contract.

BB. “Transparent” means full and open practices involving all aspects of the contractual relationship between EBD and the Contractor, where no aspect of the contract will be hidden from EBD’s review for any reason including confidential, proprietary, exclusive, and/or privileges.

CC. “Valid Defense Letters” if a beneficiary did not have Group Health Coverage (GHC) due to coverage ending, retirement, termination, etc., during the time frame of the date of service(s) listed on the Demand, an Employer should provide documentation confirming the beneficiary’s end of coverage as a Valid Documented Defense.

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 January 10, 2025

Pre-Bid Conference January 16, 2025, 2:00 PM CST

Deadline for Prospective Contractor Questions January 20, 2025

Answers to Questions Posted to ARBuy* January 27, 2025

Proposal Due Date February 10, 2025 @ 10:00 AM CST

Initial Proposal Evaluation* February 18, 2025

Interviews* February 20-21, 2025

Final Proposal Evaluation* February 21, 2025

Discussions Kick Off Meeting* February 26, 2025

Finalize Discussions* March 14, 2025

Post Anticipation to Award* March 14, 2025

Award Contract* April 2025

1.5 NON-MANDATORY BIDDERS CONFERENCE

A. TSS OSP will host a bidders conference regarding the RFP at the date and time listed in Section 1.4

Table A. Prospective Contractors may attend the conference via Microsoft Teams.

Teams Meeting Link: Join the meeting now Meeting ID: 235 455 272 563 Meeting Passcode: 3kC7Nb9w Dial-in Information: 501-244-3310 Phone Conference ID: 652 753 740#

1.6 CLARIFICATION OF SOLICITATION

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

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

https://teams.microsoft.com/l/meetup-join/19%3ameeting_M2U5NDAyMzctNjk4OS00Zjg3LTlmZWYtOGU2YTA5ZDEyYjBj%40thread.v2/0?context=%7b%22Tid%22%3a%225ec1d8f0-cb62-4000-b327-8e63b0547048%22%2c%22Oid%22%3a%22a5e9cf20-c478-4e36-8fed-351f1ae086e2%22%7d

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

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 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 Procurement Specialist of any Requirements that precludes the Prospective Contractor from submitting a Responsive Proposal.

C. Prospective Contractors may contact the TSS OSP Procurement Specialist 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.

E. Only an addendum written and authorized by the State will modify the Solicitation.

1.7 RESPONSE DOCUMENTS

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

1. Prospective Contractors must be registered in ARBuy to submit proposals responses.

B. Technical Proposal Packet

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

2. 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.

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

c. Completed Official Solicitation Price Sheet attached to the Solicitation in ARBuy.

i. Pricing must be proposed in U.S. dollars and cents.

ii. Quantities stated are estimates only and are not guaranteed. Prospective Contractor must submit unit price on the estimated quantity and unit of measure specified.

• The State may order more or less than the estimated quantity on term contracts, and the Contractor shall sell to the Department quantities ordered at no more than the submitted price.

iii. If pricing documents do not allow for accurate pricing, Prospective Contractor should notify the OSP Procurement Specialist at least seventy-two (72) hours before the proposal opening time.

iv. Prices must be firm offers for first three years and annual adjustments thereafter may be negotiated at the time of contract renewal.

• A request for a price increase must include supporting documentation demonstrating that the increase in contract price is based on an increased cost to the Contractor and that the proposed pricing is still competitive in the marketplace. The State has the right to approve or deny any request for a price adjustment.

https://arbuy.arkansas.gov/

v. Discount from list pricing is not acceptable unless requested elsewhere in the Solicitation.

vi. State or local sales taxes should not be included in the price. Trade discounts should be deducted from the unit price and the net price should be shown in the pricing response.

vii. To obtain a copy of the claims data files for the Official Solicitation Price Sheet Claim Repricing spreadsheet, the Prospective Contractor shall initiate a request via email to julie.robnolt@arkansas.gov.

