RFP for Claims Administration for the Self-Insured Preferred Provider Organization (PPO) Health Plans

The County of Orange Human Resource Services, Employee Benefits Department is soliciting proposals for comprehensive claims administration services for their self-insured Preferred Provider Organization (PPO) health plans. The Request for Proposal (RFP) seeks a qualified firm to administer four existing self-insured PPO health plans (two for employees and two for retirees) with potential expansion to High Performance Network (HPN) self-insured PPO health plans. The primary deliverables include claims processing, customer service, provider network management, utilization review, and disease management for approximately 5,600 employees and retirees. Evaluation criteria will encompass administrative capability, cost, network capabilities, performance guarantees, plan design compatibility, qualifications and experience, and responsiveness to RFP requirements. The RFP was released on February 15, 2024, with proposals due on March 15, 2024, by 4:00 PM Pacific Time. The initial contract term is three years, starting January 1, 2025, with potential renewal for up to two additional consecutive one-year terms. Qualified vendors must demonstrate experience with public sector clients, maintain a broad provider network in California and nationally, and ability to coordinate with third-party pharmacy benefit managers.

The RFP does not explicitly outline specific set-aside designations or restrictions on respondent types. The current claims administration is provided by Blue Shield of California, and the county anticipates transitioning to a new administrator. The existing infrastructure includes four health plans: Wellwise Choice, Sharewell Choice, Wellwise Retiree, and Sharewell Retiree, with medical expenditures totaling approximately $52.7 million in 2022. The county requires potential contractors to integrate with the existing OptumRx pharmacy benefits management system and be prepared to potentially implement plan design changes, including coverage for hearing aids, foot orthotics, fertility, and abortions. Vendor proposals must demonstrate robust cybersecurity protocols and compliance with healthcare regulations, with performance standards and potential penalties for administrative and service metrics. The comprehensive health plans cover both active employees and retirees, with varying enrollment tiers and demographic characteristics, including an average active employee age of 45.3 years and retiree ages ranging from 60.6 to 78.3 years.