Schedule A Statement of WorkREVISED.docx

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STATE OF MICHIGAN

Request For Proposal No. 200000001290 Administration of MPSERS Dental Benefit Plan

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 state their agreement and respond to each requirement, and when the Bidder response box indicates more information is required explain how it will fulfill each requirement. Attach any supplemental information and appropriately reference within your response. Responses must not be broad.

BACKGROUND

This is a Contract for the administration of post-employment dental benefit coverage for Members including retirees, beneficiaries, COBRA participants, and their Dependents of the Michigan Public School Employees’ Retirement System (MPSERS), administered by DTMB, Office of Retirement Services (ORS).

The Implementation Period means the period between when the Contractor is selected, and Services are commenced on January 1, 2021. The Contractor must commence performance of all Services to all Members, without interruption, on January 1, 2021. No payment will be made to the Contractor during the Implementation Period.

ORS administers the MPSERS Plan, which provides post-employment health coverage, including dental benefits, to members, including non-Medicare eligible and Medicare eligible Retirees, beneficiaries and their Dependents. Health coverage is provided to eligible retired employees of Michigan public 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. The plan is self-insured.

Approximately 261,000 Members, including 168,000 Contract Holders, are currently enrolled in the self-funded Dental Plan. Members are not required to be enrolled in one of the health insurance coverage options in order to be eligible for the Dental Plan. See also Schedule S Enrollment Data.

MPSERS is a governmental entity and therefore not subject to the federal Employee Retiree Income Security Act (ERISA). MPSERS obligations are statutory, as set forth in Public Act 300 of 1980, and the Contractor’s obligations will be pursuant to this Contract.

REQUIREMENTS

1. General Requirements For all Services / Deliverables to be provided by Contractor (and its Subcontractors, if any) under the Contract, the Plan Sponsor must not be obligated to pay any amounts in addition to the all-inclusive Administration Fee specified in the Contract. Services considered within the scope of this Contract include, but are not limited to, the following. The Contractor must:

A. Provide a fully functional Dental Plan for the Members which encompasses and manages the needs of an older, retired population. The Contractor will tailor their dental benefits program to fit the overall benefit and wellness strategy.

Bidder to confirm agreement to this requirement AND confirm ability to tailor benefits:

B. Provide Covered Products or Services that meet or exceed current industry standards in the administration of Enrollment, Claims Processing and Member Support, including review and administration of Grievances and Appeals.

Bidder to confirm agreement to this requirement:

C. 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 dental coverage and support the Plan Sponsor’s strategic planning process.

D. Provide financial management, reporting and analytical support.

Bidder to confirm agreement with this requirement AND provide detail regarding how the Bidder will accomplish this deliverable:

E. Ensure Transparency and full Pass-Through Pricing for all Services provided on behalf of the Plan Sponsor.

F. 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 covered under this Contract.

G. Agree to all stated Definitions as defined in Schedule N, Definitions. All words capitalized in this document indicate a defined word. Please refer to Schedule N for all definitions. All Definitions in Schedule N apply to all questions, grids, pricing proposal and other responses Bidders provide in their submitted proposals. These definitions will be included and applied exactly as written for this Contract. Contractor must not include additional Schedules, exhibits or other sections in Plan Sponsor's contract that contradict or redefine the contractual terms and definitions outlined in the body of the contract.

Bidder to confirm agreement with this requirement:

H. Be a licensed 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.

Bidder to confirm compliance with this requirement AND detail licensing status:

I. The total claim payment volume of business represented within this Contract is approximately $81.7 million (Gross Spend) annually. Using $81.7 million (Gross Spend) as the annual claim payment volume, the Contractor must certify that the Contract will not increase the Contractor’s annual claim payment volume by more than 25%. Contractor must not include potential business in this calculation and must only use the figures from their current book of business during the Contract period. Contractors that are found to have falsely certified meeting this requirement will have debarment pursued.

Bidder to confirm agreement with this requirement AND confirm that this Contract will not increase the Bidder’s annual claim payment volume by more than 25%:

J. Monitor, review and implement all legislation and guidance that applies to this Contract.

1.1 Services and Deliverables

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

A. Plan Design

1. The Contractor must administer the plan in accordance with the Plan Design.

2. The Contractor must duplicate the current Plan Design for the Plan Sponsor. See Schedule J Plan Design with Procedure Codes.