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

• Information and instructions for accessing the claims data files will be provided within one (1) business day of receiving the signed NDA.

d. Recommended Options Form

i. 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.

e. Copy of Prospective Contractor’s Equal Opportunity Policy

i. Pursuant to Arkansas Code Annotated § 19-11-104, OSP requires a Prospective Contractor bidding on a state contract to submit a copy of the Prospective Contractor’s Equal Opportunity (EO) Policy.

ii. Prospective Contractors not required by law to have an EO Policy must submit a written statement to that effect.

f. Proposed Subcontractors Form (see SRV-1, section 14)

3. 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:

a. EO 98-04: Contract and Grant Disclosure Form (see SRV-1, section 11)

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

c. The HIPAA-compliant Business Associate Agreement (BAA) (Attachment B) must be executed by the Prospective Contractor and all subcontractors and submitted to EBD for their records. By signing and submitting the Proposal Signature Page, the Prospective Contractor represents and warrants they shall sign and comply with the BAA as it is written.

d. Evidence of Systems and Organization Contols-2 (SOC-2) Level II and Statement on Standards for Attestation Engagements-18 (SSAE-18) compliance

e. Evidence of Utilization Review Accreditation Commission (URAC) accreditation

f. Evidence of Utilization Management Services registration

4. Prospective Contractors should 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

1. One (1) redacted (marked Redacted) copy of the Prospective Contractor’s proposal response (see Proprietary Information), if applicable.

mailto:julie.robnolt@arkansas.gov https://www.transform.ar.gov/wp-content/uploads/Services-Contract-SRV-1-Fillable-Form-V.3.6.27.22.pdf https://www.transform.ar.gov/wp-content/uploads/Services-Contract-SRV-1-Fillable-Form-V.3.6.27.22.pdf https://www.section508.gov/sell/vpat/

D. Prospective Contractors should not alter language in Solicitation document(s) or Official Solicitation Price Sheet provided by the State.

E. Prospective Contractor’s proposals cannot be altered or amended after the proposal opening except as permitted by law or rule.

F. Prospective Contractors may submit multiple proposals.

SECTION 2 – REQUIREMENTS

2.1 CURRENT ENVIRONMENT

EBD manages the group health and life insurance plans and other select benefits to build quality programs for eligible Arkansas State Employees (ASE) and Public School Employees (PSE) or their dependent(s) enrolled in one of the Plans of the Health Insurance Program members while promoting customer service, education, accessibility, and affordability. EBD is one of six divisions that make up TSS. ARBenefits is the name of the self-funded health insurance program that is available to State and Public School employees, their families, and retirees. Visit transform.ar.gov/employee-benefits/ to find out more about Arkansas’s Employee Benefits Division.

EBD seeks a TPA who can provide a program that boasts fiscal health for the State and reliable health coverage for ARBenefits members. The TPA will be responsible for administering healthcare benefits for all State and public school employees. There are approximately 160,000 total lives covered under the ARBenefits plan, which includes 70,716 members (individual employees). That breaks down to 24,538 State employees and 46,178 public school employees.

Medical Management is generally defined as the technical field of endeavor which utilizes a variety of individual, organizational, and cultural interventions to help improve the morbidity patterns and the behavioral health of populations by using a single point of contact and coordination.

Medical Management is designed to lower the overall cost trend of a defined population through the use of such tools as Evidenced-Based Medicine (EBM), Predictive Modeling across multiple clinical conditions, Personal Health Management, and intensive Case Management (CM) that is individually customized for Participants who may be either at the highest level of risk or those who are presenting symptoms of one or multiple conditions.

Currently, Medical Management Services are provided to 128,000 Members for the ASE and PSE Plans.

There are approximately 16,000 Medicare-primary Members included in the covered population which Medical Management Services are not provided in-lieu of Medicare medical management / protocol.

There are also another 16,000 members participating in an UHC MAPD Plan.

