Sample RFP Pool

City of Somewhere
REQUEST FOR PROPOSAL

FOR MEDICAL, CONTINUATION OF COVERAGE, PHARMACY BENEFIT SERVICE, PRE/POST 65 RETIREE, DENTAL, VISION, LIFE/LTD/STD AND EAP BENEFITS
Proposals must be received by:

Date
TABLE OF CONTENTS
INTRODUCTION ........................................................................................................4 PRE-PROPOSAL MEETING ............................................................................................................................4 PROPOSAL FORMAT...................................................................................................................................4 PROPOSAL QUALITY AND EVALUATION.............................................................................................................4 PROPOSAL REVIEW....................................................................................................................................5 PROPOSAL INFORMATION AND DUE DATE.........................................................................................................5 SUBMITTAL REQUIREMENTS..........................................................................................................................5 PROPOSAL DUE DATE................................................................................................................................5 AWARD OF CONTRACT...............................................................................................................................5 PROPOSAL TIMELINE .................................................................................................................................5 STATEMENT OF OVERALL REQUIREMENTS..................................................................7 OTHER FACTORS
TO
CONSIDER.....................................................................................................................9
SPECIFIC REQUIREMENTS.........................................................................................11 ID CARDS...........................................................................................................................................11 BENEFIT PLANS......................................................................................................................................11 BILLING PERFORMANCE ............................................................................................................................11 ELIGIBILITY PERFORMANCE ........................................................................................................................11 PRIVACY REQUIREMENTS ...........................................................................................................................11 QUESTIONNAIRE .....................................................................................................12 GENERAL INFORMATION............................................................................................................................12 CLAIM AUDIT INFORMATION........................................................................................................................13 EMPLOYER ACCOUNT MANAGEMENT /SERVICES.................................................................................................14 CLAIM ADJUDICATION SERVICES ..................................................................................................................14 CLAIM ADMINISTRATOR BENEFIT INFORMATION.................................................................................................16 BENEFIT CUSTOMER SERVICE.....................................................................................................................17 TECHNOLOGY........................................................................................................................................19 UNDERWRITING .....................................................................................................................................19 HIPAA COMPLIANCE ..............................................................................................................................20 BUSINESS CONTINUITY.............................................................................................................................20 REPORTING...........................................................................................................................................20 TRANSITION PLAN...................................................................................................................................20 TERMINATION........................................................................................................................................20 ELIGIBILITY INFORMATION...........................................................................................................................20 CLAIM COST MANAGEMENT.......................................................................................................................21 BENEFIT ID CARD .................................................................................................................................21 MANAGED CARE NETWORK.......................................................................................................................22 MEDICAL CARE MANAGEMENT....................................................................................................................24 CONSUMER DRIVEN/CHOICE PLAN INFORMATION...............................................................................................25 WELLNESS BENEFIT MANAGEMENT...............................................................................................................26 PRESCRIPTION MANAGEMENT......................................................................................................................27 CONTINUATION OF COVERAGE .....................................................................................................................30 RETIREE BENEFITS..................................................................................................................................31 VISION BENEFITS....................................................................................................................................32 DENTAL BENEFITS..................................................................................................................................34 LIFE/LTD/STD....................................................................................................................................37 LIFE/LTD/STD CLAIM PAYMENT SERVICES...................................................................................................39 EMPLOYEE ASSISTANCE PROGRAM................................................................................................................41 EAP REPORTING...................................................................................................................................43 DEFINE THE FEE STRUCTURE ....................................................................................................................44
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RFP for Medical, Continuation of Coverage, Pharmacy Benefit Service, Pre/Post 65 Retiree, Dental, Vision, Life/LTD/STD and EAP Benefits Copyright 2011. All rights reserved. No part of this RFP may be used or reproduced in any manner whatsoever without express written permission.
RIGHT OF REJECTION ...............................................................................................46 NON-COLLUSION AFFIDAVIT .....................................................................................47 STATEMENT OF COMPLIANCE ...................................................................................48
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INTRODUCTION
This document contains information which is considered Confidential to Employer. This document may not be copied or reproduced without prior written consent and may not be disclosed to third parties. This information is to be kept in strictest confidence. The Employer provides employee benefits (medical, continuation of coverage, dental, vision, Life, LTD, STD and EAP). The Employer is a not-for-profit organization and is tax exempt.
Pre-Proposal Meeting
Proposal review personnel are available to meet with interested representatives of firms desiring to submit a proposal. During this conference, interested parties will have an opportunity to ask any questions they have about the services requested herein. This meeting may be set by appointment only. Meetings will be scheduled between Date and Date. Meetings will only be held in the Texas Municipal Center building located at 1821 Rutherford Lane # 300, Austin, Texas.
Proposal Format
Proposals submitted in response to these specifications should be submitted in the proposal format. The employer reserves the right to reject any or all proposals, waive any technicality, issue a subsequent Request for Proposal, cancel the entire Request for Proposal and remedy technical errors in the Request for Proposal. The RFP does not commit the parties into a contract, nor does it obligate the employer to pay any costs incurred in preparation, submission or presentation of proposals or in anticipation of a contract. Reservations The employer reserves the right to request clarification of any segment of any proposal, request any additional information concerning any proposal, or negotiate any term with the proposers. The employer also reserves the right to reject any or all proposals. Disclaimer Every effort has been made to ensure the accuracy of the information presented in this request for proposal. Prospective contractors are requested to review this data and take whatever steps they feel necessary to verify the information. While every precaution has been taken to ensure the accuracy of the data and information provided herein, the Employer cannot assume responsibility for any errors in its presentation, nor would the Employer be held accountable for any service cost increase based upon the statistical data contained herein.
Proposal Quality and Evaluation

