FORMS AND TECHNICAL SPECIFICATIONSExhibit H
EXHIBIT H
FORMS AND TECHNICAL SPECIFICATIONS
A. INTENT TO BID FORM
By Friday, May 1, 2015, complete this form and email to:
Plan Sponsor Name:County of Kern
Proposer Name:______
We confirm receipt of your request for proposal and will take the following action:
We intend to bid on these medical benefits:
Yes or NoEPO ASO (Self-Funded) – Claims Administration
EPO ASO (Self-Funded) – Utilization Management
EPO ASO (Self-Funded) – Network Contracting
EPO ASO (Self-Funded) – Pharmacy Benefits Management
HMO (Fully-insured)
Proposer Contact Name:______
Proposer Contact Telephone No.______
Signature:
Date:
B. RFP-REQUIREMENTS
1. Corporate Agency Profile Summary
When responding to Section II.D.2 of the RFP, please complete and submit this form with your proposal.
Legal Name of OrganizationDate Founded
Business Entity Type as requested in Section II D.2
Contact Person’s Name
Local Kern County Vendor as defined in Section I.D.2 Address:
Name of Authorized Contact
Address
City/State
Phone Number
E-mail Address
Fax Number
Website
2. Cost of Service – Rate Quotation Form
When responding to Section II.D.7 of the RFP, please complete and submit the following form(s) with your proposal, as applicable. Please provide your enrollment assumption, underwriting requirements, and the detailed benefits description that apply to these rates.
Proposers for Self-funded Administrative Services:
All rates should be quoted on a per employee/subscriber basis, except for implementation fees or perclaim/prescription administrative fees for pharmacy benefits management (indicate per claim/prescription pharmacy fees in Exhibit “H,” Questionnaire 6 – Pharmacy Benefits Management Program, Section D, Financial Section, under “Administrative Fees”).
Per employee/subscriber or rates should not stipulate the number of enrollees or require adjustment contingent upon fluctuations in enrollment (i.e. with a reduction in enrollment of 10% rates will increase by $2.00, etc).
Rates should be all-inclusive with no “pass-through” charges. All services provided in relation to performance under the contract must be included in the per employee/subscriber rates.
Proposers for Fully Insured Plans:
Premiums for fully insured products should be rated separately for single, two-party (may be spouse or other dependent), and family coverage. Any fees outside of the premium amount should be clearly noted.
2.A – The Self-funded EPO
1. Claims Administrative Services
Monthly FeeYear 1 / Year 2 / Year 3
1. Claims Administration
- Eligibility and enrollment maintenance
- Claims administration
- Claims and appeals processing
- Reporting/analysis of member utilization andmedical trends
- Referral to IRO on appeals
- Customer service
- Reporting and resolution of provider/member complaints
- Dedicated toll-free number
- Postage
- Member and provider materials/communication
- Printing of Forms
- Any additional functions necessary for day-to-day performance under the contract but not otherwise specified
- Headcount used in the calculation: ______
2. Run In Claims Administration / ______PEPM / PEPM / PEPM
3. First Year Set-up Fees
4. Total Monthly Fees
5. Total Annual Fees
2. Utilization Management Services
Monthly FeeYear 1 / Year 2 / Year 3
1. Utilization Review
- Utilization review
- Large Case Management
- Prior Authorization Services
- Reporting/analysis of member utilization and medical trends
- Reporting and resolution of provider/member complaints
- Discharge planning
- Coordination with Claim Administrator
- Internal first review of appeals
- Referral to IRO on appeals
- Any additional functions necessary for day-to-day performance under the contract but not otherwise specified
- Headcount used in the calculation: ______
2. First Year Set-up Fees
3. Total Monthly Fees
4. Total Annual Fees
3. Network Management and Contracting Services
Monthly FeeYear 1 / Year 2 / Year 3
1. Network Contracting and Management
- Headcount used in the calculation: ______
2. First Year Set-up Fees
3. Total Monthly Fees
4. Total Annual Fees
4. Pharmacy Benefits Management Program
Monthly Fee*Year 1 / Year 2 / Year 3
1. Pharmacy Program
- Contract and manage pharmacy network
- Negotiate discounts and rebates
- Utilization Management
- Formulary Management
- Reporting/analysis of member utilization and pharmacy trends
- Reporting and resolution of member complaints
- Any additional functions necessary for day-to-day performance under the contract but not otherwise specified
- Headcount used in the calculation: ______
2.First Year Set-up Fees
3. Total Monthly Fees
4. Total Annual Fees
* For per claim/prescription fees use “Administrative Fees” in Section D, Financial Section, of Exhibit “H” Questionnaire 6 – Pharmacy Benefits Management Program.