The EAP is a comprehensive program that can be customized to offer our AR Employees the tools and resources needed to manage their overall well-being, improve and/or manage their general health and the health of their family, as well as develop personal growth in the workplace, and provide tools to handle various workplace environments. Some examples of resources for our AR Employees include, but are not limited to, the following:

• Personal Health Dashboard

• Online Wellness Coaching

• Online / Tele-Medicine Health Coaching

• Resources to help navigate o Relationships (i.e., domestic issues, caregiver issues, parenting, marriage, divorce) o Personal Development

• Financial issues (i.e., debt management, insurance, taxes, estate planning, personal finances)

2.2 OBJECTIVES AND GOALS

A. EBD is seeking a TPA(s) who can provide a program that enhances fiscal health for the State and reliable health coverage for ARBenefits members. The TPA will be responsible for administering healthcare benefits for all State and public school employees. There are approximately 160,000 total lives covered under the ARBenefits plan, which includes 70,716 members (individual employees).

That breaks down to 24,538 State employees and 46,178 public school employees. EBD is seeking TPA(s) for the administration and management of Health insurance and a Medical Management Program (and potentially EAP services) for the eligible Arkansas Recipients.

https://www.transform.ar.gov/employee-benefits/

B. EBD is seeking a TPA(s) for the administration and management of the two (2) combined Major Service Components (and potentially EAP services) for the eligible Arkansas Recipients.

C. EBD is seeking a TPA(s) to identify cost savings opportunities for the State of Arkansas via lower administration fees, larger provider discounts, or more effective medical management.

D. EBD is seeking a TPA(s) to assure overall competitive financial features.

E. EBD is seeking a TPA(s) that offers provider networks that create very good access for members.

F. EBD is seeking a TPA(s) who will avoid unnecessary disruption of the member-provider relationship.

2.3 PROSPECTIVE CONTRACTOR MINIMUM QUALIFICATIONS

A. Prior to award, the Prospective Contractor shall be authorized to conduct business in the State of

Arkansas for all Major Service Components, as required by this RFP.

B. The Prospective Contractor shall be an administrative services organization or a third-party administrator that is currently administering health insurance benefits.

C. The Prospective Contractor shall have the comprehensive and technical administration system(s) required for successful rendering of services required by this RFP in full operation and production for a minimum of one (1) year prior to responding to this RFP. This one (1) year requirement does not apply to modifications, enhancements, or system fixes to existing system(s).

D. The Prospective Contractor shall have a minimum of five (5) years’ experience with large group health insurance plans working with either State, Federal, or Local Public Entities and shall be capable of serving the needs of a geographically diverse employer population.

E. The Prospective Contractor’s experience requirements listed herein may be met by subcontractors.

The subcontractor shall perform the specific service or function which relates to the required experience.

F. The Prospective Contractor shall have experience (5 years or more) in the development, implementation, and administration of a comprehensive statewide network, including claims payments and customer service. Work with State government agencies is preferred.

G. The Prospective Contractor shall be SOC-2 Level II and SSAE-18 compliant. The Prospective Contractor shall provide a certificate of evidence of such compliance prior to award.

H. The Prospective Contractor shall be URAC (Utilization Review Accreditation Commission) accredited for a Health Plan. The Prospective Contractor may submit evidence of accreditation with their proposal submission but shall provide evidence of accreditation prior to award.

I. The Prospective Contractor shall have five (5) years’ experience in each of the following:

1. Case Management for Medical Health and Behavioral Health

2. Disease Management

3. Utilization Management

4. Maternity Management Services

5. Claims Analysis and Predictive Modeling

J. The Prospective Contractor shall have a working knowledge of, and a minimum of 10-year history of working with, Arkansas medical facilities and providers with Medical Management services.

K. The Prospective Contractor shall currently provide Medical Management services to a minimum of 50,000 Participants.

L. The Prospective Contractor shall have an Advanced Claims Analytics/Predictive Modeling software platform. An “Advanced Claims Analytics/Predictive Modeling software platform” is designed to query and explore the Plans’ health care related data to identify chronic conditions. This gives the user the ability to do in-depth queries and combine data sets which will identify risk mitigation opportunities within the data while statistically validating the outcome efficacy of the chosen solutions.

M. The Prospective Contractor shall be registered and in good standing to perform Utilization Management Services by the State of Arkansas Department of Health. The Prospective Contractor shall provide evidence of certification prior to any resulting contract award.

