Saratoga County RFP Specification 2025 - Medical and Rx (25-RFPMPDBP-1)(10135885.1).pdf

© 2025 by The Segal Group, Inc.

Saratoga County

Medical and Prescription Drug Benefit Program Request for Proposal (25-RFPMPDBP-1)

May 2025

These proposal specifications are the property of Segal and are intended for the sole use of its employees. Any duplication or reproduction of this document is prohibited without prior authorization provided by a qualified representative of Segal.

66 Hudson Blvd, E

20th floor

New York, NY 10001-2192 segalco.com

Ta b l e o f C o n t e n t s

Saratoga County

Section I: Introduction

Objective

Confidentiality

Section II. Bid Requirements and Specifications

General Bid Requirements

Required Contract Provisions

General Proposal Conditions

Timetable

Contacts

Section III: Medical

Financial Proposal – Medical

Proposal Questionnaire – Medical

Section IV: Prescription Drug

Financial Proposal – Prescription Drug

Proposal Questionnaire – Prescription Drug

Section V: Required Forms

Proposal Certification

Statement of Required Disclosures, Representations, and Certifications

Indemnity Insurance Agreement

Section VI: Acknowledgement and Statement of Exceptions Form

#10118883v9/42297.001

Section I: Introduction On behalf of Saratoga County (“the County” or “the Plan”) we invite your organization to submit a proposal for its self-funded medical and prescription drug benefit plans. The County is requesting:

• A preferred provider organization (PPO) medical network on an Administrative Services

Only (ASO) basis (including vision);

• A self-funded Pharmacy Benefit Manager (PBM) proposal assuming a traditional pricing model with 100% pass-through of earned rebates.

The program will be effective January 1, 2026. All bidders must follow the instructions in these bid specifications and complete all questions and tables. Proposed terms for each line of coverage must be firm whether administered bundled or standalone.

Saratoga County provides access to comprehensive health benefits to roughly 1,100 eligible employees and 3,500 total covered participants. The County currently partners with CDPHP for medical, vision, and prescription drug and with MetLife for dental.

Plan design information can be found on the County’s website:

https://www.saratogacountyny.gov/departments/human-resources/benefits/

Please note:

• The medical benefit is a non-grandfathered plan as it relates to the Affordable Care Act.

• The Plan’s reimbursement level for out-of-network claims payment is 80th percentile of

FairHealth.

• Additionally, stop-loss is carved out and excluded from the scope of this RFP.

We will provide an External Data File containing detailed member census, historical monthly claims and enrollment, and pricing exhibits upon receipt of an affirmative Intent to Bid from your organization (page 9).

Objective The Plan is interested in providing a high-quality program to its members with continuity of service for all members. The Plan has a strong relationship with its participants and wants to maintain this bond.

The Plan is soliciting proposals to provide a plan of benefits that is identical to the current plan design. The Plan is also interested in chronic disease management programs, telehealth solutions, initiatives around behavioral health, innovative approaches for engaging with their members, and your organization’s approach for alerting the Plan to and managing large claims.

In addition, the Plan is open to learning of alternatives that your organization has implemented to help control spend and improve overall outcomes and quality of care. Please provide alternatives that incorporate such strategies, including customized networks based on a quality/cost model, data mining and predictive modeling capabilities with effective disease management, wellness, and large case management initiatives.

Confidentiality All information presented in the RFP, including information subsequently disclosed during the proposal process, is confidential. Information and materials supplied during the RFP process should not be released to parties external to the bidding organization without the express written consent of the Plan and the Segal Company.

All proposals submitted will be retained permanently by the Plan and the Segal Company and shall remain confidential.

Section II. Bid Requirements and Specifications The following addresses each bid, contract and service requirement. Please review this section thoroughly to determine your ability to meet these requirements. At the end of this section you will find an Acknowledgment and Statement of Exceptions Form for your completion. If you are unable to meet any of the following requirements, you must note or reference them on this form.

This form must be returned with your proposal.

General Bid Requirements

1. Compliance with Specifications. Bidders must fully respond in writing to the RFP's questionnaire, forms and other requests for information. All proposals are to be prepared according to these specifications.

2. Form of Your Proposal. Your responses to the Questionnaire, the completed

Acknowledgment and Statement of Exceptions Form will constitute the essence of your proposal and should be made in writing.

3. Right to Request, Evaluate and Reject Bids. The Plan and the Segal Company reserve the right to reject any or all proposals, to request additional proposals or to waive any minor deficiency, technical variance, or immaterial technicality.

4. References.

a. Provide the following for each reference:

1) Client name

2) Address

3) Industry (if not obvious)

4) Contact name, title and phone number

5) Total number of members

6) Total number of covered lives under the health program

7) Length of time as a client of your company.

b. Bidders must submit a list of seven (7) public sector client references, of which:

1) at least two must be New York based;

2) at least two must have participation between 1,000 and 4,000 employees; and

3) at least one must be a new client (with an effective date of 1/1/2023 or later) who can attest to their experience with your implementation capabilities for each line of coverage proposed (i.e. one new client each for medical and PBM business).

c. Bidders must provide names, addresses and telephone numbers of two (2) public sector clients, with between 1,000 and 4,000 employees who terminated their relationship with your company in the last two years.

d. Please submit a national public sector client list.

e. Provide the type of plan administered for each reference.