Bidder to confirm agreement with this requirement. Bidder must also review the "Plan Design" and "Procedure Codes" tabs in Schedule J Plan Design with Procedure Codes. Bidder must confirm their ability to duplicate the current Plan Design and enter any additional notes about Bidder's ability to provide the required coverage, limitations of coverage, or any expansions of coverage available at no cost below.

3. The Contractor must not expand or reduce coverage for Members without the Plan Sponsor’s written approval.

4. Eligibility will include eligible retired Public School Employees and their dependents as detailed in Public Act 300 of 1980.

5. No participant will lose eligibility for benefits through pre-existing condition exclusions as a result of a change in carrier at transfer or during the duration of the Contract.

Bidder to confirm ability agreement with this requirement:

6. 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 the Plan Sponsor’s membership to other like groups across the Contractor’s book of business.

Bidder to confirm agreement with this requirement AND provide detail of Bidder’s ability to provide comparative analysis to other like groups across the Contractor’s book of business:

7. The Plan Design is subject to change throughout the duration of this Contract term. The Contractor must implement Plan changes as requested by the Plan Sponsor by their effective date at no additional cost to the Plan Sponsor.

8. The Contractor’s participating providers must not balance bill Members. Out of network providers that participate with Bidder via another fee schedule can charge Members the difference between theirs and the in-network fee schedule but not balance bill up to their charge. Non-participating providers can charge Members the difference between the in-network fee schedule and their charge. Note: In-network means the deepest discounted network and everything else is considered out of network.

B. Member Support

1. General Member Support

a. The Contractor must notify the Plan Sponsor immediately of any developing situation that may impact operations or service to Members.

Bidder must confirm agreement with this requirement:

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

Bidder must confirm agreement with this requirement AND provide details as to how Bidder intends to address special needs:

c. 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.

Bidder must confirm agreement to this requirement:

d. 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.

e. Contractor must attempt to resolve Member’s telephonic issues during the initial contact with the Member.

Bidder must confirm agreement with this requirement AND provide current book of business first call resolution statistics:

f. For those issues not resolved immediately, Contractor must contact Members about their issues within 24 hours 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.

g. The Contractor must measure member satisfaction on an annual basis. This random sample Member satisfaction survey must be completed within each Plan Year for the Plan Year at no additional cost. See also Schedule H Service Level Agreements for the associated SLA.

2. Customer Service Call Center

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 from 8:30 AM to 5:00 PM Eastern Standard Time (EST).

Bidder must confirm agreement with this requirement AND provide call center location and hours:

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

i. 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.

ii. Separate toll-free numbers for Members and Providers

iii. An Interactive Voice Response (IVR) system with a user-friendly menu.

iv. Methods for logging calls and recording call data and content. It is highly preferred that the recorded call be attached to the customer account.

Bidder must confirm agreement with this requirement AND provide detail regarding call logging and recording methods:

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

vi. Methods to monitor calls for quality.

Bidder must confirm agreement with this requirement AND provide details of Bidder’s quality assurance methods:

vii. A Customer Service system that can handle a current membership of 261,000 members, with a monthly call volume averaging 7,500 calls. These calls should be handled within the service levels established by the Plan Sponsor as identified in Schedule H Service Level Agreements. The system must be scalable to accommodate future demand.

3. Web-based Support.

a. The Contractor must provide web-based 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. Capability to provide the Members with secure access to information specific to their own Claims and enrollment.

ii. Ability to list the Providers based on accessibility to the Member’s home address or zip code.

iii. Capability to answer Members’ questions about the Plan (Q&A).

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

v. The Contractor must be able to provide the Members access to designated electronic Plan-specific materials, which may include documents and /or multimedia presentations, on the Contractor’s Plan-specific website.

b. Secure email / messaging. The Contractor must provide a secure email/messaging service, for both Members and Providers.

Bidder must confirm availability of this requirement AND detail measures in place to ensure messaging service is secure.

