[XLS]Medical RFP - Delawarebidcondocs.delaware.gov/OMB/OMB_11003HealthIns.xls · Web viewProvide...

Introduction 1 September 26, 2011

BACKGROUND AND ADMINISTRATIVE INFORMATIONIntroduction

Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of Delaware

The State Employee Benefits Committee (SEBC) of the State of Delaware ("the State") is soliciting proposals from qualified medical benefit administrators to provide medical administrative services for the Group Health Insurance Program (GHIP) for the State of Delaware’s active employees, pensioners, spouses, and dependents. The SEBC's current medical benefit programs include the following plans: First State Basic, PPO and Port Authority Plan, collectively “PPO Plan”; health maintenance organization (HMO); consumer directed health plan (CDHP); and a Medicare Supplement. Vendors are strongly encouraged to view the information specific to the health benefit programs governed by the SEBC at the following web site: http://ben.omb.delaware.gov/. The State of Delaware reserves the right to modify the medical plans in the future for any reason including but not limited to state or national legislation.

The SEBC is soliciting proposals from vendors who will partner with the SEBC and its contracted vendors to provide exemplary services. The program is to be effective July 1, 2012. The SEBC is requiring a quote on disease management services to be included as part of proposals for the PPO, CDHP and HMO plans. The SEBC may or may not elect to implement your disease management program on July 1, 2012. Additionally, interested bidders may provide a quote for optional wellness program services. The SEBC is not accepting bids for only the wellness program services in this RFP. Vendors who only include a bid for the Medicare Supplement plan are not to submit a quote for disease management services. Both the disease management and wellness programs may or may not be awarded effective July 1, 2012, with the contract for medical benefit administrative services.

The SEBC may or may not elect to implement the successful Bidder's medical plan on July 1, 2012 and may defer implementation and contract effective date to January 1, 2013. In this event, interested bidders must confirm that the quote provided will be deferred and is guaranteed for the initial 2 years of 1/1/2013 to 1/1/2015. In addition, the guarantee will extend if the contract is renewed for each additional renewal year based on a calendar year.

Proposals are due from interested vendors by November 14, 2011. Bids must be received no later than 12:00 p.m. (Noon), EST on the due date. This Request for Proposal (RFP) is issued pursuant to Title 29 Delaware Chapter 69 Sect. 6902(1), 6981, 6982 and 6986.

Vendors may bid on: A) All Medical Plans,

B) HMO Plan only, C) PPO Plan only : First State Basic, PPO, and Port Authority Plan,

D) CDHP only, and/or E) Medicare Supplement only.

All bids must include a Disease Management program for all plans except the Medicare Supplement. Award(s) will be made to one vendor for all plans or multiple vendors for any combination of plans with or without a

Disease Management program.

For the purposes of this RFP, the following terms are used interchangeably: “vendor(s)”, “bidder(s)”, “you”, “your”, "organization" and “proposing firm”. The following terms are also used interchangeably: “bid”, “proposal”, and “your quote”.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of DelawareDescription

pre-tax commuter benefits.

The SEBC is chaired by the Director of the Office of Management and Budget (OMB). The Controller General, Insurance Commissioner, State Treasurer, Secretary of Health and Social Services, Secretary of Finance and Chief Justice of the Supreme Court comprise the remainder of the SEBC. The SEBC provides medical benefits to approximately 114,000 covered lives of which approximately 36,000 are active employees, 25,000 are pensioners (26,000 are school district employees and members of participating groups such as municipalities) and the dependents of all these primary members. Annual plans costs for the medical program currently amount to approximately $450 million and drug costs are approximately $150 million. The Statewide Benefits Office (SBO) is a division within the OMB. The SBO functions as the administrative arm of the SEBC responsible for the implementation and administration of all statewide benefit programs with the exception of pension and deferred compensation benefits. These programs include, but are not limited to, health, prescription, dental, disability, group life, flexible spending accounts, wellness and disease management programs, an employee assistance program, and

The SEBC contracts with Ceridian for administration of COBRA and with Human Management Services (HMS) for administration of employee assistance services. The dental and vision benefit plans are 100% employee pay-all and are not included with this health plan. The Pharmacy Benefit Manager (PBM) services are carved out and are administered by Medco. The vendor will be required to share specific claim and utilization data with the PBM vendor and data warehouse vendor and possibly other vendors to be determined in the future. The Port Authority Plan is a Point of Service plan available to a closed group of approximately 275 active employees and their dependents for a total population of approximately 550. The State of Delaware utilizes multiple electronic human resource programs, such as PeopleSoft, and vendor databases at separate locations in various formats to collect and store participant personal health data.

The SBO administers the Group Health Insurance Program (GHIP). The medical insurance component of the program is self-insured. Eligible participants include active, retired, school district, charter school, university, community college, non-state groups, and COBRA participants and their enrolled dependents. Plan participants are primarily located within the State of Delaware, although a small number of participants reside in other states and countries. There are multiple employer units and non-payroll groups located in three counties throughout the State, with each exercising a high degree of independence.

The State currently contributes 100% of the First State Basic Plan health insurance premium for employees regardless of the tier they choose. The employee is then responsible for the cost difference between the First State Basic Plan and the optional coverages. The optional health benefit plans are PPO, HMO , and CDHP. Non-state groups are responsible for 100% of the premium for any health plan plus applicable monthly and annual fees.

The recent passage of House Bill 81 during the 146th Delaware General Assembly will result in changes in employee and retiree health benefits for State of Delaware employees hired on or after January 1, 2012. In addition, Senate Bill 30 of the 146th Delaware General Assembly will extend health benefits to civil union partners and their dependents beginning January 1, 2012.

The SEBC is also sensitive to the specific health care climate that exists in Delaware. Significant issues include a persistent shortage of physicians and dentists in the two southern most counties, a limited hospital market, and a demographic split between the northern and urban county and the two southern rural counties.

Current Medical Plans

The State currently contracts with Blue Cross Blue Shield of Delaware (BCBSD) and Aetna Healthcare to administer its PPO, HMO, CDHP and Medicare Supplement plans. The details of the current plans are provided in the "Plan Design" worksheet(s). Vendors must duplicate the current plan design(s) with only administrative variations. Vendors may quote on all medical plans, PPO Plan only, HMO only, CDHP only, and/or Medicare Supplement only. Vendors are strongly encouraged to view the information specific to each of the health benefit programs governed by the SEBC at the following web site: http://ben.omb.delaware.gov/.



