Schedule A - Statement of Work - Revised with Redlines 7-31-19.docx

STATE OF MICHIGAN

Request For Proposal No. 190000002803 HMO Services for MPSERS

SCHEDULE A

STATEMENT OF WORK

CONTRACT ACTIVITIES

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.

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.

The Contract resulting from this RFP will have a term of one (1) year, with four (4) one-year options. The State seeks to have services beginning no later than January 1, 2020. This includes a 69-day transition period, if necessary.

Mandatory Minimum Requirements Bidder certifies they meet the Mandatory Minimum Requirements, as specified in Section 6. Proposal Instructions:

Bidder Response to Mandatory Minimum Requirements:

Bidder must complete and sign Schedule C Mandatory Requirements Form, certifying bidder’s agreement.

Only proposals meeting the mandatory minimum requirements will be considered for evaluation.

BACKGROUND

The Office of Retirement Services (ORS) administers the Michigan Public School Employees’ Retirement System’s (MPSERS) Plans, which provide post-employment health coverage to Non-Medicare eligible and Medicare eligible Members, including Retirees, beneficiaries and their Dependents enrolled in the health plans. Health coverage is provided to retired employees of local school districts, intermediate school districts, tax-supported community or junior colleges, and certain universities. Financing for MPSERS is provided through public school employer contributions and Contract Holder premiums. ORS currently manages health coverage for approximately 233,500 Members in the MPSERS health plans. This includes approximately 201,000 members in the self-funded plan and approximately 32,500 participants in the HMOs. Approximately 16% of the Members in the self-funded plan are not Medicare eligible and 84% are Medicare eligible. Approximately 32% percent of HMO members are not Medicare eligible and approximately 68% are Medicare eligible.

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.

All words capitalized in this document indicate a defined word. Please refer to Schedule D for all definitions.

SCOPE

The Contractor must be able to provide and administer both a Non-Medicare and a Medicare product inclusive of pharmacy coverage to Eligible Members who elected enrollment in an HMO and pursuant to the requirements listed herein.

REQUIREMENTS

1. General Requirements

1.1. Services and Deliverables

The Contractor must provide Deliverables/Services and staff, and must do all things necessary for or incidental to the performance of work, as set forth below:

A. Plan Design

1. Except as otherwise specified herein, the only benefit requirement is that in-network coverage must be Actuarially Equivalent to or exceed the coverage offered under MPSERS’ self-funded Plan, a description of which is included as Schedule F, Summary of Benefits – Non-Medicare and Medicare (two separate attachments).

2. The Contractor must provide an accurate and complete comparison of its benefits with those of the Retirement System by September 1 of each subsequent contract year.

3. Plan Sponsor requires annually a signed Actuarial Equivalence Attestation from a certified actuary or a demonstration of actuarial equivalence from an underwriter. (Comparison of Benefits). This deliverable is due by September 1 of each subsequent contract year.

4. All service categories covered by the self-funded Plan must be covered by the HMO Contract.

5. Contractor must provide an accurate listing of its service area, separated by zip code, by September 1 of each subsequent contract year.

6. Many MPSERS retirees travel outside of Michigan, in some instances for three to six months of the year. Where a Member’s primary residence remains in Michigan, the Contractor must provide comprehensive benefits to members when they travel outside of the service area.

B. Member Support

1. Member Satisfaction

a. The Contractor must share with Plan Sponsor its annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results or book of business customer service satisfaction results. Results must be separated by Non-Medicare and Medicare populations. These results will be shared with Plan Sponsor at the earliest practical opportunity following completion of the survey.

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

2. Customer Services

a. The Contractor must provide a Customer Service call center, where it will maintain staff dedicated to supporting the needs of the Plan Sponsor’s Members. 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 8:00 AM to 5:00 PM Eastern Standard Daylight Time.

i. Separate, toll-free numbers for Members and Providers are required

b. Contractor must provide phone, secure email / messaging, and written correspondence options for customer contacts. Contractor must provide a phone service system, for both Members and Providers, that includes (at minimum) the following components:

i. The system must be toll-free

ii. An Integrated Voice Response (IVR) system with a user-friendly menu

iii. Methods for logging calls, recording call data and content; the recorded calls must be attached to the customer account

iv. Methods to report metrics, standards, and ad hoc report generation

v. Methods to monitor calls for quality

c. Secure email / Message Service: Contractor must provide a secure email / messaging service, for both Members and Providers, which include(s) (at minimum) the following components:

i. Methods for receiving and transmitting messages

ii. Methods for routing messages to properly trained responders

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

iv. Methods for reporting metrics, standards, and ad hoc report generation

v. Methods to monitor messaging for quality

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

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

ii. Methods for logging correspondences, recording correspondence data and content; it is highly preferred that the correspondence be attached to the customer account

iii. Methods to report metrics, standards, and ad hoc report generation

iv. Methods to monitor responses for quality

e. If the Contractor provides chat services, the Contractor must include all of the following:

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

ii. Methods for logging chats, recording chat data and content; the recorded chat must be attached to the customer account

iii. Methods to report metrics, standards and ad hoc report generation

iv. Methods to monitor chats for quality

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

i. Capabilities to provide Members with information specific to their own Claims and enrollment

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

iii. Capabilities to answer Member questions about the Plan

iv. Capability to provide quality-of-care information about Providers

v. Contractor must be able to provide Members access to designated electronic Plan-specific documents on the Contractor’s Plan-specific website

g. Contractor must have the capabilities of addressing special needs of Members, including Text Telephone (TTY) or relay services for the hearing impaired.