Proposals should respond to the specifications and describe clearly the services to be offered. Employer will evaluate proposals. Vendors must specify all deviations from these specifications on the Statement of Compliance. It is understood that the proposal is in compliance except for any deviation(s) noted on the Statement of Compliance form. All records, member files, and miscellaneous data necessary to perform the services requested in this Request for Proposal (RFP) are and will remain the property of the Employer. These records contain confidential information and are not to be disclosed to any other party. Each vendor must sign the Non-Collusion Affidavit enclosed or the proposal will not be considered. In addition, the vendor must submit the required disclosure notices pursuant
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to Texas HB 914. Since multiple political subdivisions are participating in the RFP, multiple disclosure notices may be required. All proposals received from interested parties will receive a fair evaluation. While price is a paramount consideration, the Board will consider all applicable factors in determining which is the best proposal and to accept the most beneficial proposal. The Board reserves the right to reject any or all proposals, issue a subsequent Request for Proposal, cancel the entire Request for Proposal and remedy technical errors in the Request for Proposal process.
Proposal Review
Upon receipt of the proposals, Employer will review the proposals and select potential contractors with which to schedule interviews. After the Employer has reviewed the proposals and clarified questions about the proposals during discussions with the potential contractors, the Employer may schedule visits to offices of potential contractors to observe the performance of services as requested herein.
Proposal Information and Due Date

In the event that it becomes necessary to revise any part of this Request for Proposal (RFP) or that additional information is required to enable adequate interpretation of this document, an attempt will be made to notify all known prospective vendors. However, it will be the responsibility of each vendor, prior to submitting a proposal, to ascertain, if they have received all issued addenda. All questions must be received no later than Date. Employer will respond to all questions via email and will provide all interested vendors a weekly questions and answers proposal update.
Submittal Requirements
RFPs will not be considered unless the RFP is fully completed. Pencil submittals will be rejected. Alterations and illegible submissions may not be considered.
Proposal Due Date

Proposals are due by time p.m. CST Friday, Date. Three (3) copies of all proposals should be submitted to the following: Employer: Attention: Address: In addition to the hard copies, an electronic copy of the proposal will be required. Please submit the electronic copy to the following email address:
Award of Contract
A contract will be awarded only after Employer has determined that a potential contractor can provide the quality of service desired. Employer hopes to select a contractor for the services requested herein by Date.
Proposal Timeline
For your reference the enclosed timetable as a proposal review timeline guide. April 1-20, 20XX Pre-Proposal Meetings with Vendors April 20, 20XX Vendor Questions due to Employer April 27, 20XX Proposal Due Date
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May 15, 20XX May 15, 20XX May 16, 20XX October 1, 20XX Plan Years
Proposal Committee Review Award of Contract Conference Calls with Vendors Initial Effective Date and Thereafter for Appropriate
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STATEMENT OF OVERALL REQUIREMENTS

The proposal shall be signed by a person authorized to legally bind the vendor with the understanding the proposal submitted shall remain firm for acceptance for a period of sixty (60) days from the date and time of the proposal opening, and shall be valid for the period 10/01/11-09/30/12; 10/01/12-09/30/13 and 10/01/13-09/30/14. Vendor must be authorized to do business in the State of Texas. All proposals shall be quoted net of any commissions. Commissions shall not be paid by the Political Subdivision. If any commission fee or other reimbursement arrangements are paid to any individual or company, they must be disclosed in the proposal as to who is paid and commission amount. Political Subdivisions are exempt from premium taxes and, therefore, premium taxes should not be included in any proposal. In the event that it becomes necessary to revise any part of this RFP or that additional information is required to enable adequate interpretation of this document, an attempt will be made to notify all known prospective vendors; however, it will be the responsibility of each vendor, prior to submitting a proposal, to ascertain they have received all RFP Addendums. This RFP does not commit the Employer to enter into a contract, nor does it obligate them to pay any costs incurred in preparation, submission or presentation of proposals or in anticipation of a contract. Services are to include annual education/enrollment meetings with all employees. Define education for new enrollments. At completion of enrollment the Employer is to receive a master payroll deduction list that includes age, benefit amount and premium for employee and dependent, if applicable. Include the following documents in the proposal Schedule of Benefits being proposed Benefit Book/Plan Document being proposed Sample Identification Card for Medical, Rx, Dental, Vision Network Coverage Consumer Driven/Consumer Choice Plan Options with/without Debit Card Access A list of benefits that have calendar/lifetime limitations A list of benefits that are excluded from coverage A list of benefits that are paid at 100% with no copay or deductible penalty Sample Wellness Benefit communication materials Sample of the Wellness Benefit Incentive Program Sample Onsite Enrollment/Education Materials A sample of your Online Enrollment Procedures and/or paper procedure Fee schedule for all services included in your proposal Business Continuity Plan and Test Results of Business Continuity Plan Network Coverage Area Pharmacy Benefit Management Services Pre and Post Sixty-Five Retiree Benefit Options Life, AD&D, LTD and STD Benefits Supplemental Benefit Options: Critical Care, Cancer, Accident, EAP and/or other options
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Underwriting Procedures and Rate Distribution Schedules. Renewal rates must be received at least 60 days prior to renewal date HIPAA Title I, Title II compliance and tracking of Security Breach information
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Other Factors to Consider