N. The Prospective Contractor shall have staff comprised of licensed physicians, registered nurses, and case managers qualified to perform the Medical Management services listed in this RFP.

O. EBD prefers a Prospective Contractor using innovative ideas to support the Recipients such as, but not limited to:

1. Interactive Recipient portal

2. Personnel health record

3. Gaps in Care analysis

4. Proactive Medical Management

2.4 GENERAL REQUIREMENTS

A. The Programs described in the RFP must adhere to all State and Federal laws.

B. The Contractor shall maintain compliance with all applicable State and Federal laws as they pertain to the administration and management of the services described herein.

C. The Contractor shall create and modify all forms, Recipient communication, education pieces, and all other documents as needed to maintain compliance of applicable State and Federal laws.

D. The Contractor shall provide written notification to EBD, within three (3) business days of any changes to the Contractor’s representatives, management, and/or ownership or of the Contractor’s intent to file bankruptcy.

E. Prior to the Administrative Start Date, the Contractor shall have a dedicated bank account for making all required claims payments for the Health Insurance Program.

F. The Contractor shall modify any Services as directed by EBD, for reasons such as, but not limited to, utilization results, revenues, and/or surplus funds.

G. The Contractor shall routinely review the overall effectiveness of each of the Major Service Components and provide EBD with consultation and recommendations regarding design and/or administrative adjustments. Method and frequency of review will be approved by EBD.

H. The Contractor shall complete the Plan(s) design and redesign process no later than three (3) months prior to the beginning of the new Plan Year. EBD will have the final approval.

I. Should newly enacted Federal and/or State mandates affect the scope of work of any resulting contract, the Contractor shall add, delete, or adjust the services provided to be in compliance with these mandates.

J. The Contractor shall be liable for any penalty and interest payable to the Internal Revenue Service or Arkansas Department of Finance and Administration and assessed against the State if the penalty and/or interest assessed is the result of the level of accuracy of information or services provided by the Contractor, or the failure of the Contractor to provide information and/or services. The process for reimbursement to the State for the payment of any penalties and interest will be determined by EBD during Implementation.

K. The Contractor shall not outsource to any entities, either subcontractors or wholly-owned subsidiaries of Contractor, that are located outside the continental United States for any services which include, but are not limited to, Customer Service and/or Data Storage.

L. Enrollment and changes made during the annual Enrollment period must become effective at the beginning of the new Plan Year.

M. The Contractor shall provide adequate resources to investigate unusual incidents and develop corrective action plans.

2.5 CONFLICT OF INTEREST AND LITIGATION DISCLOSURES

A. The Prospective Contractor shall disclose any actual and/or potential conflict(s) of interest pertaining to the Prospective Contractor’s company. The conflict-of-interest disclosure requirement must include but is not limited to any contract and/or financial arrangement between the Prospective Contractor and any entity, and/or subcontractor that impacts, has the potential to impact, and/or directly conflicts with the Prospective Contractor’s ability to effectively and impartially honor the terms of any contract resulting from this RFP.

B. The Contractor shall notify EBD immediately upon knowledge of any such conflict of interest.

C. During the Discussions phase the Prospective Contractor shall disclose all litigation (criminal or civil) and all bankruptcy petitions pertaining to the Prospective Contractor’s company that impacts and/or has the potential to impact the Prospective Contractor’s ability to effectively and impartially honor the terms of any contract resulting from this RFP.

D. The Contractor shall notify EBD immediately upon knowledge of any such litigation or bankruptcy petition.

E. The Contractor shall give the EBD immediate notice in writing by certified mail of any action or suit filed, and prompt notice of any claim made, against the Contractor or any subcontractor which may result in litigation related in any way to any resulting contract or the EBD.

2.6 HEALTH INSURANCE REQUIREMENTS

A. The Contractor shall provide a network of physicians, hospitals, labs, and other service providers to ensure that in-network coverage under the Plan is appropriately managed.

B. The Contractor shall provide all health insurance services (self-funded) described throughout this RFP with the understanding that the health insurance services may be selected on an a la carte basis.