Secure email / messaging service must include (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 and recording message data and content. It is highly preferred that the message be attached to the customer account.

Bidder must confirm agreement with this requirement AND provide Bidder’s plan for logging and recording message data:

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

v. Methods to monitor messaging for quality.

Bidder must confirm agreement with this requirement AND provide detail of Bidder’s quality assurance methods:

c. Chat Services. If the Contractor provides chat services, these services must have all of the following:

Bidder must confirm whether Bidder provides chat services. Bidder must respond to i.-iv only if Bidder provides chat services:

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

Bidder must confirm agreement to this requirement AND provide detail regarding storing, tracking and routing methodology:

ii. Methods for logging chats and recording chat data and content. It is required that the chat be attached to the customer account.

Bidder must confirm agreement to this requirement AND provide detail regarding logging and recording methodology:

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

Bidder must confirm agreement to this requirement.

iv. Methods to monitor chats for quality.

Bidder must confirm agreement with this requirement AND provide detail of Bidder’s quality assurance methods:

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

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

Bidder must confirm agreement to this requirement AND provide detail regarding storing, tracking, and routing methodology:

b. Methods for logging correspondences and recording correspondence data and content. It is highly preferred that the correspondence be attached to the customer account.

Bidder must confirm agreement to this requirement AND provide detail regarding logging and recording methodology:

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

d. Methods to monitor responses for quality.

Bidder must confirm agreement to this requirement AND provide detail of Bidder’s quality assurance methods:

e. Distribution of written responses to both Members and Providers.

C. Member Communication Materials and Meetings

1. Member Communication Materials

a. The Contractor must prepare and distribute all communication 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.

i. Contractor may use whatever communication methodology it considers appropriate, taking into account the time sensitivity of the message, and as mutually agreed upon by the Contractor and the Plan Sponsor. This includes, but is not limited to email, member meetings, current Plan Sponsor publications (e.g. the quarterly medical plan newsletter), and social media. Contractor recognizes that the quarterly medical plan newsletter is not mailed to all members receiving the dental benefit, so that newsletter cannot be the only method of communication.

b. The Contractor must produce Member educational materials. All communications must be customizable to better address the specific needs of the Plan Sponsor and its Members. This includes, but is not limited to, co-branding materials with the name of the Contractor and the Plan Sponsor, where desired by the Plan Sponsor.

Bidder must confirm agreement to this requirement AND that member communications are customizable:

c. All communication materials must be approved by the Plan Sponsor in advance of distribution. All communication materials presented to the Plan Sponsor for approval must allow at least seven business days for review and editing. This applies to all information developed, provided, and/or distributed by the Contractor to the Members about the Plan, including those placed on the Contractor’s Plan Sponsor-specific website.

d. The Contractor must provide a communication plan, no later than November 1st each year, which will include the description of the communication, the due date to the Plan Sponsor for prior approval, and the final targeted publication date.

Bidder must confirm agreement to this requirement AND provide a sample communication plan:

e. Communication materials required to be provided by the Contractor include, but are not limited to:

i. Membership Cards for currently enrolled Members (approximately 261,000) and for new members throughout the duration of this Contract (approximately 20,000 per year). See also Schedule H Service Level Agreements for the associated SLA.

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

a). Display of identifying logo designated by the Plan Sponsor.

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

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

iv. Explanation of Benefits (EOB) that details charges, Approved Amounts, copays, outstanding benefit limits 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. The Contractor will provide EOBs via U.S. mail for in-network services as requested.

f. The Contractor must not sell email addresses or demographic information of Members and can only disclose email addresses or demographic information to partners with the approval of the Members.