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

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

j. For those issues not resolved immediately, Contractor must contact Members about their issues within seven 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.

i. Written Member inquiries must be responded to in writing

C. Member Communications and Member Meetings

1. Member Communication Materials

a. All communication materials must be approved by the Plan Sponsor in advance of distribution. 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.

b. Contractor must provide a communication plan, no later than November 1st each 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.

c. The Contractor must prepare and distribute, at its own cost, announcements, letters, notices, brochures, forms, postage-paid response envelopes, and other supplies and Services for distribution to Members. This includes but is not limited to:

i. CMS required mailings for Medicare members

ii. Summary of Benefits

iii. Explanation of Benefits

iv. Plan update notifications

d. All communications 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.

e. The Contractor must submit for approval by Plan Sponsor, no later than 30 days prior to distribution, any material which will be distributed to Members and their Dependents during or in conjunction with enrollment/ marketing opportunities.

i. All enrollment or marketing activities must be approved by Plan Sponsor to assure equal access to all Members who reside in the HMO’s licensed service area. This applies to all information placed on the Contractor’s MPSERS-specific website relative to the Members and the Plan.

f. Contractor is expected to coordinate messaging with ORS, CMS, and with other carriers such that members are not confused by multiple messages from different sources.

D. Enrollment and Eligibility

1. Eligibility Plan Sponsor is responsible for determining eligibility and transmitting enrollment information for Members. Plan Sponsor has the sole authority to determine the effective date of the Member including retroactive adjustments. Enrollment information for Members will be transferred to the Contractor from Plan Sponsor by electronic medium including all necessary information with respect to current enrollees at a date to be determined by the Plan Sponsor. Payment of premiums is predicated on the enrollment records of the Plan Sponsor.

a. Coverage for Non-Medicare Eligible Members:

Coverage for individuals who have not reached Medicare eligibility will be in the form of a traditional HMO contract. IMPORTANT: See Continuity of Coverage in (c) below.

b. Coverage for Medicare Eligible Members:

Coverage for Medicare eligible individuals must be in the form of a Medicare Advantage plan.

c. Continuity of Coverage:

If a Member aging into Medicare resides in a county that the HMO does not offer Medicare Advantage, the Members on that Contract are no longer eligible for coverage under that HMO.

The HMO must notify ORS prior to the Member’s Medicare eligibility date that the Member will lose plan eligibility upon becoming eligible for Medicare.

HMO must also communicate termination of coverage to the Members.

d. Where the Contractor is informed by the Centers for Medicare and Medicaid Services (CMS) that a Member has been dis-enrolled from the HMO Medicare Advantage Plan, the Contractor must notify Plan Sponsor.

i. The Contractor must report this each week in a format approved by Plan Sponsor.

e. Contractor must support Plan Sponsor in confirming Member Eligibility. This includes, but is not limited to:

i. Contractor must perform Dependent eligibility verifications as defined in Section D.2.f – Coverage Rules

ii. Contractor must conduct additional eligibility verifications as mutually agreed upon by the Contractor and Plan Sponsor.

2. Coverage Rules To avoid unacceptable administrative complexity, there are several rules for who may be covered by which health plan. The primary rule is that:

a. If the Retirant elects to be covered by an HMO, then all Members of that Unit must be covered by the same HMO.

b. If one or more Members of a Unit is Non-Medicare-eligible and one or more is Medicare eligible, then the Non-Medicare-eligible(s) must be covered by the Non-Medicare HMO plan and the Medicare-eligible(s) must be covered by the Medicare plan of the same HMO.

c. In cases where two members of a Unit are both Non-Medicare-eligible at the beginning of their HMO coverage, and one attains Medicare eligibility, that individual must become covered by the Medicare plan of the HMO that covers the Non-Medicare Member.

d. In the case of those families where both Members are MPSERS Retirants, each may be treated as an individual Contract Holder if they so elect. Thus, either, or both, may elect HMO coverage without regard to any election by the other.

e. The Contractor must follow Dependent coverage rules in Schedule G.

f. Contractor is required to verify dependent eligibility on an annual basis. This process requires Contractor to send out certification letters to Plan Sponsor’s Members who have a Dependent(s) ages 19-25. Contractor must request proofs of dependency and school enrollment that meet the requirements specified in Schedule G.