5. Fees and Services
List of services included in fees(Please specify all services as this list will be included in a contract agreement should you be selected.)
1.
2.
3.
Any special fees, charges or expenses of any kind not included in fees
List of services not included in fees, along with associated fees
1
2.
3.
6. Proposed Fee to Provide All Services (Optional)
Monthly FeeYear 1 / Year 2 / Year 3
1. Proposed Fee to Provide All Services / ______PEPM / ______PEPM / ______PEPM
2.First Year Set-up Fees
3. Total Monthly Fees
4. Total Annual Fees
7. Please provide any rate guarantees after the above 36-month period.
Authorized Signature
Title
Name of Company
Date
2.B – Fully Insured HMO
1. Active and Under 65 Retirees
Proposal to provide HMO benefits currently provided by Kaiser Permanente / Assumed Number of Eligibles / Proposed Rates Effective 1/1/2016-12/31/2016 / Proposed Rates Effective 1/1/2017-12/31/2017 / Proposed Rates Effective 1/1/2018-12/31/2018Actives - Composite
Single
Two Party
Family
Rate Cap or Guarantee
Proposal to provide HMO benefits currently provided by Kaiser Permanente / Assumed Number of Eligibles / Proposed Rates Effective 1/1/2016-12/31/2016 / Proposed Rates Effective 1/1/2017-12/31/2017 / Proposed Rates Effective 1/1/2018-12/31/2018
Under 65 Retirees - Composite
Single
Two Party
Family
Rate Cap or Guarantee
2. Medicare Advantage
Proposal to provide HMO benefits currently provided by Kaiser Permanente / Assumed Number of Eligibles / Proposed Rates Effective 1/1/2016-12/31/2016 / Proposed Rates Effective 1/1/2017-12/31/2017 / Proposed Rates Effective 1/1/2018-12/31/2018Medicare Advantage
Single
Two Party
Family
Rate Cap or Guarantee
Authorized Signature
Title
Name of Company
Date
C. NETWORK ACCESS AND CLAIMS RE-PRICING
If your proposal includes either the self-funded network administration services or a fully insured plan, please provide the below information as part of your response to Section II.D.6. Proposals that should include this information and do not will be considered incomplete and may not be considered by the County. Proposers must complete and submit the signed confidentiality agreement attached as Exhibit “F” prior to receiving the required the census data and/or sample claims file, as described in Exhibit “C.”
The County will be evaluating networks based upon Geo-Access results, hospital coverage, availability of PCP’s and Specialists, and provider discounts.
1.GEO ACCESS
Both proposers for the self-funded EPO and fully insured HMO should provide geo-access information. Based on the ZIP codes provided upon request (see Exhibit “C”), please perform a geo-access study based on each of the following criteria. The geo-access study must be based ONLY ON NETWORK DOCTORS WHO ARE CURRENTLY ACCEPTING NEW PATIENTS. Please provide this report for your EPOand HMO network separately.
1 PCP in 5 miles
1 PCP in 8 miles
1 Specialist in 10 miles
1 Hospital in 10 miles
Further, please provide a listing of the following for your EPO network and HMO network separately for KERN COUNTY.
Network Hospitals
Network Medical Groups
Network Physicians
2.NETWORK LISTING
Please include a list of all cities and states where your EPO Medical network existsoutside of Kern County.
3.NETWORK DISRUPTION
As part of the bidding process Segal will also be conducting a network disruption analysis. Please provide us with electronic copies of your EPO physician and facility networks you are proposing for the County.
