Schedule A Statement of Work.docx

Michigan.gov/MiProcurement Schedule A – Statement of Work Request for Proposal No. 250000002307 Vision Insurance Administration Services for Michigan Public School Employees’ Retirement System (MPSERS) This schedule identifies the anticipated requirements of any Contract resulting from this RFP. The term “Contractor” in this document refers to a bidder responding to this RFP, as well as the Contractor who is awarded the contract. The term “Bidder” is used to identify where specific responses to the RFP are required.

The Contractor must respond to each requirement or question and explain how it will fulfill each requirement. Attach any supplemental information and appropriately reference within your response.

IMPORTANT NOTE TO CONTRACTORS/BIDDERS: There are specific requirements for which acceptance must be simply acknowledged through a checkbox(es), and others that require further explanation. Click the appropriate checkbox and complete the entries as appropriate.

Bidders may submit a Self-funded proposal, Fully-Insured proposal, or both. Bidders submitting both a Self-funded and Fully insured pricing proposal must specify in their response for each requirement, which proposal type it applies to, and also clearly describe any differences in proposal offering.

BACKGROUND

ORS administers the MPSERS Plan which provides post-employment health coverage, including vision benefits, to Members, including Retirees, beneficiaries and their Dependents enrolled in the Plan. Coverage is provided to eligible retired employees of local school districts, intermediate school districts, tax-supported community or junior colleges, and certain universities. Financing for MPSERS is provided though public school employer contributions and Contract Holder premiums.

ORS currently manages vision coverage for approximately 260,000 Members in the MPSERS vision plan. Historical enrollment data is provided in Schedule N Census. Enrollment in the vision plan is tie-barred to dental plan enrollment. However, Members may elect vision/dental coverage only and waive health coverage.

MPSERS is a governmental entity and therefore not subject to the federal Employee Retiree Income Security Act (ERISA). MPSERS obligations are statutory, and the Contractor’s obligations will be pursuant to this Contract.

For the purposes of all bidder responses (including the pricing proposal), the Contractor must accept and comply with stated definitions (Schedule 1). See Schedule A, Section 1.1.10.

SCOPE

This is a Request for Proposal (RFP) to solicit both Self-funded and Fully-insured proposals for administration of post-employment vision benefit coverage for members, including Retirees, beneficiaries, COBRA participants, and Dependents, of the Michigan Public School Employees’ Retirement System (MPSERS), administered by the Michigan Office of Retirement Services (ORS). The current plan is Self-funded.

The resulting contract from this solicitation process will replace existing Contract 071B7700186.

No payment will be made to the Contractor during the Implementation Period. The Implementation Period means the period of time between the Contract Begin or Effective Date anticipated April 9, 2026, and when Services are commenced on January 1, 2027. The Contractor must commence performance of all Services to all Members, without interruption, on January 1, 2027. Requirements Contractor must provide all Contract Activities/Services and staff, and must do all things necessary for or incidental to the performance of the work set forth below.

Bidder must specify which proposal type they are proposing: Self-funded, Fully-insured, or both.

General Requirements. The Contractor must:

1.1.1. Provide a fully functional Vision Plan for Members which encompasses and manages the needs of an older, retired population. This includes, but is not limited to: providing access to providers that can provide adequate vision care to a retired population, having an easy-to-understand and use Interactive Voice Response (IVR) (Schedule A Section 1.5.3.2) providing services for the hearing impaired (Schedule A Section 1.5.10), customizing communications to better serve a retiree population (Schedule A Sections 1.3.6.1, 1.6.1.5.2, and 1.6.1.5.4), and participating in additional member support activities (including but not limited to Schedule A Sections 1.6.2 and 1.6.3).

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1.1.2. Provide services that meet industry standards in the administration of Enrollment, Claims Processing, and Member Support, including review and administration of Grievances and Appeals. Industry standards refers to the commonly accepted benchmarks, practices, and guidelines within the vision benefits industry that ensure high-quality service delivery.