5. Commissions.

a. First Year: None

b. Second Year and Subsequent Years: None

6. Funding. The Plan is interested in an Administrative Services Only (ASO) arrangement for medical and prescription drug and fully-insured for dental.

7. Finalist Interview. Bidders must be available for a possible finalist evaluation meeting with the Plan and the Segal Company (date to be determined).

8. Implementation. The successful bidder(s) must be able and fully committed to support the Plan with all aspects of the installation process. To this end, your proposal must include a detailed implementation timetable and key task checklist, should your company be selected.

Required Contract Provisions

The successful bidder's proposal must contain provisions reserving these rights to the Plan:

1. No-Loss, No-Gain & Waiver of Actively-at-Work. Current participants in any of the

Plan’s sponsored health care plans will be provided coverage on a "no-loss, no-gain" basis. Any “actively-at-work” or non-confinement requirements will be waived on the effective date for all participants or dependents participating in the plan immediately prior to the effective date of your contract with the Plan.

2. Eligibility Rules. The bidder agrees to the specified eligibility rules established by the

Plan. The successful bidder(s) must communicate directly with the Plan regarding any uncertain claimant eligibility situations before notifying the claimant directly of an ineligible status.

3. Maintenance and Ownership of Records. Your company will be required to maintain all pertinent records for seven years. This is in conjunction with prudent business practice and ERISA provisions. Your company would be charged with the safekeeping of Plan experience information and, in the event of contract termination, would be required to cooperate with the Plan, or their representative, in the orderly transfer of this plan experience information to the Plan or its designated succeeding health plan/carrier.

4. Right to Audit. The Plan reserves the right to review and audit the health plan’s files and financial accounting data to assure that claims that are subject to each proposed coverage are evaluated and paid in accordance with the plan’s provisions.

5. Effective Date and Plan Anniversary. January 1, 2026 is the proposed effective date and anniversary thereafter.

6. Renewal Notification. The health plan must provide any rate changes in writing with full justification at least 180 days prior to a contract anniversary. The long lead-time is required due to the annual budget pricing, communications, and administration requirements associated with the Plan’s benefit program.

7. Termination Provisions. The Plan may terminate the contract at any time without cause and without financial penalty by giving 60 days written notice. The health plan may only terminate the contract prior to the date rates renew and then only by giving notice 120 days in advance, except in the event of non-payment of claims and administrative fees.

8. Variance Provision. Any provisions, references, or guidelines relating to reevaluation of proposed rates due to variation in enrollment in the plan must not be included as a condition of your proposal.

9. Performance Guarantee. As the Plan’s Claims Administrator, you must agree to serve the Plan and its staff under the terms of a performance agreement executed between the

Plan and your company. The objective of the Performance Guarantees is not to reduce your client revenue by invoking penalties but rather to reinforce your verbal and written assurances of quality service with tangible measurements. At a minimum, this performance agreement must include, but is not limited to

a. Objective accuracy benchmarks and associated penalties for failure to consistently meet the following measurements:

– Member satisfaction

– Appointments wait time

– Network Access (Percentage open panels/taking new patients)

– Healthcare Effectiveness Data and Information Set (HEDIS & CAHPS) performance measures

– Initial implementation and enrollment process

– On-time delivery of periodic and annual reports and delivery of information or notifications to the Plan.

b. A subjective service measurement that will be solely determined by the Plan; and

c. A level of financial risk that is challenging yet fair.

10. Staffing. Employ sufficient and appropriately trained dedicated staff, familiar with administering your proposed plan of benefits, to meet the service specifications outlined herein and subsequently detailed in a performance standards agreement that would be executed between the Plan and your company.

11. Indemnity Run-In. The incumbent carrier will pay run-out on incurred medical claims prior to the effective date. Your responsibility will be to provide services for claims incurred on or after the effective date only.

12. Eligibility Questions. Communicate directly with the Plan staff regarding any uncertain claimant eligibility situations before notifying the claimant directly of an ineligible status.

13. Participant Inquiries and Requests. Respond to all inquiries and requests made by the

Plan’s plan participants with a sense of urgency. Updated directories are to be mailed directly to the participants upon request. Phone calls and all correspondence are to be handled by a reasonable number of service personnel who have been trained in the area of customer service and who are familiar with the Plan’s programs.

14. Phone Service. An 800-telephone number is to be available for all plan participants.

15. System Capacity. Maintain sufficient system capacity to meet the service specifications outlined herein and subsequently in the agreement(s) between your company and the

Plan.

16. On-Line Historical Data. Maintain at least three years of the Plan’s claim (all fields indicated on the UB & HCFA) and eligibility information at all times.

17. System Problems -- Client Notification. Notify the Plan if your claim system experiences, or is scheduled to experience delays or shut down that either: a) exceeds your internal standards in this area, or b) would have an adverse impact on claim payment or customer service.

18. Turnaround Time. Reimburse all clean claims (where all the necessary information is provided to make a benefit or reimbursement determination) to both providers and participants within 14 calendar days or 10 business days.

19. Pended Claims. Make available, upon request, reports regarding the number and nature of claims pended, if your organization is processing the claims.

