Schedule 1 Definitions.docx

Request For Proposal No. 250000002307 Schedule 1 Definitions

SCHEDULE 1

DEFINITIONS

The definitions below apply to all Schedules attached to and incorporated into this Contract, except for, Schedule C (Insurance Requirements), Schedule D (Service Level Agreement for Hybrid Purchases), and Schedule E (Data Security Requirements for Hybrid Purchases). All initial capitalized terms in the Schedules that are not defined in this Schedule 1 (Definitions) shall have the respective meanings given to them in the in the applicable Schedule or the Contract Terms and Conditions. If there is a conflict between the definitions in the documents, the order of precedence is: (a) first, this Schedule 1; (b) second, the applicable Schedule; and (c) third, the Contract Terms and Conditions.

Administration Fee means the agreed upon amount that will be paid to the Contractor by the Plan Sponsor for administration of the Plan, as set forth in Schedule B.

Appeal means an action taken by a Member if they disagree with Contractor’s decision to deny a request for coverage of vision care services or payment of services already received.

Approved Amount means the contractually defined price for Covered Products or Services specified by the Vision Plan and its contracted network providers.

Benefit Guide means the publication that the Member receives which is developed and issued by the Contractor.

Business Associate means a person assisting a Covered Entity in connection with its payment, treatment or health care operations, as more fully defined in 45 CFR §160.103.

Business Day (whether capitalized or not) must mean any day other than a Saturday, Sunday, or State-recognized legal holiday from 8:00 a.m. EST through 5:00 p.m. EST unless otherwise stated.

Claim means a submission for payment of a service.

Claimant means a Member who demands payment of Covered Services.

Claims Processing means the procedures that the Contractor uses to review a Claim for Member Eligibility, coverage determination, Provider payment, and Member obligation.

Coordination of Benefits (COB) means claims administration when Members are covered by more than one vision plan.

Contract Holder means a Retiree, pension beneficiary, or COBRA participant who satisfies all of the Eligibility criteria necessary to receive vision coverage through the Plan Sponsor.

Copayment means a fixed dollar portion of the charge for Covered Services which must be paid by Members pursuant to the Plan Design.

Covered Entity means a health plan, a health care clearinghouse, or a health care Provider who transmits any health information in electronic form in connection with a HIPAA transaction. See Part II, 45 CFR 160.103.

Covered Product or Service means the vision examinations, glasses, lenses, contacts, and associated additional options that are covered pursuant to the Plan Sponsor’s Plan Design.

Days mean calendar days unless otherwise specified.

Dental Plan means a plan that provides coverage for dental services for the Plan Sponsor’s Members on behalf of the Plan Sponsor in accordance with this contract and RFP.

Deliverable means physical goods and/or services required or identified in a Statement of Work.

Dependent means an individual who satisfies, through a Contract Holder, all of the eligibility criteria necessary to receive vision coverage under the Plan Sponsor's Plan and is identified by the Plan Sponsor to the Contractor.

Direct Member Reimbursement (DMR) means a request for reimbursement of one or more Covered Products and/or Services submitted for payment by a Member.

Disruption Analysis means the identification of Members who are obtaining their vision care from Providers that are not participating in the new Contactor’s Provider Network and any proposed remediation to mitigate the disruption.

Eligibility means the status of an individual with respect to their coverage under the Plan as determined by the Plan Sponsor.

Eligibility System means the database maintained by the Contractor that contains information on the effective dates of coverage for all Members that can be accessed by authorized individuals.

Eligible Claim means a submission for payment of a Covered Product or Service, pursuant to the Plan Design.

Explanation of Benefits (EOB) means written statement sent to a Member, from the Contractor, after a claim has been reported, indicating the benefits and charges covered or not covered by the Plan.

Fee Schedule means the list of charges established or agreed to by Network Providers and the Contractor.

Fully-insured means a plan where an entity contracts with another organization to assume financial responsibility for the group’s member claims and for all incurred administrative costs.