Contents of RFP

Worksheets1. Introduction2. Minimum Qualifications3. Performance Guarantees4. Table of Contents for Questionnaire5. Questionnaire6. DM Questionnaire7. DM Pricing 8. DM Financial_Non Financial Guarantees9. DM Implementation10. Wellness Questionnaire11. Wellness Services12. Wellness Pricing13. Wellness Financial_Non Financial Guarantees14. Wellness Implementation15. GEO Access HMO16. GEO Access PPO_CDHP17. GEO Access Medicare Supplement18. Financial Exhibit19. Plan Design HMO20. Plan Design PPO21. Plan Design CDHP22. Plan Design Medicare Supplement23. Explanation Minimum Qualifications24. Explanation Questionnaire25. Explanation Disease Management26. Explanation Wellness27. Officer’s Statement

Attachments1. Professional Services Agreement2. Business Associate Agreement3. Non-Disclosure Agreement4. Account Management Survey 5. File Formats6. Required Reports List

Retiree Medical Plans

This RFP is requesting a proposal on a Medicare Supplemental plan for retirees. In addition, based on your review of the locations of the current State retirees, if you have a Medicare Advantage program that would service State retirees and be beneficial for the Group Health Program, please provide information on that plan along with rates for 7/1/2012 for evaluation purposes.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of DelawareCompensation

Census and Discount/Disruption

Intent to Bid

Your intent to bid is required by e-mail only, no later than October 10, 2011 and 4:00 p.m. EST

Financial

Contract/Rate Guarantee Periods

Performance Guarantees

The SEBC does not pay a commission to a broker or agent for the administration of its health plans. Therefore, all proposals must be quoted net of commissions.

Census and discount/disruption data will be sent after receipt of your Intent to Bid and signed Non-Disclosure Agreement as described in the next section.

YOUR BID WILL NOT BE ACCEPTED IF THE STATE OF DELAWARE DOES NOT RECEIVE AN EMAIL OR WRITTEN CONFIRMATION OF AN INTENT TO BID.

The signed non-disclosure agreement is also required by October 10, 2011 by 4:00 p.m. EST. Census and discount/disruption data files will only be provided to those bidders after a confirmation of intent to bid and a signed non-disclosure agreement is received. NOTE: Brokers cannot execute the non-disclosure agreement on behalf of their client. The non-disclosure statement is a pdf document attachment to this RFP. After signature, scan both pages and e-mail it to Ms. Laurene Eheman at [email protected] with the following information: company name, contact name and title, contact e-mail address, physical address, and phone number. The data files will be sent via UPS overnight mail and instructions to access the data file will be included with the reply email confirmation.

Please provide a pricing proposal as indicated on the Financial Exhibit worksheet for each plan type. Please carefully review the Financial Proposal section in the "Questionnaire" Worksheet for definitions and requirements you should adhere to in the preparation of your quote.

The State of Delaware plans to enter into a two (2) year contract with the selected vendor(s) effective July 1, 2012, with an option to be renewed for three (3) additional one-year extensions with predetermined rate caps in addition to discount and other financial and performance guarantees for each extension period. The vendor must guarantee the contract period rates and fees through June 30, 2014, with the right to renegotiate rates and fees after the initial two years.

The SEBC is interested in evaluating financial and non-financial performance guarantees. All bidders will be required to provide both financial and non-financial performance guarantees.

Specific questions regarding your proposed risk arrangement and the methods used in determining performance standards are included in the "Questionnaire" worksheet.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of DelawareProposal Objectives

* Aligned incentives and a business model that drives value for the State of Delaware and its members of the State's GHIP.

* Clinical and account team excellence including proficient, dedicated resources.

* Effective coordination and integration with the State of Delaware's other external vendor partners.

* New program innovations that will address cost, a healthy workforce, quality and employee satisfaction.

* Flexible, self-service reporting/data analysis tools and innovative web-based solutions.

* Best in class enrollee focus with staff who are determined to get any issues resolved in a timely manner.

Selection Criteria

Net Cost Considerations* Return on investment (ROI) potential.* Competitive fees and financial, clinical and service related performance guarantees.* Financial offering, discounts, performance guarantees, and network access.

Program Superiority* Technology that advances program objectives.* Established client references with superior client and customer service.* Ability to meet the SEBC's RFP and service contract terms.

* Ability to secure and analyze claims, utilization and data from multiple sources.* Capability to provide notification of fulfillment to a variety of employer groups.* Ability to interface with health carriers and other vendors.* Compliance with HIPAA privacy and security requirements (to include updated provisions).* Superior program implementation support.* Documented evidence of responsive account management.

The goal of this RFP is to identify a long-term medical benefit partner who can demonstrate the ability and commitment to meet current and future program goals. Specifically, the State of Delaware is seeking a provider who is willing to commit to the following:

* The best in class price as well as fair and auditable contract terms that are directly related to the cost of delivering such goods and services.

* Comprehensive account management and customer service including resources and personnel as necessary to support the State of Delaware’s broader health care strategy.

* Compliance with a detailed process measurement model that will evaluate a vendor’s performance and hold it accountable for certain guaranteed standards.

* Sophisticated, fully tested data warehousing interfaces combining medical and pharmacy claims as a basis for physician interventions.

The SEBC is committed to offering a medical benefit program which promotes cost-effective and patient-oriented care to lower collective health risks by improving individual lifestyles. Listed below are the primary selection criteria that will drive the SEBC's decision-making process.

* Ability to administer a statewide program across multiple groups and multiple locations, including members who reside throughout the United States and travel internationally.

* Capability to accept and provide electronic transfer of employee eligibility information, claims data, and utilization data to and from a variety of sources.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of Delaware* Robust client reporting. * Reputation and historical experience in the group managed medical plan market.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of Delaware* Superior disease management programs with proven results.

Evaluation Process

All proposals submitted in response to the RFP will be reviewed by the SEBC's Proposal Review Committee (PRC).

Right of Negotiation

Right to Consider Historical Information

Right to Reject, Cancel and/or Re-Bid

RFP Award Notifications

The PRC shall be comprised of representatives from each of the following offices: Office of Management and Budget; Controller General’s Office; Department of Finance; Department of Health and Social Services; State Insurance Commissioner’s Office; State Treasurer’s Office and the Chief Justice of the Supreme Court. The PRC shall determine the bidders which meet requirements pursuant to selection criteria of the RFP and procedures established in 29 Del.C. §6902(1), 6981, 6982 and 6986. The PRC shall interview at least one of the qualified bidders.

The PRC shall make a recommendation regarding the award of contract to the SEBC who shall have final authority, in accordance with the provisions of this RFP and 29 Del.C. §6982, to award a contract to the successful bidders as determined by the SEBC in its sole discretion to be in the best interests of the State of Delaware. The SEBC may negotiate with one or more bidders during the same period and may, at its discretion, terminate negotiations with any or all bidders. The SEBC reserves the right to reject any and all proposals or award to multiple vendors.

Discussions and negotiations regarding price and other matters may be conducted with vendor(s) who submit proposals determined to be reasonably susceptible of being selected for award, but proposals may be accepted without such discussions. The PRC reserves the right to further clarify and/or negotiate with the proposing bidders following completion of the evaluation of proposals but prior to contract execution, if deemed necessary by the PRC and/or the SEBC. The SEBC also reserves the right to move to other proposing bidders if negotiations do not lead to a final contract with the initially selected proposing firm. The PRC and/or the SEBC reserves the right to further clarify and/or negotiate with the proposing firm(s) on any matter submitted.