1. 2. General Benefit Plan Characteristics Effective Use of Technology A. Daily Electronic Data Interchange within 24 business hours performance guarantee B. Within 24 business hours the eligibility information will be available for benefit access C. Daily file upload for employee eligibility and terminations D. Interface with supplemental benefit vendors Define the Account Management Team including the experience of assigned team members and service levels provided Ease of contracting process as well as the transparency of the contract, including vendors willingness to disclose all revenues from supplemental benefits. Service Statistics A. Claim Adjudication Process a. Claim Turnaround Time b. Claim Procedural Accuracy c. Claim Financial Accuracy d. Subrogation Services e. Claim Audit Procedures System Audits Internal Audits External Audits Specialty Clinical Audits B. Customer Service a. Abandonment Rate b. Talk Time c. Response Accuracy d. Manned Hours e. 1.800 number access f. Bi-Lingual Support C. Security Audit a. Administrative b. Physical Medical Management/Clinical Programs A. Notification B. Concurrent Review C. Discharge Planning D. Intensive Care Management E. Professional Health Coaching F. Population Health Engagement Management a. Disease States Managed b. Stratification c. Supportive Covered Individual Intervention Techniques d. Participation Management e. Behavior Change Tracking for Population Health Engagement Pricing on a Voluntary, Contributory and/or Mandatory Basis
3. 4. 5.
6.
7.
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8.
9. 10.
11. 12. 13.
Web Based Services A. Web wellness portal B. Provider Access to Covered Individual Eligibility and Benefits a. Web IT b. Phone/Fax IT Performance Guarantees Management Reporting A. On-line claim information and eligibility reports B. Ability for month end reporting to be delivered electronically C. On-Line Debit Card Information D. On-Line Network Information E. On-Line Enrollment F. On-Line Supply Request Implementation Timeline Privacy and Security Policies and Procedures Notification regarding Breech of Protected Health Information
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SPECIFIC REQUIREMENTS
ID Cards
The selected vendor must agree to both: Allow the opportunity for the political subdivisions claim administrator to print an ID card with all benefit information (Medical, Dental, Vision, PBM, EAP) or maintain a separate card through their vendor of choice. Both options must be available per employer. Print custom ID cards for the participating political subdivisions. ID card printed by the vendor must conform to state and federal laws regarding the prohibition on the use of unique identification numbers on ID cards and other printed materials. Enclose a sample ID card.
Benefit Plans
The selected vendor must agree to provide benefit information before the plan year per employer choice of paper or electronic. Employee confirmation of receipt of benefit information is required from the Employer. Enclose sample Benefit Books and Schedule of Benefits.
Billing Performance
Billing must be from the first of the month to the end of the month. An electronic bill must be available to the group. The bill will identify the eligible individuals per each benefit. If a standard file layout for such a transmission is available, please include this in the proposal.
Eligibility Performance
It is anticipated that the eligibility information will be transmitted electronically. It is preferred to have real-time updates to the eligibility data once a file is received and loaded into the vendors system. At most, the turnaround time of data transmission and implementation will be required within twenty-four hours of transmittal. Eligibility acceptance and any error reports must be transmitted back to the source of the file, or other identified party. It is preferred to have a unique ID number for each covered member. In addition to the assigned UID, the selected vendor must be able to store the SSN of each participant and to provide a crosswalk between the UID and the SSN so that members records can be retrieved using their SSN.
Privacy Requirements
The selected vendor must agree to comply by all applicable privacy laws, including the expansion of HIPAA Title I and II, active maintenance of Business Associate agreements with all participating vendors. No claims or other information regarding covered individuals will be permitted to be disclosed to any third party, such as pharmaceutical manufactures for marketing purposes. If the selected vendor processes credit/debit card payments, the vendor must comply with all application laws regarding the privacy and security of the credit card or other financial data that will be processed by or reside in your systems, website or other media of the vendor. Any unauthorized disclosure of credit/debit card information must be reported to the member as required by law.
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QUESTIONNAIRE
General Information
1. Name A. B. C. D. E. of Company: Address: Phone Numbers including toll free: Web Site/email Address: Fax Number: Contact Person:
2. 3. 4. 5.
Who owns the company? Provide a brief ten-year history of your companys business philosophy, growth and benefit services. Brief ten-year history regarding the average medical and prescription rate increase in Texas. If applicable, describe the organizational relationship between your organization and the parent company. Is your company independently owned or affiliated as either a subsidiary or division of some other organization?
6.
Is your company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. How long have the proposed medical benefits been available in the State of Texas? Is your company outsourcing any of the services included in this proposal? When did your company begin administering the benefits included in the proposal? Is your company licensed to do business in the State of Texas? Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. What are the standard hours of customer service? Enclose a copy of your E&O Insurance Certificate. Enclose a copy of your General Liability Certificate. Enclose a copy of your most recent Financial Statement. Enclose a copy of your most recent claim audit.
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17. 18. 19. 20. 21. 22. 23.
Enclose a copy of your most recent security audit. Enclose a copy of your Business Continuity Plan. Enclose a copy of the most recent test results of your Business Continuity Plan. How many complaints are on file against your company with the Texas Department of Insurance in Texas for calendar year 2010? Is your company currently involved in any litigation as a defendant over any benefits? Please identify if any association endorses your benefits or services. Provide three Texas political subdivisions that you provide employee benefits for.
Location # of Employees
Name of Company
24.
Please provide three Texas political subdivisions that have terminated business with your company.
Name of Company
25.
Are there any other services that you or your agency would be willing to provide that are not shown in these specifications?
Claim Audit Information

1. 2. 3. 4. 5. 6. 7. Describe your system claim audit function. Describe you internal claim audit procedures. Describe your internal customer service audit procedures. Describe your internal billing and eligibility audit procedures. Describe your internal Network Repricing audit procedures. Include the most recent external financial audit for your company. Include the most recent external claim audit for your company.
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8. 9. 10.
Include the most recent SAS 70 audit for your company. Include the most recent external security audit for your company. Include the most recent 12 months internal claim audit results for your company. A. Turnaround Time B. Financial Accuracy C. Procedural Accuracy Include the most recent 12 months internal customer service audit results for your company. A. Abandonment Rate B. Talk Time C. Quality of Call D. Seconds to Answer Does your customer service A. Include e-mail customer service? B. If yes, what is the most recent turnaround time for e-mail customer service? Include most recent 12 months of Billing and Eligibility audit results for your company.
11.
12.
13.
Employer Account Management/Services

1.
Provide a copy of an on-site employee education presentation regarding medical, prescription, dental, vision, life/LTD/STD, early retiree and >65 retiree benefits. Identify the service team of personnel, tenure with the company and functional area responsibilities that would be designated to this account.
Services provide to Employer and/or membership Frequen cy of Contact
2.
Name
Functional Area of Expertise
Title
Tenure with Company
3.
If your company is chosen as the administrator, will you be able to provide enrollment materials within three weeks of notification for each plan year? Does your company provide onsite claim look up and education meetings for employees and their dependents?
4.
Claim Adjudication Services