2. Member Communication Meetings

a. The Contractor must provide speakers at meetings designated by the Plan Sponsor at no additional charge to the Plan Sponsor. Meeting requests may vary from year-to-year, but will 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 Member’s geographic location) and up to 13 day-long sessions in Michigan, of which three may be in the Upper Peninsula. All meetings will require the combined participation of the Contractor, the Plan Sponsor, the Medical Plan Contractor, the PBM Contractor, the Vision Plan Contractor, and HMO Contractors as deemed appropriate by the Plan Sponsor. Each Contractor is responsible for their own travel arrangements, but the planning and organizing of these meetings is the responsibility of the Medical Plan Contractor. Associated cost which includes, but is not limited to, venue cost, technology, and member invitations, is to be shared equally with the other Contractors, including the cost of a number of Plan Sponsor representatives as deemed appropriate by the Plan Sponsor. The number of meetings per year may vary, and the format of the meetings is subject to change.

b. In addition to Plan Sponsor’s designated meetings, the Contractor may receive requests for speakers from the Member support organizations. 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.

i. Contractor must provide meeting activity reports within 45 days following the close of each calendar quarter. The reports must contain the date, location, and size of the meetings as well as the sponsoring organization and contact person.

Bidder must confirm agreement to this requirement (1.1.C.2.b and i):

c. The Contractor must coordinate written and spoken messaging with Plan Sponsor and with other carriers such that members are not confused by multiple messages from different sources.

D. Enrollment and Eligibility

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

2. Eligibility information for Members will be transferred to the Contractor from the Plan Sponsor by a secure electronic medium including all necessary information with respect to current enrollees at a date to be determined by the Plan Sponsor.

3. Payment of Administration Fee/premiums is predicated on the enrollment records of the Plan Sponsor. Payment will be issued by Plan Sponsor on a monthly basis, separate from the claim invoice process.

4. The Contractor must comply with all applicable requirements of HIPAA, as amended. The Contractor must sign Plan Sponsor’s Business Associate Agreement (see Schedule P HIPAA Business Associate Agreement) and may be required to recertify annually.

5. The Contractor must have the ability to store Member information. Any changes, additions or terminations of the Member enrollment information or changes or additions to the Member demographic information (including email addresses) 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. The Contractor must not make any changes to Member information that would result in the Contractor and the Plan Sponsor having different information for the same Member.

6. The Contractor must maintain a Member’s enrollment in the Plan unless otherwise notified by the Plan Sponsor regardless of notifications from any other source.

7. The Contractor must support the Plan Sponsor in confirming Member Eligibility.

8. The Contractor must have the capability to accept electronic data transfer on a weekly basis, more frequently if necessary, from the Plan Sponsor, in a HIPAA compliant 834 format, and which is provided through the State of Michigan’s data exchange gateway, File Transfer Service, or similar State of Michigan approved file transfer protocol service. See Schedule F1 834 Example and Schedule F2 834 Use Case.

9. The Contractor must have the capability to conduct full enrollment audits on an as-needed basis, but at minimum, two times per year. The Contractor must work with the Plan Sponsor in the implementation of secure data transfers for all exchanges.

10. 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. The Contractor must work with the Plan Sponsor to develop a timeline for implementation and testing of any system changes. The Contractor must maintain a testing environment for such purposes.

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

12. 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, in a format defined by the Plan Sponsor.

13. The Contractor must execute all Member enrollment updates in real-time upon verbal and/or written notifications from the Plan Sponsor.

Bidder must confirm agreement to this requirement AND confirm Bidder’s ability to execute enrollment updates in real-time:

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

15. 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. The Plan Sponsor requires that all access be established using unique usernames and passwords (i.e., no shared or generic passwords).

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

E. Technology and Support

1. IT Policies, Standards and Procedures (PSP):

Contractors are advised that the State has methods, policies, standards and procedures that have been developed over the years. Contractors are expected to provide proposals that conform to State IT policies and standards. All services and products provided as a result of this RFP must comply with all applicable State IT policies and standards.

IT Policies, Standards and Procedures (PSP): https://www.michigan.gov/dtmb/0,5552,7-358-82547_56579_56755---,00.html

Bidder must review all links provided in proposal AND state their compliance.

a. ADA Compliance:

The State is required to comply with the Americans with Disabilities Act of 1990 (ADA), and has adopted a formal policy regarding accessibility requirements for websites and software applications. The State is requiring that Bidder’s proposed Solution, where relevant, comply with level AA of the World Wide Web Consortium (W3C) Web Content Accessibility Guidelines (WCAG) 2.0. Bidder may consider, where relevant, the W3C’s Guidance on Applying WCAG 2.0 to Non-Web Information and Communications Technologies (WCAG2ICT) for non-web software and content. http://www.michigan.gov/documents/dmb/1650.00_209567_7.pdf?20151026134621

2. User Type and Capacity:

Bidder must provide their system capability for concurrent users (If you have multiple that will be utilized under this contract, disclose and address for all systems).