The PRC and/or the SEBC reserves the right to consider historical information regarding the proposing firm, whether gained from the proposing firm’s proposal, question and answer conferences, references, or any other source during the evaluation process.

The PRC and/or the SEBC specifically reserve the right to reject any or all proposals received in response to the RFP, cancel the RFP in its entirety, or re-bid the services requested.

After review by the PRC a recommendation will be made to the SEBC for award of the contract. The contract shall be awarded to the vendor whose proposal is determined by the SEBC to be most advantageous, taking into consideration the evaluation factors set forth in the RFP. It should be explicitly noted that the SEBC is not obligated to award the contract to the vendor who submits the lowest bid or the vendor who receives the highest total point score, rather the contract will be awarded to the vendor whose proposal is the most advantageous. The award is subject to the appropriate State of Delaware approvals. After a final selection(s) is made, the winning vendor(s) will be invited to negotiate a contract with the State; remaining vendors will be notified in writing of their selection status.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of DelawareAward of Contract

Evaluation Criteria

1. Plan Administration2. Plan Design Capabilities and Services3. Network Access4. Financial Terms5. Experience and References6. Performance Guarantees

The PRC reserves the right to:

* Select for contract or negotiations a proposal other than that with lowest costs.

* Reject any and all proposals received in response to this RFP.

* Make no award or issue a new RFP.

* Waive or modify any information, irregularity, or inconsistency in proposal received.

The final award of a contract is subject to approval by the SEBC. The SEBC has the sole right to select the successful vendor(s) for award, to reject any proposal as unsatisfactory or non-responsive, to award a contract to other than the lowest priced proposal, to award multiple contracts, or not to award a contract, as a result of this RFP. Notice in writing to a vendor(s) of the acceptance of its proposal by the SEBC and the subsequent full execution of a written contract will constitute a contract, and no vendor will acquire any legal or equitable rights or privileges until the occurrence of both such events.

Vendors whose proposals are received by the deadline and meet the "Minimum Requirements" will be evaluated further. If a vendor cannot meet all the criteria in the Minimum Requirements worksheet, the proposal will not be evaluated further. All proposals shall be evaluated using the same criteria and scoring process. The following criteria shall be used by the PRC to evaluate proposals.

The SEBC will use the information contained in your proposal for an initial analysis to determine whether you will be selected to interview as a finalist. All follow-up responses and presentation materials will be considered part of your proposal. Only the finalists will be scored to determine whether you will be selected for contract negotiations. The bidder’s Disease Management Program will be evaluated within this criteria as an optional program. The proposal the SEBC selects will be a working document. As such, the SEBC will expect the proposing firm to honor all representations made in its proposal.

It is the proposing firm’s sole responsibility to submit information relative to the evaluation of its proposal and the SEBC is under no obligation to solicit such information if it is not included with the proposing firm’s proposal. Failure of the proposing firm to submit such information in a manner so that it is easily located and understood may have an adverse impact on the evaluation of the proposing firm’s proposal.

The proposals shall contain the essential information for which the award will be made. The information required to be submitted in response to this RFP has been determined by the SEBC and the PRC to be essential in the evaluation and award process. Therefore, all instructions contained in this RFP must be met in order to qualify as a responsive vendor and to participate in the PRC’s consideration for award. Proposals which do not meet or comply with the instructions of this RFP may be considered non-conforming and deemed non-responsive and subject to disqualification at the sole discretion of the PRC.



* Request modification to proposals from any or all contractors during the review and negotiation.

* Negotiate any aspect of the proposals with any organization.

* Negotiate with more than one organization at the same time.

* Select more than one contractor/vendor to perform the applicable services.

Confidentiality of Documents

Proposal Response Requirements

All documentation submitted in response to this RFP and any subsequent requests for information pertaining to this RFP shall become the property of the State of Delaware, OMB and shall not be returned to the proposing firm. All proposing bidders should be aware that government solicitations and responses are in the public domain. If the proposing firm wishes, those parts of its proposal dealing with trade secrets and commercial or financial information may remain confidential, but must be stated clearly in accordance with the process stated in the Confidentiality of Documents paragraph below. Such requests will not be binding on the SEBC to prevent such a disclosure but may be evaluated under the provisions of 29 Del.C. Chapter 100. Any final decisions regarding disclosure shall be made at the sole discretion of the OMB.

The OMB is a public agency as defined by state law, and as such, it is subject to the Delaware Freedom of Information Act, 29 Del. C. Ch. 100 (FOIA). Under the law, all the State’s records are public records unless otherwise declared by law to be confidential and are subject to inspection and copying by any person. Proposing firms are advised that once a proposal is received by the State, a decision on contract award is made and the contract awarded, its contents will become public record and nothing contained in the proposal will be deemed to be confidential except proprietary information once the contract is fully executed.

The State of Delaware acknowledges that the pricing and discount terms under the purview of this RFP and in the contract to be awarded under this RFP are proprietary information and not public record subject to disclosure under the Delaware Freedom of Information Act. This determination applies only to the file entitled "State of Delaware Discount Report Template", that will be on the provided disk, submitted in your bid response; the State will not honor any attempt by a bidder to designate its entire bid proposal as proprietary. Therefore, you may deem your pricing and discount terms with providers as confidential and proprietary. Administrative fees are not confidential and proprietary. To claim this designation on those sections of your bid you must follow the instructions set forth in this Confidentiality of Documents section.

Proposing firms must submit one hard copy of any information the firm is seeking to be treated as proprietary in a separate, sealed envelope labeled “Proprietary Information” with the RFP name included (Medical Benefit Program RFP). The envelope must contain a letter from the Proposing firm’s legal counsel describing the documents in the envelope, representing in good faith that the information in each document is not public record as defined by FOIA at 29 Del. C. § 10002(d) and state the reasons that each document meets the said definitions. The documents must also be provided electronically on a separate CD from the bidding documents. In order to submit a complete electronic copy, you must scan the letter as the first page so that the file is clearly designated. See the Submission of Proposal section for additional instructions.

Upon receipt of a proposal accompanied by such a separate, sealed envelope, the State will open the envelope to determine if the procedure described above has been followed. Any final decisions regarding disclosure under FOIA shall be made at the sole discretion of the OMB.



Submit your bid to:Ms. Laurene Eheman

RFP and Contract Coordinator, Statewide Benefits OfficeOffice of Management and Budget

500 W. Loockerman Street, Suite 320Phone 302-739-8331

Fax [email protected]

TimetableThe following timetable is expected to apply during this marketing effort:

Event Target DateRFP Release/Advertisement Dates September 26 & October 3, 2011Receive confirmation for Intent to Bid* October 10, 2011Receive signed nondisclosure agreement October 10, 2011Vendor's deadline to submit questions October 17, 2011Responses to questions sent to Vendors October 31, 2011Deadline for RFP responses / bids November 14, 2011Notification of finalists Early December, 2011Finalist Interviews ** Week of January 9, 2012Selection of Vendor February 2012Contract Award February 2012Plan Effective Date July 1, 2012

*Your bid will not be accepted if the State of Delaware does not receive an e-mail or written confirmation of an intent to bid.