3. Population Population data is available via the Plan Sponsor upon request. Population is reported by individual enrollee type and includes the following indicators:

· Contract Owner Zip Code

· Enrollee Gender

· Medicare Indicator

· MEDI indicates the individual is a Medicare member,

· NMED indicates the member is a non-Medicare member

· Relationship

· Self is the primary contract holder.

Additional relationships include: spouse, child (including adopted and step-), and parent (mother / father).

4. Enrollment

a. The Contractor’s system, processes, subcontractors, and partners must comply with all applicable requirements of HIPAA. Contractor must provide Plan Sponsor with an annual attestation that it meets this requirement.

b. The Plan Sponsor is the source for all demographic and enrollment data. The Contractor must store and use the Member information provided by the Plan Sponsor.

i. Plan Sponsor will maintain a record of each Member’s election in a format that can be easily, accurately and quickly reproduced, upon written request, by Contractor and/or CMS, as necessary.

ii. Any changes, additions or terminations of the Member enrollment information or changes or additions to the Member demographic information (including email addresses and phone numbers) must originate from the Plan Sponsor. This includes Members responding to optout notifications for Medicare eligible Members.

i. The Contractor must not make any changes to the Member information that would lead to the Contractor and the Plan Sponsor having different information for the same Member.

ii. The Contractor must provide the Plan Sponsor with all enrollment and eligibility information about the Plan Sponsor’s members received from affiliate sources such that the Plan Sponsor remains the enrollment and eligibility system of record. Information must be provided in a method determined by the Plan Sponsor.

iii. Contractor should provide reports provided by CMS that affect Medicare eligibility to the Plan Sponsor within one week of receipt from CMS. These reports will be processed by the Plan Sponsor and any enrollment changes that result from those reports will be transmitted to the Contractor.

c. The Contractor must support the Plan Sponsor as needed via telephone and email anytime during business hours for immediate contact to confirm the enrollment status of a Member at any given time. Responses surrounding the enrollment status of a member must not exceed 48 hours.

d. The Contractor must have the capability to accept digital transmission on a weekly basis from the Plan Sponsor, in a HIPAA compliant 834 format, inclusive of all fields contained in the Schedule H and Schedule H2, 834 File Layout, and which is provided through a State of Michigan provided DEG. Each weekly transmission will include two files – one containing Medicare members, and the second, non-Medicare members.

i. The Contractor must work with the Plan Sponsor on the implementation of secure data transfers for all exchanges.

ii. All files that include HIPAA-protected information must be transmitted using the State’s DEG.

e. The Contractor must participate in reconciliations of the full membership as scheduled by the Plan Sponsor, at minimum, two times per calendar year.

f. The Contractor is responsible for any changes, and any associated costs therein, to their systems or processes required to support the receipt and processing of the Plan Sponsor’s enrollment files.

i. The Contractor must work with the Plan Sponsor to develop a timeline for implementation and testing of any changes to either the Plan Sponsor or the Contractor processing systems.

ii. The Contractor must maintain a testing environment for such purposes.

g. The Contractor must have validation edits in place to ensure, for each data load, that all fields are properly populated and readable.

i. 100% of all accurate records that pass the Contractor’s validation edits must be uploaded according to the Plan Sponsor’s schedule within one Business Day with confirmation of changes submitted to the Plan Sponsor.

ii. Any records that do not pass the Contractor’s validation tests must be reported to the Plan Sponsor within two Business Days after the file has been uploaded.

iii. All discrepancy reporting must be in the format defined by the Plan Sponsor.

h. The Contractor must have the ability to adjust an enrollment record real-time upon the request of an authorized Plan Sponsor employee.

i. The Contractor must provide to the Plan Sponsor, by means of a secured Internet portal, read-only access to the system used to maintain Enrollment.

i. All access must be controlled with a user-specific User ID and password. Generic or shared passwords will not be permitted.

j. The Contractor must provide to the Providers, by means of a secured Internet portal, access to Enrollment.

k. Communication involving any identifiable Member information must be transmitted to the State through a secure channel defined by the Plan Sponsor.

l. It is anticipated the Contractor will begin enrolling new members for coverage effective January 1, 2020. All enrollments will originate with the Plan Sponsor, who will forward enrollment information to the Contractor by digital transmission using the standard 834 format.

i. The Plan Sponsor currently uses a common insurance application which must be completed by all new enrollees. The form indicates whether Members are enrolling in the standard plan or an HMO plan. Enrollment is considered complete once the common insurance application has been certified by the Plan Sponsor. The Contractor must work to achieve the Member’s effective date provided by Plan sponsor.

ii. All enrollments and enrollment changes will be submitted electronically.