C. All health insurance services requested must be available and offered in the potential event that a dual-carrier solution (two (2) Contractors) is selected for implementation.

D. The Contractor shall serve as TPA, interpret and define medical coverage policies, eligibility of benefits, and defined Member assistance.

E. The Contractor shall adjudicate claims on behalf of the Plan for medical claims submitted by health care providers.

F. The Contractor shall administer the State’s benefit designs without any changes for actives and retirees until or unless the State wants to change said designs.

2.7 OVERALL ADMINISTRATIVE SERVICE REQUIREMENTS

A. The Contractor shall support the EBD effort to administer any or all of the individual service items provided by this RFP, should EBD elect to administer a service item.

B. The Contractor shall accept liability for costs incurred due to Contractor’s inaccurate or erroneous claims adjudication. Neither EBD nor Recipients will be held responsible by the Contractor and will not be exposed to billing from the provider.

C. At the appropriate time (e.g., during implementation) the Contractor shall provide a blank copy of all provider/facility contracts that will be used during the life of any resulting contract, including special programs such as: value-based programs, accountable care organization, and global payment arrangements.

D. The Contractor shall provide all fee schedules used for claims adjudication process, as well as denial codes and meanings, on award of any resulting contract during implementation phase. Contractor shall include fee schedules for all special programs such as: value-based, accountable care organization, and global payment arrangements.

E. The Contractor shall not make any changes to any of the Services without a written request from the EBD Director or his/her designee.

F. The Contractor shall provide Transparent administration of all Services required by this RFP, including, but not limited to, claims adjudication process, financial reporting, administration, and reimbursement practices and procedures, and shall make available all aspects of the Contractor’s operation and/or financial accounting for EBD’s review regardless of confidentiality, proprietary, or exclusive rights and/or privileges.

G. The Contractor shall abide by EBD’s coverage policy decisions. In the absence of a specific Service policy, the Contractor’s primary coverage policies will apply. Contractor shall amend and/or adopt policies as directed by EBD to ensure consistency.

H. The Contractor shall allow EBD to have final determination on any coverage policy considered experimental and investigational.

I. The Contractor shall develop and maintain the employer benefit Plan(s) providing benefits as specified by EBD.

J. The Contractor shall provide any information or documentation pertaining to the services provided by the Contractor under the terms of any resultant contract to EBD within three (3) business days of request by EBD, in a format acceptable to EBD.

K. The Contractor shall utilize a secure file transfer protocol (SFTP) as defined by EBD.

L. The Contractor shall provide subrogation/recovery services.

M. The Contractor shall aggressively pursue all Medicare Secondary Payer claims. and shall accept responsibility for payment of any Center for Medicaid and Medicare Services (CMS) interest and/or penalty due on these claims if they fail to collect the Medicare Secondary Payer claims.

N. The Contractor shall complete all required reporting to Center for Medicare and Medicaid Services

(CMS).

O. The Contractor shall process all Valid Defense Letters from CMS within forty-five (45) days of receipt.

Contractor shall notify EBD within five (5) days of receipt of a Valid Defense Letter from CMS.

Contractor shall update EBD of responses to the submitted Valid Defense cases.

P. The Contractor shall not make any adjustments in any way to any Services as a result of any changes implemented by EBD that may reduce the enrolled population.

Q. The Contractor shall provide claims data in the format outlined by EBD on a schedule determined by

EBD.

R. Administrative Fees must be based on EBD’s in-house system reported numbers and will be paid on amount owed, not amount billed.

S. The Contractor shall submit form 1099 to the providers and IRS on EBD’s behalf.

T. The Contractor shall provide a letter to EBD stating the 1099 process has been completed on behalf of EBD by March 15th of each year.

U. The Contractor shall comply with the Unclaimed Property Act 18-28-201 on behalf of EBD and shall submit monies and report directly to the Auditor of State’s Office.

V. The Contractor shall provide a letter to EBD stating that the Unclaimed Property Act 18-28-201 has been complied with on behalf of EBD by November 15th of each year.

