RFP NO. 05-16/TW
DUVAL COUNTY PUBLIC SCHOOLS
ATTACHMENT B1 – PROPOSAL WORKSHEET- MEDICAL AND EAP SERVICES & PHARMACY SERVICES
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 (0-15 points)
Company Information
Proposer/Company Name
Primary RFP Contact Person Name:
Phone No:
Fax: No:
E-mail Address:
Subcontractor Information if applicable
Pharmacy Benefit Manager
Employee Assistance Program (EAP)
Health Savings Account
Disease Management
Company:
Indicate the Appropriate Company or Companies that are included in your Company’s Proposal
Page 1 of 23
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
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.
2.
Proposer shall have accreditation by the National Committee for Quality Assurance (NCQA) as
applicable as of the proposal due date.
3.
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.
4.
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.
5.
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.
6.
Proposals shall be submitted net of commissions
Company:
No
Page 2 of 23
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
1.
2.
3.
4.
5.
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
Company:
Page 3 of 23
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.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Issue
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.
State your member call in customer service location and hours of operation.
List the percent of customer service calls for 2015 that resulted in problem resolution on the initial call.
For 2015, indicate your service performance results in the following categories (format indicated in
parenthesis):
a. Average speed of telephone answer (number of seconds)
b. Average telephone call abandonment rate (percentage)
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.
Confirm that all customer service support involving interaction with members shall be handled within the
territorial limits of the United States of America.
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.
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.
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.
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.
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.
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.
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.
Confirm that your Company agrees to the following:
Company:
Response
a.
b.
Page 4 of 23
15.
16.
17.
18.
19.
20.
21.
22.
Issue
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.
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.
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.
For 2015, indicate the performance results in the following categories (format indicated in parenthesis):
a. Clean claims processed within tem (10) days (percentage)
b. Clean claims processed within thirty (30) days (percentage)
c. Average claims turnaround time (number of days);
d. Claims coding accuracy (percentage);
e. Claims dollar accuracy to include over and under payments (percentage);
List the percent of medical claims in 2015 that were received electronically and claims completely
adjudicated electronical manually
Confirm that your Company will allow retroactive eligibility and claims adjudication at no additional cost the
District.
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.
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.
Indicate where your claims processing system or patient record captures and can report on the following:
a. Laboratory values specific to the member
b. Compliance with periodic physicals and preventive diagnostic services specific to the member
c. Plan sponsored biometric screening values specific to the member performed by a third party
vendor selected by the District
d. Plan sponsored biometric screening values specific to the member performed by a third party
vendor selected by the District
e. Prescription medication adherence and compliance
Company:
Response
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
Page 5 of 23
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:
a.
a. Frequency and timing of formulary changes
b.
b. Method to notify employer, including summary of member impact
c.
c. Method to notify specific members impacted
d.
d. Method to notify providers
e.
e. Availability of formulary via hard copy and on website
Company:
Page 6 of 23
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.
1.
2.
3.
4.
5.
6.
7.
8.
Issue
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.
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.
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.
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.
Describe your ability to include two levels of copayments with lower
copayments for network physicians in a high performance limited
network.
Confirm that your networks have 85% of providers Board
Certified/Board Eligible, and an annual turnover rate of less than 3%.
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)
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)
Response
County
Family Practice/IM
Total #
% BC/BE
Specialists
Total #
% BC/BE
Duval
Baker, Nassau, St. Johns, Clay
County
Duval
Baker, Nassau, St. Johns, Clay
9.
Indicate any network gaps where in-network specialty providers are
not available in Duval, Baker, Nassau, St. Johns, and Clay Counties, if
applicable.
Company:
Page 7 of 23
Issue
10. Confirm your network shall include state and national access for nonemergency and emergency care, including services provided at
Centers of Excellence?
11. Confirm your network shall include allowances for international
emergency and non-emergency care?
12. 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
13. List the contracted services where capitation fee is applied. Confirm
that you provide encounter data for services covered under your
capitation arrangement.
14. 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.
15. Confirm that your Company shall monitor network performance based
on nationally recognized quality standards
Response
16. How does your Company monitor the performance of your network
and what corrective actions are taken?
17. 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?
18. Confirm that your Company will include mail order and specialty
pharmacy services.
19. Describe how pharmacy service allowances for international and nonemergency prescription services.
20. How does your Company communicate with regional pharmacies on
plan design changes?
