SMCO-TPA-RFP-03242025.pdf

REQUEST FOR PROPOSALS

RFP#: SCG03242024

for

Third-Party Medical Plan Administration Services:

March 24, 2025

Proposals Due:

May 9, 2025 by 3:00 p.m. MST/MDT

Overview

Summit County Government (“County”) is soliciting bids from qualified contractors to provide services for Third-

Party Medical Plan Administration:

A. Medical Claims Repricing/Payment/Administration

B. Direct Contracting Network Development and Maintenance

C. PPO Network Access

D. Health Care Management, including:

i. Prior Authorization (PA);

ii. Utilization Review (UR);

iii. Large Case Management (LCM); and

iv. Disease Management (DM).

E. Member Advocacy/Concierge

F. Telemedicine/Telehealth/Teledoc

G. Integrated Cost Savings Solutions

For additional information about the County and their current plan offering carefully review Part IV – Project

Description of this request for proposal.

Scope of Services

Contractor shall furnish all labor, transportation, and incidentals necessary to perform the requested service(s).

Work shall be completed as set forth in a contract to be negotiated with the County, based upon the contractor’s written proposal.

Date and Time of Service

Effective Date: The County anticipates the effective date of these coverages to be fully implemented with a plan effective date as early as October 1, 2025 but no later than January 1, 2026 with annual plan renewals on January 1.

A. Contract Period and Fees – Medical TPA/ASO Services

The contract term is for a three-year period, renewable for an additional three-year term, subject to satisfactory performance. Administrative fees are set on a per-employee per-month (capitated) basis and are subject to annual negotiation. However, the maximum increase of the administrative fee per employee per month for any given contract year (January 1 – December 31) must not exceed the Consumer Price Index

(CPI-U, US City Average, All Items) as published in November immediately preceding the renewal.

Requests for changes in the administrative fee or notice of cancellation of services must be presented for negotiation to the County by July 1 for an effective date on the following January 1. Requests for changes in fees must include documentation of the reasons and necessity for the change.

B. Contract Period and Fees – Direct Network Contracting, Negotiations and Network Maintenance

The contract term is for a three-year period, renewable for one additional three-year period, all subject to satisfactory performance. Administrative fees are to be set on a per-employee per month (capitated) basis, subject to annual negotiation. However, the maximum increase of the administrative fee per employee per https://www.bidnetdirect.com/ month for any given contract year (January 1 – December 31) must not exceed the Consumer Price Index

(CPI-U, US City Average, All Items) as published in November immediately preceding the renewal.

Requests for changes in the administrative fee or notice of cancellation of services must be presented for negotiation to the County by July 1 for an effective date on the following January 1. Requests for changes in fees must include documentation of the reasons and necessity for the change.

C. Contract Period and Fees – Health Care Management Services (Prior Authorization (PA), Utilization

Review, Large Case Management, and Disease Management)

The contract term for PA, UR, LCM, and DM is for a three-year period, renewable for additional one to three-year term, all subject to satisfactory performance. Any additional fees for PA, UR, LCM, and DM are to be set on a per-employee per-month (capitated) basis, subject to annual negotiation. However, the maximum increase of the fee per employee per month for any given contract year (January 1 – December 31) will be no greater than the Consumer Price Index (CPI-U, US City Average, All Items) as published in

November of the immediate prior year.

Requests for increases in the fees or notice of cancellation of services must be presented for negotiation to the

County by July 1 for an effective date on the following January 1. Requests for changes in fees must include documentation of the reasons and necessity for the change.

D. Contract Period and Fees – Member Advocacy, Concierge and/or Telemedicine, Telehealth, Teledoc

The contract term for Member Advocacy and/or Telemedicine is set for a three-year period, renewable for additional one to three-year term, all subject to satisfactory performance. Member Advocacy and/or

Telemedicine fees are to be set on a per-employee per-month (capitated) basis, subject to annual negotiation.