Note: Plan Sponsor reserves the right to submit hard-copy enrollments (or enrollment changes) in certain (rare) circumstances.

m. Member Identification (ID) Cards must be mailed within 10 days of the Contractor’s receipt of an eligibility record from the ORS for Non-Medicare members, and CMS-approved enrollment for Medicare members.

i. Contractor is encouraged to provide online access to printable, temporary Member ID cards.

n. Plan Sponsor acknowledges that final enrollment in Contractor’s MA plan is contingent upon a Member: (1) being entitled to Medicare Part A and enrolled in Part B; (2) not being enrolled in any other MAPD or Prescription Drug Plan; (3) residing in the Contractor’s MA plan service area; and (4) and being approved by CMS.

E. Medicare Advantage Requirements

1. Plan Sponsor will notify Contractor of any Member that will be enrolled in Contractor’s MA Plan through a group enrollment process utilizing electronic procedures and formats for the transfer of enrollment data.

2. Contractor must advise eligible Members that Plan Sponsor intends to enroll them into the Contractor’s MA plan through an automatic enrollment process unless the Member affirmatively opts out of such enrollment. Contractor must ensure that all such Members will be provided enrollment information at least 21 days prior to the effective date of the Member’s enrollment in the MA plan, along with a copy of the summary of benefits offered under the selected plan, an explanation of how to get more plan information, and an explanation of how to contact Medicare for information on other Medicare health plans that might be available to the Member. The Plan Sponsor’s enrollment information submitted to Contractor must comply with CMS requirements

3. Contractor must submit the enrollment data received from Plan Sponsor to CMS for enrollment or dis-enrollment in the Plan within the time frame specified by CMS. Upon receipt of confirmation of acceptance, denial or rejection of an individual from CMS, Contractor must load the accepted Members into the Plan within three business days and report the rejected or denied members back to the Plan Sponsor within two business days for correction or other action. Plan Sponsor will provide Contractor with any corrections to the rejected or denied members within 14 days of Plan Sponsor’s receipt of the report from Contractor.

4. Contractor must reconcile any terminations (including retroactive terminations made by CMS) at least once each year.

5. Member Communications. All Member communication materials are subject to the terms and requirements of the Contract, provided that such terms and requirements do not conflict with CMS requirements. If there is a disagreement concerning the interpretations of CMS requirements regarding Member communication materials by either party, both parties will negotiate in good faith to reach a mutually acceptable resolution. Plan Sponsor acknowledges that CMS mandates that Contractor send Member communications by certain dates and that Contractor will be constrained to send CMS model language if an agreement cannot be reached.

6. Opt-Out Notices. Pursuant to the foregoing, the Contractor must identify new Eligible Participants and mail the Opt-Out Notices to those Eligible Participants. If an Eligible Participants chooses to opt-out, such Eligible Participant will contact Plan Sponsor (or if the Contractor is notified, the Contractor must provide to Plan Sponsor) and Plan Sponsor will process the Opt-Out request and promptly update the eligibility file. Each Party will comply with the Opt-Out Notice Requirements applicable to the Opt-Out Notice functions each are providing. Further, due to the fact that the Contractor has delegated certain Opt-Out Notice functions to Plan Sponsor, Plan Sponsor will provide to the Contractor documentation of its compliance with applicable Opt-Out Notice Requirements upon request by the Contractor or CMS.

7. Retroactive Disenrollment. If CMS determines that a Member was not eligible for Contractor’s MA plan and requires that Contractor retroactively disenroll such Member, Contractor must comply with requirements set forth by CMS.

8. Contractor, or its subcontractor, must submit to CMS the enrollment data transfers that it receives from Plan Sponsor for verification and final enrollment in Contractor’s MA plan. CMS will review such enrollment data and determine if a Member will be enrolled in the Contractor’s MA plan. Plan Sponsor certifies to the best of its knowledge and understanding to Contractor, that all enrollment data transfers submitted to Contractor are accurate, complete and truthful. Plan Sponsor acknowledges that Contractor is relying upon Plan Sponsor’s accuracy of its enrollment data transfers because Contractor must certify the accuracy of such enrollment information to CMS.

9. The Contractor’s MA plan must not deny, limit, or condition the coverage or furnishing of benefits to Members eligible to enroll on the basis of any factor that is related to health status, including, but not limited to a medical condition, including mental as well as physical illness; Claims experience; receipt of health care; medical history, genetic information, evidence of insurability, including conditions arising out of acts of domestic violence; or a disability.

10. Required Disclosures. At the time of enrollment, and at least annually thereafter, and in compliance with the timeframes as set forth by CMS, Contractor must disclose the following to Members:

a. Service area. Contractor’s service area and any enrollment continuation area and any out-of-area coverage provided under the plan

b. Benefits. An evidence of coverage document and summary of benefits offered under Contractor’s MA plan, including applicable conditions and limitations, premiums and cost-sharing (such as copayments, deductibles, and coinsurance) and any other conditions associated with the receipt or use of benefits; and for purposes of comparison:

i. The benefits offered under Original Medicare, and

ii. the availability of the Medicare hospice option and any approved hospices in the service area, including those that Contractor owns, controls, or has a financial interest in, if any.

c. Emergency coverage. Contractor’s MA plan must cover emergencies in accordance with 42 CFR 422.113 and discloses to Members the appropriate use of emergency services; Prior Authorization is not required for services; the process and procedures for obtaining emergency services; and the use of the 911 telephone system

d. Prior Authorization and review rules. Contractor must disclose any Prior Authorization rules and other review requirements that must be met in order to ensure payment for the services and instructions to Members that, in cases where non-contracting providers submit a bill directly to the Member, the Member should not pay the bill, but submit it to Contractor for processing and determination of Member liability, if any.