21. Provide your Company’s specialty pharmacy facility name, location,
and years of service for your Company.
22. 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)
Company:
Page 8 of 23
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
a.
health of the population with comprehensive initiatives including voluntary programs for:
b.
a. Weight management for healthy weight, overweight, obese or morbidly obese members;
c.
b. Diabetes control and prevention;
d.
c. Tobacco cessation;
e.
d. Comprehensive cardiology program, including hypertension control and prevention;
f.
e. Chronic Obstructive Pulmonary Disease (COPD);
g.
f. Healthy pregnancy;
h.
g. Compliance with preventive screening guidelines.
h. Nutritional education for adults
i.
i. 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.
Company:
Page 9 of 23
Issue
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?
Response
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)
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 the finance arrangements for the self-funded health plan includes documentation for claims
reimbursement and will meet the accounting and payment needs of the District, as determined by the
District policy. The School Board shall pay for fees and medical pharmacy claims via monthly ACH wire
transfer.
2. Confirm your Company will accept self- billing by the District for administrative fees which is based on
eligibility provided?
3. Confirm that you agree to claims payment via monthly ACH wire transfer
4. Confirm that your Company will bill the District on a monthly basis for claims processed by your
Company in each previous month.
5. Confirm your Company’s capability to integrate any biometric screening results, specific to each
member and performed by the Contractor or by an independent screening company, into the utilization
history of each member?
6. List the standard reports your Company will make available to the District on a daily, weekly, monthly,
quarterly or annual basis. Include sample Reports under Tab 5
7. Confirm that your Company will make available eligibility, claims and utilization data on a monthly basis;
and eligibility discrepancy reporting on a weekly basis via secure web-based portal.
8. Confirm that your Company will provide medical and/or pharmacy claims and eligibility file downloads
(data dumps), in a HIPAA compliant, standard industry format to the District benefits consultant on a
monthly basis and will include, at minimum, all fields listed in Exhibit 6 – Claims File Layout.
9. Confirm that your Company agrees to include a pharmacy claims interface from the independent PBM
on no less than a weekly electronic claims feed, if applicable.
Company:
Page 10 of 23
Section 6 – Pharmacy Services– Complete the section below using the information and instructions found in Section 2.6 of the Request for Proposal. The committee will assign up
to 10 points for services proposed within Section 5. (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 of pharmacy services includes $0
administrative fees.
2. Confirm that pharmacy pricing and guarantee shall meet the following:
a.
a. Single-Source Generic prescriptions, Multiple-Source generic
b.
prescriptions, MAC and Non-MAC prescriptions will be included in
c.
the generic medication category for discount and fill rate guarantee
d.
calculations.
e.
b. Single-Source Generics will be identified as having 2 or less
f.
manufacturers for discount and fill rate guarantee calculations.
g.
c. Usual and Customary (U & C) Claims, Zero Balance Claims,
h.
Compounds and Over-the-Counter claims will be excluded for
i
discount and fill rate guarantee calculations.
d. “Ingredient Cost” will mean the lesser of MAC price, discounted AWP .j.
k.
or the dispensing pharmacy’s U & C.
l.
e. Contractor will utilize the timeliest, expansive, and cost effective
m.
MAC list of behalf of the District.
f. Plan members will always be charged the lesser of their plan
copayment, the PBM’s contracted price, the pharmacy U&C, or the
cash price.
g. Contractor will base AWP (Average Wholesale Price) on date
sensitive, 11-digit National Drug Code (NDC) of the actual product
dispensed as supplied by Medi-Span for retail, mail order, and
specialty adjudicated claims.
h. Proposed discount guarantees and other guarantees will be the
minimum guarantees (not fixed) regardless of whether the District
implements any additional specific clinical management programs
such as step therapies or prior authorizations.
i. Rebate revenue that is earned by the District during the term of the
agreement with the Proposer will be paid to the District at least
quarterly and will be paid following termination of the agreement, as
long as claims reimbursements remain current.
j. Auditing of all claims will be permitted versus a claims sample.
k. Each distinct pricing guarantee being measured and reconciled on a
component basis (i.e. generic and brand; specialty; rebates; and
generic fill rate) with no surpluses in one component offsetting
deficits in another component.
l. Guarantee shortfalls will be guaranteed on a dollar-for-dollar basis
with 100% of any shortfall in any component recouped by the
Company:
Page 11 of 23
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Issue
District.
m. Proposer to use the Centers for Medicare and Medicaid Services
(CMS) definition of a specialty medication.