3. End User Operating Environment:

The Contractor must provide current minimum browser requirements and the Contractor must publish the minimum browser requirements on the Contractor’s proposed system solution for member access.

The Bidder must confirm agreement to this requirement AND disclose current minimum browser requirements for all systems that will be utilized under this Contract.

4. Software Licensing/User Agreement:

If Bidder is proposing a licensing/user agreement with their proposed solution, the licensing/user agreement must be included with the proposal. State N/A if it is not applicable.

5. Contractor Hosted Software and Terms:

The Contractor must comply with Schedule D Contractor Hosted Software and Terms.

Bidder to confirm agreement to requirement.

a. Service Availability:

The Contractor must utilize the template in Schedule M Service Availability Report, to report service availability on all systems utilized under this Contract as required per Schedule D, Exhibit 1.

Bidder to confirm agreement to requirement AND submit with proposal a listing of all systems in Schedule M Service Availability Report.

6. Storage of all State Data and information including but not limited to provider portal, member portal, State of Michigan system access/portal, and claims or eligibility or related information or data:

All State data must be stored, maintained and managed within the contiguous 48 states.

Bidder must confirm agreement to requirement AND indicate where all data under this Contract would be stored (i.e. cloud-based solution, on-premise/physical data center) and include city, state, and detail. Response must also include detail if for any portion of the contract is provided by a subcontractor.

7. Back-up of Data: The Contractor must keep back-up computer data files maintained in connection with this Contract in a place of safekeeping satisfactory to the State. Backup copies of State data must be kept off-site from the primary processing site, and at a location that is at least 500 miles from the primary data repository location. All computer data files of the Plan Sponsor, as maintained by Contractor, must at all times remain the property of the State notwithstanding the fact that such records may be stored upon or within one or more computer or data retention systems owned, operated or leased by Contractor. The State, or its representatives, must, at all reasonable times, have access to the records. To the extent that any such records are to be maintained upon a computer system or any other data retention system which is not owned by the Contractor, the Contractor must provide the State with assurances from the owner of such computer facilities, satisfactory to the State, of continued availability and security of such records at all times. See also Schedule E Data Security Requirements.

Bidder must confirm agreement to this requirement AND disclose location of back-up data files:

8. Within 24 hours of request by the State, the Contractor must provide the State access to all back- up source materials reports, books, records, computer programs and all other information and documentation relating to the Plan, as reasonably required so that the State and/or its designated officers, agents and accounts, can conduct a financial examination and/or audit of the plans.

9. Security:

Data must be securely maintained for the duration of the Contract. The Contractor must comply with Schedule E Data Security Requirements.

Bidder must confirm agreement to this requirement AND confirm compliance with Schedule E Data Security Requirements:

10. The Contractor must maintain and keep a documented Disaster Recovery Plan that will be made available to the State or Plan Sponsor upon request.

Bidder must confirm agreement to this requirement AND provide Bidder’s current Disaster Recovery Plan, submitting with proposal as Schedule O Contractor’s Disaster Recovery Plan.

F. SSAE Audit:

1. The Contractor must have an SSAE 16 SOC 2 Type 2 audit conducted annually. The Contractor must provide the State with a copy of their current year SOC report once the Contract is effective. See also Schedule E Data Security Requirements.

Bidder must confirm agreement to this requirement and provide detail regarding Bidder’s external audits:

2. If the Contractor’s current SOC report has exceptions, the Contractor must provide the Plan Sponsor with an explanation of those exceptions and the corrective action plan, in a timeframe mutually agreed upon by the Contractor and the Plan Sponsor and provide regular updates until issues have been corrected.

Bidder must confirm agreement to this requirement and provide detail regarding any current exceptions:

3. The Contractor must supply the Plan Sponsor with an annual electronic copy of the results of this audit within 45 Days of completion of the report.