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1.1.3. Collaborate with the Plan Sponsor to provide Plan updates and Services to ensure the future success and ability of the Plan to continue to offer competitive vision coverage.

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1.1.4. Provide financial management, reporting, and analytical support.

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1.1.5. Provide the Plan Sponsor with the lowest cost-per-service and highest discount levels that the Contractor has negotiated with Providers, either on its own behalf or that of its other customers for similar products and Services covered under this Contract.

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1.1.6. Self-funded Proposals: Ensure Transparency and Pass-Through Pricing for all Services provided. See also Proposal Instructions Section 6 Mandatory Minimum Requirements.

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This requirement applies to Self-funded pricing proposals only. Bidders submitting exclusively a Fully-insured proposal should indicate so in this response box.

1.1.7. Contractor must maintain confidentiality of all data collected by the Contractor. See also Hybrid Contract Terms, Sections 36, 37.

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1.1.8. The Contractor’s system, processes, subcontractors, and partners must comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Business Associate Agreement between Contractor and Plan Sponsor is attached to and incorporated herein as Exhibit 2 to Schedule E – HIPAA BAA. Contractor may be required to annually recertify compliance with the Business Associate Agreement.

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1.1.9. Contractor must work in partnership and collaboration with the Plan Sponsor, and all other Contractors, including Plan Sponsor’s Medical and Prescription Drug Plan Contractors, Dental and HMO partners, Data Management Vendor, and Healthcare Actuarial and Consulting Vendors. This partnership and collaboration must relate to Member servicing, communications, data analysis, reporting, transitioning Members amongst different lines of business, strategic initiatives, Plan Design changes, and other areas as needed for the clarity of Members and administration from Plan Sponsor.

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1.1.10. All words capitalized in this document indicate a defined word. Please refer to Schedule 1 - Definitions for all definitions. Contractor must agree to all stated Definitions as defined in Schedule 1 - Definitions.

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1.1.11. The Contractor, which includes any of its subcontractors, must be a licensed Third Party Administrator (TPA) in the State of Michigan, or insurance company licensed to do business in Michigan, or must qualify in any other capacity as an entity that is properly licensed by statute to provide administrative services only and cost-plus arrangements, or to act as a TPA. Contractor must provide proof of licensure to the State for itself and any subcontractors prior to functioning as a TPA, including any renewals. See also Proposal Instructions Section 6 Mandatory Minimum Requirements.

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Bidder must provide proof of current licensure:. Contractor must also provide proof of licensure for any subcontractors who will function as a TPA in Contractor’s proposed arrangement, if applicable.

1.1.12. The Contractor must provide independent ratings of financial strength to the Plan Sponsor, such as an A.M. Best Financial Strength Rating.

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Bidder to provide their statement of agreement and a copy of their independent ratings of financial strength with their proposal in the space below. In addition, Bidder’s independent ratings of financial strength will be evaluated for indicators of, and level of, vulnerability to default on financial commitments:

Plan Design Requirements

1.1.13. The Contractor must administer the Plan at the direction of the Plan Sponsor.

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1.1.14. Contractor must fully implement the Plan Sponsor’s current Plan Design as provided in Schedule F. See also Proposal Instructions Section 6 Mandatory Minimum Requirements.

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1.1.15. The Plan Design is subject to change throughout the duration of this Contract.

1.1.15.1. Self-funded proposals only: The Contractor must implement Plan changes as requested by the Plan Sponsor by their effective date at no additional administrative cost to the Plan Sponsor. Plan Sponsor acknowledges plan design changes may result in changes to claims cost.

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1.1.15.2. Fully insured proposals only: The Contractor must implement Plan changes as requested by the Plan Sponsor by their effective date and with no additional cost beyond the agreed-upon changes in the fully insured premium that may occur as a direct result of plan design changes.

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Bidder must explain their process for implementing plan changes.

1.1.16. The Contractor must not expand, reduce, or otherwise modify coverage for Members without the Plan Sponsor's written approval.

