RFP No. 05-16/TW

duval county public schools

AttachmentB1 – Proposal Worksheet- Medical and EAP services & PharmacyServices

Health plan services

Section 1 - General Information and Medical and EAP and/or Pharmacy Administrative Services–The committee will assign up to 15 points based on the information proposed within Section 1 (0-15points)

Company Information
Proposer/Company Name
Primary RFP Contact Person Name:
Phone No:
Fax: No:
E-mail Address:
Subcontractor Information if applicable / Indicate the Appropriate Company or Companies that are included in your Company’s Proposal
Pharmacy Benefit Manager
Employee Assistance Program (EAP)
Health Savings Account
Disease Management
Minimum Requirements:

Minimum Qualifications must be present in each proposal before further consideration will be given. Below is a checklist to ensure that the Proposer understands and confirms that all Mandatory Minimum Qualifications are included in the RFP response. If the stated feature is included in your proposal as requested, check “Yes”. If the stated feature is not included in your proposal, check “No”.

Important Note: Your proposal will be removed from consideration if any feature indicates a “No” check OR IF ANY ‘YES’ ANSWER INCLUDES EXCLUSIONS

Feature / Yes / No
  1. Proposers shall have experience providing Administrative Services Only (ASO) health plan services to four or more employers each having 12,000 or more subscribers within the past five (5) years.

  1. Proposer shall have accreditation by the National Committee for Quality Assurance (NCQA) as applicable as of the proposal due date.

  1. Proposer shall agree to provide a Statement on Auditing Standards (SAS) No. 70 or Statement on Standards for Attestation Engagements (SSAE) No. 16, Service Organizations examination annually to the District and its benefits consultant.

  1. Proposer shall allow the District or a mutually agreeable firm selected by the District to conduct annual medical and/or pharmacy claims audits. Proposer will provide full access, regardless of any confidentiality or trade secrets, to applicable records, files, and documents related to all medical and pharmacy claims, administrative fees and other elements of the contract in order to conduct the annual audit at no additional cost.

  1. Proposer shall allow the State Auditor General and the District’s independent auditors full access (at no additional cost and regardless of any confidentiality or trade secrets) to conduct a claims audit as part of its scope of work when conducting an audit of the District. State audits may occur every three (3) years. This would be in addition to any annual claims audit that the District performs through contract with a firm for independent auditing services.

  1. Proposals shall be submitted net of commissions

Health Plan Service Background:
# Years Providing Health Plan Self-Funded Administrative Services in Duval County
Number of Employer Groups (Self-Funded) in Duval County Area (Duval, Baker, Nassau, St. Johns, and Clay Counties) over 10,000 Lives
Total # Covered Lives in Duval County Area (Duval, Barker, Nassau, St. Johns and Clay counties)
Number of Employer Groups in Florida over 10,000 Lives
Total # Covered Lives in State of Florida
References:
List below four or more references of your Company where Administrative Services Only (ASO) and the Pharmacy Benefit Management (PBM) services of the Company you are proposing are or were provided to employers with 12,000 or more subscribers within the past five (5) years.
Client / Contact Name / Phone #/ Email Address / # Years of Contractual Relationship / Number of Enrolled Employees
Company Representatives

List the name of each employee that your company will assign to help administer the District’s Plan.

Role / Name / Location / Years with Company / Current Number of Clients
Account Manager
Account Service Contact
Medical Director
Pharmacy Director
Eligibility Contact
Financial Contact
Health Management and Wellness Contact
Implementation Manager
Onsite Full time Representative
Medical and Pharmacy Administrative Services: Complete the following questions. When a response can be confirmed, indicate “Confirmed” only. If a brief description is requested please state key components succinctly.
Issue / Response
1.Confirm that your Company will have accessible hours of customer service, a dedicated customer service team familiar with the District’s plan design and claims administration, and demonstrated service results to administer the comprehensive health plan, including all medical and/or prescription drug benefits for active employees, COBRA participants, retirees, and eligible dependents.
2.State your member call in customer service location and hours of operation.
3.List the percent of customer service calls for 2015 that resulted in problem resolution on the initial call.
4.For 2015, indicate your service performance results in the following categories (format indicated in parenthesis):
  1. Average speed of telephone answer (number of seconds)
  2. Average telephone call abandonment rate (percentage)