Please send data that conforms to the following specifications. Deviations from these specifications may result in the removal of your network from our analysis:
Medical
Acceptable File Format
Microsoft Access or Excel
Required Fields (please include file layout)
National Provider ID (MUST BE PROVIDED)
Provider TIN
Provider last name – LAST NAME WITHOUT PROFESSIONAL DESIGNATION (DO NOT COMBINE FIRST AND LAST NAME IN THIS FIELD)
Provider first name – FIRST NAME ONLY WITHOUT MIDDLE INITIAL OR LAST NAME
5-digit ZIP code
Street address
County
Phone number
Specialty code
Primary Care:001 or PCP(includes General Practice, Family Practice, Internal Medicine, OB/GYN and Pediatrician)
Specialists:002 or SPE(all other physicians)
Inpatient Hospital:003 or IHO
Ambulatory Facility:004 or AMB(includes surgical centers and imaging centers)
Specialty category
You may also include any other fields (such as City or State) that are in your data files, but only the fields listed above are required.
Pharmacy
Acceptable File Format
Microsoft Access or Excel
Required Fields (please include file layout)
NABP Number
Provider Name
5-digit ZIP code
Street address
Phone number
City
Please include a data dictionary clearly describing all data fields and acronyms.
Note:Be careful not to send us duplicate records unless a provider has two or more locations. Our experience dealing with electronic provider listings is that we very often receive two or more records for the same provider (e.g., “John Smith” and “John A. Smith” with the same provider ID/TIN).
4.COMPARATIVE CLAIMS PRICING
Proposers for network contracting and management services for the self-funded EPO medical option must provide a comparative pricing for the sample claims provided and the total discount available for the sample claims provided. Claims costs are the County’s largest financial exposure with a self-funded plan option and, in addition to active management of plan utilization, network discounts offer the largest impact to overall costs.
D. PROPOSAL QUESTIONNAIRE
General Requirements and Questions for All Proposers
When responding to Section II.D.6of the RFP, please complete and submit the following questionnaire(s) as supplementary material to your proposal, as applicable. Proposals that do not include the appropriate questionnaires for the items bidwill be considered incomplete and may not be considered. Each question must be answered specifically and in detail. Please do not provide lengthy responses. Reference should not be made to a prior response, or to your contract, unless the question involved specifically provides such an option. Be sure to refer to the entire RFP before responding to any of the questions, so that you have a complete understanding of all of the requirements with respect to the bid.
If you are proposing more than one plan and your response varies for different plans, please make sure you answer them specifically for each plan.
Note: Please make sure to include an electronic copy of your completed questionnaire in Word Format on the CD with your response.
QUESTIONNAIRE
PART 1
All Proposers Are Required to Complete This Section
- GENERAL PROPOSER REQUIREMENTS
For this section of the questionnaire, answer the question/requirement with a simple “Yes” or “No” answer. If you answer “No” to any of the questions/requirements in this section, please explain the response at the end of the section. The explanation will be reviewed; however, failure to agree to all of the terms requested in this section may cause the County to deem your proposal non-responsive.
- Will you agree to be bound by the terms of your proposal until a final contract is executed?
- Do you agree to all the terms and conditions in Section I and Section II of this RFP?
- The County reserves the right to offer awards of contract to multiple Proposers for any, or all, plans of benefits contained in this RFP. The County also reserves the right to waive its right to award a contract for any plan of benefits contained in this RFP. Confirm your agreement with this provision.
- Confirm that your proposed administrative fee for the EPO plan and premium rates for the HMO plan are guaranteed for 36 months.
- Confirm that your proposed rates exclude commissions.
- Other than the quoted premium rates in your proposal, there should not be any other charges or fees of any kind that will or could apply to the County such as start-up costs, booklets or printing. The fees quoted shall include all services and supplies that could reasonably be expected to be provided to the County during the course of your administration of the plans. Confirm your agreement to this requirement.
- Please confirm that there will be no adjustments to the proposed rates based on actual enrollment or subsequent shifts in enrollment.
- The County requires that retroactive changes, additions and deletions to eligibility be permitted up to one year in arrears of the initial eligibility effective date and may include adjustment, payment, or recovery of claims. Does your company accept these terms?
- The County requires that it maintain the right to terminate the contract at any time provided that it gives 30 days advance written notification to the contractor. Do you agree to this provision?