20. Telephone Quality Assurance (QA). Monitor the activity of the phones with emphasis on the frequency of busy lines and hold times. Provide the Plan with periodic management information regarding the phone activity including, if possible, the number or frequency of all connected calls, unsuccessful or busy calls, calls placed on hold, the average duration of hold time, and some information indicating the general nature of participant inquiries beyond merely anecdotal accounts.

21. Internal Audit. Conduct regular and diligent internal audits to monitor quality.

Communicate the findings of these audits and similar QA procedures to the Plan no less frequently than semi-annually.

22. External Audit. Cooperate with any outside audit firm the Plan selects to perform a claim administration audit. This might include the provision of space and system terminals for a reasonable period of time to accomplish the audit objectives.

23. Communication Materials. The Plan will require prior approval of all communication materials before forwarding to the participants. Materials will be bilingual (English and

Spanish).

24. Plan Reporting. Plan reports should be available online. The online system should provide Plan specific reports/data files including but not limited to:

a. Monthly, by plan -- Medical and COBRA -- paid claim reports/files with year-to-date accruals broken down by member, spouse and children. These reports should give dollar and claim incidence totals and identify network versus non-network experience.

These reports/files should also include all information found on a UB or HCFA.

b. Service and diagnostic specific reports capturing all multiple diagnoses (primary, secondary, etc.) submitted by provider.

c. Utilization data to include by not limited to: inpatient census, outpatient census, prior authorization approvals and denials, case management, concurrent reviews;

d. Lag report that identifies claims by incurred month to include all information found on a UB or HCFA.

e. Monthly turnaround time statistics for the previous month’s claims.

f. Monthly claims files with all payment fields to be provided to the Plan.

g. Claims portal with real-time access to view claims.

General Proposal Conditions

Below are the general requirements for submitting proposals.

1. Award or Rejection: Any award will be made to that bidder whose proposal is deemed to be in the best interest of the plan sponsor. The plan sponsor reserves the right to reject any or all proposals.

2. Intent to Bid: All bidders must submit a completed Intent to Bid form.

3. Costs for Proposal Preparation: All costs incurred by bidders in preparing or submitting proposals are the bidders’ sole responsibility. Proposals will not be returned.

4. Oral Explanations: The plan sponsor will not be bound by oral explanations or instructions given during the competitive process or after the award of the contract.

5. Time for Acceptance: The bidder agrees to be bound by its proposal until the effective date of January 1, 2026, during which time the plan sponsor and/or Segal may request clarification of the proposal for the purpose of evaluation. Late proposals may not be accepted.

6. Exceptions: Any exceptions to terms, conditions, or other requirements in any part of these specifications must be clearly pointed out in the appropriate section of the proposal.

Otherwise, it will be considered that all items offered are in strict compliance with the specifications. Amendments or clarifications shall not affect the remainder of the proposal, but only the portion so amended or clarified.

7. Bidder’s Representative: The proposal must be signed by a legal representative of the bidding firm, who is authorized to bind the firm to a contract in the event of the award. All rates, fees and terms presented will be considered legally binding.

8. General Compliance: All bidder services must adhere to relevant federal and state laws and regulations, including the Patient Protection and Affordable Health Care Act (PPACA or ACA) of 2010, as applicable.

9. HIPAA Compliance: All bidder systems and services must be in compliance with the

HIPAA EDI, Privacy and Security regulations as well as the HITECH Act on the appropriate dates established by the Department of Health & Human Services.

Failure to meet any of these conditions may result in disqualification of bids. Bidder written responses, including all documents provided during this RFP process will serve as the contract between the parties until replaced by a signed written contract.

Timetable

Below is a preliminary timetable of major events during this RFP process:

Action/Event Target Date

Release of RFP May 7, 2025

Intent to Propose Form Due May 14 2025

Proposals Due May 28, 2025

Analysis Complete June 2025

Finalist Selection Mid-June – Mid-July 2025

Decision Date September 1, 2025 (120 days implementation)

New Contract Term Effective Date January 1, 2026

Contacts

Proposals are to be submitted both electronically and in hard copy (one copy). The electronic copy must be provided to Segal by the proposal deadline and the hard copy may follow.

Electronic proposals should be sent to bhemmings@segalco.com and lkearney@segalco.com.

Brandon Hemmings Lisa Kearney

Vice President, Health Consultant SVP, Health Consultant bhemmings@segalco.com lkearney@segalco.com

The hard copy proposals, 1 (one) original and 4 (four) copies, are to be mailed to:

Saratoga County Purchasing Department c/o John Warmt

50 West High Street

Ballston Spa, NY 12020

There is to be no direct or indirect contact made with the Plan during this process. All communication should be directed to The Segal Company.

Designate the individual(s) with the following responsibilities:

The individual(s) representing your company during the proposal process:

Representative Name mailto:bhemmings@segalco.com mailto:lkearney@segalco.com mailto:bhemmings@segalco.com mailto:lkearney@segalco.com

E-mail

The individual(s) responsible for day-to-day service (if different):

Representative Name

E-mail

The Segal Company

Intent to Bid & UDS Specification Form for Saratoga County

All bidders must complete this page and return it to:

Brandon Hemmings Segal bhemmings@segalco.com

Name of Bidder

We confirm the receipt of your request for proposal and will take the following action:

☐ We intend to bid on the Administrative Services Only (ASO) medical benefit (including vision, see current plan description)

☐ We intend to bid on the Administrative Services Only (ASO) prescription drug benefit

☐ We intend to provide an alternate [please explain]

☐ We decline to bid [please provide reason]

Signature

Name

Telephone #

Email

Date

INTENT TO BID FORMS MUST BE RECEIVED BY May 14, 2025

Section III: Medical

Financial Proposal – Medical

Administrative Fees and Network Access Charges

Complete the following table for your administrative costs. Fees must be provided in the following formats. Fee exhibits are provided for your organization’s response in the External

Data File. Alternatives may be considered. Please include information on all capitated arrangements.