Bidder must confirm agreement to this requirement and provide estimated annual availability date:

4. The Contractor must provide, to the Plan Sponsor, additional information pertaining to internal controls upon request.

5. The Contractor must provide the Plan Sponsor with a corrective action plan on all actionable items within 30 days from delivery of the report to the Plan Sponsor (or as mutually agreed upon between Contractor and Plan Sponsor) and provide regular updates on those items until they are resolved.

G. Financial Administration

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

Bidder must confirm agreement to this requirement and provide details regarding current ratings of financial strength:

2. The Contractor must establish an account during the Contract Implementation Period with the Plan Sponsor’s bank, which will be used as a conduit or actual source for the payment of Eligible Claims. Payment will be determined at a frequency to be mutually determined by the Plan Sponsor and the Contractor.

3. The Contractor must establish and pay for an electronic mail link with the Plan Sponsor for purposes of communicating wire transfer requests. Such a link must be secure in order to protect the data communicated to the Plan Sponsor.

4. The Contractor must electronically transmit a signed written statement which certifies that the wire request correctly and completely reflects Plan Sponsor’s financial obligation for the time period defined.

5. The Contractor must prepare and distribute to Providers or other sources any State and Federal forms required by law.

6. All interest accrued from account(s) used to pay Eligible Claims, including all revenue, must accrue to the Plan Sponsor.

7. Financial errors made by the Contractor that are identified outside of a normal audit process and which would result in a financial settlement to the Plan Sponsor must be paid to the Plan Sponsor within 30 Days of discovery. Any outstanding payment, in part or in full, beyond 30 Days is subject to the actuarially determined interest rate, compounded, which is currently 8%.

H. Audits

1. The Contractor must agree to pass through to Plan Sponsor 100% recovery of audit recoveries and overpayments.

2. The Contractor must allow Plan Sponsor the right to audit all aspects of the dental program managed by the Contractor including financial terms, service agreements, administration, and guarantees at no cost to the Plan Sponsor. The review of all aspects of the dental program may include but must not be limited to paid claims, the claim processing system, performance guarantees, pricing guarantees, onsite assessments, operational assessments, and customer service call monitoring. Audits must be conducted by a firm selected by Plan Sponsor. The Contractor must not charge Plan Sponsor or audit firm for any data required for audit or for any audits requested by the Plan Sponsor.

3. The Contractor agrees to not impose limitations on the number of claims to be audited and no additional charges to Plan Sponsor for audits, including, but not limited to, onsite pre-implementation audit, annual claims audit and annual benefit audit, etc.

4. The Contractor agrees to provide written confirmation acknowledging the Contractor’s approval of the timeline for the claims audit 5 days after the audit kickoff meeting.

5. The Contractor must provide any requested data elements required to complete a benefit and claims audit 30 days from receipt of the data request by the Plan Sponsor’s auditor.

6. The Contractor must provide their responses to the claims that require review within 30 days of receipt of claim inquiries and/or exceptions from the Plan Sponsor’s auditor.

7. If necessary, the Contractor and the State will meet to review each audit report after issuance. The Contractor must respond to each audit report in writing within 30 days from receipt of the report, unless a shorter response time is specified in the report. The Contractor and the State must develop, agree upon and monitor an action plan to address and resolve any deficiencies, concerns, and/or recommendations in the audit report.

8. If the audit demonstrates any errors in the documents provided to the State, then the amount in error must be reflected as a credit or debit on the next invoice and in subsequent invoices until the amount is paid or refunded in full. However, a credit or debit may not be carried for more than four (4) invoices. If a balance remains after (4) invoices, then the remaining amount will be due as a payment refund within 45 days of the last quarterly invoice that the balance appeared on or termination of the Contract, whichever is earlier.

9. In addition to other available remedies, if the difference between the payment received and the correct payment amount is greater than 10.00%, then the Contractor must pay all reasonable costs of the audit.