However, the maximum increase of the administrative fee per employee per month for any given policy year

(January 1 – December 31) must not exceed the Consumer Price Index (CPI-U, US City Average, All Items) as published in November of the immediate prior year.

Requests for increases in administrative fees or notice of cancellation of services must be presented for negotiation to the County by July 1 for an effective date on the following January 1.

E. Contract Period and Premiums – Integrated Cost Savings Solutions

The contract term for any Integrated Cost Savings Solutions is for a three-year period, and renewable for additional one to three-year term, all subject to satisfactory performance. Fees may be subject to renewal negotiation. Requests for increases in fees or notice of cancellation of services must be presented for negotiation to the County by July 1 for an effective date on the following January 1.

F. Termination of Contract/Cancellation

The County reserves the right to cancel, with or without cause, all contracts resulting from this RFP by giving thirty (30) days written notice. Inadequate delivery, unsatisfactory service, or failure to adhere to the contract covenants are examples of situations that may result in cancellation of the contract. The contractor shall be responsible for reimbursing the County for expenses incurred as a result of unacceptable service.

Except for a material breach of contract, as described below, or failure to pay fees or premiums in accordance with contract provisions, the contractor may only cancel any or all contracts resulting from this RFP by giving written notice on or before July 1, with an effective date of the following January 1. If either party determines that a material breach has occurred that would be cause for cancellation of the contract, the party wishing to cancel shall notify the other party of the alleged breach in writing and allow the other party thirty

(30) days in which to cure the alleged breach. If the alleged breach is not cured, or substantial steps to cure the alleged breach are not taken within this period, the non-defaulting party may cancel the contract at the end of said thirty (30) day period.

Indemnification and Insurance

Contractor shall indemnify and hold harmless the County from and against all claims, damages, losses, and expenses arising out of or resulting from acts or omissions of the Contractor, Contractor’s sub-contractors or otherwise arising out of the performance of services by Contractor. No later than seven (7) days following the execution of an

Independent Contractor Agreement between the County and Contractor, the Contractor shall provide the County with certificates of insurance evidencing the types and amounts of insurance specified below:

A. Worker’s Compensation and Employer’s Liability:

i. Worker’s Compensation must be maintained with the statutory limits.

ii. Employer’s liability is required for minimum limits of:

a. $1,000,000 Each Accident

b. $500,000 Disease Policy

c. $1,000,000 Disease Each Employee

iii. Commercial General Liability:

a. $1,000,000 Each Occurrence

b. $2,000,000 General Aggregate

c. $2,000,000 Products Completed Operations Aggregate

iv. Automobile Liability: Contractor will maintain business auto liability coverage covering liability arising out of any auto (including owned, hired and non-owned autos) used in the performance of services under this Agreement.

a. $1,000,000 Combined Single Limit Each Accident

Insurance coverage shall not be reduced below the limits described above or cancelled without the County’s written approval of such reduction or cancellation. Certificates of such insurance, of agents and subcontractors, shall be provided to the County upon request. With regard to all insurance, such insurance shall:

• Be primary insurance to the full limits of liability herein before stated and, should County have other valid insurance, County insurance shall be excess insurance only; and

• Not cancelled without thirty (30) days prior written notice to the County.

Proposal Format

Costs for performing services outlined in this request for proposals shall be clearly stated to allow the County to effectively evaluate each proposal.

Refinements and Improvements

Contractors should feel free during the proposal submission process to provide any suggestions or comments that might be advantageous for the County to consider in terms of efficiencies, issues, or processes. The County is not committed to any single scenario, but efficiency and recommendations are welcome.

A contractor may submit more than one proposal, each of which must follow the Proposal Response Outline section and satisfy the requirements of this RFP. The supplier's primary proposal must be complete and comply with all instructions. Alternative proposals should be in abbreviated form, following the Proposal Response Outline, and should provide complete information only for sections that differ from those contained in the primary proposal. Each proposal submitted will be evaluated on its own merits.

The following pages contain the RFP instructions and owner’s requirements.