11. Grievance and appeals procedures. Contractor must provide to Members all grievance and appeals rights and procedures as required by CMS regulations.

12. Disenrollment rights and responsibilities. Contractor must provide all disenrollment rights and responsibilities to Members as defined by CMS.

13. Changes in Contractor’s MA Plan Rules. If changes are made to the rules for Contractor’s MA plan, Contractor must:

a. For changes that take effect on January 1, notify all Members at least 15 days before the beginning of the Annual Coordinated Election Period defined in section 1851 (e)(3)(B) of the Social Security Act.

b. For all other changes, notify all Members at least 30 days before the intended effective date of the changes.

14. Required disenrollment. Contractor must disenroll Members under the following circumstances:

a. The Member loses entitlement to Medicare Part A or Part B benefits.

b. Death of the Member.

c. Member is no longer eligible for Plan Sponsor’s coverage.

d. Member no longer resides within the designated approved service area.

e. Member is enrolled in another MA plan, MAPD plan, or Individual Part D plan.

f. The Plan Sponsor terminates its contract with Contractor.

g. CMS terminates its contract with Contractor.

Notice. Before disenrollment, Contractor must provide the Member with notice of disenrollment in accordance with CMS Enrollment Guidance.

15. Disclosures upon request. Upon the request of a Member eligible to elect Contractor’s MA plan, Contractor must provide to the Member the following information:

a. Benefits under original Medicare, including covered services, Member cost-sharing, such as deductibles, coinsurance, and copayment amounts and any Member liability for balance billing.

b. Contractor’s procedures to control utilization of services and expenditures.

c. The number of disputes, and the disposition in the aggregate, in manner and form described by the Secretary of the Department of Health and Human Services. Such disputes must be categorized as grievances according to 42 CFR 422.564 and appeals according to 42 CFR 422.578.

d. A summary description of the method of compensation for physicians.

e. Contractor’s financial conditions, including the most recently audited information regarding, at least, a description of the financial condition of Contractor.

f. Medicare Advantage plan quality and performance indicators to the extent they are available.

F. Financial Administration

1. Premiums Insured rate quotations from any HMO must meet the following requirements:

a. Premium Rates:

Premiums for the initial contract term are outlined in Schedule B, Pricing. By August 1 of each subsequent Contract year, the Contractor will be notified of the maximum allowable premium. At that time, the Contractor may adjust the benefit design, subject to Plan Sponsor approval, and as long as the value of the plan remains actuarially equivalent to or exceeds the value of the self-insured Plan (detailed in Schedule F).

Bidder shall check the box below, confirming agreement.

I have reviewed the above requirement and agree.

b. Renewals:

Not later than September 1 of each subsequent Contract year, the Contractor must notify the Program Manager and Plan Sponsor of its willingness to continue participation and specify any adjustments it intends to make to the benefit plan design to Plan Sponsor for their review and approval. This deliverable is satisfied via the completion of the Insurance Options Summary document by September 1 of each subsequent Contract year. The Plan Sponsor reserves the right, at its sole discretion, to accept or reject any benefit design adjustment. An updated service area listing, sorted by zip code, is also due with the renewal, by September 1 of each subsequent Contract year.

Bidder shall check the box below, confirming agreement.

I have reviewed the above requirement and agree.

c. Low Income Subsidy:

Contractor must have the capability to administer all aspects related to the Low Income Subsidy (LIS) process including the Low Income Premium Subsidy (LIPS) and Low Income Cost Sharing CMS components. This includes, but is not limited to:

i. Identify members based on Medicare reports.

ii. Determine how much of a premium subsidy eligible members should receive.

iii. Pass-back of applicable subsidy amounts. The Contractor must pass-back applicable subsidy amounts directly to members.

iv. Pass through of remaining subsidy amounts to Plan Sponsor.

v. Administer Low Income Cost Share for eligible members.

vi. Provide robust reporting to Plan Sponsor, as requested.

Bidder shall check the box below, confirming agreement.

I have reviewed the above requirement and agree.

d. Late Enrollment Penalty:

Contractor must have the capability to administer the Late Enrollment Penalty (LEP) for members where applicable. This includes, but is not limited to:

i. Identify members based on Medicare reports.

ii. Determine the LEP applicable members should receive.

iii. Provide robust reporting to Plan Sponsor as requested.

iv. Invoice the Plan Sponsor on a monthly basis for applicable amounts.

Bidder shall check the box below, confirming agreement.

I have reviewed the above requirement and agree.