Administrative Services Only Fees

The marketplace has shown a move toward unbundling some of the administrative services handled under the self-administered plans. These charges have regularly taken the form of a percentage of the savings. Please clearly specify any additional services that are paid under any form, per member per month, percentage of savings, etc. If there are any pieces to the claims administration or payment that are capitated, please clearly indicate. In addition, many of the fees are for services that are not done internally but are performed by outside providers.

Clearly indicate the total fee charged to the fee as well as the amount that is paid to the service provider and what is retained by your organization.

Admin Fees PMPM1 Policy Year

Year 1 Year 2 Year 3 Year 4 Year 5

Base Fee

Network Access Fees

Claims Processing Fee

Utilization Management Fee

Case Management Fee

Disease Management

Diagnostic Review Fee

Behavioral Health (excluding EAP)

Telehealth/Telemedicine

Radiology Fee

Quality Management Fee

ID Cards

Provider Directory

Booklets/SPDs

SBCs

1 PMPM represents per member (employee) per month. Provide the estimated annual fees assuming the lives provided on the census.

Admin Fees PMPM1 Policy Year

Year 1 Year 2 Year 3 Year 4 Year 5

Data Reporting – Standard

Stop Loss Reporting

Banking

Claims Fiduciary

Run-out Claims Processing at Termination (provide term/months included and corresponding fee)

Rx Integration File Feeds

Third Party Data Feeds

Standard Transition File Feeds at Termination

No Surprises Act related fees

Other (Explain)

All Inclusive Fee (PMPM, other)

Total Annual Estimated Fees $ $ $ $ $

The chart above includes a comprehensive list of all services under the various options requested. Please clearly state the fee that is applicable for a bundled arrangement as well as the alternatives that are proposed specific to the alternates offered by your organization.

If any extra fees will be billed to the Plan, specify the organizations that will perform the functions provided, define fully the functions to be performed and estimate the fees that will be charged and the basis on which the fees will be based (e.g., as a percentage of savings).

Fee as a Percentage of Savings

Additional Administrative

Services

Year 1 Year 2 Year 3 Year 4 Year 5

Estimated BOB Savings PMPM

Organization to Perform Service

Wrap Network Fee

Bill Negotiation Fee

Subrogation

COB

Other

NOTES:

a) All services to be provided for the quoted fee should be listed including quantities and frequencies.

b) Fees must exclude commissions.

c) Individual fee components will be assumed to be self-supporting stand-alone services.

d) Provide estimate of fee for alternative options of services, on requested basis.

e) Fees quoted must be valid until the effective date of January 1, 2026 and guaranteed for each 12-month period.

f) List services/supplies not covered under the fees quoted above (i.e., custom reports, printing, etc.).

g) Fees quoted are to cover services for claims incurred on or after the contract effective date.

h) Fees are to include costs of all transition files upon contract termination, including but not limited to deductible accumulator and transition of care files.

Allowances and Credits

Please complete the following table:

Allowance Description Response

Pre-Implementation Audit

Place the flat dollar ($) amount you are offering the Plan to be used to conduct a pre-implementation audit (one-time).

Implementation Place the $ (dollar) Per Member amount or the flat dollar ($) amount you are offering the Plan (one-time).

Audit Place the dollar ($) Per Member amount or the flat dollar ($) amount you are offering the Plan to be used annually to conduct a claims audit (annual).

General Place the $ (dollar) Per Member amount or the flat dollar ($) amount you are offering the Plan for general expenses related to the management of the medical program such as wellness programs, communication expenses, clinical programs, consulting fees, or be used as a credit against claim invoices (annual).

Claims Re-pricing

In the External Data File we will be providing a detailed claims file containing the Plan’s utilization data for the claims for the year ended December 31, 2024. The file will contain inpatient hospital, outpatient hospital and professional claims information, and will serve as the template for the Claims Re-pricing component of this RFP.

For your proposed network, please provide the actual average discount off eligible charges for each provided TIN. Please do not include anticipated deals in the historical figure. Be sure to include a network indicator (actual status of provider: participating, non-participating, non-participating contracted, or wrap, regardless of how the claim is paid) for your proposed network as well as a network indicator for any high-quality networks available.

In addition, please provide the average projected 2025 discount, which will include any adjustments that are based on finalized future changes to provider discounts.

Finally, please provide an indicator for those providers with a negotiated incentive payment along with the estimated total incentive payment as a percent of total reimbursement and on a per attributed member basis for your commercial Book of Business.

Definition of Terms

• Submitted Charges: All charges submitted by the provider for payment

• Eligible Billed Charges: Sometimes referred to as "Covered Charges.” Eligible Billed

Charges = (Submitted Charges less Ineligible Charges) before application of fee schedules or contractual reimbursement provisions

• Negotiated Savings: Sometimes referred to as "Provider Discount.” Savings resulting from fee schedules or contractual reimbursement provisions. Reductions that result in member balance billing should not be included as Negotiated Savings. Negotiated Savings should be reduced for any NY Surcharge owed for this claim.