Part I - ADMINISTRATIVE INFORMATION

Issuing Officer

This Request for Proposals (“RFP”) is issued by the Human Resources Department by Stefanie Miranda, Director of HR, at stefanie.meranda@summitcountyco.gov. For an electronic copy of this RFP visit BidNet

Direct or Summit County’s website.

Purpose

This RFP provides prospective contractors with sufficient information to prepare and submit proposals for consideration by the County. To be considered responsive, each proposal must provide for completion of the tasks outlined in the RFP.

Scope

This RFP contains the instructions governing the proposals to be submitted and the materials to be included therein. These are mandatory requirements that must be met to be eligible for consideration. The information provided in this RFP is intended to assist contractors in properly responding to this request. The RFP has been designed to provide interested contractors with sufficient basic information to submit proposals meeting minimum requirements. However, the RFP is not intended to exclude any relevant or essential data. Suppliers may include additional information as outlined in Part II – Proposal Content Section

Scheduling

Proposals must be submitted electronically, Via the BidNet Direct website.

All bids and alternative bids are due by Friday, May 9, 2025 no later than 3:00 p.m. MST/MDT.

Inquiries and Questions

Prospective contractors are welcome to make inquiries and ask questions concerning the RFP to obtain clarification of the any requirements. All questions regarding this proposal must be submitted in writing electronically:

Via BidNet Direct website.

All questions are due no later than Friday, April 11, 2025 no later than 3:00 p.m. MST/MDT.

Time Schedule

Monday, March 24, 2025 Request for Proposals publicly advertised and posted on County website

Friday, April 11, 2025 no later than 3:00 p.m. MST/MDT. Deadline for all Questions

Friday, April 18, 2025 All Questions, Comments and Responses to Questions posted by the County on

BidNet Direct and Summit County’s website

Friday, May 9, 2025 Proposals must be submitted via BidNet Direct no later than 3:00 p.m. MST/MDT.

Monday, May 12, 2025 Official Bid Opening at 9:00 a.m.

Based on total number of bid responses, the County reserves the right to adjust the below timelines at the full discretion of the County.

Monday, June 30, 2025 at the County’s discretion interview short-listed Proposers, if necessary (estimated week of)

Monday, July 14, 2025 contract negotiations, if needed (week of) mailto:stefanie.meranda@summitcountyco.gov https://www.bidnetdirect.com/ https://www.summitcountyco.gov/how_do_i/apply_for/bid_postings.php https://www.bidnetdirect.com/ https://www.bidnetdirect.com/ https://www.bidnetdirect.com/ https://www.summitcountyco.gov/how_do_i/apply_for/bid_postings.php

Monday, July 21, 2025 the County reserves the right to conduct an additional round of finalist interviews, but is not required to hold these interviews

Monday, July 28, 2025 if final interviews are held, the County reserves the right to conduct one round of best

& final negotiations (estimated week of)

Monday, August 14, 2025 Notice of Award and send Unsuccessful Bidder letter (email) to all proposers

(week of)

Instructions for Submission of Proposals

Contractors are REQUIRED to submit proposals via BidNet Direct, to avoid any large file issues.

Late Proposals

It is the responsibility of each contractor submitting a proposal to ensure that electronic proposals post on

BidNet Direct by 3:00 p.m. MST/MDT on Friday, May 9. THE COUNTY WILL NOT MAKE

EXCEPTIONS FOR LATE PROPOSALS.

Proprietary Information

Any restrictions on the use of data contained within a proposal must be clearly stated in the proposal itself.

Response Material Ownership

All materials submitted regarding this RFP become the property of the County and will only be returned at the

County's option.

Incurring Costs

The County is not liable for any costs incurred by those who have submitted proposals prior to issuance of a signed contract.

Acceptance of Proposal Content

The contents from the selected contractor’s proposal will become contractual obligations if a subsequent agreement is reached. Failure of the successful contractor to accept these obligations may result in cancellation of the award and such contractor may be removed from future solicitations.