F. Data

1. Data Transfer Contractor must agree to work with the Plan Sponsor-chosen data management contractor (hereafter referred to as the “data vendor”) in a manner inclusive of, but not limited to the following:

a. Contractor must deliver Member data files to Plan Sponsor data vendor in agreed-upon format that meets the data vendor’s functionality specifications for file layout and submission. Refer to Schedule I Medical Claim Layout.

i. Delivery of data files with all required fields correctly populated must be completed within 15 Days after the close of each month.

b. Contractor is responsible for all expenses, including the cost of any subcontractors, related to producing the data and providing it to the data vendor. This includes any costs associated with resubmissions and processing costs incurred by the data vendor due to the transmittal of incomplete, inaccurate, or unreadable data files belonging to the Plan Sponsor.

c. Contractor must work with the data vendor, including developing any process improvement procedures needed, to correct all issues that impede or prevent accurate data reporting from the database.

d. Member data must be securely maintained for the duration of this Contract, in compliance with State policy, Schedule L of the Standard Contract Terms, Data Security Requirements

e. Upon termination or expiration of the Contract, the Contractor must deliver all data to the data vendor within ten Days of request for the same (see Section 31 of Standard Contract Terms).

f. The Contractor must be able to provide summary enrollment statistics by various categories, along with other enrollment data, upon the Plan Sponsor request.

g. If the Plan Sponsor adds additional contractors, the Contractor must provide data feeds to these contractors without additional costs.

G. Provider Network

1. Geographic Regions HMOs may only be offered in the State of Michigan. An HMO must be made available and marketed to all Members who reside in the HMO’s licensed service area in Michigan. An HMO may not be offered in only a portion of the Contractor’s Michigan service area.

2. Coverage Area The Contractor must explain, in detail, its rules for coverage outside its service area, especially outside of Michigan.

Bidder must explain, in detail, its rules for coverage outside its service area, especially outside of Michigan:

H. Claims Processing

1. Contractor must undertake responsibility for providing Organization Determinations, including full and fair review of Claims Appeals by Members, in compliance with CMS requirements

2. The Contractor must be able to provide Members with an Explanation of Benefits that accurately reflects the approved listed items in a format that is easily understood by members.

3. Contractor must maintain confidentiality of all data collected by the Contractor, according to all applicable laws, rules and regulations.

4. Contractor must have a process in place to detect, prevent, and correct fraud, waste, and abuse. Contractor’s employees and Members must be made aware of how to report suspected fraud, waste, and abuse.

5. If there are administrative changes in the Contractor’s systems, processes, or procedures that impact the Plan Sponsor or Members, the Contractor must notify the Plan Sponsor as soon as possible and provide written notification explaining the change, the impact to the Plan Sponsor and/or to Members and the related timeline, in writing, 60 days prior to the change (or as soon as the Contractor is aware).

I. Comparison of Benefits The Bidder must provide an accurate and complete comparison of its benefits with those of the Retirement System’s Master Health Care Plan. This response is critical for the State’s understanding of the Bidder’s benefits and the response to this should be thorough and easy to understand. Comparison of Benefits must be accompanied with an Attestation of Actuarial Equivalence to the Retirement System’s Master Health Care Plan.

Bidder must provide an accurate and complete comparison of its benefits with those of the Retirement System’s Master Health Care Plan as well as an Attestation of Actuarial Equivalence:

Refer to Schedule J Benefit Comparison and Actuarial Attestation – Bidder must complete the form and submit completed Schedule J and Attestation of Actuarial Equivalence by proposal deadline.

1.2. Training

A. The Contractor must provide an ad hoc reporting tool that Plan Sponsor can use to directly access utilization and other Plan-specific data. This includes training for a limited number of Plan Sponsor representatives.

B. The Contractor must provide to the Plan Sponsor, by means of a secured Internet portal, read-only access to the system used to maintain Enrollment. This includes training for a limited number of Plan Sponsor representatives.

The Contractor must provide documentation and training materials.

2. Services Levels – Deleted per Q&A dated 7/31/19 (Question #6)

2.1 Service Level Agreements

A. Contractor Performance Evaluation Refer to Schedule E – Account Management Satisfaction Survey. The Plan Sponsor’s satisfaction with Contractor performance must be rated an average of 4.00 or above on a scale of 1 to 5. The Contractor will be measured using the Plan Sponsor’s annual survey to assess the Contractor’s Performance within the following categories:

The Contractor’s total Performance score will be determined by weighting equally the overall satisfaction scores of each of the five categories. This evaluation will be completed on an annual basis. Failure to meet an overall score of 4.00 will result in a credit of $1,000.00. Failure to score at least 3.50 will result in an additional $500.00 credit.

Bidder Response to 2.1.A.:

B. Eligibility Uploads 100% of all accurate records that pass the Contractor’s validation edits must be uploaded according to the Plan Sponsor’s schedule within one Business Day of receipt.