• Contracted Amount: Sometimes referred to as "Allowed Amount.” Contracted Amount =

(Eligible Billed Charges less Negotiated Savings resulting from fee schedules or contractual reimbursement provisions) prior to member cost sharing. Please identify the re-pricing methodology:

In order to prepare a discount comparison that is specific to the utilization patterns of the Plan, we request that the average discount be provided for each provider and facility TIN.

Proposal Questionnaire – Medical

General Requirements and Questions for All Bidders

In order for your proposal to be considered and accepted, your organization must provide answers to the questions presented in this section. All questions must be answered. Reference should not be made to a prior response, or to your contract, unless the question involved specifically provides such an option. Be sure to refer to the earlier sections of this request for proposal (RFP) before responding to any of the questions so that you have a complete understanding of all of this Plan’s requirements with respect to the bid.

If your proposal is different in any way (whether more or less favorable) from that indicated in this request for proposals, clearly indicate where. If you do not specify a difference, the submission of your proposal will be deemed a certification that you will comply in every respect

(including, but not limited to, coverage provided, funding method requested, benefit exclusions and limitations, underwriting provisions, etc.) with the requirements set forth in this RFP.

If you are unable to perform any required service indicate clearly: a) what you are currently unable to do; b) what steps will be taken (if any) to meet the requirement; c) the timetable for that process; and d) who will be responsible for the implementation.

General Issues

1. Provide an Annual Report for your Company (including the Parent, if applicable) which includes the most current audited financial statements (balance sheet, income statement and statement of cash flows).

2. List other group benefit services your organization provides, other than what is being proposed.

3. Designate the individual(s) with the following responsibilities. Include the name, title and address of each individual, along with a brief description of his/her qualifications and experience.

The individual(s) representing your company during the proposal process.

The individual(s) who will be assigned to the overall ongoing account management.

The individual(s) who will be responsible for day-to-day service.

4. As the contract will be issued in the state of New York, the contract must be in full accord with the laws of that jurisdiction. Please confirm that your proposal and plan design offered is in compliance with all federal and state laws and regulations that pertain to employee benefit programs, relevant state insurance regulations and other related laws.

Administrative Services

Account Service

5. Do you agree to notify the Plan immediately if the network loses any accreditation, licenses or liability insurance coverage or bonding?

6. How will administrative fees be billed?

7. If your organization already provides insurance (e.g., life insurance, EAP, etc.) or a service coverage (e.g., dental administration, etc.) to the Plan, do you coordinate billing procedures so that the Plan receives one comprehensive bill?

8. What on-line services/functions will be made available to the Plan via the Internet?

Provide name of the website.

Member Service (i.e., customer service, Internet access, etc.)

9. Do you offer any website or smartphone app capabilities that allows members to select and/or locate network physicians?

10. a) Will a toll-free number be made available to the Plan and participants to handle service issues? b) What hours will the lines be staffed? c) Who will staff the lines during normal business hours and after hours?

11. Does your organization offer Spanish language member services? What, if any, additional languages are services offered in?

12. Indicate your average telephone wait time to speak to a live customer service representative (not just an operator).

13. Average wait time for year ended December 31, 2024 (if available):

14. Indicate the ways in which your organization is able to accommodate the special needs of enrollees. Check all that apply.

☐ No special accommodations.

☐ Have a TDD (Telecommunications Device for the Deaf) or other voice capability for the hearing impaired.

☐ We accommodate non-English speaking enrollees by contracting with an independent translation service.

☐ We maintain customer service staff with the ability to translate the following languages:

☐ Other

15. Do you offer a Nurse Triage (nurse advice/demand management) telephone program for enrollees? Check one only.

☐ Yes, staffed by live health professionals, 24 hours/day, 7 days/week.

☐ Yes, staffed by live health professionals, ___ hours/day, ___ days/week.

☐ No, enrollees are to seek information/guidance from their physician.

☐ Other:

16. Do you have a telephone system that allows enrollees to dial in to hear Health Care

Information on certain health topics? Check one only.

☐ Yes, this system is available _____hrs/day, _____days/week.

☐ No, not yet.

☐ Other (specify)

17. Indicate how your organization typically responds to an enrollee who calls to complain that a network provider is balance billing them for an amount of money above and beyond the patient’s required copay or coinsurance? Check one only.

☐ We ask that the patient communicate to their doctor that a network provider does not permit balance billing.

☐ Our organization contacts the provider directly to discuss the issue and have the provider stop balance billing.

☐ Other (specify)

☐ Not an issue, as none of our network providers ever balance bill an enrollee.

☐ Unknown.

18. What support do you provide for selecting and/or locating network physicians and for answering provider credential questions that participants may have? What other member services are provided with regard to provider selection assistance?

19. Do you provide on-line access to network provider listings and locations to assist participants with provider selection? Do you specify the languages providers speak?

20. In the following grid, indicate the average percentage of complaints/calls received by your customer/member service department, by the type of the call.

Type of Calls (Last 12 months available) Average % of Complaints/Calls

a. New Enrollment Issues (e.g. ID cards, directory received, how to use plan, etc.)