W. The Contractor shall create and coordinate all printed/published communications to Recipients, including Summary Plan Description (SPD) updates, with the exception of Recipient-specific PHI, and submit for approval through the EBD Communications Manager prior to distribution. Should EBD deny approval, the Contractor shall make necessary edits until the material is approved by EBD.

https://law.justia.com/codes/arkansas/title-18/subtitle-3/chapter-28/subchapter-2/

2.8 STAFFING REQUIREMENTS

A. The Contractor shall provide a Staffing Plan during the Discussions phase. The Staffing Plan must, at minimum, meet the requirements set forth in this section of the RFP.

B. The Contractor shall provide an Account Manager with health care industry experience who shall be solely dedicated to EBD and any contract resulting from this RFP.

C. The dedicated Account Manager shall be physically located in the Greater Little Rock area and shall have written authorization from the Contractor authorizing the performance of certain functions which must include, but are not limited to, the following:

1. Overseeing and supporting all day-to-day matters arising from the administration and management of the services listed within this RFP.

2. Working with EBD on the administration and management of the Major Service Components as necessary (i.e., interpreting the Contractor’s policies, providing coverage criteria information, resource for outreach and education of our staff/Recipients as needed) to fulfill the requirements of this RFP and as requested by EBD.

3. Making all final decisions regarding claims, administrative, and/or programmatic issues arising from the operation of the Services and possessing the final decision-making authority necessary to implement changes presented and approved by EBD.

4. Meeting weekly with EBD regarding topics such as the status of the operation of the Services, escalated issues, and other topics as determined necessary and requested by EBD.

5. Facilitate the development of report(s) and creation of data files.

6. Responding to EBD requests for data as needed.

7. Resolving problems.

D. The Account Manager shall present annual and quarterly reports to EBD’s management staff. The Account Manager shall make the presentation in person at a location determined by EBD. The specific details regarding location and time will be published on the ARBenefits website. In the event that the published information is altered, the EBD Administrative staff will supply the Account Manager, via email, the updated information, at least two (2) weeks prior of the presentation date.

E. The Contractor shall include, in the Staffing Plan, individuals with sufficient relevant expertise and experience to accomplish the requirements of the RFP.

F. EBD shall have the right to approve or reject proposed staff members prior to the finalization of the plan after Contract Award.

G. The Contractor shall include, in the Staffing Plan, a provision to address the vacancies of the Account Manager or other key personnel. In the event of the vacancy of a key person, the Contractor shall provide replacement candidates to EBD for review within fifteen (15) calendar days of the Contractor learning of the vacancy. EBD will have the right to approve or reject proposed replacements if they do not meet the minimum requirements set forth in the RFP.

H. The Contractor shall replace key personnel upon request by EBD for justified reasons including, but not limited to, performance, behavior, and security.

I. The Contractor shall provide and maintain sufficient staffing resources to provide timely service for the life of any resulting contract.

J. Upon receipt of request, the Contractor shall remove or facilitate the removal of the dedicated Account Manager, key personnel, or other team member from State property immediately.

K. The Contractor shall replace the dedicated Account Manager, key personnel, or team member with a person having equal or greater qualifications than the person being replaced.

L. The Contractor shall perform the necessary replacement procedures without disruption to daily operations as they pertain to the requirements of this RFP.

M. At commencement of any resulting contract and prior to the hiring of staff, including any new or replacement staff, the Contractor shall provide proof of the background checks for all personnel involved in any aspect of the process described in this RFP at the Contractor’s expense.

N. EBD will have the right to refuse personnel based on the results of the criminal background checks.

2.9 NETWORK DEVELOPMENT, RENTAL, AND MANAGEMENT REQUIREMENTS

A. The Contractor shall maintain and manage an existing Any Willing Provider compliant provider network that will be provided for the use in managing the Services as described within this RFP.

B. The Contractor shall assist with developing a proprietary network, if EBD so chooses.

C. The Contractor shall maintain all provider contracts, terms and conditions, and shall make such contracts available to EBD upon request.

D. The Contractor shall handle all provider quality of care issues, providing documentation on related issues to EBD within five (5) business days from request of this information.