Acceptance Time

The County intends to make a proposal selection within one-hundred and twenty (120) business days after the closing date for receipt of proposals.

Budget/Pricing

Proposals should illustrate the cost of each product and/or service on a stand-alone basis. If there is any cost advantage or credit available by combining two or more of the products, please detail the advantages, credits and provide the rates for each product if purchased on a package basis. Suppliers may respond to any one or all the requested services or coverages by responding to the appropriate sections of this RFP. Suppliers interested in responding should follow the outline of the RFP as described in Part II – Proposal Content.

While non-complying proposals may be considered, failure to provide written response to items indicated in the RFP may be interpreted by the County as an inability by the supplier to provide the requested services or functions. All cost proposals must remain in effect for one-hundred and eighty (180) business days. See

Appendix B - Current Medical SPD, summary of benefits, and program details and Appendix C – Census information.

PART II – PROPOSAL CONTENT

The proposal submitted must clearly address the requirements outlined in the RFP. Any concerns that the contactor may have about meeting these requirements shall be specifically identified in the proposal. ALL contractors must respond to Section 1 – General Info and all other sections appropriate to the product(s)/service(s) being offered.

Proposal Requirements

A. Cover Letter

The letter should include an introduction of the contractor’s company, the name, address, telephone number, fax number and e-mail of the person to be contacted along with others who are authorized to represent the company in dealing with this RFP. Any other information not appropriately contained in the proposal itself should also be included in the letter.

B. Executive Summary

An executive summary will briefly describe the supplier's approach and clearly indicate any options or alternatives being proposed. It should also indicate any major requirements that cannot be met by the supplier.

C. Detailed Discussion (Q&A)

This section will constitute a major portion of the proposal and brief and concise responses for each section in this RFP are required. Detailed discussion responses to this RFP must be submitted in MS Excel.

Outline numbers should correspond, in order, to the section numbers contained in this RFP. Failure to provide a written response to items indicated in this RFP will be interpreted by the County as an inability by the supplier to provide the requested product, service, or function. See Appendix D – Q&A for detailed discussion section of RFP.

D. Cost Proposal

The contractor must submit a detailed cost proposal allowing these to be evaluated independently of other criteria in the proposal. All products and/or services should be rated separately on a standalone basis;

however, if a package discount is available, please include the packaged rates as well.

E. Financial Reports and Ratings

Copies of ratings by services such as A.M. Best, Standard and Poors, Moody, etc. must be included. The contractor shall also furnish a copy of the annual audited financial report for the company's most recent fiscal year.

F. Miscellaneous

Miscellaneous additional information and attachments, if any, may be submitted by the contractor.

G. References

If selected as a finalist, contractor shall provide at least five (5) references for customers which have received services similar to those required by the County. Include business name, address, phone number and contact person for each reference. The County reserves the right to contact or visit any of the contractor’s current and/or past customers to evaluate the level of performance and customer satisfaction.

PART III – PROPOSAL EVALUATION AND SELECTION

The County intends to engage the most qualified contractor or multiple contractors for these services while minimizing the costs to the County. Responsiveness to the RFP will be a principle basis for evaluation. Proposals shall provide a straightforward and concise presentation adequate to satisfy the requirements of the RFP. The proposal should clearly express the contractor's understanding of the County's specific requirements, indicating the contractor's qualifications to conduct this service in a thorough and efficient manner.

Failure to disclose a conflict of interest is a misdemeanor criminal offense under Colorado Law. Such conflict may arise if any public official exercises any substantial discretionary function in connection with a government contract, purchase, payment or other pecuniary transaction without necessary disclosures as defined by Colorado

Revised Statutes (C.R.S.) Section 18-8-308 as amended.

Selection Process

A. The County reserves the right to reject any and all proposals, to consider alternatives, to waive irregularities and to re-solicit proposals.