☐ Unknown ☐ _____%

b. Service Issues (e.g. access, referral problems, etc.) ☐ Unknown ☐ _____%

c. General Information ☐ Unknown ☐ _____%

d. Other (specify) ☐ Unknown ☐ _____%

TOTAL (sum of a-d should =100%) ☐ 100% ☐ 100%

21. Describe the grievance and appeals protocols in place for Plan participants?

22. Please describe how you will coordinate with the Plan when a participant appeal is received.

23. Do you have a response time goal for which to respond to other questions and complaints?

24. Do you participate in CAPHS or other member satisfaction surveys? If so, for calendar year 2022, indicate the enrollees who responded they were at least “satisfied” with your organization. Check one only.

☐ A total of_______ enrollees were at least “satisfied” which represents ______% of those surveyed. (Response valid only if a copy of your survey is attached.)

☐ Unknown.

☐ Enrollee satisfaction surveys not currently conducted.

Communications

25. How often are provider directories updated for Plan participants?

26. Please submit a sample of all forms that would be used in the administration of this plan

(e.g. ID cards).

27. Are there any forms required for plan administration, the cost of which are not included in your fees? If so, please describe the forms and specify additional cost.

28. a) Describe how you will communicate the network features and rules to participants. b)

Please attach sample communication materials you have produced for your clients, in the appendix. c) Is the cost of these communication materials included in your regular fee for the use of the network? If not, what is the additional cost?

29. Will your organization offer bi/multi-lingual communication materials?

30. What Literacy level are your communications? Are you capable at producing communications between the 4th to 6th grade level if requested?

31. Provide sample patient/member education materials sent to enrollees in the last 12 months. In particular, provide examples educating members on benefits of urgent care over emergency room and information on Telehealth services.

Implementation

32. Will you agree to guarantee complete implementation within one of the following timeframes, after being awarded the contract?

☐ Within 60 days of receiving eligibility

☐ Within 90 days of receiving eligibility

☐ Within 120 days of receiving eligibility

☐ Cannot provide a guarantee on implementation timing.

33. Provide a detailed proposed implementation plan and timetable, assuming the proposed effective date. Begin with the award of business to effective date of coverage, including:

a. Steps required to implement the program.

b. Role played by the client/vendor.

c. Contacts and personnel assigned to each step of the implementation process.

d. Production and distribution of ID cards, directories, and enrollment materials.

34. Please describe the implementation process that you will follow (and expect the Plan to follow) for implementing claims exchange procedures? Please include a sample implementation work plan that identifies expected activities, roles and responsibilities and timing.

35. Will you allow the Plan to conduct implementation testing prior to the plan going live?

☐ Yes

☐ No

36. In addition to testing, what other assistance do you offer internal staff, at no cost to the

Plan, to familiarize them with the new system?

☐ Yes

☐ No

37. Please identify and describe any technical and networking requirements (i.e., file transfer protocol, workstation requirements, connectivity, and transmission software) that must be implemented to facilitate the electronic exchange of claims information.

Network Access

38. Using the Plan’s census, please provide detailed information on your proposed provider network in the tables found on the Network Access tab of the External Data File.

Network Management

Network Turnover

39. Do you notify the Plan and/or participants if a network physician terminates his/her contract during the plan year?

40. If so, how and when are participants notified?

41. What happens to patients that are receiving on-going treatment from a network physician that moves out-of-network?

42. Can the Plan or Plan participant nominate providers to be considered for inclusion in the network panel? If so, what is the procedure for the Plan and/or participant? What is the average length of time for review of these nominations?

43. For all service areas applicable to the Plan, provide the number of Network Providers that have terminated their contract:

Provider Type Unknown

Total # of Terminations in the Past 12 Months

Terminations Equate to What % of Your Contracted Providers?

Most Common Reasons For Termination (e.g.

fraud, fees, quality)

Hospital Facilities

Physicians

a. List any counties in the service areas that impact this plan sponsor that have had 5% or more physician turnover in the last 12 months? If so, please list each county and explain.

County % of Physicians No Longer in Network Reason for Physician Turnover

b. With respect to network contracted outpatient hospital facilities, do all individual physicians within a group practice participate in your network? If not, please explain.

c. Please list all hospitals, within those counties where participants reside, that your organization does not have a negotiated hospital rate for all outpatient services.

44. Do you offer Telemedicine services? Please provide details on the firm that is providing the services, an overview of the service model, and the cost per service as well as any applicable administrative fee. Please also provide key service metrics in the table below:

Telemedicine Service Metrics Details

# of members covered under telehealth

# of physicians and specialists included in telemedicine services

Does the network include behavioral health providers?

% of network physicians in US

Credentialing process

Physician response time via phone

Physician response time via secure email

Will patients be referred into the Plan’s medical provider network?

How are Rxs processed?

Minimum/Maximum member age

Accreditation

45. Complete the following grid with respect to your organization’s accreditation status. Be sure to answer all three columns regarding the current levels of accreditation and the duration of each type of continuous accreditation, certifications and recognitions.

Type of Accreditation, Certification, Recognition

Current Level of Accreditation, Certification, Recognition

Duration of Continuous Accreditation, Certification, Recognition (# of years)

None

☐ American

Accreditation Health Care Commission Inc. (AAHCC), formerly known as

URAC

Check one:

☐ Full accreditation

☐ Denied/non-accredited

☐ Pending (initial certification requested but not yet finalized).