E. The Contractor shall ensure re-credentialing and re-validating of Providers, at a minimum of every three (3) years.

F. The Contractor agrees to undergo targeted recruiting of Providers currently treating the State’s enrolled participants but not currently in Contractor’s network.

G. The Contractor shall implement and support a rural health initiative designed to increase Member access to care, to include virtual care options, telehealth and/or other technological solutions.

2.10 TELEHEALTH SERVICES

A. The Contractor shall provide a solution which offers options around virtual health care including but not limited to telehealth, mobile clinics, or other alternative care delivery models.

2.11 CLAIM ADJUDICATION PROCESS

A. The Contractor shall provide a comprehensive claims adjudication processing, payment services for the Services listed within this RFP.

B. The Contractor shall electronically provide a complete list of Contractor fee schedules/allowed amounts on a semi-annual basis for the Contractor’s Provider Network, National Network, and Transplant Network for audit purposes in a format to be determined by EBD. This is not claims-specific but will be used to validate billed and allowed charges on the individual claims to be provided to EBD. All non-participating claims must reflect the fee schedule/UCR allowable (i.e., PPO network).

C. The Contractor shall provide any additional data that alters allowed amounts of adjudicated claims including, but not limited to, capitation arrangements, value-based payment initiatives, and innovative payment initiatives.

D. The Contractor shall apply industry standards for bundling/unbundling coding logic (i.e., multiple and bi-lateral surgery logic, bundled lab panels, etc.) for the claim adjudication processing and payment, where applicable.

E. The Contractor shall convert all paper claims received to an electronic record that must be transmitted in the same HIPAA-compliant electronic format as electronic claims (see An Introductory Overview of the HIPAA 5010 | Guidance Portal). Paper claim images must be provided to EBD as requested.

F. The Contractor shall provide EBD with provider and facility information weekly, in a format determined by EBD, to populate EBD’s systems.

G. The Contractor shall aggressively pursue the collection of overpayments to Members, providers, and facilities. The Contractor shall actively pursue the overpaid amounts in writing from the Members, providers, and facilities and shall continue collection efforts on behalf of EBD until collected, unenforceable, or instructed by EBD to discontinue the collection efforts.

H. The Contractor shall provide Explanation of Benefits (EOB) for all claims (medical/health/wellness) to Members and shall also provide an electronic report to EBD of EOB activity. The frequency and format will be defined by EBD and will be consistent with Federal mandates (see An Introductory https://www.hhs.gov/guidance/document/introductory-overview-hipaa-5010 https://www.hhs.gov/guidance/document/introductory-overview-hipaa-5010 https://www.hhs.gov/guidance/document/introductory-overview-hipaa-5010

Overview of the HIPAA 5010 | Guidance Portal). All EOB’s must contain all information required under Federal Regulations in the required timeframes and formats.

I. The Contractor shall work cooperatively with any of EBD’s contracted vendors (i.e., pharmacy benefits manager).

J. EBD retains the authority to require pre-authorization for any Service at any time. The Contractor shall implement the necessary requirements of Act 815 of 2017.

K. All claims adjudication/payments processes must be made in accordance with applicable State or Federal law, to include, but not limited to, processing clean claims and related timelines.

L. The Contractor shall provide an electronic copy of every Explanation of Benefits generated for Recipients in a format and using a naming convention defined by EBD and transmit to EBD using secure file transfer protocols as defined by EBD. File types such as PDF or 835 must be an option.

M. The Contractor shall provide a portal accessible by EBD that provides details of all claim adjudication data, provider participation, facility participation, value-based programs, and Recipient eligibility as reflected. This data must contain multiple methods of searching this data such as by Recipient name, Recipient plan ID, by rendering provider, claim status, etc.

2.12 MEDICARE AS PRIMARY COVERAGE

A. Claims payment must be coordinated as if Medicare Part A and Part B are both in force at the time of

Service. If the Member is eligible for Medicare Part B but does not elect coverage, the Plans must pay as though the Member does have Medicare Part B, and the Member will have full financial responsibility for incurred claims

B. The Contractor shall adjudicate Medicare Part A, B, and C claims for pricing requirements when Services are considered non-covered by Medicare.