1. How many claim analysts will be assigned to this account?
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2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22.
What is the minimum amount of experience your company requires to process and release claims for payment with little to no supervision of upper management? What is the minimum acceptable processing and financial accuracy that is acceptable to you for all claims adjusters? Does your company auto-adjudicate any medical claims? (If yes, what percentage is currently being electronically paid?) What is your standard turnaround time? What percentage of your business is currently being processed within standard? What will your company do to increase the percentage paid within goal time? Does your claim system check for duplicate charges? What is the criterion used for the duplicate checks? Does the claim system check for bundling/unbundling claims? What criteria are used? Describe the process for appeal of a contested claim. Describe your procedure(s) for Co-ordination of Benefits when your plan(s) are considered as the secondary carrier. Does your company provide a monthly paid claim summary? What system is used for claim adjudication? Is there an upgrade or plan to change claim adjudication systems in the next twelve months? What percentage of claims paid <30 days, 31-60 days, 61-90 days and >90 days? Enclose a sample copy of an Explanation of Benefits. Will the Explanation of Benefits be available in other languages besides English? Define the Percent of Turnover in your Claims Department. Describe you claim adjudication process. Where will claims be paid? How do you track pended, suspended and held claims? How do you monitor benefit accumulator information?
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23. 24. 25.
How do you comply with the prompt pay guidelines? Do you require a claim form to be completed by the employee, doctor, and/or hospital? If so enclose a copy of the claim form. Does your company outsource the claim adjudication function? If so, please define.
Claim Administrator Benefit Information

1. 2. 3. 4. 5. Describe the educational meeting provided to the employee population. Define the frequency of the educational meeting information and if multiple meetings may be held due to the shifts employees work. Define coverage for vaccines/immunizations and age/gender criteria? How does your company comply with State mandates? How does your company comply with the Patient Protection Accountable Care Act (PPACA) Healthcare Reform mandates? Define your PPACA compliance or your grandfather clause implementation. What benefits are paid at 100% of the network price? What benefits have calendar, dollar, visit and lifetime limitations? Describe the pre-existing limitation benefit. How do you recognize creditable coverage? What is the Other Insurance Procedure? What is the Right of Recovery Procedure? Define your Coordination of Benefit Procedure. How do you integrate/coordinate with Medicare for disabled individuals? How do you integrate/coordinate with Medicare for End Stage Renal individuals? How to you interface with Medicare in regards to the Medicare Secondary Payer regulations? Do you interface Medical only or Medical and Prescription? Provide a list of excluded/calendar or lifetime limited benefits. What services are included under your Wellness Benefit Program? Define your procedure for second opinions. Does you plan implement a no loss/no gain procedure during the transition?
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6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.
Describe your procedure for handling appeals, denied claims and/or disputed claims. Define your procedure for covered individuals request for the external appeal process. Will you honor deductibles that have been satisfied for the current calendar year and what evidence would employees need to furnish? How do you cover sick baby services at time of birth? How do you cover well baby services at time of birth? Do you implement a mandated waiting period? Describe your morbid obesity benefit. Include a copy of the pertinent schedule of benefits. Describe the management of unproven/experimental benefits. Define the actively-at-work provision. Define the no loss/no gain provision. Do the medical benefits require voluntary, contributory and/or mandatory subsidy. 32. Are the benefits provided at a voluntary, contributory, mandatory employer option?
Benefit Customer Service

1. 2. 3. 4. 5. 6. Does your company provide a 1-800 customer service line at no additional charge? Identify the multi-lingual services your customer service department can provide to the employee/dependent population. What are the hours of operation for your customer service department? Do you have a tracking system to log-in customer service calls and content of customer service calls? Do you record any calls? If so, what percentage? Identify the specific services and information an employee, dependent and provider could expect during a customer service call: A. Notification B. Eligibility C. Benefit Information D. Claim Status
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E. F. 7. 8.
Network Information Out of Pocket Expenses
What is the ratio of customer service representative to 1,000 members? Is the same number used for customer service, billing and eligibility, medical management, network information, patient advocacy and complaints? Does your company have a service for handling calls after standard business hours? Please define. Will there be a dedicated customer service unit? Does your company outsource Customer Service? If so, please define. A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of Vendor I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
Name of Company Location # of Employees
9.
10.
11.
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V.
Provide three Texas political subdivisions that have terminated business with the company.
Name of Company
W.
Technology
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Does your company provide an on-line enrollment service? Please describe and identify if there is an additional fee for this service. Does your company provide access to a web wellness portal? Please describe and identify if there is an additional fee for this service. Is your company compliant with 835 and 837 claim administrative functions? Does your company provide for on-line eligibility look up? Is your company compliant with the timelines in regards to the HIPAA transition from 4010 to 5010 guidelines? Does your company provide Phone/IT eligibility fax correspondence? Does your company provide e-mail customer service? If so, what is the guarantee of turnaround time on e-mail customer service correspondence? Does our company pay providers electronically? Does the website have access to provider grade point system? How does the eligibility information get transferred to any outsourced vendors? What is the security guarantee of the transition of protected health information to outsourced vendors
Underwriting
1. 2. 3. 4. 5. What is the percent for operating expenses in your company? Define your underwriting formula for manual rate development? Define your underwriting guidelines regarding medical and prescription trends. Define your companys utilization of the manual rating procedure, claim utilization and predictive modeling information. Are the rates your company is quoting guaranteed for twelve months?
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6. 7.
Do the health rates include IBNR (Incurred but not reported) reserves? Do the health rates include IBNR and the Lag Report reserves?
HIPAA Compliance
1. 2. 3. 1. 2. 3. Define the Plans Compliance with HIPAA Title I Define the Plans Compliance with HIPAA Title II How are employers notified of a HIPAA breach? Enclose your Companys Business Continuity Plan. Enclose copies of the tests you have conducted or will conduct on your Business Continuity Plan. Enclose the last audit conducted regarding the functionality of your Business continuity Plan.
Business Continuity
Reporting
1. Enclose samples of monthly, quarterly and annual reporting information
Transition Plan
1. 2. 3. Please include the transition/implementation plan with functions and dates that will be required. Do you provide an implementation team? What minimum amount of notice time would be required for your Company to meet the employers Plan Year effective date?
Termination
1. 2. Does this proposal include run-out services? If so, is there an additional cost? Upon termination will you provide claim information and high dollar (>$10,000) utilization information, diagnosis and prognosis for the proposal process?
Eligibility Information
1. 2. 3. Are eligibility/billing reporting available on-line to Human Resource Staff? Does your eligibility system have the ability to run reports per civil servants and civilians? Define eligibility guidelines for: A. Active Employees B. Dependents C. Dependent Children
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D. E. F. G. H. 4. 5. 6. 7.
Dependent Spouse Grandchildren Early Retirees Retirees Survivors
Describe your ability to bill employer, the employee, or split bill the employer and the employee. Describe your ability to bill the employer, the employee, or split bill the employer and employee for Continuation of Coverage, Pre/Post Sixty-Five Retirees. Does your company provide on-site enrollment assistance? If so, please define. Does your company outsource the Eligibility Management function? If so, please define.
Claim Cost Management