Confirm your proposal commits to minimum guarantees on retail and
mail order generic and brand pharmacy discounts and costs on an
annual aggregate basis for a minimum of three (3) years?
Confirm that your Company shall commit to retail 90 day fill program?
Response
Confirm your proposal commits to minimum guarantees on specialty
pharmacy discounts and costs on an annual aggregate basis for a
minimum of three (3) years? While specialty drug type and dispensing
channel may be on a drug-by-drug basis, the minimum guarantee is to
apply.
Confirm your proposal commits to minimum rebate guarantees on all
brand and specialty drugs dispensed for a minimum of three (3) years?
Confirm your proposal commits to minimum generic dispensing fill rate
guarantees for a minimum of three (3) years?
Confirm that your Company will notify impacted members of negative
formulary changes that may occur throughout the plan year.
Confirm your proposal includes any programs available to impact
pharmacy utilization such as step therapy and clinical prior
authorizations for consideration by the District? Include return on
investment guarantees.
List your step therapy programs your Company will include in the ASO
fees proposed for the District.
List your prior authorization programs your Company will include in the
ASO fees proposed for the District
Describe your specialty pharmacy clinical support.
Indicate how your Company monitors medication adherence and what
steps your Company will take to improve compliance.
Indicate how your Company will identify high risk pharmacy use and
actively manage polypharmacy issues.
Company:
Page 12 of 23
Section 7 – EAP Services– Complete the section below using the information and instructions found in Section 2.7 of the Request for Proposal.
The committee will assign up to
5 points for services within section 6. ( 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
Response
1. Confirm that you are proposing a single contract that includes EAP
services. Subcontracting for EAP services is permitted.
2. Confirm that your company shall include EAP services for up to six (6)
face to face counseling sessions per incident for conditions such as:
Marital and Family Relationships; Stress Management; Alcohol and
Drug Issues; Work-related Concerns; and Bereavement.
3. Confirm that your Company shall include Work/Life Balance assistance
for conditions such as: Financial and Budgeting Concerns; Legal
Services; Day Care and Nursing Facility Selection Assistance; Life
Coaching Services.
4. Confirm that EAP services shall have the ability to interface with medical
services for purposes of wellness and health care cost containment
activities?
5. List EAP member tools and online services for obtaining EAP clinical
and non-clinical information?
6. Confirm your EAP telephonic customer service and urgent / crisis
response counseling functions, which shall be available 24 hours 7 days
a week familiar with the District’s account?
7. Confirm that your Company will timely assist members with scheduling
counseling sessions.
8. Confirm that referrals will be integrated with the behavioral health
benefits offered through the District’s health plan.
9. Confirm that your Company will record and maintain information
regarding service-related or other complaints reported by members.
10. Contractor communication materials, as approved by the District, are to
be supplied throughout the year to educate members and bring
awareness to the EAP and Work Life services available.
11. Will your Company assign an account manager who shall be available to
meet on a quarterly basis with the District and its administrative staff,
and wellness team, or more frequently as deemed necessary by the
District?
12. Confirm that your Company will supply quarterly management reports
and observations on methods to enhance the behavioral health and EAP
benefit for members.
13. Confirm your Company supplies an annual training session for all
District supervisory personnel?
14. Confirm your Company offers a minimum of 120 hours of onsite EAP
seminars for District employees annually?
Company:
Page 13 of 23
Issue
15. Confirm that your Company will participate and attend the District’s
health fairs and quarterly new hire sessions.
16. Confirm that your Company will provide licensed, professional EAP
counselors of varying degrees of professional licensing (e.g., certified
psychologist, family and marriage counselors) and experience in
providing EAP services.
17. Confirm your Company provide comprehensive EAP National and
Statewide provider networks?
18. Confirm your Company provide access to quality licensed providers
specifically in Duval, Baker, Nassau, St. Johns, and Clay Counties?
19. Confirm your Company’s ability for self-referral and supervisor referrals.
20. Confirm your proposal include consultation to Supervisors to assist them
in resolving workplace issues and in making necessary referrals?