Your proposal must conform to the requirements set forth in this RFP. The SEBC reserves the right to deny any and all exceptions taken to the RFP requirements. RFP information can be obtained by emailing Ms. Laurene Eheman at [email protected]. See the Intent to Bid paragraph for the process to obtain the confidential claims and census file data.

Census and Discount/Disruption data files will only be provided to those bidders after a confirmation of intent to bid and a signed nondisclosure agreement is received. The nondisclosure statement is a pdf document attachment to this RFP.

The SEBC anticipates this will be an interactive process and will make every reasonable effort to provide sufficient data and support for vendor responses. Vendors are invited to ask questions during the proposal process and to seek additional information, if needed. All proposing vendors must submit their questions electronically to Ms. Laurene Eheman no later than October 17, 2011 4:00 p.m. EST. The SBO will then put all questions received and the responses into one document and send to all vendors electronically who confirmed their intention to bid. Do not contact any member of the SEBC about this RFP or the Medical Benefit Program selection process.

All questions regarding this proposal should be directed only to, and by email only, to Ms. Laurene Eheman, [email protected].



Officer Certification

Completeness

Submission of Proposal

To record your response:* Click on the response cell in the Response column;* Click on the down arrow which appears directly to the right of the cell;* Click on the response that best describes your answer.

**The SEBC will require each of the finalists to make presentations in Dover, Delaware. All such presentations will be at the expense of the proposing firm.

All vendors participating in this RFP will be required to have a company officer attest to compliance with RFP specifications and the accuracy of all responses provided. Instructions are given in the "Officer" worksheet for the completion of this sign-off.

The proposal must be complete and comply with all aspects of the specifications. Any missing information could disqualify your proposal. Unless noted to the contrary, we will assume that your proposal conforms to the State’s specifications in every way.

Proposals will not be accepted via e-mail. Proposals must be submitted in writing/hard copies (three complete original copies) and electronically (two complete PDF copies). Additionally, the Excel document with declarative responses must be provided electronically. In other words, the PRC must have three complete hard copy sets and two complete electronic pdf copies along with the responsive electronic Excel document. Complete means that it includes all information you may deem proprietary and confidential. In other words, the information deemed proprietary and confidential must not be separated from the rest of the information and therefore would require the SEBC to manually merge the documents in order to read the material in the order and format requested. (Accordingly, information you may deem proprietary and confidential would be duplicative because it is also in the complete copy.) To provide a complete electronic copy, you must scan all the documents; for example, your cover letter and the Officer's Statement. Please label and carefully package the CDs. (CDs rather than flash drives are preferred.) Your cover letter must indicate for which program(s) you are submitting proposal(s).

The majority of the questions in this RFP have been structured to elicit declarative responses through the use of drop down boxes. All proposals must be submitted using the Excel file, including the various worksheets contained in the workbook. Remember to ensure that the contents of the Excel cells can be read when printed on the hard copy and on the pdf version! Use the specified file naming conventions for your attachments as required in the Requested File Attachments section, preceded by your company's name. Information deemed Proprietary and Confidential must be submitted in hard copy format. See the Confidentiality of Documents section for a complete explanation of the required elements. Additionally, it must be included electronically on both discs with the letter scanned as the first page so that the file is clearly designated. Please review the list above to ensure that you have provided each item.

To enter your responses where a numeric, percent or ratio value is indicated as the answer format, simply enter the value in the corresponding response cell.

If you have any difficulty entering data in the appropriate cells, please contact Ms. Laurene Eheman at 302-739-8331, 7:30AM - 4:00PM EST.

Next to each response cell, additional space is available for a brief text explanation. However, if the length of the explanation is greater than 400 characters, you must go to the "Explanation" worksheet to provide your detailed explanation. All explanations must be referenced by worksheet name, section, and numbered to correspond to the questions to which they pertain and should be brief.



Requested File Attachments

Attachments must be obtained by email request to the RFP Coordinator, Ms. Laurene Eheman, at

[email protected].

Minimum QualificationsPerformance Guarantees

Please provide complete answers and explain all issues in a concise, direct manner. If you cannot provide a direct response for some reason (e.g. your company does not collect or furnish certain information), please indicate the reason rather than providing general information that fails to answer the question. “Will discuss” and “will consider” are not appropriate answers. However, if you are bidding on the Medicare Supplement plan only, some questions may not apply and you may indicate “not applicable”. All information requested is considered important. If you have additional information you would like to provide, include it as an appendix to your proposal.

Failure to respond to any request for required information applicable to the plan(s) you are bidding on may result in rejection of the proposal at the sole discretion of the SEBC.

Required information must be submitted using the appropriate worksheets in this RFP. In addition, you are asked to provide supplemental electronic materials as referenced in the questionnaire.

In order to help you organize your proposal and ensure that it is complete, please review the following list to ensure that you have provided each required item:

1. Cover letter which clearly states which plan(s) your proposal contains. 2. Signed Officer’s Statement 3. Geo-Access Report(s) 4. Electronic version of Questionnaire

Questionnaire:1. Financial Statement2. Proposed Timetable for Availability of Electronic SPDs3. Sample Communication Materials to Members4. Management Report Package5. Standard Forms6. Premium Billing7. Conversion Services8. Appeal Policies9. ID Card10. Enrollment Materials

Disease Management Program Section:1. Sample Communication Materials2. Sample Reports3. Implementation Plan



Vendor Errors/Omissions

Wellness Program Section:1. Risk Assessment2. HRA Citations3. HRA Reports4. Sample Communication Materials5. Sample Reports6. Implementation Plan7. Wellness Resources

The SEBC will not be responsible for errors or omissions made in your proposal. You will be permitted to submit only one proposal. You may not revise or withdraw submitted proposals after the applicable deadline.


Request for Proposal for Medical Benefit Administrative Services (PPO/HMO/CDHP/Medicare Supplement) for the State of DelawareGeneral Modifications

Modifications to Submitted Proposal

Incurred Costs

Basis of Cost Proposal

Certification of Independent Price Determination

Improper Consideration

Representation Regarding Contingent Fees

Confidentiality

The SEBC reserves the right to issue amendments or change the timelines to this RFP. All firms provided with a copy of the RFP will be notified in writing via e-mail of any modifications made by the SEBC to this RFP.

Changes, amendments or modifications to proposals shall not be accepted or considered after the time and date specified as the deadline for submission of proposals. Any changes, amendments, or modifications to a proposal must be made in writing, submitted in the same manner as the original response, and conspicuously labeled as a change, amendment or modification to a previously submitted proposal.

This RFP does not commit the SEBC to pay any costs incurred in the preparation of a proposal in response to this request and vendor/bidder agrees that all costs incurred in developing its proposal are the vendor/bidder's responsibility.

Your proposal must be based on your estimated cost of all expenses for the services and funding arrangements requested. Rates submitted in your proposal must be based on active and retired populations in one group.