Any records that do not pass the Contractor’s validation test must be reported to the Plan Sponsor within two Business Days after the file has been uploaded in a format specified by the Plan Sponsor.

The Contractor must measure its performance on this SLA on a monthly basis and report on a quarterly basis. The SLA report must show weekly activity defined as the number of records uploaded, number of records not accepted, and the timeframe for presenting the discrepancy reports to the Plan Sponsor.

Failure to meet this SLA will result in a $1,000.00 credit for each month missed.

Bidder Response to 2.1.B.:

3. Acceptance

3.1. Acceptance, Inspection and Testing

The acceptance process is defined in Section 20. of the Standard Contract Terms, unless otherwise defined in this section.

4. Staffing The Contractor must provide sufficient staff to provide the services as required in this Contract.

4.1. Contractor Representative

The Contractor must appoint a single point of contact, who is specifically assigned to State of Michigan accounts, that will respond to State inquiries regarding the Contract Activities, answering questions related to ordering and delivery, etc. (the “Contractor Representative”). The Contractor must notify the Contract Administrator at least 30 calendar days before removing or assigning a new Contractor Representative.

Bidder must identify their proposed Contractor Representative:

4.2 Contract Administrator

The Contract Administrator for each party is the only person authorized to modify any terms of this Contract, and approve and execute any change under this Contract (each a “Contract Administrator”):

Mary Ostrowski 525 W Allegan St., 1st Flr NE Lansing MI 48909 ostrowskim@michigan.gov 517-249-0438 [Name] [Street Address] [City, State, Zip] [Email] [Phone]

4.3 Program Manager

The Program Manager for each party will monitor and coordinate the day-to-day activities of the Contract (each a “Program Manager”):

Sarah Humphreys 530 W. Allegan St.

Lansing, MI 48909 humphreyss@michigan.gov 517-284-4584 [Name] [Street Address] [City, State, Zip] [Email] [Phone]

4.4. Customer Service Toll-Free Number

The Contractor must specify its toll-free number for the State to contact the Contractor Representative. The Contractor Representative must be available for calls during the hours of 8 am to 5 pm EST.

Bidder must specify its toll-free number:

4.5. Technical Support, Repairs and Maintenance

The Contractor must specify its toll-free number for the State to contact the Contractor for technical support, repairs and maintenance. The Contractor must be available for calls and service during the hours of 8 am to 5 pm EST.

4.6. Work Hours

The Contractor must provide Contract Activities during the State’s normal working hours Monday – Friday, 7:00 a.m. to 6:00 p.m. EST, and possible night and weekend hours depending on the requirements of the project.

4.7. Key Personnel

1. The Contractor must appoint a Senior Account Manager (SAM) who will be directly responsible for the day-to-day operations of the Contract (“Key Personnel”). Key Personnel must be specifically assigned to the State account, be knowledgeable of the contractual requirements, and respond to State inquires within 24 hours.

Additional functions of the SAM include, but are not limited to:

A. Supporting resolution of Enrollment and Membership issues with Plan Sponsor and Contractor’s internal units.

B. Presenting on at least a quarterly basis unless mutually agreed upon by Contractor and Plan Sponsor.

1. Presentation to include: Plan experience, trends, Member issues, and Contractor’s Healthcare Effectiveness Data and Information Set (HEDIS) measurements. Reporting and comparative analysis that is specific to the Plan Sponsor enrollment with Contractor is required for overall cost-use metrics, but not for HEDIS metrics.

C. Attendance at annual Member meetings (if requested) within the State of Michigan. These meetings are intended to provide Members the opportunity to become educated on their coverage for the following year. The Contractor is responsible for their proportional costs of all expenses related to the meetings and Contractor’s own travel expenses.

D. Attendance at Plan Sponsor bi-monthly Board meetings (as requested) E. Keeping primary work location and assignment at the Contractor’s Michigan office F. Serving as the single point of accountability for all projects initiated between the Contractor and Plan Sponsor for management of the Contractor’s Account Team G. Availability onsite at Plan Sponsor’ location within 48 hours of a request of the same by Plan Sponsor H. Authority and ability to make day-to-day decisions regarding service issues and to escalate issues which need to be escalated above the SAM I. Ability within the Contractor’s organization to obtain the use of Contractor’s resources, both direct and indirect, as necessary.

J. Designating one qualified back-up to the SAM, whose role and responsibilities must include involvement in account management and who is capable of performing the responsibilities of the SAM in the event that the SAM is unavailable. The Contractor’s SAM back-up must be familiar with all specific requirements of this Contract. This back-up role may be filled by another key-staff person.

Bidder must identify their proposed SAM:

2.The Contractor must identify the Key Personnel, indicate where they will be physically located, describe the functions they will perform, and provide current chronological resumés.

Contractor’s Key Personnel must be on-site at Plan Sponsor’s location during the following times: monthly work plan meetings (if requested), quarterly performance review meetings, annual performance review meeting, bi-monthly Board meetings (if requested), and at other times as requested by the Plan Sponsor.