b.
5.Confirm that your Company will have an experienced, dedicated account management team assigned to the District to assist with claims, eligibility and day-to-day service issues.
6.Confirm that all customer service support involving interaction with members shall be handled within the territorial limits of the United States of America.
7.Confirm that your Company will assign a full time onsite medical customer service representative to assist the District and its health plan members with health plan issues, eligibility, and day to day service issues, program management and onsite educational meetings.
8.Confirm that your Company agrees to attend quarterly meetings to review plan performance; meet monthly to review ongoing administrative, service, and plan management issues; and make available a Medical and/or Pharmacy Director for ongoing involvement in plan performance initiatives.
9.Briefly list the web-based administrative tools that will be made available to the District’s benefits department to manage eligibility on an ongoing basis.
10.Briefly list the web-based informational and educational tools available to health plan members providing information on issues such as claims status, explanation of benefits (EOBs), network providers by specialty, health and wellness topics, and provider / treatment cost calculators that are based on the specific plan designs of the District.
11.Confirm that your Company will prepare and maintain the Summary Plan Description (SPD) and annually required Summary of Benefits and Coverage (SBC) on behalf of the District and provide these documents electronically for posting on the District’s website.
12.Confirm that your Company will assist the District with: annual enrollment by training the benefits and enrollment staff on plans; creating District specific enrollment and educational materials; attending on-site enrollment meetings (typically 20 onsite sessions are held); providing web portal assistance for annual enrollment; providing a representative for new hire orientation meetings; and providing representatives for on-site building meetings as requested.
13.Confirm that your Company agrees to accept the District’s benefits enrollment files electronically on an ongoing basis from the District’s enrollment vendor, currently FBMC Benefits Management.
14.Confirm that your Company agrees to the following:
Contractor shall be the claims fiduciary and accept fiduciary responsibility for claims payment decisions and for defense of actions taken for claims adjudicated and related appeals, including the legal defense of claims determinations and medical and /or pharmacy clinical decisions processed. The District will be responsible for the legal defense of claims for which the District made the choice as to the determination of coverage. The Contractor shall be responsible for the legal defense of claims that involve the claim determination based on the Contractor’s medical and/or pharmacy, and authorization standards. The District shall be informed of appeals and Contractor decisions on appeals, but is not to be responsible for any claims determination matters or appeals.
15.Confirm that your Company will have contractual arrangements in place with external claims review companies that will be made available to the District’s members and will be responsible for facilitating all aspects of the external review process, and will provide the external review company with the claims and plan information needed for an appropriate determination to be made.
16.Confirm that your Company agrees to process and adjudicate all medical and/or prescription drug claims in accordance with the health plan document and will be held liable for claims adjudicated outside of the terms and conditions of the health plan document.
17.For 2015, indicate the performance results in the following categories (format indicated in parenthesis):
  1. Clean claims processed within tem (10) days (percentage)
  2. Clean claims processed within thirty (30) days (percentage)
  3. Average claims turnaround time (number of days);
  4. Claims coding accuracy (percentage);
  5. Claims dollar accuracy to include over and under payments (percentage);

18.List the percent of medical claims in 2015 that were received electronically and claims completely adjudicated electronical manually
19.Confirm that your Company will allow retroactive eligibility and claims adjudication at no additional cost the District.
20.Describe your Company’s ability to identify claims that could potentially be subject to third party liability such as workers compensation, auto accident, and coordination of benefits, and take action on the claims using the same standards in place for the Contractor’s fully insured health plan clients.
21.Confirm that your Company will adhere to standards of care by agreeing to use the care, skill, prudence and diligence under the circumstances then prevailing that a prudent claims administrator/fiduciary acting in a like capacity, and familiar with such matters, would use under similar circumstances as the standard of care for medical and/or pharmacy services.
22.Indicate where your claims processing system or patient record captures and can report on the following:
  1. Laboratory values specific to the member
  2. Compliance with periodic physicals and preventive diagnostic services specific to the member
  3. Plan sponsored biometric screening values specific to the member performed by a third party vendor selected by the District
  4. Plan sponsored biometric screening values specific to the member performed by a third party vendor selected by the District
  5. Prescription medication adherence and compliance

Section 2 – Plan Design–The Committee will assign up to 5 points for the services outlined within this section 2a (0-5 points)

Complete the following questions. When a response can be confirmed, indicate “Confirmed” only. If a brief description is requested please state key components only as succinctly as possible.