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1.1.17. Upon request of the Plan Sponsor, the Contractor must provide support of strategic planning efforts and identify areas of improvement. This includes, but is not limited to, comparative analysis of Plan Sponsor’s membership to other like groups across Contractor’s book of business.

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Bidder must provide their plan for meeting the requirement:

Claims Processing Requirements

1.1.18. The Contractor must administer claims in conformity with the Plan Design as described in Schedule F, and in compliance with any changes made to the Plan Design by the Plan Sponsor.

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1.1.19. Processing and payment of Claims is subject to the terms and requirements set forth in this Contract.

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1.1.20. The Contractor must only charge against the Plan Sponsor’s account Claim payments authorized under the Plan Sponsor’s Plan Design. If it is determined that Claims have been improperly paid due to Contractor system rules or programming error(s), the Plan Sponsor will be reimbursed for the cost of improper payment and the Member will not be billed. System rules or programming errors that result in improper payment of Claims or payment of Claims to ineligible Members will be considered financial errors.

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1.1.21. The Contractor must only pay Eligible Claims for Eligible Members. If a claim payment for an ineligible Member is made, the Contractor must reimburse the Plan Sponsor. If a paid Claim or Member is later determined to be ineligible and can be identified, the Contractor must recover such payments from Members or Providers or reimburse Plan Sponsor for such payments from Contractor’s own funds.

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Bidder must provide their plan for meeting the requirement:

1.1.22. The Contractor must adjudicate Eligible Claims so as to reflect the status of Members’ cost share amounts pursuant to the Plan, as of the commencement of its administration. The Contractor must be able to provide Members with an Explanation of Benefits (EOB) that accurately reflects the approved listed items in a format that is easily understood by Members.

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Bidder must provide their plan for meeting the requirement and include a sample EOB below or attached to the proposal and labeled [BIDDER NAME]-Sample EOB:

1.1.23. The Contractor must undertake responsibility for providing Organization Determinations, including full and fair review of Claims Appeals by Members. Contractor must have a documented Claims Appeals process.

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1.1.23.1. Contractor’s Appeals process must be customizable to Plan Sponsor’s specifications upon request as long as such request complies with applicable regulatory requirements as mutually determined between the Plan Sponsor and Contractor.

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1.1.23.2. At minimum, Contractor’s Appeals process must include a managerial-level conference conducted in person or over the telephone.

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1.1.23.3. Reporting must comply with Plan Sponsor’s Claims Appeals reporting requirements. See Schedule A, Section 5.6 Reporting.

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Bidder must provide their Claims Appeals process:

1.1.24. The Contractor must capture and store all Claim data elements involved in the processing and payment of Claims. The Contractor must also capture and store all Claim data elements involved in Direct Member Reimbursement (DMR) claims. This includes claims, whether Member- or Provider-submitted, determined to be out of network.

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1.1.25. The Contractor must maintain a claims processing department that can image and scan paper claims, process high volume and complex claims, process out of country claims, and have experienced staff to handle claims that require manual intervention.

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Bidder must provide their plan for meeting the requirement, including confirmation of Bidder’s ability to process the claim types listed above, and the staffing of the claims department:

1.1.26. The Contractor must process Direct Member Reimbursement (DMR) Claims.

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Bidder must provide detail of the process for submitting DMR claims, including acceptable submission types (via web, in app, hard copy, etc.):

Bidder must provide detail of bidder’s process for processing of DMR claims, including processing timeframes:

1.1.27. The Contractor must maintain an on-line Claim processing system that interfaces with its Eligibility System to verify coverage when processing Claims. This system must be updated as Eligible Claims are paid and must include sufficient information to link Claims to Eligibility. See also Schedule A Section 2, Specific Standards.