1. Does your company provide access to tiered, provider network, fee negotiation and/or patient advocacy services? A. Premium: B. Preferred: C. Out of Network: D. Secondary Network: E. Professional Negotiations: F. Patient Advocacy: How do you establish usual and customary or reasonable and customary information? When are usual and customary or reasonable and customary information implemented. Does this proposal include run-out services? If so, is there an additional cost? Does you proposal deduct an employees previous covered and paid medical expenses from you maximum calendar and lifetime benefits? Define your overpayment collection services and frequency of reporting to the employer regarding collection efforts. Once, overpayment funds are collected, how are they applied? Does your company outsource claim cost management? If so, please define.
2. 3. 4. 5. 6.
7.
Benefit ID Card
1. 2. What is the average turnaround time for supplying ID cards? Are the cards mailed to the employer or the covered individual?
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3. 4. 5.
Do the ID cards include medical and prescription information or do you provide two separate cards? Are Benefit Books and ID cards customized for the Employer? Identify cost (if applicable) for annual ID cards and replacement ID cards.
Managed Care Network

1. 2. 3. 4. 5. 6. 7. 8. 9. Where is your primary place of business? Is your network accredited by NCQA and/or URAC or neither? How many member lives do you service in the Dallas market? Is your network National? If your network is not national, do you have a network wrap for access to healthcare outside the State of Texas? Will you add providers per the employers request? If so, describe the process. Who reprices the network claims? Describe the workflow process for claim adjudication once the claim is received electronically or by mail. Are there any network centers of excellence? Describe by provider specialty category. What A. B. C. D. E. F. G. type of contract do you have with the providers? DRG Per Diem Case Rate Percentage of Discount RBRVS CPT code specific Other
10. 11. 12. 13. 14. 15.
Provide a Provider Network geo access report. By Geo access, identify the number of primary care physicians, specialists and hospitals per zip code. What is the network stability over the last three years? What is your average discount in the Texas Market place by county, region and/or zip code? How is the employer notified of provider network changes? Enclose the most recent paper provider directory.
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16.
Describe the network credential process and average timeline for a provider to go through the contracting and credentialing process. What is the average discount received in the Dallas Market? Does your company outsource the Network services? If so, please define and respond to the following information: A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of Vendor I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is the company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
17. 18.
V.
Name of Company
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W.
Medical Care Management

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Define your standard benefits that required pre-certification/notification. Define the penalty for no pre-certification/notification information. Define your Intensive Care Management Program. Define your Professional Health Coach Services. Define your Population Health Engagement Services and how the population health engagements are measured, monitored and reported to the employer. Define your nurse lines and hours of service. Identify your NCQA/HEDIS scores state and national. Do you employee a MD medical advisor/consultant? If so, defined the role. How do you handle complicated Specialty Medical Reviews? Do you outsource your Medical Management Services? If yes, please describe how the services are integrated into the claim system. Define your multi-lingual Medical Management Services? If an External Vendor provides the Medical Care Management Services, please complete the following: A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of Vendor I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the medical management services included in the proposal? L. Is the company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service?
Page 24 of 48
11.
12.
O. P. Q. R. S. T. U.
Enclose a copy of the E&O Insurance Certificate. Enclose a copy of the General Liability Certificate. Enclose a copy of the most recent Financial Statement. Enclose a copy of the Business Continuity Plan. Enclose a copy of the test for the Business Continuity Plan. Is the company currently involved in any litigation as a defendant over any benefits? Provide three Texas political subdivisions that they provide employee benefits for.
Name of Company
V.
W.
Consumer Driven/Choice Plan Information

1. 2. 3. 4. 5. Define and include a sample of your standard Section 125 Plan with associated costs. Please indicate whether this is paper or debit card accessed. Define and include a sample Health Savings Account Plan with associated costs. Please indicate whether this plan is paper or debit card accessed. Define and include a sample Health Reimbursement Account Plan with associated costs. Please indicate whether this plan is paper or debit card accessed. Define and include a sample Retiree Reimbursement Account Plan with associated costs. Please indicate whether this plan is paper or debit card accessed. In the A. B. C. D. E. F. G. H. I. J. definition of each plan please include information pertaining to: Annual Enrollment Procedures New Hire Procedures Qualifying Event Procedures Tracking and Reporting Utilization Transaction, fund balances Is information regarding account activity available on-line? Document the pre/post tax procedures for each plan. Document compliance with the Internal Revenue Code. Define if monthly, quarterly, annually reports are submitted to participants pertaining to account activity and fund balances. Identify correspondence due to ineligible purchases. Identify required documentation for purchases using a consumer driven plan.
Page 25 of 48
6.
I.
Does your company outsource the Consumer Driven Plan Management Function? If so, please define. A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of Company Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Name of Company
W.
Wellness Benefit Management

