Tempe_Union_School_District_-_Medical_RFP_-_2026(6005777.2).pdf

SCOPE OF WORK/SPECIFICATIONS

BACKGROUND

Nestled in the Greater Phoenix area, the Tempe Union High School District is located in Tempe, Arizona and services approximately 11,000 students in six comprehensive high schools. The District encompasses 162 square miles and serves the City of Tempe, the Town of Guadalupe, the Gila River Indian Community, the Ahwatukee Foothills areas of Phoenix and parts of Chandler.

For purposes of determining final rates, all proposals should be submitted net of commissions. Segal is compensated through a consulting fee.

The District currently offers a choice of two self-funded medical plan options (BNN and BPN), bundled with pharmacy, through Banner Aetna to Active and COBRA employees and their eligible dependents. The District contributes 100% of the eligible employee premiums for the BPN plan.

Aetna also offers an eight (8) visit Employee Assistance Program (EAP) to all full-time and part-time, excluding substitute and seasonal, employees and their household members. The District pays 100% of the cost of the program.

PROJECT SCOPE

It is the intention of the District to continue to offer the current or a similar plan designs for the July 1, 2027 through June 30, 2032 plan years for:

Third-party Administrator (TPA) for the claims administration o Clinical Case Management o Network Access o Wellness programs

Pharmacy Benefit Management (PBM) bundled with Medical Employee Assistance Program (EAP)

In addition, the District is interested in potentially adding a third plan which would be a qualified High Deductible Health Plan (HDHP). A summary of the proposed HDHP plan is included in the financial workbook.

The following components should be included in your response to this section of the RFP:

1. ACCOUNT MANAGEMENT

• Provide a designated Account Manager and Account Management Team

2. CUSTOMER SERVICE

• Provide a designated call and claim unit with toll free telephone access.

• Provide customer service to answer inquiries on claims, eligibility, services, coverage, or other inquiries from participants Monday through Friday from 8:00 AM to 6:00 PM (AZ time)

• Provide prompt response to all telephone inquiries from plan participants and providers of service.

3. OPEN ENROLLMENT SUPPORT

• Prepare and provide Benefit Presentations in collaboration with the District

• Attend four (4) days of Annual Open Enrollment Meetings in Tempe, Arizona during normal business hours.

4. COMMUNICATION/EDUCATION SUPPORT

• Provide bilingual communication/educational materials

5. ID CARDS/BOOKLETS

• Coordinate and mail ID cards and policy summary/certificates to participants’ homes, (as applicable).

6. CLAIMS ADMINISTRATION

• Provide claims forms (as applicable)

• Determine benefits payable under the Plan, pursuant to the terms and conditions of the District’s

Benefit Plan booklets

• Receive claims and process payments of benefits in accordance with the plan designs for all claims incurred

• Correspond with participants if additional information is necessary to complete the processing of claims

• Coordinate benefits payable under the Plan and with other benefit plans, if applicable

• Provide notice to the Participants regarding the reason(s) for denial of benefits (which are denied) and provide for the review of such denied claims

• Provide an explanation of benefits resulting from claims transactions to plan participants

7. PROVIDER NETWORK

• Maintain a panel of participating providers to provide services to eligible plan participants.

8. ELIGIBILITY/ENROLLMENT ADMINISTRATION/NOTICES

• Accept eligibility from the District

• Administer eligibility based on the District’s eligibility criteria

• Provide access to an online enrollment maintenance system for the District staff

• Provide eligibility services, including, but not limited to, tracking and determination of disability for adult children approaching and over age

9. PHARMACY

Bidders are to offer comprehensive PBM services including, but not limited to, the following:

• Claims Adjudication

• Ability to Integrate PBM services with other vendors (e.g., Disease Management, Care Management, Medical), if applicable

• Eligibility Maintenance

• Patient and Provider Education

• Systematic Prospective, Concurrent, and Retrospective Drug Utilization Review

• Network Pharmacy Management

• Formulary Management and 100% Pass Through of Rebates Sharing

• Data Reporting (standard and ad-hoc reporting)

• Distribution of ID Cards and Pharmacy Directories

• Mail Service Pharmacy

• Specialty Pharmacy Program

• Complete Availability of IT services, including Online/Real Time Availability to the Fund and/or its designee(s)

• Pricing Administration

• Member Services, including quality and functionality of member website and mobile app

• Ad Hoc Reporting

• Clinical Programs

10. REPORTING REQUIREMENTS

Provide timely management reports or internet access to monitor financial and service level performance. Such reports must include the following information, as applicable based on type of coverage being provided:

MEDICAL and PHARMACY

Monthly

• Enrollment (subscriber/member) by coverage tier and status (active/COBRA), including reports by plan design

• Claims paid by status (active/COBRA) and in-network vs out-of-network split by plan design (Medical and Pharmacy segregated)

• Utilization Report, including In Patient Days per 1000, number of Admits per 1000, large claim reports by diagnosis, number of scripts, cost per script, and enrollment by age/gender