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Bidder must provide the name of the Claim processing system and Eligibility system and their plan for meeting the requirement:

1.1.28. The Contractor must have the ability to capture additional Claim data elements, if requested by Plan Sponsor.

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1.1.29. The Contractor must provide access to the Plan Sponsor to Claims data once services begin at the onset of the Contract, by means of a secured Internet portal for the term of the Contract and any end-of-Contract transition periods (see Schedule A, Section 1.8 and Hybrid Contract Terms Section 29).

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1.1.30. The Contractor must comply with the statutory mandate for Coordination of Benefits (COB), Michigan Public Act 64 of 1984 – The Coordination of Benefits Act. MCL 550.251-550.255. Contractor must update processes as needed to remain in compliance in the event of changes to this legislation.

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Bidder must provide their process(es) related to Coordination of Benefits:

1.1.31. Contractor must provide comprehensive claims processing services to promote thorough and accurate claims reporting and drive lower care costs.

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1.1.31.1. The Contractor must have processes in place to prevent, detect, and correct non-compliance with billing requirements.

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Bidder must provide their processes to prevent, detect, and correct non-compliance with billing requirements:

1.1.31.2. The Contractor must have processes in place to detect, prevent, and correct fraud, waste, and abuse. Where fraud and abuse are discovered, the Contractor must Attempt to make recoveries as agreed upon by Plan Sponsor. Contractor’s employees and Members must be made aware of how to report suspected fraud, waste, and abuse. Activities must be provided at no additional cost to the Plan Sponsor.

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Bidder must provide their processes to detect, prevent, and correct fraud, waste, and abuse:

1.1.31.3. The Contractor must have procedures for handling recoveries for Members, along with overpayments for both Members and Plan Sponsor. Any procedures for correcting overpayments and recoveries must be mutually agreed upon. The Plan Sponsor must be notified in advance of any overpayments and recoveries that directly impact Members. Member notifications for recoveries or overpayments must be approved by the Plan Sponsor. Recoveries made as part of subrogation must be passed through 100% to the Plan Sponsor at no additional cost to the Plan Sponsor.

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Bidder must provide their procedures for handling overpayments and recoveries, specifying any differences in experience for Providers and Members:

1.1.32. The Contractor and Plan Sponsor shall cooperate in good faith to identify and implement mutually agreed upon processes related to Contractor’s recovery process. The parties shall seek to reach agreement on the recovery process.

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1.1.33. If there are administrative changes to the Contractor’s systems, processes, or procedures that impact the Plan Sponsor or Members, the Contractor must notify the Plan Sponsor, in writing, 60 days prior to the change (or as soon as the Contractor is aware)

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Network Requirements

1.1.34. The Contractor must manage and maintain a broad national Provider Network for the Plan Sponsor and Members.

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1.1.35. The Contractor must have and use a valid process to credential, monitor and re-credential Network Providers.

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Bidder must explain their process to credential, monitor and re-credential Network Providers:

1.1.36. The Contractor must maintain a Provider Network in areas where Members reside and network benefits must be available in all 50 states and the District of Columbia. The Contractor must provide network access to vision Providers and retailers in accordance with the parameters set forth in the table below. Telehealth Providers cannot be used to satisfy this requirement.

>3,000 population per square mile Suburban Members 1,000-3,000 population per square mile Rural Members <1,000 population per square mile

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1.1.37. GEO Access Report:

Bidder must complete the GEO Access report provided as Schedule H, identifying the percentage of Members who meet the access standards based on their home address ZIP Code. See Schedule N for a current ZIP Code census. Bidder must complete additional copies of Schedule H if information is being provided for multiple networks.

1.1.38. The Contractor must be able to add Providers to the Provider Network in accordance with the Access Standards referenced in the table above (Schedule A, Section 1.4.3). The Contractor must improve provider access in any areas where the access standard is not met or upon request by Plan Sponsor. Timing for improvement of provider network referenced in the table above (Schedule A, Section 1.4.3) must be completed by the services start date of 1/1/2027. Timing for adding new providers to Contractor’s network throughout the term of the Contract must not exceed 6 months.