- Will you transfer enrollment cards, claim information, and other administrative records to any carrier that would replace you in the event of termination of this contract at no charge?
- Do you agree to the provision that changes in the rates may only occur on the anniversary date unless required by mandatory benefit changes?
- The County requires written notification of renewal actions at least 90 days preceding the contract expiration date. Confirm your agreement to this requirement.
- Confirm that you agree to waive any and all actively at-work restrictions and pre-existing condition limitations for employees enrolled in the plan on the contract effective date and waive any pre-existing limitation for employees that enroll after the policy effective date. Contract should include such language.
- Will you guarantee that all insured (including COBRA participants), who would have continued to be covered on the plan effective date if there had been no change in carriers, will be covered by your policy on the plan effective date?
- Are your EPO and HMO networks licensed in the state of California?
- Will you agree to include in your contract a hold harmless provision that indemnifies the County against liability that arises as the result of negligent acts, errors, omissions, fraud and other criminal acts committed by your network providers, officers, employees, and agents of the organization?
- Do you agree to maintain compliance with HIPAA privacy and security for the duration of the contract with the County?
- Do you agree to accept all eligibility rules and eligibility determinations established by the County?
- Confirm that your company is in compliance with all state and federal laws applicable to the programs you are proposing.
- Do you agree to provide monthly, quarterly, and annual reporting as requested (i.e., premium, claims, enrollment, and utilization)?
- Confirm that you have reviewed the County’s master contract terms and conditions in Exhibit “B” and will agree to the terms contained therein if selected.
Explain any “No” answer provided in the requirements above:
QUESTIONNAIRE
PART 2
All Proposers Are Required to Complete This Section
A.Contractual Requirements
CONTRACTUALREQUIREMENTS / VENDOR RESPONSE1)Will there be any additional charges if the plan of benefits is restructured or new classes are added? If so, what is that charge?
2)The County wishes to include in the contract the right to cancel the contract at any time should it find performance of the organization paying claims (or performing non-claims paying functions) to be unsatisfactory. Do you agree to include this provision in your contract?
3)The contract provides the County shall have the right to audit the performance of the plan and services provided. Indicate what services, records and access will be made available to the County at no additional charge. Also, indicate frequency and notice requirements that are part of the right to audit provision.
4)Do you agree that the fees, rates, performance guarantees and responses you provided in this proposal are legally binding? For what period of time are these responses valid?
5)Please confirm that your company will not receive any shared savings, commissions or overrides, volume bonuses or payments of any kind from the providers or vendors that you are contracting with to perform the services under the proposed contract. All income must be disclosed to the County from any source which results from conducting business on behalf of the County. / Confirmed
Not Confirmed
(If not confirmed, disclose here the source and amount of all revenue your company will receive other than fees paid directly by the County.)
6)Please confirm that:
a. All fees are guaranteed for 36 months from contract inception. Fees are guaranteed for 12 months upon renewal after the initial contract expiration (at the County’s option), and that all future rate adjustments will be subject to annual renewal (e.g., at least 12 months) in the absence of benefit revisions. / Confirmed
Not Confirmed
b. All future rate adjustments will be communicated at least 90 days in advance of the effective date. / Confirmed
Not Confirmed
c. Your fees are payable at the end of a 30-day grace period. / Confirmed
Not Confirmed
d. Your fees include printing of benefit statements, enrollment forms, benefits applications, and all other routine supplies and materials. Fees should also include routine printing and mailing costs (e.g., EOBs, checks). / Confirmed
Not Confirmed
e. Guarantee a reduced or discounted post-termination administrative fee. / Confirmed
Not Confirmed
f. Transfer all records to the County or the successor administrator within 30 days of termination in a form that is acceptable to the County and recipient at no added cost. / Confirmed
Not Confirmed
g. Have reviewed the County’s Sample Master Terms and Conditions attached as Exhibit “B” and agree to the terms outlined therein. / Confirmed
Not Confirmed
7)Detail any rights reserved by your firm to charge any additional fees.
8)Will your contract provide that changes in fees may be instituted only as of a renewal rate anniversary?
B.Implementation and Transition Issues