21. Confirm that your proposal includes Fitness for Duty assessment for
employees, as needed including verbal and written reports back to
District if requested.
22. Does your proposal include on-site intervention incidents? (e.g., Critical
Incident Stress Debriefing or Emotional Incidence Stress Debriefing) that
includes mobilizing responders for same day on-site services if needed.
23. Confirm that your proposal includes EAP services for the District
employees who are eligible for, but waived, health plan coverage.
Company:
Response
Page 14 of 23
Section 8 – Cost of Services and Performance Guarantees– Complete the section below using the information and instructions found in Section 2.8 of the Request for Proposal.
The committee will assign up to 30 points for services proposed within section 7. (0-30 points)
The following provides a summary of the current enrollment by plan and paid claims experience.
Plan Membership Based on RFP Census – see Exhibit “3” – Census for enrollment detail the census is the actual census for the January 2016 enrollment eligibility.
Health Plan - Contributory
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Child(ren) Only
Total
Subscribers
2,158
310
534
201
2
3,205
Members
2,158
620
1,533
800
3
5,114
Health Plan – Non-Contributory
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Child(ren) Only
Total
Subscribers
9,114
526
1,313
490
2
11,445
Members
9,117
1,051
3,663
1,943
2
15,776
Health Plan - HDHP
Employee Only
Employee + Spouse
Employee + Child(ren)
Employee + Family
Total
Subscribers
18
2
1
0
21
Members
19
4
5
0
28
Company:
Page 15 of 23
Paid Claims Summary – see Exhibit “4” – Claims Experience for claims and enrollment by month and claims lag report.
1.
Guaranteed ASO Fees: List your Company’s proposed Health Plan Administrative Services Only (ASO) Fees below. ASO fees shall be inclusive of all administrative
and Network management services. Any service not included in the ASO fee shall be disclosed in the response to question 4 below.
Self-Funded Administrative Services Only (ASO) Fees
The Plan Administrative Services Only (ASO) fees shall be stated and guaranteed for 2017, 2018, and 2019 and quoted on an incurred claim basis. Additional rate
guarantees for years four (4) and five (5) (2020 and 2021) are requested and desired, but not mandatory. Claims administration for run-out claims following termination
of the Contract shall be included in the Per Subscriber Per Month (PSPM) fees as proposed. Use the “Subscriber” counts provided to calculate the PSPM total costs.
Administrative Services Only (ASO) Fees
REQUIRED
Fee Per Subscriber Per Month
Contributory Plan
Non-Contributory Plan
HDHP Plan
Total ASO Monthly Cost
Total ASO Annual Cost
2.
Subscribers
3,205
11,445
21
2017
OPTIONAL
2018
2019
2020
2021
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Medical Discounts and Trend - Complete the following sections using the claims data found in Attachment “E” & “F” to the RFP. Only provide Contractor’s aggregate
amounts. All amounts, summaries, reports, and discounts listed shall be subject to verification. The verification process will be conducted, at Contractor’s facility, with
Contractor’s specific data being kept proprietary to the extent allowed under Florida law. Only the aggregate amounts as verified shall be disclosed.
a.
Claims Re-pricing. Using the claims information found in Attachment “E” – Medical Claims Pricing File, complete the chart below by listing the aggregate
allowable cost for each category. Contractor shall complete the re-pricing exercise; however do not submit this detailed information with the proposal. The
responses provided below are subject to validation by reviewing the completed re-pricing file and provider contracts onsite at Contractor’s facility as a part of the
evaluation process.
Category
Inpatient Hospital
Outpatient Facility
Professional
Total Amount
b.
Company:
Total Billed Amount
Billed Amount Re-priced
Total Allowable
Aggregate Cost
$41,442,233
$17,062,759
$64,817,295
$123,322,287
Provider Discount Pricing. Using the utilization and cost information provided in Attachment “F” - Medical Discount Pricing File, indicate Contractor’s
current average percent medical network discounts for the service categories listed below. You must complete the worksheets provided in Attachment F;
however do not submit this detailed information with your proposal. The responses provided below are subject to validation by reviewing the completed
worksheets in Attachment F and provider contracts onsite at Contractor’s facility as a part of the evaluation process.
Page 16 of 23
Network Provider Category
Total Billed Charges
Facility
Ancillary
Professional
Total Medical Provider Charge
c.