1. Define your Wellness Program and Services.
Page 26 of 48
2. 3. 4.
Identify the plan and employee/dependent out of pockets cost in accessing the Wellness Benefit Program. Do you provide access to discounts for wellness services that are not covered under the benefit plan (ie Gym membership, Alternative Medicine Services, etc.)? Does your Wellness Program include an incentive package for Population Health Engagement?
Prescription Management
1. Is the Pharmacy Benefit Manager (PBM) outsourced to an external vendor? If yes, answer the following questions: A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Location
Page 27 of 48
Name of Company
# of Employees
W. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Identify the PBM network options. Please note if the PBM offers a value tiered network option. Enclose current Texas Network. Identify if the PBM includes a value tiered option. Identify the AWP Discount Per plan, network options and type of prescription. Define access to Over the Counter, formulary, generic, brand, and biotech prescriptions. Provide a schedule of benefits identifying eligible and ineligible prescriptions. Define the source the retail and mail order AWP is derived. Define the MAC List Repricing Component. Define your prior-authorization procedures and what prescriptions require priorauthorization. Define the procedure and the prescriptions accessed through a step-therapy program. How is the formulary developed and managed? Define the administrative, dispensing fee costs. Define the rebate refund process. How is the biotech/specialty list of prescriptions developed and managed? How will the mail order prescriptions be transitioned to the new vendor to minimize disruption? Define the education process for employees to be educated on more cost effective prescriptions. Identify the Prescription Benefit Managers customer service hours? Is the Pharmacy Benefit Manager National? Enclose sample reports that would be distributed: A. Top Prescription Utilization Report
Page 28 of 48
B. C.
D.
Top Dollar Prescription Report Retail Utilization a. Generic Utilization b. Formulary Utilization c. Multi-Source Utilization d. Brand Utilization e. Biotech Utilization Mail Service a. Generic Utilization b. Formulary Utilization c. Multi-Source Utilization d. Brand Utilization e. Biotech Utilization
21. 22. 23. 24. 25.
Identify the PBMs Substitution Stats for the most recent 12 month. Does the plan limit extended release prescriptions? Enclose a retail and mail service schedule of prescription benefits. Does the plan offer retail maintenance purchase options? Define your recommendations on managing Therapeutic class categories.
Category Top Drugs Cost Management Recommendations Cholesterol Lowering Lipitor, Crestor, Vytorin Anti-ulcer Nexium, Prevacid Antidepressant Lexapro, Cymbalta, Effexor Antihypertensive Avapro, Cozaar Antidabetic Actos Anti-asthmatic Advair Diskus, Singulair Analgesic anti- Celebrex, Enbrel, Humira, inflammatory Orencia Misc. Endocrine Fosamax, Boniva, Actonel, Metabolic Forteo Anticonvulsant Topamex, Lamictal, Lyrica Analgesic, Opiod Vicodin, Oxycontin
26.
Are the benefits provided at a voluntary, contributory, mandatory employer option?
Page 29 of 48
Continuation of Coverage
1. Is Continuation of Coverage Services outsourced to an external vendor? If yes, please answer the following questions: A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Name of Company
W. 2. 3.
Define their Continuation of Coverage (COBRA) Procedures. Enclose a COBRA Plan Document.
Page 30 of 48
4.
Enclose your companys procedures for the Continuation of Coverage premium Subsidy American Recovery and Reinvestment Act of 2009 administration.
Retiree Benefits
1. 2. 3. 4. Define the benefit services offered to the Pre-65 Retiree population? Enclose your companys Medicare Supplemental Plan Options and fee structure. Enclose your companys Medicare Advantage Plan Options and fee structure. Does your company outsource the retiree benefits? If so, please define and answer the following questions. A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of customer service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Location
Page 31 of 48
Name of Company
# of Employees
W. 5.
Are the benefits provided at a voluntary, contributory, mandatory employer option?
Vision Benefits
1. Does your company outsource vision benefits to an external company? If yes, please answer the following questions: A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Location
Page 32 of 48
Name of Company
# of Employees
W. 2.
Enclose a schedule of benefits for your Vision Plan. 3. Are the benefits provided at a voluntary, contributory, mandatory employer option?
4. 5. 6. 7. 8. 9. 10. 11.
Does your vision plan access a network of providers? If so, enclose a directory. Enclose a copy of the Vision Exclusion and/or limitations to Benefits. Do you offer an indemnity vision benefit plan? If so, please enclose a sample. Enclose information regarding vision plan utilization. Is there a materials guarantee for frames? Lenses? Contact Lenses? If so, what are the limits for each? Describe the network provider credential process. Does the plan cover for lasik services? Does the benefit cover for lens options such as tint, UV coding and lens protection services. 12. 13. 14. 15. 16. 17. 18. What would be the transition plan for current covered individuals who are accessing current Vision Services? What employee education meetings does your company provide for the employer and is there additional cost for employee education meetings? Describe and attach samples of your vision utilization reporting. Is there a materials guarantee for frames? Lenses? Contact lenses? If so, what are the time limits for each? Discuss preparations and guidelines your organization has implement regarding HIPAAs regulations for Protected Health Information. Will all participants receive an ID card? If no, how do providers confirm eligibility for members? Are ID cards sent in bulk to the Employer for distribution, or are they sent to the members homes? Is there an additional charge for mailing them to the members home?
Page 33 of 48
19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.
Is a separate vision card required or can the Employer include information on the medical card? If selected, please confirm that you will provide a Summary Plan Description and benefit plan document? Define and price any Optional Services/Benefit Riders that are available. Describe underwriting guidelines for applicants subject to vision cost review. Is there a waiting period and if so, will it be waived for initial enrollment? Is the policy a group or individual product? Is the policy portable and guaranteed renewable for life as long as premiums are paid when due? What are the termination provisions of policy? Do the policy benefits reduce at any age? Does the premium stay consistent regardless of employment or health condition? Have there been any premium rate increases? If yes, how many times and when? Does the policy pay in addition to any existing major medical or vision plan that the employee and/or their dependents may currently have in force at the time the services are received? Does the Policy offer more than one level of benefit? If yes, show benefit levels. Does policy provide for Experimental Treatment? If yes, how much?
31. 32. 33.
Does the policy provide benefits for refractive surgery? If yes, what are the limitations?
Dental Benefits
1. Does your company outsource the Dental benefits, if yes please answer the following questions? A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number
Page 34 of 48
I.
G. Contact Person H. Ownership of the company Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Name of Company
W. 2. 3. 4. 5. 6.
Enclose a schedule of benefits for the Dental Plan Are the benefits provided at a voluntary, contributory, mandatory employer option? Does you dental plan access a network of providers? If so, enclose a directory. Enclose a copy of the Dental Exclusion and/or limitation to Benefits. Define elements of dental utilization management that are implemented within your dental program. Enclose information regarding dental plan utilization.
Page 35 of 48
7. 8. 9. 10. 11. 12. 13. 14.
What percentage of total dental claims is routed for dental clinical review? Identify the three most common procedures or combination of procedures that are questioned by dental clinical reviewers. Do you offer an indemnity dental plan? If so, please enclose a sample. Describe the network provider credential process. Explain benefit access and include sample descriptions of how the process will work for orthodontics, endontics, surgical periodontics and cowns/prosthodontics. What percentage of claims are professional reviewed? List the three most common procedures or combination of procedures that are questioned by clinical staff and/or possibly provider abused. Describe in detail Vendors communication program as it related but not limited to the following: A. Enrollment B. Identification card distribution process; C. Plan document; D. Newsletters; E. Preventive/incentive type programs; State how plan members are notified when a provider is no longer a part of the plan. Provide a sample contract between Vendor and a network provider (physician and non physician). State whether the terms and conditions are standard to all providers participating in Vendors network. State how Vendors primary and specialty providers are reimbursed (i.e. negotiated fee schedule, capitation, etc.). Does Vendor require its providers to agree to an exclusive contract prohibiting them from participating in other managed care plans? Do the dental rates include IBNR (Incurred but not reported) reserves? If no, what are your companys procedures for developing IBNR (Incurred but not reported) reserves for the renewal? Under what conditions can the contract between Vendor and a provider be terminated? Describe the process involved in the recruitment, credentialing and quality assurance standards for providers?
15. 16.
17. 18. 19. 20. 21. 22.
Page 36 of 48
23.
Describe fully your use of R&C. What percentile is commonly used? Will the City have the option to set the R&C percentile? Is application of R&C automatic in your system, or are claims pended for manual review? How often is the R&C updated? Is it geographically based?
Life/LTD/STD
1.
Does your company outsource this service? If so, please define and answer the following questions. A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company I. Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
V.
Name of Company
Page 37 of 48
W. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
Is coverage provided for all currently insured employees who are actively-at-work? Is the actively-at-work requirement waived for currently insured employees who are not covered by the existing carriers Extension of Benefits provision? Is coverage provided for all current classes of employees in accordance with the existing provisions at each participating school corporation? What is the length of the rate guarantee? What is the Guarantee Issue limit for basic life coverage? Are current insured employees subject to a Guarantee Issue limits? What is the volume of basic life insurance assumed in your rating? What is the volume of basic AD&D coverage assumed in your rating? Please indicate if Paid Premium and Paid Claim reports for each line of coverage will be provided at the time of future renewal offers? Does your plan have age reductions? Does your plan include an accelerated death benefit option? Will you agree that no employees will lose coverage as a result of changing insurance carrier? Confirm that your plan includes waiver of premium for disabled? What is the Waiver of Premium Elimination Period? Are other options available? Is Waiver of Premium based on Own Occ or Any Occ? Are there options available? At what age does Waiver of Premium terminate? Will Life Waiver of Premium claims automatically be filed if you also write the STD/LTD? When do ported contracts terminate? When do conversion contracts terminate? 21. Do your rates include the cost of printing booklets and certificates?
22.
Is enrollment material available in Spanish?