By submission of a proposal, the proposing firm certifies that the fees submitted in response to the RFP have been arrived at independently and without – for the purpose of restricting competition – any consultation, communication, or agreement with any other proposing firm or competitor relating to those fees, the intention to submit a proposal, or the methods or factors used to calculate the fees proposed.

Bidder shall not offer (either directly or through an intermediary) any improper consideration such as, but not limited to, cash, discounts, service, the provision of travel or entertainment, or any items of value to any officer, employee, group of employees, pensioners or agent of the SEBC in an attempt to secure favorable treatment or consideration regarding the award of this proposal.

By submission of a proposal, the proposing firm represents that it has not retained any person or agency to solicit or secure a contract for the services described herein upon an agreement or understanding for a commission or a percentage, brokerage, or contingent fee. The SEBC will not pay any brokerage fees for securing or executing any of the services outlined in this RFP. Therefore, all proposed fees must be net of commissions and percentage, contingent, brokerage, service, or finder’s fees.

All information you receive pursuant to this RFP is confidential and you may not use it for any other purpose other than preparation of your proposal.

Minimum Qualifications 15 September 26, 2011

Minimum Qualifications

I. GENERAL Answer Format Format Type Response

1. drop down box Listbox,ListYesNo


a. Management of the account drop down box Listbox,ListYesNo

b. drop down box Listbox,ListYesNo

c. Recruitment and retention of providers drop down box Listbox,ListYesNo

d. drop down box Listbox,ListYesNo

e. Appropriate Medical Directors as needed drop down box Listbox,ListYesNo

f. drop down box Listbox,ListYesNo

g. drop down box Listbox,ListYesNo

h. Strategic planning drop down box Listbox,ListYesNo








To Vendor: Please confirm your agreement with each of the Minimum Qualifications listed below. If a vendor cannot meet all the criteria in the Minimum Requirements section, the proposal will not be evaluated further.

Meeting with the State and its representatives as necessary

As requested, the Bidder shall provide at no cost to the State, staff to participate in meetings, conference calls, etc. to support management of the Plan including, but not limited to those responsible for the:

Management of claims processing and medical services

Development and implementation of medical policy

Management information systems and member relationsSupport of other benefit programs provided by the State

Must prepare and provide electronic print-ready Summary Plan Descriptions and other formal Plan documents, brochures, advisory letters and communication materials at no cost to the State. The State maintains complete flexibility to edit all communication materials.

Must assist in assessing the fiscal and policy impacts of legislation and regulations at the State and federal level including their direct impact upon the State health plans.

Performance standard guarantees with at least 20% of administrative fees at risk.

With reasonable notice by the State, the Bidder agrees to the State’s right to modify benefits, number and type of plans offered, employer contribution, funding arrangement, and scope of services to be provided during the contract period.

Agree to accommodate existing benefit plan designs as outlined in State’s health benefit summary plan descriptions (www.ben.omb.delaware.gov) and confirm agreement to coordinate as necessary with other State vendors to provide information and reporting to the State for any benefits involving lifetime coverage limitations.

Confirm five (5) years of experience as group medical plan administrator.













II. ENROLLMENT AND ELIGIBILITY Answer Format Format Type Response



Confirm at least two hundred and fifty thousand (250,000) lives in your Book of Business.

Confirm experience servicing clients with excess of 50,000 eligible lives (i.e., total of employees, retirees and their dependents).

Provide a copy of a Delaware Business License or Delaware Business Application.Provide evidence of professional liability insurance in the amount of $5,000,000.

Confirm full HIPAA, EDI and Privacy compliance and that all State member data will be maintained in accordance with applicable federal, state and local regulations to ensure protection and confidentiality.

Confirm the existence of strict policies and procedures for the protection of client and member Personal Health Information (PHI) and avoidance of security breaches under HIPAA and HITECH. Confirm the existence of breach notification procedures in the event of a release of PHI.

Confirm ability and inclusion of services required to assist the State in any and all reporting and compliance efforts related to local, state and federal legislation, such as New York HCRA, Massachusetts creditable coverage requirements, and so forth.

Confirm that Bidder's proposal, to the extent it includes any combination of PPO, HMO or CDHP coverage, includes disease management for those plans.

Confirm that the Bidder must participate and contribute as required in the Delaware Health Information Network.

At no cost to the State, the Bidder must support the annual Open Enrollment period established by the SEBC. The support includes assistance with plan design changes and materials including health benefit plan documents, presentations and attendance at health benefits fairs. All materials provided must be approved by the State prior to distribution.

At no cost to the State, the Bidder must support any special open enrollment period. The support may include communication to employers and subscribers. A special open enrollment is triggered when the SEBC deems it necessary.














At no cost to the State, the Bidder must produce and distribute member Identification Cards to enrolled members within ten (10) business days of receipt and processing of a subscriber’s eligibility record or a change warranting the production and release of a new member Identification Card. The format of the membership Identification Card must be approved by the State of Delaware. One ID card must be sent to the individual subscriber or two ID cards to all other tiers.

The Bidder must accept the Plan Eligibility and Termination Files transmitted from the State (4 separate electronic files – PHRST, Pension Office, University of Delaware, Delaware Transit Corporation) weekly and update its eligibility records weekly. Bidder must accept the file formats as provided by the State for each separate electronic file. See Attachments.

The Bidder must also accept Eligibility and Termination information via facsimile for those groups participating in the State plan which do not have electronic Eligibility functionality.

The Bidder must be able to accept Plan Eligibility File effective dates that may be up to 120 days in the future.

The Bidder must securely transmit the necessary and appropriate information to any other organization that the State has contracted with to perform any services applicable to the provision of benefits under the Plan as approved by the State.

The Bidder must be able to receive the entire Plan Eligibility Files and only process those fields in which the resident information has been added, deleted or changed.

The Bidders must have the ability to terminate coverage for employees/retirees and their dependents at the end of the month except for termination due to divorce which takes effect the day after divorce.

The Bidder must store historical information by member with the Social Security Number and employee/retiree identification number as an access key.

The Bidder must support retroactive enrollments and terminations of up to one year for members in situations allowable under the Patient Protection and Affordable Care Act.

The Bidder must store dependent information as sent by the State and only pay claims for those dependents actively enrolled.








III. Answer Format Format Type Response







The Bidder must ensure that only State-originated eligibility information and changes will be reflected on the Plan records contained in Bidder’s files and that discrepancies between State-originated eligibility information and information contained in the vendor’s systems is reported on within 72 hours following successful upload of weekly eligibility files.

The Bidder must provide edits/security to ensure the integrity of the data on the Bidder files.

The Bidder must accept alternative sequence numbers in lieu of actual SSNs for newborns and foreign nationals.

The Bidder must maintain its records so that it can categorize members in the following employer types: Merit Agency, Public Education, Higher Education, State of Delaware Retirees, Non State Participating Groups as well as by Plan type and actives, non Medicare retirees and Medicare retirees.

REQUIRED CLAIM ADMINISTRATION SERVICESThe Bidder must process claims for services incurred on or after the Effective Date of coverage.