☐ Not yet requested

☐ Less than 1 year

☐ 1 year

☐ More than 1 year, but less than 2 years

☐ 2 years

☐ More than 2 years, but less than 3 years

☐ 3 years or greater

☐ JCAHO Check one:

☐ Accreditation with commendation

☐ Accreditation

☐ Accreditation with recommendation or improvement

☐ Conditional accreditation

☐ Provisional accreditation

☐ Preliminary non-accreditation

☐ Denied/non-accredited

☐ Pending (initial visit requested but not yet visited)

☐ Not yet requested

☐ Less than 1 year

☐ 1 year

☐ More than 1 year, but less

☐than 2 years

☐ 2 years

☐ More than 2 years, but less than 3 years

☐ 3 years or greater

☐ NCQA Check one:

☐ Excellent (full 3 yrs)

☐ Commendable (full 3 yrs)

☐ Accredited (1 year)

☐ Provisional

☐ Denied/non-accredited

☐ Pending (initial visit requested but not yet visited)

☐ Not yet requested

☐ Less than 1 year

☐ 1 year

☐ More than 1 year, but less than 2 years

☐ 2 years

☐ More than 2 years, but less than 3 years

☐ 3 years or greater

Provider Credentials

46. Complete the following table regarding your organization’s hospital credentialing requirements. [Copy chart and complete all columns of the following table separately if rural hospital credentialing differs]

Hospital Criteria

Check if the criteria is included in standard credentialing

Percent of Your Network Hospitals that Satisfy Criteria

Check if the criteria is included in standard re-credentialing

Require State Licensure ☐ ☐

Review Malpractice Coverage and History

Require full disclosure of current litigation & other disciplinary activity

Review CMS/Medicare certification status

Require JCAHO Accreditation ☐ ☐

Review state health department citations

Review CMS/Medicare citations/problems

Patient Safety ☐ ☐

47. When are contracted hospitals re-credentialed? (Check only one)

☐ Every year

☐ Every two years

☐ Every three years

☐ Less frequently than every three years

☐ Other timeframe (specify)

48. Please complete the following table regarding your monitoring of network hospitals for

CMS “never events”:

CMS Never Event

Do you monitor network hospitals for CMS “never events”?

If yes, what is the total percent of hospital infringement over the last 12 months?

Unintentional retention of a foreign object after surgery.

☐Yes ☐No

Air embolism ☐Yes ☐No

Blood incompatibility ☐Yes ☐No

Pressure ulcers (Stages III and IV) ☐Yes ☐No

Hospital-acquired injuries from falls and certain traumas (fracture, dislocation, intracranial injury, crushing injury, burns and/or electric shocks)

☐Yes ☐No

Manifestations of poor glycemic control ☐Yes ☐No

Catheter-associated urinary tract infections

(UTI)

☐Yes ☐No

Vascular catheter-associated infection ☐Yes ☐No

Deep vein thrombosis (DVT) or pulmonary embolism following total knee replacement and hip replacement procedures

☐Yes ☐No

Surgical-site infections following certain orthopedic procedures, mediastinitis following coronary artery bypass graft (CABG) and/or following bariatric surgery for obesity

☐Yes ☐No

Surgery on the wrong body part ☐Yes ☐No

Surgery on the wrong patient ☐Yes ☐No

Wrong surgery performed on a patient ☐Yes ☐No

49. What percentage of your network providers in the following specialties are Board

Certified? (Complete all)

Specialty Percent Board Certified

Pediatricians

Primary Care Physicians (e.g., include all general and family practitioners, and internists

OB/GYNs

50. Which of the following criteria does your organization use for credentialing physicians in your network? Check one in each credentialing criteria.

Requirement Physician Credentialing Criteria

a. Medical license requirements: ☐ Currently not restricted or revoked, but past history exists.

☐ Never been restricted or revoked.

b. Board certification requirements: ☐ Require Board certification in specialty practice area.

☐ Board eligibility or certification not required.

☐ Must be Board eligible or Board certified.

c. Residency training requirements: ☐ Completed residency training with any institution/program.

☐ Residency must have been completed in a

LCGME or AOA accredited institution/program.

☐ Residency training not required.

d. Drug Enforcement Administration (DEA) requirements:

☐ Current valid certificate with no history of revocation or limitation.

☐ Valid certificate not required.

☐ Current valid certificate with prior history.

e. Hospital privileges: ☐ Has admitting privileges to at least one community or teaching hospital and privileges have never been revoked or restricted.

☐ Hospital privileges not required.

☐ Has admitting privileges to at least one community or teaching hospital and privileges are currently not revoked or restricted.

f. References ☐ Not required.

☐ Requested but not always investigated.

☐ Requested and references are contacted and queried.

g. Proof of malpractice insurance. ☐ Not required.

☐ Required.

h. Onsite assessment of the physician’s office by your staff, prior to contract finalization.

☐ Not required.

☐ Required.

i. Full disclosure of current litigation and other disciplinary activity.

☐ Not required.

☐ Required.

j. Practice patterns and utilization results.

☐ Not required.

☐ Required.

k. Primary source verification. ☐ Not required.

☐ Required.