Current % Discount from
Billed Charges
$59,234,693
$7,622,507
$56,465,087
$123,322,287
Provider Discount Guarantee. Indicate the minimum discounts Contractor shall guarantee for 2017, 2018 and 2019 with no corridor included in the guarantee.
Performance Guarantees shall be based on the aggregate medical provider discount guarantee.
Network Provider Category
Guaranteed %
Discount for 2017
Guaranteed %
Discount for 2018
Guaranteed %
Discount for 2019
Facility
Ancillary
Professional
Aggregate Medical Provider Discount
Aggregate Medical Provider Discount Guarantee Limitations and Conditions: List any limitations and conditions that will apply to your Contractor’s Performance
Guarantee.
d.
Medical and Prescription Drug Trend. List Contractor’s medical and prescription drug trends for the Duval County area in the following calendar years.
Medical Trend
Medical Cost
Increase (Medical
Trend)
Prescription Drug
Cost Increase
(Rx Trend)
Overall Cost
Increase
(Overall Trend)
2014
2015
2016 Anticipated
3.
Pharmacy Guarantees. Pharmacy guarantees are required for all ASO self-funded proposals. Contractor’s pharmacy discounts, rebates and dispensing fees shall
be guaranteed for at least 2017, 2018, and 2019. Additional guarantees for years four (4) and five (5) (2020 and 2021) are requested and desired but not mandatory. No
administrative fees shall be charged. Single source generics are generic drugs in the first six (6) month exclusivity period following a brand drug losing its patent. Single
source generic discount guarantees shall be included in the generic discount/Rx from AWP. Discounts shall be applied to zero balance claims, where the Member
copayment equals to total cost of the drug, but are to be excluded from the guarantees. One hundred percent (100%) of the rebates received shall be shared with the
District. The lesser of Usual and Customary fees, or the guaranteed discounts, shall apply. Guarantees shall be separated into the following three (3) categories: generic
and brand, retail and mail order; specialty pharmacy; and rebate guarantees.
a.
Pharmacy Pricing Guarantees.
Retail Pharmacy Discounts and Fees
30 Days
Company:
2017
30 Day Retail Guarantees- Required
2018
2019
Optional
2020
2021
Page 17 of 23
Generic Discount/Rx from AWP
Generic Drug Dispensing Fee/Rx
Brand % Discount from AWP
Brand Drug Dispensing Fee/Rx
Brand Drug Rebate/ Brand Rx
Retail Pharmacy Discounts and Fees
Over 84 Days
Generic Discount/Rx from AWP
Generic Drug Dispensing Fee/Rx
Brand % Discount from AWP
Brand Drug Dispensing Fee/Rx
Brand Drug Rebate/ Brand Rx
Mail Order Pharmacy Discounts and Fees
Over 84 Days
Generic Discount/Rx from AWP
Generic Drug Dispensing Fee/Rx
Brand % Discount from AWP
Brand Drug Dispensing Fee/Rx
Brand Drug Rebate/ Brand Rx
2017
30 Day Retail Guarantees- Required
2018
2019
Optional
2020
2017
Mail Order Guarantees - Required
2018
2019
2020
2017
Specialty Rx Guarantee - Required
2018
2019
2020
Specialty Pharmacy Discounts and Fees
2021
Optional
2021
Optional
2021
% Discount from AWP
Drug Dispensing Fee/Rx
Drug Rebate/ Specialty Rx
b.
Pharmacy Cost Guarantee Worksheet
Confirm that Contractor has completed the Pharmacy Pricing Guarantees Worksheet,
Attachment D, and it is included with the response.
c.
Generic Fill Rate Guarantee. Indicate the generic fill rate Contractor shall guarantee for the following years. Guarantees shall be factored on a dollar for dollar
basis for any shortfall.
Generic Fill Rate
Amount of Guarantee
4.
