Schedule F Definitions.docx

STATE OF MICHIGAN

Request For Proposal No. 230000003226

HMO Services for MPSERS

SCHEDULE D - DEFINITIONS

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.

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

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

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

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

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 healthcare product or service.

Claimant means a Member who demands payment for Covered Products or 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.

Coinsurance means that portion of the charge for Covered Services, calculated as a percentage of the charge, which is to be paid by Members pursuant to the Plan Design, and specific to prescription drug, means that portion of the charge for Covered Services, calculated as a percentage of the allowed charge, which is to be paid by Members pursuant to the Plan Design (or for certain Participating Pharmacies, if less, the U&C of the Covered Products).

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.

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

Covered Product or Services means the hospital and medical services covered under the Plan Design. May also refer to the prescription pharmaceuticals, ancillary devices, and prescription and/or medical supplies covered under the Plan Sponsor’s 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 Covered Services are eligible for payment as stated in the Plan Design.

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

DME means Durable Medical Equipment.

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

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

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.

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

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

Grievance means any complaint or dispute, other than one involving an Organization Determination, expressing dissatisfaction with the manner in which a 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.

HITRUST means the Health Information Trust Alliance that created and maintains the Common Security Framework (CSF), a certifiable framework to help healthcare organizations and their providers demonstrate their security and compliance in a consistent and streamlined manner.

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

Implementation Period means the period of time between when Contractor is selected, and Services are commenced on January 1, 2025.

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.

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 not enrolling in coverage when first eligible.

Medicare means the federally funded program that pays for medical services for U.S. citizens age 65 or older, persons of any age who are permanently disabled, or persons with end-stage renal disease.

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 services to Members.

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.

Out-of-Pocket means Deductibles, Copayments and Coinsurance (i.e., expenses that the Plan does not cover) that the Member is required to pay for health care services and products, and/or prescription drugs.

Participating Pharmacy means a contracted retail, mail, or specialty network pharmacy (or pharmacy provider) which has agreed to provide pharmaceutical services to all Members and to be reimbursed at an agreed upon rate by the Contractor.

Plan means the Plan Sponsor’s program which provides hospital, medical, and/or prescription drug coverage to Members.

Plan Design means a description of the Plan Sponsor’s Plan related to medical and prescription drug coverages 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 Michigan Office of Retirement Services.

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

PMPM means Per Member Per Month.

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

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

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

Self-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.

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