51. What is the minimum amount of malpractice coverage you require?

Malpractice Coverage Minimum Amount

Per Hospital Occurrence

Per Physician Occurrence

52. Will your firm make information regarding provider sanctions and complaints available to the Plan and its participants? If no, please explain.

☐ Yes

☐ No. If no, please explain.

53. For wrap-network providers (if applicable), does your organization monitor the credentialing criteria used by your network partners?

54. If there is an issue with a wrap-network provider, would the member work with your organization to resolve the issue or would they need to work with the wrap-network partner with the direct contract?

Provider Audits

55. Please provide latest statistics regarding on-site clinical quality audits of your contracted providers.

Provider Audits On-Site Electronic/Paper

Percent of Physicians Audited Annually

Percent of Random Audits Performed

56. Please describe fraud and abuse policies and procedures including how you identify and investigate abusive practice patterns.

57. What items do you audit electronically? (Check all that apply)

☐ Claims payment accuracy

☐ Claims coding accuracy

☐ Provider credentials

☐ Abusive provider practice patterns

☐ Provider sanctions

☐ None of the above or unknown

☐ Other

58. As a result of onsite electronic audits, what percentage of providers were terminated or removed from the network in the last 12 months?

Percent terminated as a result of audit

On-Site Electronic/Paper

Network Hospitals

Network Providers

Provider Profiling

59. Do you compare individual network provider practice patterns against best practices or averages on any of the following: (Check all that apply)

☐ Referral rates to specialists

☐ Frequency and quality of prescription drug dispensing

☐ Rates of Diagnostic Procedures ordered (Lab/Imaging)

☐ Rates of surgical procedures relative to peers

☐ Repeat Procedures within given timeframes

☐ Hospital Readmission Rates

☐ Emergency Room Admission Rates

☐ Other (please describe)

☐ Do Not Track

For all that apply, please provide sample information.

60. What training or outreach do you offer network providers that are not performing well against benchmarks?

Provider Contracts

61. How do you ensure that someone using a network hospital will not get balance billed or charged an out-of-network benefit level due to the hospital using independent non-network provider (e.g., anesthesiologist)? Do you address in your provider contracts? If so, please provide contract language.

62. Related, insurance companies will sometimes use the pressure of contracting with facilities to bring doctors into the network. We have noted movement in certain categories over the years. To that end, we would like the following grid completed for the top 40 facilities utilized by Plan participants.

% In Network % Out of Network

Radiologists

Anesthesiologists

Pathologists

Emergency Room Doctors

63. Does your provider contract specify the minimum amount of fidelity and surety insurance or bond coverage each provider must maintain? If so, what are those minimums?

64. There are some facilities that remain out of network and charge exorbitant prices for standard services. Please describe what tools and policies your organization has in place to help protect the Plan and the member from such billing practices.

65. Are referrals restricted to contracted facilities only? (Check only one)

☐ Yes

☐ No

☐ Yes, unless we do not have a needed facility in our network

66. Does the Plan have the ability to pay certain providers (same type of physicians) at a different coinsurance or have a different copay structure? Can the Plan “bonus” providers?

67. Does the Plan have the ability to contract directly with a network provider or a center of excellence to arrange special rates for certain services?

68. Which of the following provisions are contained in your standard provider contracts?

(Check one in each provision)

a. Penalty if patient is referred to non-network provider/facility?

☐ Yes

☐ No

☐ Unknown

b. Reciprocity of discounts for enrollees from another state/plan.

☐ Yes

☐ No

☐ Unknown

c. Require network provider to submit detailed encounter data.

☐ Yes

☐ No

☐ Unknown

d. Prohibit network providers from balance billing above network discount amount.

[except for any member required copay or coinsurance]

☐ Yes

☐ No

☐ Unknown

e. Performance guarantees between the network and the provider.

☐ Yes

☐ No

☐ Unknown

f. Provision that discount does not have to be honored if claim not paid within a certain timeframe, such as 90 days.

☐Yes, describe

☐No

☐Unknown

69. Is there a timeframe in which the negotiated discount would apply if a claim is paid?

☐ Yes

☐ No

☐ If yes, what is the time frame?

☐ Beyond 6 months

☐ Beyond 9 months

☐ Beyond 12 months

☐ Other, specify

70. Does your contract have a prompt pay provision?

☐ Yes

☐ No

If yes, what is the percentage savings that would apply?

71. Does your contract have a pay-for-performance feature?

☐ Yes

☐ No

If yes, please explain:

72. Provide at least three samples of current physician, hospital, specialist and diagnostic network provider contracts.

73. Would you allow the Plan to audit network provider contracts?

☐ Yes

☐ No

Network Provider Outcomes & Quality Management

The following two sections concern provider quality and outcomes. The Plan is interested in providing enhanced support to improve the overall health of participants. This may include the implementation of programs that guide participants to high-quality, high-performance providers.

74. The envisioned network will be created with the objective of population health management tied to quality and outcomes. Please indicate your willingness to partner with the Plan to create such a network, if one is not currently in place.

75. Describe any networks that you may currently have in place for other clients driven by quality, cost-effectiveness and evidence-based outcomes.

76. Describe the programs and the technology that your organization has in place to measure performance and quality variations between medical providers (hospitals and physicians).

77. Provide a description of the source of that information.

78. Explain how the…