10. The Contractor must allow full, onsite auditability.

11. The Contractor must not offset audit recovery overpayments by any potential underpayments identified by the audit.

12. The Contractor must allow Plan Sponsor, or Plan Sponsor's consultant, the right to review the internal testing completed for Plan Sponsor's dental plan, if applicable, prior to the effective date of the plan on an annual basis.

13. The Contractor must allow Plan Sponsor, or Plan Sponsor's consultant, the right to create and submit test claims for Plan Sponsor's dental plan, without limitations on the number of test claims, as part of a pre or post implementation audit on an annual basis.

14. During the Contract implementation period, the Contractor must provide 40 claims that would typically be tested in advance of a new client's Contract effective date, to ensure the plan is set up accurately.

15. The Contractor must allow Plan Sponsor to audit customer service calls.

16. The Contractor must not hold a Member, a Provider or the Plan Sponsor financially responsible for the Contractor’s errors that are identified in an audit. If a pattern of payment errors is identified for a particular Provider, the Contractor must assume the cost of auditing that Provider.

I. Data

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

a. The Contractor must provide the data contractor claims data as described in Schedule G Generic Medical Claim Layout. This information is to be provided to the data contractor monthly and by a date no later than the 15th Day from the last Day of the reporting month.

Bidder must confirm agreement to this requirement. In addition, Bidder must confirm their ability to meet the specifications in Schedule G by the stated monthly due date:

b. Upon termination or expiration of the Contract, Contractor must deliver all data to the State and/or the designated data contractor as requested by the State, within 5 Days.

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

d. The Contractor is required to work with the data contractor, including developing any process improvement procedures needed, to correct all issues that impede or prevent accurate data reporting from the database.

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

J. Service Level Agreements (SLAs)

1. The Contractor must comply with Schedule H, Service Level Agreements. See also Section 4.3 for reporting of SLAs.

K. Credits

1. Implementation Credits: The Contractor must provide Plan Sponsor with a $60,000 implementation credit or allowance. The Plan Sponsor can utilize the credit to offset any expenses related to changing dental plan vendors, and/or the implementation, including consulting fees, as deemed appropriate by the Plan Sponsor. The Contractor will reimburse all expenses upon receipt of proper documentation of incurred costs. These credits do not expire during the Contract term.

2. The Contractor must accommodate a pre- or post-implementation audit at the Contractor’s expense, providing a fund in order to verify the Contractor’s readiness to administer the Plan Sponsor program. The pre-implementation audit must be completed before the program effective date and the post-implementation audit must be conducted at a mutually agreed upon timeframe post effective date. These audits may include but are not limited to: ID card production and turnaround time, eligibility, claims processing, customer service, plan design, and overall pricing. The review must be conducted by an audit firm selected by Plan Sponsor and would include test claims developed independently by the audit firm to represent Plan Sponsor’s unique requirements.

L. Claims Processing

1. The Contractor must administer claims in conformity with the Plan Design as specified in Schedule J Plan Design and Procedure Codes and in compliance with any changes made to the Plan Design by the Plan Sponsor.

Bidder must confirm agreement to this requirement AND confirm ability to process claims in accordance with the Plan Design. Bidder must also detail how it will comply with Plan Design changes:

2. 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 participants or reimburse the Plan Sponsor for such payments from Contractor’s own funds.

3. The Contractor must only charge against the Plan Sponsor’s account Claim payments authorized under the Plan Sponsor’s Plan Design.

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

5. The Contractor must adjudicate Eligible Claims 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 that accurately reflects the approved listed items in a format that is easily understood by Members.

6. The Contractor must maintain a claims processing department that is experienced in processing high volume and complex claims, adjudicating coordination of benefits, processing out of country claims, and handling recoveries, and have experienced staff to handle claims that require manual intervention.

Bidder must confirm agreement to this requirement AND provide detail regarding Bidder’s claims department experience and capabilities:

7. 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.

8. The Contractor must capture and store all Claim data elements involved in the processing or payment of Claims.

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

10. The Contractor must provide a detailed Claims Paid Report to the Plan Sponsor on an annual basis if requested by the Plan Sponsor as described in Section 4.3 Reporting.