B. The County reserves the right to conduct such investigations of, and discussions with, those who have submitted proposals (“Proponents”) or other entities as it deems necessary to assist in the evaluation of any proposal or to secure maximum clarification and completeness of any proposal.

C. All proposals submitted must be valid for a minimum period of one-hundred and eighty (180) business days after the date of the proposal opening. Each Proponent must submit with the proposal a list of all subcontractors, independent contractors or sub-consultants employed or proposed to be employed by the

Proponent in the performance of the contract.

D. Selection of a contractor will be made at the sole discretion of the County. The County may consider the following criteria when evaluating proposals that includes but is not limited to:

i. Claims Cost Savings/Discounts

Demonstrated discounts available to the Plans and Members as appropriate, as shown through the required re-priced claims data and/or demonstrated available discounts, combined with access and choice of providers. See Appendix E - Paid claims data for re-pricing analysis and Appendix F -

Claims experience and budget history.

ii. Direct Provider/Network Contracting Ability

Ability to provide choice and access to the employee population of the County as appropriate through

Direct Provider Contracts and other appropriate wrap networks.

iii. Administrative Costs

The County will initially review and score administrative costs from insurance carriers offering services under an Administrative Services Only (ASO) arrangement separately from the administrative costs proposed by third party administrators offering services under a Third-Party

Administrator (TPA) arrangements. Once completed, finalists from each category (ASO & TPA) will be further reviewed and rescored as part of the final analysis by the institution.

iv. General Services

a. Ability to provide the services, reports, administration, and all that is expected by the County, that, in the sole opinion of the County, will be in the best interest of the County.

b. Administrative capabilities: demonstration of ability to administer the program(s) in the manner required by the County.

c. Reporting capabilities: demonstration of reports and options available to the County to obtain data and information needed by the institution to properly design, manage, and ensure compliance of the program(s).

d. Service capabilities to the County: how the supplier will provide the required services to the institution regarding their concerns, issues, and questions.

e. Service capabilities to the participants: how the supplier will respond to participant questions and concerns, how will the employee interact with the supplier.

v. Experience, Past Performance, and References

a. The quality, experience, and performance of the requested functions and services as demonstrated by the responses to the RFP and may be further enhanced through discussions with references provided by finalists.

b. The list of at least 10 Public Entities, Hospital, and/or private corporations of comparable size to the County, who use services similar to those being requested in this RFP will be reviewed.

c. Upon notification of being a finalist, suppliers should be prepared to provide at least five references of customers that have used services similar to those requested by the County as detailed in this RFP. Reference may be contacted by the County to discuss their experience with the contractor, including, but not limited to, the implementation process, problem resolution, and overall feeling of the reference regarding the relationship with the supplier.

E. Contract negotiations will take place with the most qualified contractor or contractors. The County reserves the right to incorporate specific contract provisions into the Proponent’s standard contract if the County’s standard contract cannot be used. Such provisions include but are not limited to insurance and indemnification provisions and governmental immunity provisions. If a contract cannot be negotiated, the negotiations will be terminated in writing and negotiations will begin with the next most qualified contractor.

PART IV – PROJECT DESCRIPTION

Introduction

Summit County Government, CO (“the County”) is requesting quotes from qualified medical plan administrators.

The County currently uses a medical TPA for its medical program administration. These services include but are not limited to medical claims adjudication with direct provider network contracting (approximately 140 direct contract that will require re-establishment) and leased network pricing, as well as coordinating the integrations for other vendor partners (e.g., Stop Loss, PBM, telehealth, data warehousing, etc.). The County has a robust benefit strategy that includes a variety of carve-out programs including PBM, specialty PBM carve-out, stop loss, data warehousing, telehealth, etc. The County is looking for a contractor or multiple contractors that can demonstrate timely and accurate plan administration with a highly customizable benefit solution.

For pricing reference only, the client has approximately 497 enrolled employees and total membership of 946.

Please assume standard claim and utilization assumptions for this size customer.

