Fully-Insured Medical Plans

The Washington State Health Care Authority is soliciting proposals for up to three fully-insured health plans per bidder under RFP 2025HCA5, with proposals due January 14, 2027. The five targeted jurisdictions are Franklin, Grant, Grays Harbor, Chelan, and Yakima counties. No set-aside or preference program is identified in the available documentation.

Plans must serve both the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs with identical designs across both groups. Acceptable plan types include Alternative Payment Models (APM), Exclusive Provider Organizations (EPO), Health Maintenance Organizations (HMO), and Preferred Provider Organizations (PPO). All plans must maintain a federal Actuarial Value between 80 and 92 percent and comply with standardized medical deductible and maximum out-of-pocket limits specified in Exhibit G. Plan A must match the Uniform Medical Plan (UMP) Classic design; Plan B and Plan C offer greater flexibility within specified parameters. Covered services include contraceptives, diabetes prevention, preventive care, hearing aids, doula services, and gender-affirming care; mental health parity compliance is required. Bidders must maintain NCQA accreditation, establish network adequacy in a minimum of two Washington counties, and participate in value-based purchasing initiatives with a goal to tie 90 percent of state-financed healthcare payments into qualifying value-based contracts. All administrative services, clinical decision-making, claims processing, and data storage must be performed within the United States. Bidders must comply with Bree Collaborative care transformation initiatives on Complex Discharge and Social Determinants of Health, submit data to Washington's All Payer Claims Database, and provide HEDIS measures stratified by race and ethnicity. AI governance requires 90-day advance notice for new system implementation and HCA prior approval for high-risk uses including claims processing and prior authorization.

The contract term begins January 1, 2027, with annual renewal through Request for Renewal processes. Bidders must submit completed mandatory attestations (47 requirements across operational categories), forms and certifications, a subcontractor list, service area coverage selections across all 39 Washington counties, and detailed claims data submissions in specified formats supporting actuarial analysis by Milliman. Proposals are submitted via the State of Washington's Managed File Transfer system. No contract value, pricing structure, incumbent carrier name, or evaluation weightings are specified in the available documents.