2017
%
Required
2018
%
Optional
2019
%
2020
%
2021
%
Services Included and Cost. Indicate whether the following services are included in the proposed self- funded ASO fee:
Company:
Page 18 of 23
Service
Included in
Additional Cost and/or Limitations (must be disclosed)
Proposal (Yes/No)
Current plan design administration
Full time member service representative on-site at the District
Dedicated account management team
Attendance at quarterly administrative and Plan management meetings
Medical and Pharmacy Clinical Director attendance at annual utilization review meetings
Annual enrollment training and on-site enrollment meeting participation as outlined in RFP
Master accumulator for medical and pharmacy deductible and out of pocket maximums
Integration of pharmacy claims from independent Pharmacy Benefits Manager (PBM)
Run-out claims administration following termination of Contract for a minimum of one year
Provide run out claims data following termination of contract
On-line capability for eligibility additions, changes and deletions (prospective and retroactive)
Weekly eligibility discrepancy reports
Eligibility data interface with the District and its contracted vendor for retiree and COBRA
participants on an ongoing basis
Monthly comprehensive eligibility, claims and utilization experience downloads
Retroactive eligibility and claims reprocessing
Printing and distribution of ID cards initially and when Plan deductibles, co-pays, and coinsurance changes are made and when replacement cards are issued
Customize ID card to include applicable plan copays including carve out pharmacy if applicable
On- line access to provider Network directory
Development and maintenance of Summary Plan Description (SPD) and Summary of Benefits
and Coverage (SBC)
Posting of the Plan Summary Plan Description (SPD) and Summary of Benefits and Coverage
(SPC) on your Company website for Member access
Printed Summary Plan Description (SPD) for hard copy requests (approx. fifty (50) per year)
Web-based access to administrative tools for Network providers to access Member coverage
details
Web-based administrative tools for Members to view specific Plan information and access claims
history and educational tools on provider Network, cost comparisons and wellness issues
Provider Network administration and access to a local and national Network of providers,
including Centers of Excellence
Claims adjudication, including review and defense of appealed claims, up to the external claims
review
Physician and Pharmacy claims adjudication and benefit appeals
Full claims fiduciary responsibility, including all coverage determinations
External claims administration and selection of review agency for medical and pharmacy appeals
Cost of external claims review
Legal defense of claims appeals involving clinical decisions Contractor made
Fraud, waste and abuse program
Third party liability recovery (subrogation) services
Coordination of benefits recoveries
Company:
Page 19 of 23
Service
Included in
Additional Cost and/or Limitations (must be disclosed)
Proposal (Yes/No)
Overpayment recovery services
Hospital bill audit services
Facility Reasonable and Customary (R&C) charge determination services
Out-of-Network discount negotiation services
Full Access to records and staff necessary to conduct annual external audits conducted by the
District, State Auditor or its designated auditing firm
Monthly full claims detail to District’s benefits consultant in accordance with the fields outlined in
Exhibit 6.
Monthly reporting of large dollar claims to independent stop loss insurance carrier and
submission of all data necessary for claims recovery to the District
File transfer acceptance for pharmacy claims if the District determines to provide pharmacy
benefits through an independent pharmacy benefit manager
Predictive modeling and ongoing outreach and management of members at risk
Case management with a dedicated case management nurse working closely with the District
Disease management programs
Healthy pregnancy program
Assistance with comprehensive health management program design and implementation
Annual health fair participation
Wellness educational materials – electronic and printed
Telemedicine service administration
Online health risk assessments
Biometric screening administration onsite at various District locations as part of the annual
wellness program
Ability to upload biometric screening results from a third party vendor to the individual member
health record and ability to auto-populate the member’s health risk assessment
Activity tracking for wellness and health management activities and administration/tracking of
incentives
Administration of value based benefit design for participation in health management programs
Pharmacy clinical prior authorization program and review
Pharmacy step therapy program and review
Pharmacy retrospective utilization review
Pharmacy clinical review for medical necessity
Formulary disruption letters to impacted members when changes occur
Targeted letters to members on pharmacy-related issues (any additional costs should be quoted
on a per letter basis)
Pharmacy patient safety audits at point of sale
Claims data requests for GASB and other state and federal reporting requirements
Online report access with query capabilities including detailed eligibility, claims and utilization
data
Direct Member claims reimbursement (paper claims)
Open file transfers to new Contractor using industry standard formats at termination
Company:
Page 20 of 23
Service
Included in
Additional Cost and/or Limitations (must be disclosed)
Proposal (Yes/No)
Provide all required notifications and data necessary to comply with any out-of-state
requirements, e.g. New York Surcharge.