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Bidder must explain their process to add providers to the provider network. The Bidder must also provide their plan for improving provider access in any areas where the access standard is not met according to the timeframe indicated in the requirement. Bidder Response:

1.1.39. The Contractor must pursue all providers that the Plan Sponsor requests to be added to the network. Providers must pass credentialing requirements and agree to contract and fee schedule to be added as an in-network provider.

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Bidder must explain their process to add Providers to the Provider Network including any limitations of the Plan Sponsor to nominate Providers for inclusion in the Provider Network:

1.1.40. The Contractor must notify the Plan Sponsor, in writing, of the removal of large/national Providers/retailers.

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1.1.41. The Contractor must have a process in place to audit Network Providers for compliance with contractual terms of the Contract between the Contractor and the Provider, and also ensure the accurate administration of the Plan Sponsor’s Plan .

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Bidder must provide their process to audit Network Providers for compliance with contractual terms of the Contract between the Contractor and the Provider:

1.1.42. The Contractor must support Provider access to Protected Health Information (PHI) by means of a secured Internet portal. See also Schedule A Section 2, Specific Standards.

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1.1.43. Disruption Analysis. The Contractor’s provider network must not result in a member disruption that exceeds 25%. The Contractor must effectively work to reduce any disruption to 15% or less by the services start date of January 1, 2027. Timing to maintain or lessen disruption into the acceptable range of 15% or less must be met by the Contractor by the services start date of January 1, 2027 or the Contractor may be considered to be in breach, as determined by the Plan Sponsor (Hybrid Contract Terms, Section 27 Termination for Cause).

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Bidder must complete and submit with proposal, Schedule M Vision Disruption Analysis.

Member Support

1.1.44. The Contractor must provide a United States based Customer Service call center, where it will maintain staff dedicated to supporting the needs of the Plan Sponsor’s Members and prospective Members. All call center staff, whether employed by Contractor or Contractor’s subcontractor, must be physically located within the United States. The State prefers that the call center is located in Michigan. The Contractor’s call center must be available to receive inbound calls Monday through Friday from 8:30 AM to 5:00 PM Eastern Standard Daylight Time.

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Bidder must provide their plan for meeting this requirement, including but not limited to, whether this will be managed in house or subcontracted, specific locations, average staffing, and how Contractor will scale up if needed throughout the contract term while maintaining the requirement. See also Section 4.7 Disclosure of Subcontractors. Information must correlate with the information in Section 4.7 if third party subcontractors are utilized:

Bidder must provide detail on Bidder’s process for assisting prospective members who have not yet enrolled in the Plan but will be eligible to do so in the future:

1.1.45. The Contractor must notify the Plan Sponsor immediately of any developing situation or known or suspected system issues that may impact operations or service to Members.

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1.1.46. The Contractor must provide a phone service system, for both Members and Providers, which includes (at minimum) the following components:

1.1.46.1. The system must be toll-free with separate numbers for Members and Providers.

1.1.46.2. An IVR system with a single front-end toll-free telephone number with touch-tone routing (if necessary) for Customer Service staff to respond to Member requests and/or questions. The IVR system must have a user friendly menu.

1.1.46.3. Methods for logging calls, recording call data and content; all recorded calls must be attached to the Member account.

1.1.46.3.1. All recorded calls must be kept for 12 months or until any Appeal or Member escalation is resolved, whichever is later.

1.1.46.3.2. All recorded calls must be provided to Plan Sponsor within 24 hours of request by the Plan Sponsor. Contractor must not redact call recordings.

1.1.46.4. Methods to report Plan Sponsor- specific metrics, standards and ad hoc report generation.

1.1.46.5. Methods to monitor calls for quality.

1.1.46.6. A Customer Service system that can handle a current membership of 260,000 members, with a monthly call volume averaging 1,500 calls. These calls must be handled within the service levels established by the Plan Sponsor and agreed to by the Contractor. See Schedule A Section 9 Service Level Agreements.