About the County

Summit County was established in 1861 and is in the Colorado Rockies. The County services an estimated population of 27,994 residences. The County is home to several world-class ski resorts and is an ideal year-round outdoor recreation destination. Summit County is located about one hour from the Denver metropolitan area.

The County has a history of stability with suppliers; the current suppliers are aware of this request for proposal.

The County is reviewing the market and is seeking to enter into an agreement(s) with suppliers that can provide excellent customer support and quality administration of programs, as outlined in this RFP.

For additional general information about Summit County please visit the County's homepage at https://www.summitcountyco.gov/ https://www.summitcountyco.gov/

About the County’s Plan

As a self-funded plan sponsor, the County is a participating member of the Peak Health Alliance (“Peak”), a

501(c)(3) nonprofit organization. Peak’s primary responsibility is to analyze the cost of care within various communities and investigate the willingness of hospitals, physicians, and other care providers to accept lower rates based on community needs. Peak is prohibited from bearing risk and cannot hold any fiduciary responsibility or legally binding contracts with providers. As such, Peak is limited in its scope of responsibilities to its members.

Peak’s primary duties are to complete cost-of-care analysis, approach hospitals, clinics, and providers, and confirm their willingness to accept discounted rates. Once the acceptable rates are confirmed, Peak documents the agreed-upon rates, referenced here as “The Rate Sheet.”

Peak then provides the Rate Sheet to participating Plan Sponsors (Peak members) and/or their contracted TPA and/or claims re-pricer for actual direct contract development and claims repricing administration. The TPA and/or claims repricing partner will develop their own contract language and reference the Peak Rate Sheet for direct negotiations with the providers that have agreed to the negotiated rate structure.

Summit County uses these Rate Sheet listed providers as their “Tier 1” narrow network, with Aetna Signature as the wrap-around network called “Tier II.” It is expected that the TPA and/or claims re-pricer will re-establish the

Tier 1 network contracts on the County’s behalf and represent the County in ongoing direct contracting negotiations, regular contract maintenance, and compliance with subsequent federal and, if any, state compliance obligations, such as the Affordable Care Act, No Surprises Act, Consolidated Appropriations Act, Mental Health

Parity and Addiction Equity Act, HIPAA Privacy, etc.

Additionally, the County incorporates programs such as the Payer Matrix specialty carve-out. The County is interested in reviewing cost-savings programs. The preference is that these programs are currently integrated into your administration solutions, for example, infusion therapy, musculoskeletal/orthopedic, cancer, diabetes, maternity, etc. The overall goal of such programs is to balance plan savings while minimizing member abrasion and avoiding potential delays in care.

The current PBM is carved-out with Prime Therapeutics (previously MagellanRx). Stop Loss is currently with

Aetna for aggregate coverage and Skyward for specific coverage. Additionally, if a member is enrolled in the medical plan, the member is automatically eligible to register and receive service through CirrusMD. It is expected that the awarded contractor will integrate with eligibility feeds, deductible and out-of-pocket maximums, as well as stop loss reporting as required by the Stop Loss carriers.

The County’s is in the process of integrating an analytics warehouse, it is expected that the awarded contractor will assist with API data integration. If this type of integration is provided at an additional cost, this must be clearly disclosed in your cost proposal.

Service Expectations

The County is looking to award contract or contracts to bidder that have a dedicated customer service model.

It is expected that the County will have a dedicate service contacts. Please review the detailed discussion items of this RFP for additional service team model details.

APPENDICES AND ATTACHMENTS

A. HIPAA Business Associate Agreement – To receive a secure copy of Appendix C, E & F. Please sign and send the Appendix A – Business Associate Agreement to the attention of James Everett, james.everett@summitcountyco.gov, Deputy Director of HR.

Related materials will be returned to bidder via secure encrypted email.

B. Current Medical SPD, summary of benefits, and program details

C. Census information

D. Q&A for detailed discussion section of RFP

E. Paid claims data for re-pricing analysis

F. Claims experience and budget history mailto:james.everett@summitcountyco.gov