Maintain current complete and accurate records of all claims and correspondence associated with each claim. Each claim will, upon receipt, be immediately assigned an appropriate tracking number which will remain with the claim until it can be reviewed for completeness before adjudication.

Request in writing from the provider, the State, or, if appropriate, the member, whatever additional information is necessary for the appropriate disposition of the claim if it finds during the adjudication process, that information essential to the accurate coding and subsequent determination of benefits has not been provided.

Maintain and utilize a nationally recognized software for purposes of determining usual, reasonable and customary allowance.

Maintain and utilize software containing edits to identify and track members by services received, level of care assigned, and conditions treated.

Maintain and utilize software containing edits to identify and track providers by services rendered and claim dollars received.







10. Verify member eligibility before paying claims. drop down box Listbox,ListYesNo








Maintain appropriate systems edits and critically examine charges for all services that appear aberrant, excessive or fraudulent. Examine such services with the provider, when necessary and appropriate.

Conduct account-specific audits (separate from routine claim office audits) of its own office(s) and those of affiliated organizations and subcontractors for the State to ensure accurate processing and must furnish to the State quarterly reports showing the level of accuracy achieved.

Investigate claims and medical services to determine medical necessity, appropriateness of care, over and under-utilization of medical services, and the existence of other coverage.

Timely and accurately process all claims received in conformity with the Claim Administration Performance Standards that appear in the RFP.

Review and process all claims submitted and issue reimbursement as per contract design and an Explanation of Benefits (EOB) as appropriate.

Issue electronic funds transfers, benefits checks to contracted providers and facilities as appropriate and to non-contracted providers and facilities or members in a timely manner.

Participate in Voluntary Data Sharing Agreement with Centers for Medicare and Medicaid and accept electronically-transmitted Medicare claims and coordinate those claims with the Plan.

The Bidder’s participating providers must be prohibited from balance billing members for charges for periods of confinement that were not approved by the Bidder.

As required by the Plan, contracted hospitals and the Bidder will perform preadmission/precertification review, concurrent review, discharge planning and retrospective review. The existence of concurrent review and discharge services will be transparent to the member.

Notify claimants of denied claims, the reason for the denial, explanation of benefit and appeal process.





a. drop down box Listbox,ListYesNo





Review denied claims that are appealed by a member to the Bidder in accordance with standards established by the State or by law. In order to do so, the State delegates to Bidder the authority, responsibility and discretion to initially interpret and construe the provisions of the Plan, as necessary to reach factually supported conclusions and to make a full and fair review of each claim and to notify each member in writing of each claim that has been denied. Consult with the State on the resolution of member claim disputes by members who have exhausted the Bidder’s internal appeals process (as well as external appeals process for non grandfathered plans) and who are now appealing to the State.

The Bidder must inform each member, whose claim is denied after exhausting the Bidder’s internal appeals process (as well as external appeals process for non grandfathered plans), that the member has a right to appeal to the State, stating the address and procedure for such an appeal. Final authority to interpret and construe the provisions of the Plan, on appeal by the member, remains with the State and the Bidder must comply with the State’s decisions.

The Bidder must make a reasonable effort to recover claim amounts overpaid or paid in error and refund the recoveries to the State or credit these recoveries against any amounts payable by the State. The Bidder may pursue the overpayment with the provider and/or member.

The Bidder must make all reasonable efforts to recover claims paid in error when the member has been involved in a workplace accident. Reasonable efforts include: asserting liens, appearing in workers’ compensation court to recover liens and all correspondence with member’s attorney.

With regard to recovery of overpayment to members, the Bidder must never pursue legal remedies such as placing liens for overpayment without first advising the State. After reasonable attempts are made to recover the overpayment, the Bidder may deduct the overpayment from future payments to the member. If the overpayment was the result of an error of the Bidder, the overpayment will be immediately absorbed by Bidder and will not be charged to the State, or to the member.

The Bidder must disclose and fully account to the State any and all funds received by it as a recovery of an overpayment or incorrect payment. Reports to be provided quarterly.






IV. FRAUD ACTIVITIES Answer Format Format Type Response


V. SUBROGATION Answer Format Format Type Response



VI. COORDINATION OF BENEFITS Answer Format Format Type Response




Monies recovered such as subrogation outside of Delaware of a claim or lien must be fully disclosed and accounted for and credited to the State’s claims account. Reports to be provided quarterly.

The Bidder must assign a dedicated account manager for the State to call concerning claims paid. The account manager must be available during the working hours of 8am to 5pm, Monday through Friday, Eastern Standard Time.

The Bidder must develop procedures to identify providers and/or members who appear to be committing fraud and work with the State and appropriate law enforcement agencies to pursue prosecution; and when notified by the State, that a member or provider is being investigated or prosecuted, provide all claim information and participate as a fact or an expert witness as necessary.

The Bidder must inquire of the member whether a third party may be liable for the cost of the care received, and, if yes, request that the identity of the third party be provided for purposes of instituting subrogation.

The Bidder must actively pursue the State’s right of subrogation to recover claim payments from third parties, including pursuing payments made when there is a work related accident or illness.

The Bidder must accept State’s electronic Spousal Coordination of Benefits file as well as paper forms where applicable (Retirees) and produce an annual report after open enrollment and then weekly reporting to the State and the Prescription Benefit Manager of members who are noncompliant with the State’s Coordination of Benefits policy.

The Bidder must monitor eligibility for Medicare coverage and notify the State and members when member is first eligible and of any changes in eligibility.

The Bidder must inquire as to the existence of other group medical or Medicare coverage and coordinate payment of claims with other payers.







VII. CUSTOMER SERVICE Answer Format Format Type Response



VIII. FINANCIAL Answer Format Format Type Response


2. Form of Compensation and Payment


The Bidder must accept paper Adult Dependent Coordination of Benefits forms and produce weekly reporting to the State of members who are noncompliant with the State’s policy through fiscal year 2014.

The Bidder must provide designated staff to proactively monitor claims for medical coverage due to any reason, including age or ESRD.

The Bidder must provide written notice to members that enrollment in Medicare A and B is mandatory.

The Bidder must provide at a minimum a dedicated customer services unit to inform members as to the specifics of the Plan and answer claim processing questions from 8:30 a.m. to 7:00 p.m., Monday through Friday, EST. The Bidder’s call center is subject to the Performance Standards set forth in the RFP.

The Bidder must provide a dedicated customer service toll free number(s) as well as a website and fax services to members.

At minimum, guarantee proposed ASO fees and provider network discounts for 2 contract years: July 1, 2012 to June 30, 2014 with three (3) one-year extensions, each at the discretion of the SEBC. Rate caps and minimum network discount guarantees must be provided for each of the three (3) one-year extensions.