Annual satisfaction survey specific to District Members
Health Saving Account administration and monthly service fees for members selecting the high
deductible health plan
List any additional services Contractor will perform that have not been previously disclosed that
will result in additional administrative charges to the District or any additional fees for Contractor
Other services not included in ASO Fees
Cost of a full-time on-site clinical care coordinator (Registered Nurse or clinical equivalent). The
clinical care coordinator shall assist Members in achieving optimal health through identification of
risks, closing gaps in care, assisting with District wellness initiatives, conducting educational
sessions at various locations, and developing health improvement strategies.
Other services
5.
EAP Services Cost
The EAP Services fees shall be stated and guaranteed for 2017, 2018, and 2019. Additional rate guarantees for years four (4) and five (5) (2020 and 2021) are requested
and desired but not mandatory. Use the “Subscriber” counts provided to calculate the PSPM total costs.
EAP Fees
REQUIRED
OPTIONAL
Subscribers
2017
2018
2019
2020
2021
Fee Per Subscriber Per Month
14,920
$
$
$
$
$
Total EAP Monthly Cost
$
$
$
$
$
Total EAP Annual Cost
$
$
$
$
$
EAP Services
Included in
Proposal (Yes/No)
Indicate any
additional cost
Limitations (must be disclosed)
Six (6) face to face counseling sessions per incident
Minimum of one hundred- twenty (120) hours of on-site EAP seminars for District employees
annually
Behavioral health fitness for duty exams for employees, as needed.
Substance Abuse Professional (SAP) services following U.S. Department of Labor,
Commercial Driver License and Florida Drug-Free workplace regulations.
On-site intervention incidents (e.g., Critical Incident Stress Debriefing or Emotional Incidence
Stress Debriefing).
EAP Services for employees eligible for Health Plan coverage but waived coverage are
included in the EAP Services Cost listed above
List other proposed services where and additional cost may apply
Company:
Page 21 of 23
EAP Services
6.
Included in
Proposal (Yes/No)
Indicate any
additional cost
Limitations (must be disclosed)
Performance Guarantees: List your proposed performance guarantees, including a description of the guarantee and measurement and dollar amount at risk for each of
the categories listed below. Guarantees shall be for a minimum of three (3) years.
Area of Guarantee
Implementation
Plan Implementation (plans loaded, tested; staff trained; eligibility accurate and ID
cards issued before 1/1/2017)
Contract negotiations completed by June 30, 2016
Summary of Benefits and Coverage (SBC) completed by September 1, 2016
Plan documents received by November 1, 2016
Administration
Summary of Benefits and Coverage (SBC) completed by September 1st of each year.
Plan documents received by November 1st of each year.
Claims Financial Accuracy by using total claims dollars processed, compared to the
combined over and under payment errors, with a minimum of 99% accuracy
Claims Processing Accuracy of at least 99% of the total number of correct claims
divided by the total claims processed
Clean Claims Turnaround Time minimum of 94% clean claims in 14 calendar days and
100% all clean claims in 30 days
Timely Reporting due by the 20th of the following month
Timely Data Transfer
Account Management
Standard that demonstrates the Proposer’s commitment to maintain experienced,
dedicated account service contacts that provide ongoing and timely service to the
School Board’s administrative staff, conduct service meetings with the School Board to
review the status of the account and services deliverable, and issue resolution as
needed.
Customer Service Standards
Average speed of answer
Percent of issues answered on initial call
Call abandonment Rate
Medical and Pharmacy
Minimum Aggregate Network provider percentage guarantee
Network shall include a minimum of eighty-five percent (85%) of providers being Board
Certified or eligible
Company:
Metric Required to Meet Guarantee
Dollar Amount at Risk
Page 22 of 23
Area of Guarantee
Provider turnover rate of less than three percent (3%) annually
Generic discounts, brand discounts, and dispensing fee guarantee for retail and mail
order
Specialty discount guarantees
Rebates on all brand and specialty drugs
generic fill rate guarantee
Satisfaction
Account management satisfaction survey scores
Employee satisfaction survey scores
Other performance guarantees you will provide
Metric Required to Meet Guarantee
Dollar Amount at Risk
As an officer of the Company, I certify that the information contained in the proposal worksheet is accurate, and Contractor shall be bound by the contents of the proposal.
Please return this Word document in print and electronic format with your responses and a separate PDF file of this signed certificate page.
Signature: _______________________________________________________
Name:
Date: _____________________
_______________________________________________________ Title: _______________________________________________________
Company:
Page 23 of 23