Issue / Medical Response
1.Confirm that your proposal for the medical plans include an open-access (non- Gatekeeper) model option.
2.Confirm that your proposal includes health plan options that closely match the current health plans as outlined in Exhibit “5”. List any differences in health plan options.
3.Confirm your Proposal has the ability administer the current plan design and list any deviations of the coverage comparing your administrative capabilities to the Plan Documents included with this RFP as Exhibit ”5”
4.Briefly list discount arrangements for complementary and alternative medicine services not covered under the District’s Plan.
5.Confirm that your Company will have the ability to separately accumulate medical and pharmacy member costs toward a medical and pharmacy annual deductible and medical and pharmacy out-of-pocket maximums.
6.Confirm that your Company is a contractor of medical services and shall agree to be the master accumulator for medical and pharmacy deductibles and out-of-pocket maximums if the medical and pharmacy member costs accumulate collectively.
7.Confirm that your Company shall identify and assist members with End Stage Renal Disease in applying for Medicare benefits.
8.Confirm completion of Attachment C- Formulary Worksheet
9.Regarding your Company’s drug formulary list, indicate:
  1. Frequency and timing of formulary changes
  2. Method to notify employer, including summary of member impact
  3. Method to notify specific members impacted
  4. Method to notify providers
  5. Availability of formulary via hard copy and on website

Section 3– Network Services– Complete the section below using the information and instructions found in Section 2.3 of the Request for Proposal. The Committee will assign up to 5 points for services outlined within this section 2b (0-10 points)

Complete the following questions. When a response can be confirmed, indicate “Confirmed” only. If a brief description is requested please state key components only as succinctly as possible.

Issue / Response
  1. Confirm that your proposal includes a completed Network Participation Worksheet,Attachment C. In addition, network physicians designated as a high performing provider, meeting your provider established cost and quality of care guidelines, and included in a high performance limited network as listed in appropriate column.

  1. Confirm that your proposal includes a comprehensive statewide and national network of hospitals, outpatient facilities, physicians, other covered healthcare providers,and pharmacies specifically in Duval, Baker, Nassau, St. Johns, and Clay Counties.

  1. Confirm that your Company’s local hospital network includes coverage at a minimum at Baptist, St. Vincent’s, Memorial, Orange Park, Shands-Jacksonville, and Mayo Clinic Hospitals, as of the proposal due date.

  1. List any provider contracts with Duval County Area hospitals, free standing facilities and large physician groups that expire or will be renegotiated for the 2017 calendar year.

  1. Describe your ability to include two levels of copayments with lower copayments for network physicians in a high performance limited network.

  1. Confirm that your networks have 85% of providers Board Certified/Board Eligible, and an annual turnover rate of less than 3%.

  1. Indicate the total number of in-network Family Practice/Internal Medicine physicians in the Duval County Area and list the percent Board Certified/Board Eligible (BC/BE) in each: (note count each physician only one time)
/ Family Practice/IM
County / Total # / % BC/BE
Duval
Baker, Nassau, St. Johns, Clay
  1. Indicate the total number of in-network Specialists in the Duval County Area and list the percent Board Certified/Board Eligible (BC/BE) in each: (note count each physicians only one time)
/ Specialists
County / Total # / % BC/BE
Duval
Baker, Nassau, St. Johns, Clay
  1. Indicate any network gaps where in-network specialty providers are not available in Duval, Baker, Nassau, St. Johns, and Clay Counties, if applicable.

  1. Confirm your network shall include state and national access for non-emergency and emergency care, including services provided at Centers of Excellence?

  1. Confirm your network shall include allowances for international emergency and non-emergency care?

  1. Does your Company have telemedicine service for members included in your proposal? Briefly describe the process a member would follow to access the service, and how the service would be billed

  1. List the contracted services where capitation fee is applied. Confirm that you provide encounter data for services covered under your capitation arrangement.