Payment by Bidder of any amount payable under the Plan must be made by checks drawn by Bidder payable through a bank (referred to in this Contract(s) as “the Bank selected by Bidder”) or via electronic fund transfers to providers.




b. drop down box Listbox,ListYesNo

c. drop down box Listbox,ListYesNo


e. drop down box Listbox,ListYesNo

f. drop down box Listbox,ListYesNo

g. drop down box Listbox,ListYesNo

h. drop down box Listbox,ListYesNo

The Bidder must request reimbursement for claim checks that have cleared their bank account and for electronic fund transfers Bidder has paid to providers. The Bidder will be reimbursed for claim checks and electronic fund transfers to providers that have cleared the Bidder’s bank account by the Bidder transmitting the total amount cleared via electronic mail or facsimile machine to the State by 11:00 a.m., EST each Friday. To determine the total amount that will be funded by Automated Clearing House (ACH) transfers to the Bidder’s designated bank by noon Wednesday of the following week or by noon of the third business day due to a State closing. The transmission must include a breakdown by health plan.

The Bidder agrees that all reimbursements from the State for claims, administrative fees and other charges will be paid by Automated Clearing House (ACH) transfers. State will not fund payments via wire transfers or checks.

The Bidder agrees that if in the normal course of business, it, or any other organization with which Bidder has a working arrangement, chooses to advance any funds that are due, to any provider, subsidiary or subcontractor, the cost of such advance must not be charged back to the State except the State must reimburse Bidder within the confines of the provisions contained in this Contract(s).

The Bidder must disclose, fully account for, and remit, to the State any and all funds received by it as the result of a recovery of an overpayment or incorrect payment, rebates, or subrogation of a claim or lien. Any discounted or negotiated rates or payment arrangements, any price adjustment, or refunds, and any retroactive or supplemental payments or credits negotiated with regard to covered services received by State members must be remitted to the State. Administrative Services Only (ASO) fees must take into consideration this provision.

The Bidder will never charge the State for a claim payment that is greater than the actual amount paid by Bidder.

The Bidder must submit to the State an itemization of the charges and fees (other than claim payments) and credit for services provided in the administration of the Plan.

The Bidder must provide the State with an estimate of incurred unpaid claims, administrative fees and amounts of outstanding checks no later than 45 days following the close of each fiscal quarter.




i. drop down box Listbox,ListYesNo

IX. TECHNICAL RESOURCES/COMMUNICATIONS Answer Format Format Type Response







X. AUDITS Answer Format Format Type Response

The Bidder must provide financial reporting 45 days (under no circumstances to exceed 60 days) following the end of each quarter.

There may be special projects initiated by the State requiring IT resources beyond those allocated for general support. For this type of project, the Bidder will provide to the State a proposal that provides cost projections for the project.

The Bidder must resolve/accommodate all data processing problems/changes within a reasonable time period mutually agreed upon, and the required changes must be implemented in a timely manner. The State will identify how the technical priorities will be set.

The Bidder’s staff will be required to participate in IT system status meetings on at least a semi-annual basis. This would include but not be limited to, the Account Executive, IT, Eligibility and Claims Managers. The meetings will focus on open IT problems/changes and any issues associated with them.

At no cost, the Bidder must agree to submit on-going eligibility, claims and provider files to other vendors as requested by the State (i.e. PBM, Data Mining, Disease Management, Wellness). Bidder must utilize file formats as provided and agree to frequency as requested by the State. System modifications necessary to accommodate file transmissions shall be borne by the Bidder. See Attachments

All changes, (State or Bidder generated) must be tested between the State and the Bidder prior to implementation.

The Bidder shall immediately notify the State of technical problems that impact the website availability or any other service that impacts the member or the State.










The State reserves the right to review and audit all records associated with the administration of the Plan for cause at any time during the normal business hours of the Bidder after providing written notice. Audits must encompass records held by any subcontractor or related organization and held by any entity that is a member of the Bidder group of companies. The Bidder agrees that the results of any review or audit are for the State’s exclusive use. The Bidder must cooperate with all external audits related to the Bidder’s administration of the Plan at no extra charge.

All reviews or audits may be performed by the State or any designee chosen by the State, other than a designee whose action would reasonably be considered by the Bidder to be a conflict of interest. The findings of any designee authorized to perform a review of the audit will be presented in a written report to the State. The Bidder will have the right to read the report prior to submission to the State and Bidder’s written comments pertinent to the audit, if furnished, will be submitted to the State with the audit as a supplementary statement.

The State reserves the right to request a routine audit. The Bidder must also conduct routine audits and control inspections of randomly selected claims under the Plan (Bidder must report quarterly on such audits to comply with Performance Standards noted in the RFP).

The Bidder must conduct, upon request, eligibility audits between the State’s electronic files and the Bidder’s eligibility files. The frequency of the audits will be established by the State. The Bidder must be able to accommodate various cutoff dates which may apply to specific experience groups. Currently, eligibility audits are conducted quarterly.

The Bidder shall ensure that the audits, reports, and findings, are the property of the State and not disclosed to other entities without written authorization from the State.

The Bidder must annually submit to the State the American Institute of Certified Public Accountant’s Statements on Standards for Attestion Engagements (SSAE) 16 as well as other certifications that may either supplement or replace SSAE 16. At the time of the submission the Bidder must also supply the State with a report of the actions taken to deal with any weaknesses or deficiencies identified.




XI. RECORD KEEPING Answer Format Format Type Response






XII. Answer Format Format Type Response




The Bidder must have no interest in, nor have any obligation to provide any aggregate claim or payment data maintained or copied by Bidder for its own uses outside of the scope of this Contract. Such information may not be used for any purposes which may be detrimental to the State.

All Claims Records and other records possessed by Bidder as claims administrator under this Contract (“Records”) must be retained in accordance with applicable Federal and State record retention requirements, but in any case will be kept and retrievable for no less than seven (7) years. Records must be retained for two (2) years on-line from the date of service or from the date final payment is made on the claim, whichever is later.

Confirm all data records (claims and administration) will be maintained by the administrator but will be the property of the State of Delaware (or another party designated by the State) within 30 days of notification of termination and without cost.

If a claim becomes the subject of litigation, then Bidder must provide the State all claim information related to that claim as necessary for litigation purposes and participate as fact or expert witnesses. In the case where an expert witness is necessary, then one must be provided at a reasonable and customary fee. This provision will survive termination of this Contract.

The provisions of this Section must survive the termination of this Contract or termination of coverage of a member and must bind the State and the Bidder so long as they maintain any Personally Identifiable Information.

MEDICAL MANAGEMENT / UTILIZATION MANAGEMENT SERVICESThe Bidder must provide Utilization Management (UM) services for both in-network and out-of-network treatment.

The Bidder must compile and submit to the State an annual report on the UM activities it has undertaken, results and subsequent actions. Report to be provided no later than 120 days after the close of the plan year.

The Bidder must accept and provide prescription drug data and eligibility status from/to the State’s pharmacy benefit manager on a routine basis, not less that once per week.





XIII. Answer Format Format Type Response




XIV. Answer Format Format Type Response




At no additional cost a voluntary case management program must be provided by the Bidder.

MENTAL HEALTH / DRUG ABUSE / ALCOHOL TREATMENT

The Bidder will be responsible for the provision and administration of all covered mental health, alcohol abuse and drug abuse services to all eligible enrollees.