• Invoice and detail for each non-claim related expense

• Lag Report

11. SECURED INTERNET ACCESS

• Access to Enrollment/Eligibility Administration Portal for Employer

• Access to Claims Administration Portal for Employee to track medical and pharmacy claim history, compare medical service providers for quality and price, search for providers and print/request personal ID cards

• Employer and/or Designated Consultant access to Claims Data reporting portal

12. MEDICAL CASE MANAGEMENT, UTILIZATION REVIEW

Utilization Management (UM) including Precertification Services

• Oral Maxillofacial Surgical (OMFS)

• Pharmacy services, including Part B drugs

• Inpatient admissions and outpatient requests with medication codes on the NPL

• Inpatient/Outpatient chemotherapy requests with drug codes on the NPL

• Authorization of experimental or investigational treatments or devices

• Comprehensive (Comp) and Advanced Reproductive Technology Infertility (ART) services

• Transplant services

• Gender Affirmation Services

• Behavioral Health Outpatient/Inpatient services

• Appeals or grievances

• Travel* and Lodging reimbursement requests for Transplant, IOQ and Special Case Services

• Retrospective Review

• NICU admissions

• Predeterminations

Concurrent Review

• Determine the appropriateness and level of care for ongoing stays. Since most of the ongoing stays for the current network is contracted with a DRG reimbursement, concurrent review is established if a member moves to a lower level of care that is reimbursed on a per diem basis such as long-term acute care, skilled nursing, or inpatient rehabilitation.

Comprehensive Case Management (CM) Program

Core Services

• Personalized care coordination for high-risk or complex members

• One-on-one member outreach and engagement

• Assistance navigating the healthcare system

• Coordination between providers, specialists, hospitals, and the health plan

• Identification and closure of gaps in care

• Support for achieving member health goals

Clinical Support

• Complex condition management

• Chronic disease support

• Diabetes education

• Medication management and pharmacist consultation

• Behavioral health referrals and coordination

• Discharge planning and post-hospital follow-up

Social Determinants of Health (SDoH) Support

• Transportation assistance resources

• Food access resources

• Housing and community support referrals

• Addressing social and behavioral barriers to care

• Connecting members with local community programs

Additional Services

• Face-to-face member engagement when appropriate

• Home visits and inpatient visits for eligible high-risk members

• Coordination with local Banner Health providers and facilities

• Community-based support and local resource connections

Claim and UM Appeals

• Handle all levels of the Appeal Process for services provided. (no litigation)

12. DISEASE MANAGEMENT/WELLNESS PROGRAMS

• Care advocate team to proactively support high-risk participants.

• 24/7 nurseline

• 24/7 telehealth program providing diagnosis and treatment of

• Lifestyle and condition coaching via one-on-one phone support, online group coaching, and online information and resources concerning chronic conditions and lifestyle topics

• Health Risk Assessments and digital support

• Fitness related reimbursement and discount program

• Annual wellness allowance to use at the District’s discretion for wellness activities

13. EMPLOYEE ASSISTANCE PROGRAM (EAP)

• Provide thorough patient assessment, record-keeping and evaluation, on a short term basis with one-on-one EAP counseling for up to eight (8) visits (at no cost to the plan participant), including referral to an appropriate provider for necessary services, considering the plan’s network and benefit design.

• Provide 24-hour access to an EAP counselor qualified to assess and triage cases. Maintain this 24-hour service seven days a week, through a toll-free number, including telephonic crisis counseling.

• Provide education material to all enrollees eligible for the EAP (printing only, not mailing).

• Provide initial training for the District’s staff and appropriate managers and supervisors regarding the EAP program, proper referrals, early warning signs, problem employees, etc.

• Provide orientation meetings, as requested by the District, for eligible employees and their families.

MEDICAL

The current medical schedule of benefits and SBCs re attached as Attachment B1 and Attachment B2, respectively. Please note that the District is exploring the option of adding a third medical plan effective July 1, 2027. The plan would be a qualified high-deductible health plan, but final details of plan design are unknown at this point in time. Shown below is a three-year rate history of the medical plan (enrollment experience is available in Attachment B3):

Medical – Fee History

07/01/2024- 06/30/2025 07/01/2025- 06/30/2026 07/01/2026-06/30/2027

Administration Fee –

BPN (PEPM) $41.44 $42.98 $43.96

Administration Fee – Choice II (PEPM) $41.44 $42.68 $43.96

EMPLOYEE ASSISTANCE PROGRAM (EAP)

Shown below is a four-year rate history (utilization is available in Attachment B4).

EAP – Fee History

07/01/2023- 06/30/2025

07/01/2025- 06/30/2027

EAP Service Fee

(PEPM)

$1.60 $1.75

Please contact Khin Han at khan@segalco.com with a carbon copy (cc) to Rachel Calisi at rcalisi@segalco.com for the attachments and exhibits not contained in this document.

Since some of this information contains confidential data, you will be required to have a current (within last 5 years) executed Confidentiality Agreement or bid-related NDA on file with Segal to receive the documents which will be sent to you via secure email service. If you do not have a current executed Confidentiality Agreement or NDA on file with Segal, you will be sent the necessary form for completion and submission before the data will be released.