C. The Plans must cover Services for Medicare Primary Members the same as for active and non- Medicare Members. If Medicare does not cover a particular service but it is described in the Summary Plan Description (SPD) as being covered for active and non-Medicare Members, then the Plans must provide coverage.

1. ASE Summary Plan Description: https://www.transform.ar.gov/employee-benefits/arkansas-state-employees/

2. PSE Summar Plan Description: https://www.transform.ar.gov/employee-benefits/public-school-employees/

D. The Contractor shall download the SPD from this link to determine benefit limitations. These are subject to changes implemented by EBD or State Legislature.

E. All physician, hospital, out-patient facilities and medical services offered to Medicare Primary retirees on the Schedule of Benefits must be subject to the provisions of that schedule. Not all services allowed by Medicare may be allowed by the Plans (for example, the Plans will not pay the twenty percent (20%) for gastric bypass surgery).

F. The Contractor shall provide confirmation back to the submitter, of the receipt of claims submitted online within one (1) business day. All eligible, qualified, clean claims must be routed for adjudication within three (3) business days of receipt by the Contractor.

G. The Contractor shall notify the Member of receipt of any ineligible, suspended, or pending claim that is unprocessed and shall notify the Member via the Member’s preferred method of communication which may include telephone, fax, mail, web portal, mobile app, or email.

1. The Contractor shall include the following information in the notification to the Member:

a. Provider of Service

b. Claim Amount

c. Date of Service

d. Reason for Payment Denial https://www.hhs.gov/guidance/document/introductory-overview-hipaa-5010 https://www.arkleg.state.ar.us/Acts/Search?tbType=&ddBienniumSession=2025%2F2025R&hdnSessions=z2017R%2C&ddChamber=A&tbActNumber=815&tbBillNumber=&ddSponsor=&tbAllWords=&tbExactPhrase=&tbOneWord=&tbWithoutWords=&ddExclusivity=Only https://www.transform.ar.gov/employee-benefits/arkansas-state-employees/ https://www.transform.ar.gov/employee-benefits/arkansas-state-employees/ https://www.transform.ar.gov/employee-benefits/public-school-employees/ https://www.transform.ar.gov/employee-benefits/public-school-employees/ https://transform.ar.gov/wp-content/uploads/2024-ARBenefits-Summary-Plan-Document-Executed-2.pdf

H. The Contractor shall process and correctly pay all claims in accordance with the State of Arkansas and EBD established policies, procedures, and practices as it relates to the claims adjudication process.

I. EBD’s polices, procedures, and practices can be accessed by visiting the ARBenefits website at https://www.transform.ar.gov/employee-benefits/arbenefits-member-portal-2/.

J. EBD has the right to adjust one or more of its policies, procedures, or practices. Should EBD make any of the aforementioned changes, the Contractor shall process and pay all claims in accordance with any adjusted and/or updated policy, procedure, and/or practice as defined by EBD.

K. The Contractor shall process pending claims. The act of processing pending claims must include, but not be limited to, following up with appropriate parties (i.e., provider, Member, facility) in order to obtain information applicable to the correct processing of pending claims.

L. The Contractor shall screen all claims to prevent payment duplication and shall maintain procedures that provide consistency of claims payments in accordance with the Program requirements.

2.13 HEALTH INSURANCE REPORTING REQUIREMENTS

A. The Contractor shall provide reporting based on the divisions as defined by EBD (i.e., ASE/PSE, group numbers, etc.) in formats approved by EBD.

B. The Contractor shall negotiate with EBD to develop mutually agreeable reporting formats and deadlines. EBD reserves the right to establish formats and deadlines, if negotiations fail.

C. The Contractor shall understand that all reports specifically mentioned in this RFP will be created at no additional charge.

D. The Contractor shall negotiate with EBD to develop mutually agreeable quality performance reporting criteria for Population Health/Custom Care targets.

E. Reporting data must be auditable and verifiable, and, at minimum, able to cross reference to invoice payment requests received by EBD

2.14 MEDICAL MANAGEMENT…