Page 38 of 48
23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.
Will enrollment deductions?
material
be
pre-populated
with
employee
information
and
Is portability available at retirement? How will rates and renewals be determined-based on actual claims experience, manual rates, or a blend? What is your target loss ratio? Are interest credits paid to the beneficiary from date of death? If so, state rate. Besides pending life claims, does your Company require the establishment of any additional reserves? If so, explain the amount and formula. Enclose a sample of the claim form(s) that will be used by members. Will your Company accept the Employers enrollment card(s) for all transferred business and new business? See samples attached Please explain how your Company will take over our existing group. Provide a brief explanation on the steps necessary to convert a life benefit. Is a Life Conversion Application, sample Life Conversion Policy, and current rates attached? Is the Employers self-billing procedure acceptable? If your Company cannot guarantee a rate for more than one (1) year, can they agree to a formula for the 2nd and 3rd year rates? If yes, what is the formula? If there are any commissions included in the proposal, please state the amount.
Life/LTD/STD Claim Payment Services

1. 2. 3. 4. 5. 6. 7. 8. What is the claims turnaround time for the last twelve months? What is the quality of claim payment for the last twelve months? Enclose a sample of the claim form(s) that will be used by members attached? Where will claims be paid? What is normal claim processing time? Describe documentation needed for payment of a claim? Describe your procedure for claim declination. Describe your procedures for handling appeals of denied or disputed claims.
Page 39 of 48
9. 10.
Will you or your agency complete claim forms over the telephone? Are the plans available at voluntary, contributory and/or mandatory employer subsidy options?
Page 40 of 48
Employee Assistance Program