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Bidder must provide the name and description of Bidder’s phone service system and their plan for meeting each of the requirements listed above:

1.1.47. The Contractor must provide a secure email/messaging service, for both Members and Providers, which includes (at minimum) the following components:

1.1.47.1. Methods for receiving and transmitting messages securely.

1.1.47.2. Methods for routing messages to properly trained responders.

1.1.47.3. Methods for logging messages, recording message data and content; the message must be attached to the Member account.

1.1.47.4. Methods to report Plan Sponsor-specific metrics, standards and ad hoc report generation.

1.1.47.5. Methods to monitor messaging for quality

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Bidder to provide their plan for meeting the requirements. Bidder must supply the name of any solution(s) used to provide secure email/messaging services

1.1.48. If the Contractor provides chat Services, the Contractor must have all the following:

1.1.48.1. Methods for storing, tracking and routing chats to properly trained responders.

1.1.48.2. Methods for logging chats, recording chat data and content; it is required that the chat be attached to the Member account.

1.1.48.3. Methods to report Plan Sponsor-specific metrics, standards and ad hoc report generation.

1.1.48.4. Methods to monitor chats for quality.

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If Bidder provides chat services, Bidder must describe their chat services, solution(s) used to support the service, and provide their plan for meeting the requirements.

1.1.49. The Contractor must provide Web-based (Internet) support to the Plan Sponsor and its Members. This must be a Plan-specific website (referred to as a microsite) dedicated solely to the Plan Sponsor and Members. The web-based system must include, but not be limited to, the following:

1.1.49.1. Capabilities to provide Members with information specific to their own Claims (including the ability to view/print EOBs) and enrollment.

1.1.49.2. Ability to make detailed Provider Network information accessible to Members. This includes having network information searchable by specialty/provider type.

1.1.49.3. Ability to list providers based on accessibility to Member’s home address or ZIP Code.

1.1.49.4. Ability to provide quality-of-care information about Providers.

1.1.49.5. Capabilities to answer Member questions about the Plan (Q&A).

1.1.49.6. Ability to provide Members access to Plan-specific benefit documents and videos.

1.1.49.7. Provide access to the Member portal for Plan Sponsor staff, which will include access to a demonstration website (URL and password), including access to the Member, Provider and client sections of the site. See also Schedule A Section 2, Specific Standards.

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Bidder must name the solution(s) used to support this service (if applicable) and provide their plan for meeting each of the requirements 1.5.6-1.5.637 above:

1.1.50. The Contractor must provide written correspondence services, for both Members and Providers, which include (at minimum) the following components:

1.1.50.1. Methods for storing, tracking and routing correspondence to properly trained responders.

1.1.50.2. Methods for logging correspondences, recording correspondence data and content. The correspondence must be attached to the customer account.

1.1.50.3. Methods to report Plan Sponsor-specific metrics, standards and ad hoc report generation.

1.1.50.4. Methods to monitor responses for quality.

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Bidder must provide their plan for meeting the requirements, including the name of any solution(s) used:

1.1.51. Contractor must provide a mobile app for Members. Contractor’s mobile app must comply with Schedule A Section 2, Specific Standards. The mobile app must include, but not be limited to, the following:

1.1.51.1. Capabilities to provide Members with information specific to their own Claims (including the ability to view EOBs) and enrollment.

1.1.51.2. Ability to list Providers based on accessibility to Member’s home address.

1.1.51.3. Capability to provide benefit information about the Plan.

1.1.51.4. Ability to allow Members to view Member ID card(s).

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Bidder must provide their plan for meeting the requirements, including the name of all solution(s) used to support the mobile app:

1.1.52. Contractor’s Customer Service system must be scalable to future demand, as will be defined by Contractor and Plan Sponsor during the Implementation Period.

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Bidder must provide detail of system scalability:

1.1.53. The Contractor must have the capabilities of addressing special needs of Members, including, but not limited to, TTY or relay services for the hearing impaired.