  1. Confirm that your Company shall hold members harmless from balance billing when using in-network providers, when being referred for specialty services by an in-network provider, and for services provided by an in-network provider that are not approved by your Company.

  1. Confirm that your Company shall monitor network performance based on nationally recognized quality standards

  1. How does your Company monitor the performance of your network and what corrective actions are taken?

  1. The District may have an interest in a Patient Centered Medical Home (PCMH) model at a future date. What is your Company’s current capability to provide the service?

  1. Confirm that your Company will include mail order and specialty pharmacy services.

  1. Describe how pharmacy service allowances for international and non-emergency prescription services.

  1. How does your Company communicate with regional pharmacies on plan design changes?

  1. Provide your Company’s specialty pharmacy facility name, location, and years of service for your Company.

  1. Describe your Company’s normal delivery service of mail order and specialty medication times and delivery and indicate any additional cost for prescription requests with expedited service.

Section 4 – Health Management– Complete the section below using the information and instructions found in Section 2.4 of the Request for Proposal. The committee will assign up to 15 points for services proposed in Section 3. (0-15 points)

Complete the following questions. When a response can be confirmed, indicate “Confirmed” only. If a brief description is requested please state key components only as succinctly as possible.

Issue / Response
1.Confirm that your Company will include an online health risk assessment (HRA) tool, accessible to members, capable of having biometric screening results loaded into an individual’s HRA, and will provide an aggregate report on the responses, including the changes in risk factors.
2.Confirm that your Company will include in the ASO fees onsite biometric screenings at convenient times and at a minimum of 60 locations each year for members.
3.Briefly describe how your Company shall demonstrate their ability to increase preventive care utilization?
4.Describe how your Company shall identify large case and high risk plan members and assist them in managing their health. What proactive steps will your Company take?
5.Describe your proposed dedicated case management team assigned to the District to address the specific needs of seriously ill plan members.
6.Confirm that your Company shall provide a full-time, dedicated clinical coordinator (Registered Nurse or clinical equivalent) who will assist individual members: in achieving optimal health through identification of risks; closing gaps in care; assist with medical conditions; necessary resources; assist with referrals to appropriate programs, case management, disease management; and appropriate programs within the District’s health plan; navigate within the health plan and act as the central conduit among District, provider and network (PCP, Specialist) and all available programs and resources. The dedicated clinical coordinator must be able to meet with individual members at various District locations as determined.
7.Confirm that your Company shall assist the District as a resource with wellness initiatives, and health improvement strategies.
8.List the Disease Management programs your Company will include as a part of the ASO fees proposed
9.Indicate your Company’s average active engagement rate in each Disease Management Program.
10.Confirm your Company’s ability to track and manage health and wellness activities, administer incentives report performance and provided improvement recommendations to the District.
11.Confirm that your Company shall assist the District with customized, targeted initiatives to improve the health of the population with comprehensive initiatives including voluntary programs for:
  1. Weight management for healthy weight, overweight, obese or morbidly obese members;
  2. Diabetes control and prevention;
  3. Tobacco cessation;
  4. Comprehensive cardiology program, including hypertension control and prevention;
  5. Chronic Obstructive Pulmonary Disease (COPD);
  6. Healthy pregnancy;
  7. Compliance with preventive screening guidelines.
  8. Nutritional education for adults
  9. Other

12.Confirm your Company has the ability to process onsite immunizations, such as flu shots, as a medical claim from the District’s selected vendor?
13.Confirm that your Company shall have the capability to administer co-payment incentives specifically for members participating in and adhering to the qualifications of health and wellness activities and District targeted initiative programs.
14.Confirm your Company has a Fraud, Waste and Abuse (FWA) policy that results in demonstrated success?
15.Confirm your proposal includes a Wellness Fund of an annual minimum of $125,000 in the ASO fees for the initial contract term, for the District to help support the health management initiatives?

Section 5 – Financial Services, Reporting, and Data Interface– Complete the section below using the information and instructions found in Section 2.5 of the Request for Proposal. The committee will assign up to 10 points for services proposed in this section 4. (0-10 points)