Grievance means any complaint or dispute, other than one involving an Organization Determination, expressing dissatisfaction with the manner in which a Vision Plan or delegated entity provides vision services, regardless of whether any remedial action can be taken. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item or service. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Vision Plan, provider, or facility.

HIPAA means the Health Insurance Portability and Accountability Act of 1996.

Implementation Credit means a payment by the Contractor to the Plan Sponsor to offset both implementation and ongoing expenses.

Implementation Period means the period of time between when Contractor is selected and Services are commenced on January 1,2027

Incident means any interruption in any function performed for the benefit of the Plan Sponsor.

Individual Fee means a per Member per month administration fee as set forth in Schedule B.

Inquiry means any oral or written request to the Contractor, one of its Subcontractors, or received by Plan Sponsor and forwarded on to Contractor.

Medical Plan means Plan Sponsor’s program which provides medical and hospital coverage to Members.

Member means each Contract Holder and eligible Dependent.

Member Communication Materials mean those materials published by the Contractor for distribution to Members.

Network Provider means a Provider who has an agreement with the Contractor to provide Covered Products or services to Members.

New Work means any Services/Deliverables outside the scope of the Contract and not specifically provided under any Statement of Work, such that once added will result in the need to provide the Contractor with additional consideration. “New Work” does not include Additional Service.

Organizational Determination means any decision made by the Contractor on behalf of the Plan regarding payment or benefits to which a Member believes he or she is entitled.

Pass-Through Payments: All payments to Contractor for Covered Products and/or Covered Services.

Pass-Through Pricing means that all charges to the Plan are equal to the Contractor’s payments to Providers without any additional charges that have not been explicitly disclosed to the Plan Sponsor.

Plan means the Plan Sponsor’s program which provides vision coverage to Members.

Plan Design means a description of the Plan Sponsor's Plan related to vision coverages and limitations thereto, including the framework of policies, interpretations, rules, practices and procedures applicable to such coverages, required and signed by the Plan Sponsor and submitted to Contractor.

Plan Sponsor means the Office of Retirement Services.

Plan Year means a calendar year, from January 1 through December 31.

Prescription Drug Plan means the Plan Sponsor’s program which provides prescription drug coverage to Members.

Protected Health Information (PHI) means individually identifiable health information related to the past, present, or future physical or mental health or condition of a Member; the provision of health care to a Member; or the past, present or future payment for the provision of health care to a Member, as more fully defined in 45 CFR §164.501 or otherwise considered confidential under federal or state law.

Provider means a vision provider or facility that provides vision services to Members.

Provider Discount means the difference between what a Network Provider charges for Covered Services or Covered Products and the contractual amount that the Contractor is obligated to pay for those services or products

Provider Network means that set of Providers with which the Contractor has contracted to provide services to Members.

Retiree means a member who retires with a retirement allowance payable from reserves of the Retirement System. The Public School Employees Retirement Act. MCL 38.1307(4).

Self-funded means that the Plan Sponsor has financial responsibility for providing the funds used to pay Eligible Claims.

Services means any function performed for the Plan Sponsor as required in the Statement of Work.

Speed of Answer means the average time elapsed between when a caller elects to speak to a Customer Service representative and when the call is connected to a Customer Service representative.

State Location means any physical location where the Plan Sponsor performs work. State Location may include state-owned, leased, or rented space.

Subcontractor means a company selected by the Contractor who is chosen to perform a portion of the Services, but does not include independent contractors engaged by Contractor solely in a staff augmentation role.

Third Party Administrator (TPA) means an entity who processes Claims pursuant to a service contract and who may also provide one or more other administrative services pursuant to a service contract, other than under a worker's compensation self-insurance program pursuant to section 611 of the Worker's Disability Compensation Act of 1969, 1969 PA 317, MCL 418.611. TPA does not include a carrier or employer sponsoring a plan.

Transparency means the full disclosure by the Contractor as to all of its sources of revenue that enables the Plan Sponsor (and its agents), as well as complete and full access to all information necessary to determine and verify that the Contractor has met all terms of this Contract and satisfied all Pass-Through Pricing requirements.

Vision Plan means a plan to provide for vision screening, eyeglasses, and contact lenses.