Bidder must identify their proposed Key Personnel:

3. The State has the right to recommend and approve in writing the initial assignment, as well as any proposed reassignment or replacement, of any Key Personnel. Before assigning an individual to any Key Personnel position, Contractor will notify the State of the proposed assignment, introduce the individual to the State’s Program Manager, and provide the State with a resume and any other information about the individual reasonably requested by the State. The State reserves the right to interview the individual before granting written approval. In the event the State finds a proposed individual unacceptable, the State will provide a written explanation including reasonable detail outlining the reasons for the rejection. The State may require a 30-calendar day training period for replacement personnel.

Paragraph 4. is deleted per Q&A dated 7/31/19 (Question #7)

4. Contractor will not remove any Key Personnel from their assigned roles on this Contract without the prior written consent of the State. The Contractor’s removal of Key Personnel without the prior written consent of the State is an unauthorized removal (“Unauthorized Removal”). An Unauthorized Removal does not include replacing Key Personnel for reasons beyond the reasonable control of Contractor, including illness, disability, leave of absence, personal emergency circumstances, resignation, or for cause termination of the Key Personnel’s employment. Any Unauthorized Removal may be considered by the State to be a material breach of this Contract, in respect of which the State may elect to terminate this Contract for cause under Termination for Cause in the Standard Terms. It is further acknowledged that an Unauthorized Removal will interfere with the timely and proper completion of this Contract, to the loss and damage of the State, and that it would be impracticable and extremely difficult to fix the actual damage sustained by the State as a result of any Unauthorized Removal. Therefore, Contractor and the State agree that in the case of any Unauthorized Removal in respect of which the State does not elect to exercise its rights under Termination for Cause, Contractor will issue to the State the corresponding credits set forth below (each, an “Unauthorized Removal Credit”):

(i) For the Unauthorized Removal of any Key Personnel designated in the applicable Statement of Work, the credit amount will be $3,300 per individual if Contractor identifies a replacement approved by the State and assigns the replacement to shadow the Key Personnel who is leaving for a period of at least 30 calendar days before the Key Personnel’s removal.

(ii) If Contractor fails to assign a replacement to shadow the removed Key Personnel for at least 30 calendar days, in addition to the $3,300 credit specified above, Contractor will credit the State $110.00 per calendar day for each day of the 30 calendar-day shadow period that the replacement Key Personnel does not shadow the removed Key Personnel, up to $3,300 maximum per individual. The total Unauthorized Removal Credits that may be assessed per Unauthorized Removal and failure to provide 30 calendar days of shadowing will not exceed $6,600 per individual.

Contractor acknowledges and agrees that each of the Unauthorized Removal Credits assessed above: (i) is a reasonable estimate of and compensation for the anticipated or actual harm to the State that may arise from the Unauthorized Removal, which would be impossible or very difficult to accurately estimate; and (ii) may, at the State’s option, be credited or set off against any fees or other charges payable to Contractor under this Contract.

4.8. Organizational Chart

The Contractor must provide an overall organizational chart that details staff members, by name and title, and subcontractors.

Bidder must provide their organizational chart:

4.9. Disclosure of Subcontractors

If the Contractor intends to utilize Subcontractors, the Contractor must disclose the following:

1. The Subcontractor’s legal business name, address and telephone number;

Bidder Response:

2. A description of subcontractor’s organization;

3. A description of the Contract Activities to be performed and information concerning the Subcontractor’s ability to provide the Contract Activities;

4. Whether the Contractor has a previous working experience with the Subcontractor. If yes, provide the details of that previous relationship.

4.10. Security

The Contractor will be subject the following security procedures

A. Contractor’s work and deliverables must comply with all applicable State information technology policies and standards including the Michigan Department of Technology, Management and Budget (DTMB) Data Security Requirements (Schedule L of the Standard Contract Terms) including that:

1. Contractor must develop a security plan that includes physical security, business continuity, change management, and that identifies all controls for confidentiality, integrity, and availability.

2. Contractor must have written policies and procedures addressing the use of any protected health data and information that falls under the Health Insurance Portability and Accountability Act (HIPAA) requirements. The policies and procedures must meet all applicable federal and State requirements including the HIPAA requirements. These policies and procedures must include restricted access to the protected health data and information by the Contractor’s employees.

Note: Plan Sponsor makes no warranty or representation that compliance by Contractor with this Section, HIPAA, the HIPAA Rules, or other applicable laws pertaining to Protected Information will be adequate or satisfactory for Contractor’s own purposes. Contractor is solely responsible for all decisions made by Contractor regarding the safeguarding of Protected Information.

3. The Contractor must have, in place, a security plan that details the security requirements of the information system, identifies security controls that satisfy those requirements, and enables periodic reviews and/or timely revisions responsible to system and provide to the Program Manager updates and organizational changes.

4. The Contractor must comply with the compliance requirements of all State and federal Laws, including but not limited…