11. The Contractor must undertake responsibility for providing Organization Determinations, including full and fair review of Claims Appeals by Members that have been denied either in full or in part. The Contractor’s Claims Appeals process must comply with the Plan Sponsor’s Claims Appeals process as stated in Schedule K Policy Appeals Processes. The Contractor’s Claims Appeals reporting must comply with Plan Sponsor’s Claims Appeals reporting requirements.

12. The Contractor’s system, processes, subcontractors, and partners must comply with HIPAA.

13. The Contractor must comply with the statutory mandate for Coordination of Benefits (COB) found in the Public School Employees Retirement Act (PA 300 of 1980). See also Schedule L, Coordination of Benefits.

Bidder must confirm agreement to this requirement and ability to comply with the Act and provide detail regarding COB procedures:

14. The Contractor must process Direct Member Reimbursement Claims.

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

Bidder must confirm agreement to this requirement AND provide detail regarding Bidder’s processes:

16. The Contractor must have processes in place to detect, prevent, and correct fraud, waste, and abuse. Where fraud and abuse is discovered, the Contractor must reimburse the Plan Sponsor and attempt to make recoveries.

17. The Contractor must have procedures for handling overpayments and recoveries.

18. 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).

19. The Contractor must file, collect and redistribute any class action lawsuit settlements on Plan Sponsor’s behalf.

M. Provider Network

1. The Contractor must manage and maintain a national network of Providers for the Plan Sponsor and Members. This network must provide high quality service and control and reduce the cost of dental care.

Bidder must confirm agreement to this requirement AND provide the name and description of Bidder’s network(s):

2. The Contractor must maintain a network of Providers in areas where Members reside.

3. The Contractor must provide access to dental Providers based on the following criteria:

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

Bidder must confirm ability to meet this requirement AND complete and submit with proposal, Schedule Q Geo Access:

4. The Contractor must commit to improving Provider access in any areas where the access standard is not met.

Bidder must confirm ability to meet this requirement AND provide detail regarding any areas where the access standard is not met. Bidder must also detail how it plans to improve access in areas where the standard is not met:

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

6. The Contractor must be able to add providers to the Provider Network.

7. The Contractor must support Provider access to Protected Health Information (PHI) by means of a secure internet portal.

8. The Contractor must provide full Pass-Through Pricing to the Plan Sponsor.

9. The Contractor must not charge the Plan Sponsor, or any Member, any amount above that which is paid to the Provider under the terms of the Contract between the Contractor and the Provider.

10. Disruption Analysis: A disruption analysis must be performed to determine the potential network access disruption that would result from the Contract award by identifying all ‘in network’ and ‘out of network’ providers based on the list of providers currently utilized by the Plan Sponsor’s Members.

Bidder must complete and submit with proposal, Schedule R Disruption Analysis. The Bidder must provide to the Plan Sponsor a summary of how many Members are currently going to Network Providers that would not be covered by the Bidder’s proposed Provider Network AND provide any additional details regarding the results of the disruption analysis:

11. 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.

Bidder must confirm agreement to this requirement AND provide detail regarding Bidder’s provider auditing processes:

1.2. Training

The Contractor must provide training for a limited number of Plan Sponsor representatives on use of the Contractor’s ad hoc reporting tool used to directly access utilization and other Plan-specific data. Training must occur at a location determined by the Plan Sponsor.

Bidder must confirm agreement to this requirement AND provide detail regarding Bidder’s training capabilities:

2. Acceptance

2.1. Acceptance, Inspection and Testing

The State will use the following criteria to determine acceptance of the Contract Activities: see Standard Contract Terms, Section 20.

3. Staffing

3.1. Contractor Representative

A. The Contractor’s appointed Senior Account Manager (SAM) will serve as the Contractor Representative. This representative must be specifically assigned to State of Michigan accounts, that will respond to State inquiries regarding the Contract Activities. See also Section 3.3.C.1.

Bidder must confirm agreement to this requirement AND identify proposed SAM, including name, phone, email:

B. The Contractor must notify the Contract Administrator and Program Manager at least 30 calendar days before removing or assigning a new Contractor Representative.

3.2 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”):

Bidder must complete green highlighted section:

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]

3.3 Program Manager

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

Bid…