1. Does your company outsource the benefit? If so, please describe and answer the following questions. A. Name of Vendor: B. Address: C. Phone Numbers including toll free: D. Is there additional charge for toll free access? E. Web Site/email Address F. Fax Number G. Contact Person H. Ownership of the company? Is this company currently involved in any discussions that would change the ownership or basic structure of the organization? If so, please provide details. Is there any purchase, sale, change in ownership or other change anticipated in the next three (3) years that may prevent your firm from being able to honor the proposed three (3) year engagement? J. How long has the service been licensed in the State of Texas? K. When did your company begin administering the benefits included in the proposal? L. Is your company licensed to do business in the State of Texas? M. Provide a brief biography of the senior official responsible for the overall service of the account and for the day-to-day operations. N. What are the standard hours of customer service? O. Enclose a copy of the E&O Insurance Certificate. P. Enclose a copy of the General Liability Certificate. Q. Enclose a copy of the most recent Financial Statement. R. Enclose a copy of the Business Continuity Plan. S. Enclose a copy of the test for the Business Continuity Plan. T. Is the company currently involved in any litigation as a defendant over any benefits? U. Provide three Texas political subdivisions that they provide employee benefits for.
I.
V.
Name of Company
W. 2.
Are the plans available at voluntary, contributory and/or mandatory employer subsidy options?
Page 41 of 48
3. 4.
What would be the transition plan for current covered individuals who are accessing current EAP Services? Describe the following types of referrals: A. Self-referral: B. Supervisory referral: What employee education meetings does your company provide for the employer and is there additional cost for employee education meetings? What is average timeline delay in scheduling appointments? A. Emergency: B. Routine: Attach Network of EAP providers in State of Texas. If mental health/chemical dependency services are required beyond EAP services, what referral procedures do you use? Do your referral procedures include accessing the employer's network providers? Identify procedures for covered employee integration back into the workplace. What protocol do you use to assess and manage the utilization of mental health/substance abuse medication prescribed by non-psychiatrist MDs. A. What interface requirement is necessary with the claim administrator and the Pharmacy Benefit Manager? B. What list of prescriptions do you extract for review? C. What frequency of prescription utilization access to you implement? D. Define the protocol to manage the above utilization. E. What return on investment have you documented due to the above utilization management techniques? Describe staff qualifications and tenure per job area: A. Administration B. Intake C. Counselor D. Psychologists E. Psychiatrists F. Medical Director Identity licensure requirements and coverage volume per functional area and zip code Document and define what Counseling Services are available:
Available Subcontrac Included in Additional t Basic Fee Cost
5. 6.
7. 8. 9. 10. 11.
12.
G. 13.
Service Family crisis/planning Domestic violence
Page 42 of 48
Service Available Compulsive gambling Gay/Lesbian Personal financial management Stress Emotional Alcohol, tobacco, and drug abuse Family eldercare Vocational/work related Legal Marital Psychological Adolescent Pre/Post Retirement Health/Wellness Disability-Oriented Literacy Elderly Care
Subcontrac Included in Additional t Basic Fee Cost
14. 15. 16. 17.
Describe your 24-hour toll free services. Describe follow-up services. Does your organization provide any optional services? If so, describe. Complete the following chart with your call/customer center statistics?
Your Standard Actual 2005-2006 Results
Measurement Average speed to answer Average time on hold Average length of call Abandonment Rate
18.
Complete the following table with the expected results of calls to the EAP from your experience.
Percentage
Result No referral Referral to community resource Referral for Service other than Mental Health /Chemical Dependency treatment Referral for emergency Mental Health treatment Referral for outpatient Mental Health treatment Referral for any Chemical Dependency treatment
EAP Reporting
1. 2. Describe and attach samples of your utilization reporting. Enclose samples of monthend, quarterly and annual reporting.
Page 43 of 48
Define the Fee Structure

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Fully funded premiums per the attached census and most recent twelve month claim utilization information: Provider network access: Medical Management: Pre-certification, concurrent review and discharge planning Population Coaching: Health Engagement (Disease Management)/Professional Health
Implementation/Orientation Cost: Employee Education Meetings: Enrollment Assistance: On-Line Services Employee Correspondence: Customer Service: Claim Adjudication Service: Continuation of Coverage Services: Consumer Driven Plans A. Section 125 B. Health Savings Accounts C. Health Reimbursement Accounts D. Retiree Reimbursement Accounts Does your proposal reflect twelve months of utilization or nine months of utilization? Prescription Benefit Management Services Continuation of Coverage Services Retiree Benefits Early Retiree Reimbursement Program Services Vision Benefits Dental Benefits Life/LTD/STD Benefits
Page 44 of 48
14. 15. 16. 17. 18. 19. 20. 21.
22.
Employee Assistance Plan
Page 45 of 48
RIGHT OF REJECTION
Employee reserves the right to reject, in part or in whole, any and all proposals. No obligation exists on the part of Employer, either expressed or implied to make an award for the services or for costs incurred in the preparation of any proposal in response to this request for proposal.
Page 46 of 48
NON-COLLUSION AFFIDAVIT
STATE OF COUNTY OF , of lawful age, being first duly sworn, on oath says, that (s)he is the agent authorized by the vendor to submit the attached proposal. Affiant further states that the vendor has not been a party to any collusion among vendors in restraint of freedom of competition by agreement to propose at a fixed price or to refrain from proposing; or with any state official, city employee, Board Trustee, Pool staff member, or benefit consultant as to quantity, quality, or price in the prospective contract, or any other terms of said prospective contract; or in any discussions or actions between vendors and Pool staff member, city employee, Board Trustee, or benefit consultant concerning exchange of money or other things of value for special consideration in the letting of this contract.
Subscribed and sworn to before me this
day of
, 20
Notary Public State of My Commission Expires:
Page 47 of 48
STATEMENT OF COMPLIANCE
We hereby acknowledge receipt of the Request for Proposal for Medical, Continuation of Coverage, Pharmacy Benefit Service, Pre/Post Sixty-Five Retiree, Dental, Vision, Life/LTD/STD and EAP benefits and certify that our proposal conforms to the RFP except as detailed below:
Company Name Authorized Signature Zip Print or Type Name Title City
Street Address PO Box
State
Zip
(Area Code) Telephone Number
Page 48 of 48

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City of Somewhere

REQUEST FOR PROPOSAL

Proposals must be received by:

Proposal Quality and Evaluation

Proposal Information and Due Date

Proposal Due Date

STATEMENT OF OVERALL REQUIREMENTS

Other Factors to Consider

11. 12. 13.

17. 18. 19. 20. 21. 22. 23.

Claim Audit Information

Employer Account Management/Services

Functional Area of Expertise

Tenure with Company

Claim Adjudication Services

23. 24. 25.

Claim Administrator Benefit Information

Benefit Customer Service

Network Information Out of Pocket Expenses

Dependent Spouse Grandchildren Early Retirees Retirees Survivors

Claim Cost Management

Managed Care Network

10. 11. 12. 13. 14. 15.

Medical Care Management

Consumer Driven/Choice Plan Information

Wellness Benefit Management

21. 22. 23. 24. 25.

Are the benefits provided at a voluntary, contributory, mandatory employer option?

Are the benefits provided at a voluntary, contributory, mandatory employer option?

31. 32. 33.

7. 8. 9. 10. 11. 12. 13. 14.

17. 18. 19. 20. 21. 22.

Is enrollment material available in Spanish?

Will enrollment deductions?

Life/LTD/STD Claim Payment Services

Employee Assistance Program

Service Family crisis/planning Domestic violence

Subcontrac Included in Additional t Basic Fee Cost

14. 15. 16. 17.

Define the Fee Structure

14. 15. 16. 17. 18. 19. 20. 21.

Employee Assistance Plan

Subscribed and sworn to before me this

Notary Public State of My Commission Expires:

Street Address PO Box

(Area Code) Telephone Number

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