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Bidder must provide their plan for meeting the requirement, including the name of any solution(s) used to meet the requirement:

1.1.54. The Contractor’s Customer Service staff must have complete on-line access to all computer files and databases that support the system for applicable programs.

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1.1.55. Information on how to access Customer Services must be clearly communicated in all Plan-specific booklets, claim kits/post-enrollment, newsletters and other Member Materials.

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1.1.56. Contractor must attempt to resolve Members’ telephonic issues during the initial contact with the Member. For those issues not resolved immediately, Contractor must contact Members about their issues within two business days of receipt of Member contact. This response must either resolve the outstanding issue(s) or inform the Member as to when resolution can be expected.

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1.1.57. Written Member inquiries must be responded to in writing.

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1.1.58. Contractor’s customer service team must respond to Claims, Inquiries, questions, and problems regarding operations from the Plan Sponsor and/or Members in accordance with the Service Level Agreement (SLA) requirements in Schedule A, Section 9 Service Level Agreement.

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Member Communication Materials and Meetings

1.1.59. Member Communication Materials:

1.1.59.1. All communication materials must be approved by the Plan Sponsor in advance of distribution. Contractor must allow for at least 10 business days for review and/or editing by the Plan Sponsor. This applies to all information developed, provided, and/or distributed by Contractor to Members about the Plan—including those placed on the Contractor’s Plan Sponsor-specific website. This requirement applies to both planned and ad hoc communications.

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1.1.59.2. The Contractor must provide a communication plan, no later than November 1st each year for the upcoming year, which must include the description of the communication, the due date to the Plan Sponsor for prior approval, and the final targeted publication date. See Schedule A Section 5.6 Reporting.

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1.1.59.3. All communications and Member educational materials produced by the Contractor must be customizable to better address the specific needs of the Plan Sponsor and its Members. This includes co-branding materials with the name of the Contractor and the Plan Sponsor, where desired by the Plan Sponsor.

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1.1.59.4. The Contractor must prepare and distribute all communications materials for the Plan Sponsor and its Members at its own cost. This includes planned Member communications and ad hoc communications where desired by the Plan Sponsor.

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1.1.59.5. Required Member communication materials to be provided by Contractor includes, but is not limited to:

1.1.59.5.1. Membership Cards for currently enrolled Members (approximately 260,000). Contractor must also produce and issue membership cards to new Members upon enrollment (approximately 10,000 per year), and provide replacement cards upon Member request.

1.1.59.5.1.1. The Membership cards are subject to Plan Sponsor’s initial approval of the card template during Implementation and approval of any subsequent changes during the Contract Term must also be approved. In both cases, the Plan Sponsor will need at least five Business Days for approval.

1.1.59.5.2. Plan Sponsor-specific welcome kit including a summary of benefits for currently enrolled Members and for new Members throughout the duration of the Contract. It must also be available to Members upon request. These materials must meet the following criteria:

· Display of identifying logo designated by the Plan Sponsor

· Be printed in large type readability (e.g., equal or equivalent to Arial 12 point font size)

1.1.59.5.3. Explanation of Benefits (EOB) that details charges, Approved Amounts, copays, outstanding benefit limit and contact information for following up with Inquiries, Grievances and/or Appeals. It is acceptable to the Plan Sponsor if EOBs are provided electronically upon Member request.

1.1.59.5.4. Vision related articles for the Member newsletter. The Member newsletter is published and distributed by the Plan Sponsor’s Medical Plan Contractor and informs Members of current events, health and wellness, and any Plan updates. The Contractor must provide vision related articles on a quarterly basis to the Plan Sponsor’s Medical Plan Contractor for inclusion in the newsletter.

1.1.59.5.5. Summary of Benefits

1.1.59.5.6. Benefit Booklet

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Bidder must provide their plan for meeting the requirements, confirming Bidder’s ability to provide each of the communications in compliance with the requirements stated:

1.1.59.6. Contractor must prepare and distribute to Members, Providers, or other sources any State and federal forms required by law.

