Schedule D - Definitions.docx

STATE OF MICHIGAN

Request For Proposal No. 190000002803

HMO Services for MPSERS

SCHEDULE D - DEFINITIONS

24x7x365 means 24 hours a day, seven days a week, and 365 days a year (including the 366th day in a leap year).

Actuarial Equivalences/Actuarially Equivalent means the financial value of the coverage and the cost sharing provisions are the same for a given population and spending pattern.

Additional Service means any Services within the scope of the Contract, but not specifically provided under any Statement of Work.

Appeal means any of the procedures that deal with the review of adverse Organization Determinations on the health care services an enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services (such that a delay would adversely affect the health of the enrollee), or on any amounts the enrollee must pay for a service as defined in 42 CFR 422.566(b). These procedures include reconsideration by the Medicare health plan and if necessary, an independent review entity, hearings before Administrative Law Judges (ALJs), review by the Medicare Appeals Council (MAC), and judicial review.

Audit Period means the seven-year period following Contractor’s provision of any work under the Contract.

Bidder(s) are those companies that submit a proposal in response to this RFP.

Master Agreement is an alternate term for Contract and is used in the Plan Sponsor’s computer system.

Breach means the acquisition, access, Use or Disclosure of Protected Health Information or Personal Identifying Information in a manner not permitted under the Privacy Rule or the Michigan identify Theft Protection Act, as applicable, which compromises the security or privacy of such information.

CAHPS means Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey(s).

Center for Medicare and Medicaid Services (CMS) means the federal agency that administers and oversees the Medicare and Medicaid programs.

Claim means a submission for payment of a Service.

Claimant means a Member who demands payment for Covered Services.

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

Community Rates mean premium rates filed with State of Michigan that vary by benefit plan and by demographics but not by an individual’s or group’s claims experience.

Contract means a binding agreement entered into by the State of Michigan and an HMO for health care coverage for Retirement System Members.

Contract Holder means a Retiree, pension beneficiary or COBRA participant who satisfies all of the Eligibility criteria necessary to receive hospital/medical/pharmacy coverage through the Retirement System.

Contractor means the organization selected to administer the Plan for both non-Medicare and Medicare Eligible Members.

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

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

Covered Product or Services means the hospital and medical services covered under the Plan Design.

Customer Service means a web based and / or telephonic system by which Members can make inquiries about the Plan and the Contractor can answer or resolve them.

Data (Management) Vendor means a third-party administrator of the Plan Sponsor’s database and reporting systems.

Days means calendar days unless otherwise specified.

Deductible means a predetermined amount of money that a Member must pay before Covered Products and Services are eligible for payment as stated in the Plan Design.

DEG means Data Exchange Gateway. This is the State of Michigan standard for sharing data with external partners. The DEG provides a web-based https Secure Internet File Transfer mechanism between agencies within the State of Michigan and their external partners, using an Internet browser without the need for external software.

Reserved means that section is not applicable or included in this RFP. This is used as a placeholder to maintain consistent numbering.

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

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

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

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

ERISA means the Employee Retirement Income Security Act of 1974.

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

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

Grievance means any complaint or dispute, other than one involving an Organization Determination, expressing dissatisfaction with he manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item or service. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration or invoked an extension to an organization determination or reconsideration time frame.

Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used to measure health care plans in terms of performance and service.

Health Maintenance Organization (HMO) means a type of managed care organization (MCO) that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other Providers with which the HMO has a contract.

Health Plan means a plan that provides health coverage for the Plan Sponsor’s Members.

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

Identification (ID) Card means the card produced by the Contractor that documents the Member’s coverage under the plan.

Identity Theft Protection Act means Public Act 452 of 2004, MCL 445.61, et.seq.

Implementation Period means the period of time between when Contractor is selected, and Services are commenced on January 1, 2020.

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

Inquiry means any oral or written request to the Contractor, one of its subcontractors, or received by Plan Sponsor and forwarded on to Contractor, that does not involve a request for Organization Determination / exception request.

Low Income Premium Subsidy means the premium paid by the low-income subsidy beneficiary for basic prescription drug coverage after the premium subsidy is applied.

Late Enrollment Penalty means the amount a beneficiary owes for enrolling in coverage when first eligible.

Medicare Advantage (MA) Plan means any plan which is available to Medicare beneficiaries and that is operated by an entity that has been approved by CMS.

Medicare-Eligible Member means a Member who is eligible, as determined by CMS, for Medicare Parts A, B and D benefits.

Member means each Contract Holder and eligible Dependent.

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

MPSERS means the Michigan Public School Employees Retirement System; also referred to as the "Retirement System".

NCQA means the National Committee for Quality Assurance, a private, not-for-profit organization which provides tools for the measurement, analysis, and improvement of health care systems.

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

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

Non-Medicare Member means a member who is not a Medicare-Eligible Member.

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

ORS means the Office of Retirement Services.

Personal Identifying Information or PII has the same meaning as the term Section 3(q) of the Identify Theft Protection Act.

Plan means the Plan Sponsor’s program which provides hospital/medical/pharmacy coverage to Members.

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

Plan Sponsor means the Office of Retirement Services.

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

PMPM means Per Member Per Month.

Practitioner means a licensed physician or other licensed health care provider authorized to provide health care services.

Premium means the periodic payment made on an insurance policy.

Prior Authorization (PA) means an advance verification or confirmation that certain criteria are satisfied for specific Covered Services and Products before processing the Claim for Covered Services or Products.

Privacy Rule means the Standards for Privacy of Individually Identifiable Health Information at 45 CFR Part 160 and Part 164, Subparts A and E.

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

Provider means a health care professional or a health care facility that provides medical services to Members.

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

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

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

SLA means Service Level Agreement.

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

Subcontractor means a company selected by the Contractor who is chosen to perform a portion of the Services but does not include independent contractors engaged by Contractor solely in a staff augmentation role. It also means a person or entity that creates, maintains, or transmits Protected Information on behalf of Contractor.

Unit means a Contract Holder and their Dependent(s).

Work in Progress means a Deliverable that has been partially prepared but has not been presented to the Plan Sponsor for Approval.

834 File is the standard electronic process in the industry.