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1.1.60. The Contractor must provide representatives at meetings designated by the Plan Sponsor at no additional charge to the Plan Sponsor. The Contractor’s representatives must be prepared to answer Member questions, document Member feedback, provide Plan information, and present publicly on the Plan. The number of representatives needed will depend on expected meeting size. Meeting requests may vary from year-to-year, but may include up to 10 day-long sessions out-of-state (primarily Florida and Arizona, but could include other U.S. states, as directed by the Plan Sponsor, based on the Members’ geographic location) and up to 13 day-long sessions in Michigan (three may be in the Upper Peninsula), and supporting meetings in an online format. All meetings require the combined participation of the Plan Sponsor, the Medical Plan Contractor, the Prescription Drug Plan Contractor, the Dental Plan Contractor, the Vision Plan Contractor, and HMO Contractors as deemed appropriate by the Plan Sponsor. Any travel and accommodations and meals expenses for State employees, and/or other Plan Sponsor representatives must be covered by the participating Contractors. Each Contractor is responsible for their own travel arrangements and expenses, but the planning and organizing of these meetings is the responsibility of the Medical Plan Contractor. Associated costs for these meetings are to be shared equally amongst participating Contractors. Associated costs include, but are not limited to, meeting venues , meeting invitations, recording and editing presentation videos, and developing and maintaining a website for online meetings. Contractor must process payment to the Medical Plan Contractor within 45 Days of receipt of an invoice from Medical Plan Contractor. If Plan Sponsor incurs expenses related to these meetings that need to be reimbursed by Contractor, Contractor must process payment to Plan Sponsor, in a format determined by Plan Sponsor, within 45 Days. See Scheule A, Section 7 Financial Administration and Pricing Requirements.

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Bidder must provide their plan for meeting the requirement:

1.1.61. In addition to the Plan Sponsor’s’ designated meetings, the Contractor may receive requests for speakers from the Member support organizations, which are independent professional organizations designed to support the needs of retired public school employees. A reasonable effort must be made to accommodate requests for in-state meetings at no charge to the retiree support organizations or the Plan Sponsor. Reporting of interactions with the member support organizations is required. See Section 5.6 Reporting.

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Bidder must provide their plan for meeting the requirement:

1.1.62. The Contractor must coordinate messaging with Plan Sponsor and Plan Sponsor’s other health plan Contractors such that Members are not confused by multiple messages from different sources.

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Bidder must provide their plan for meeting the requirement:

Enrollment, Eligibility, and Data Interface

1.1.63. The Plan Sponsor is responsible for transmitting eligibility and enrollment information for Members. The Plan Sponsor has the sole authority to determine the effective date of a Member, including retroactive adjustments.

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1.1.64. The Contractor must maintain a system for enrollment and eligibility and be prepared to accept and load, on a weekly basis, one or more data files from the Plan Sponsor in a HIPAA compliant 834 format, inclusive of all fields contained in Schedule I ORS File Layouts.

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1.1.65. Enrollment and eligibility information with respect to current enrollees will be transferred at a date to be determined by the Plan Sponsor. After implementation, enrollment and eligibility information for Members will be transferred on a weekly basis, and more frequently if necessary, by the Plan Sponsor, via File Transfer Service (FTS) (or another method selected by the State). The Contractor must work with Plan Sponsor in the implementation of this data transfer.

The Contractor must maintain and update their enrollment system based on weekly eligibility files received by the State.

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1.1.66. The Contractor must accept, load, store and maintain Member information. The Contractor must maintain a Member’s enrollment in the Plan unless otherwise notified by Plan Sponsor regardless of notifications from any other source. Any changes, additions or terminations of Member enrollment information or changes or additions to Member demographic information must originate from the Plan Sponsor, unless otherwise specifically agreed upon. Any exceptions to this process must be agreed upon by the Plan Sponsor prior to any change in process.