The State provides to its employees access to an Employee Assistance Program (EAP) through a separate vendor. This program is staffed by professional counselors who assist employees and their dependents in handling problems such as stress, drug and alcohol abuse, and mental health conditions. An employee and/or their dependents may receive up to five (5) counseling sessions before being transferred to their medical plan to receive additional counseling. The State expects the Bidder to fully cooperate with the EAP in their assistance to all eligible enrollees.

The Bidder must support the State in compliance with all requirements of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008.

NETWORK ACCESS AND NETWORK MANAGEMENT

Services must extend to all State employees and retirees with a guaranteed level of network coverage in all three Delaware counties for the HMO/Port Authority programs and national access to network providers for the PPO and CDH plans. Confirm that this will be incorporated into the final performance guarantees to be negotiated with the selected Bidder(s).

Bidder must provide for access to medical care and health services that satisfy all applicable requirements of the federal and state statutes and regulations pertaining to medical care and services.

In the performance of its network management duties, the Bidder must verify initially and routinely (at least every three years) thereafter that all contracted facilities are appropriately licensed by the State in which they operate.









The Bidder must in the performance of its network management duties verify initially and routinely thereafter (at least every three years) professional education, training, quality of care, licenses and other credentials and where applicable the admitting and other privileges granted by a facility to each Network Provider.

In regard to additions and deletions of Network Providers, the Bidder must provide at least 45 days advance written notification to the State of any change in provider networks that will effect a 1% or greater change in the number of providers in the network or a disruption that would impact 3% or greater of the members. The Bidder will provide the State, at the same time, with a list of the names and employee/retiree identification numbers of the members that will be affected by the discontinuation of the Network Provider Contracts involved in the network change. The Bidder will provide 30 days written notice to affected members. The State may establish a special open enrollment for those affected.

The Bidder must require that each and every licensed Network Provider contracted in connection with this Agreement maintain professional liability (medical malpractice) insurance with limits of at least $1 million for each occurrence and $3 million in the aggregate, except where in any identified geographic area, other professional liability coverage limits are appropriate and usual for the Network Provider’s clinical specialty and/or services in that Network Provider’s geographic area. It is the Bidder’s responsibility to ensure that the insurance is valid at the time of credentialing and recheck credentials routinely thereafter in accordance with the National Committee for Quality Assurance (NCQA) standard.

The Bidder must provide on-line access to network of providers and routinely maintain to ensure accuracy.

Bidders of the HMO plan must confirm that administration will include monitoring, evaluating and taking action to address improvements in the quality of health care delivered by all network providers through the implementation of a continuous quality assurance program.

Performance Guarantees 29 September 26, 2011


I. Implementation

Category Standard

1. 2.0%

2. 1.0%

3. Adherence to key deadlines 2.0%

4. Plan Design 2.0%


To Vendor: The following charts summarize the minimum performance standards and financial guarantees the State of Delaware requires; more aggressive guarantees are encouraged. Under the “Actual Guarantee” and "Actual Fees at Risk" column, please indicate either your agreement to the proposed standards or your proposed, more stringent standards. If you are unable or unwilling to provide the requested standard, please include an explanation as to why you are unable/unwilling to provide and why your proposed solution is at least as good as what was requested. If the requested standard should differ for PPO, CDHP, HMO and/or Medicare Supplement, those have been noted in the requested minimum standards within the chart.

All metrics should be measured against State of Delaware-specific experience (not Bidder's book of business), unless otherwise specified.

Per the Minimum Qualifications, Bidders must provide at least 20% of administrative fees at risk for standard, annual services. This includes

• Claims administration/Customer service• Reporting• Account management• Network management and development

In addition, you are being asked to provide guarantees in three additional categories. Each of these additional guarantees should be separate from the 20% (minimum) of fees at risk for standard services.

1. Financial performance: As a key element in the financial performance of the overall SEBC benefit program, SEBC is requiring financial guarantees around your in-network discounts off billed charges, network utilization rates and annual trend management. 2. Implementation. While some implementation activities occur each year, such as reviewing/updating plan design features and issuing employee communications, the bulk of the implementation activities will take place in Year 1. Since a successful program depends on a flawlessly executed implementation, a separate fee guarantee on implementation activities is required. This requirement does apply to the incumbents.

3. Disease management. SEBC requires a guaranteed return on investment for your proposed disease management programs. Your guarantee is to be based off of a percent of the disease management administration fee rather than the overall administration fee. See separate sheet entitled Disease Management Financial Guarantees.

Actual Guarantee (Bidder to complete this column)

Requested Fee at Risk

Actual Fees at Risk (Bidder to complete this column)

Comment: All measures will be evaluated at the end of the implementation period. This requirement does apply to incumbents.

Implementation and Account Manager Performance

Implementation manager and account executive/manager will participate in every implementation call and will be prepared to lead call, based on detailed agenda sent to team in advance.

Maintenance of detailed project plan

Project plan must delineate due dates, responsible parties and critical linkages between tasks, as appropriate.

Project plan is to be updated and distributed in advance of each implementation weekly call.

All key dates will be met to the extent Bidder has control and/or has notified SEBC of risks of failure in advance of due date; SEBC and Bidder will agree at the beginning of implementation on which deadlines are critical to program success.

Systems will be updated for accurate plan designs in time for SEBC to conduct a pre-implementation audit.




5. Account Structure 1.0%

6. Enrollment support 2.0%

7. Initial ID Card distribution 1.0%

8. Customer Service 1.0%

II.

Category Standard

1. Turnaround Time for Claims 1.5%

2. Financial Accuracy 1.5%

3. Payment Incidence Accuracy 1.0%

4. Coding Accuracy 1.0%

5. First Call Resolution 1.0%

6. 1.5%

7. Call Abandonment Rate 1.0%

Bidder will be prepared to replicate existing account structure, and conduct meeting with SEBC to review current account structure to ensure it is adequate to meet current reporting needs.

Accurate enrollment materials will be distributed to SEBC employees in advance of open enrollment period.

ID cards will be distributed at least 20 days in advance of effective date.

Customer Service center will be trained and available to respond to employee inquiries prior to the Annual Enrollment period and will remain open and available continuously from that point on.

Total Implementation Fees at Risk

Claim Administration / Customer Service




Comment: Note that the requested fees at risk by category add up to more than 20%. SEBC will accept a proposal that caps total penalty accumulators to 20%. The following categories must be measured quarterly and reported to the SEBC unless otherwise noted.

92.0% processed within 12 Calendar Days (From date received to date processed)

99.0% accuracy for claims paid ([Total dollars of audited claims paid – sum of absolute dollar value of all over/under payments]/total dollars of audited claims paid)

97.5% average year end accuracy (Number of correct audited payments/total number of payments audited)

97.0% coding accuracy (Coding error is defined as any error that results in an incorrect payment of a claim. Formula = total number of correct claims/total number of claims audited)

85% (Percent of calls resolved during initial phone call. Measured based on repeat phone calls on same call topic within 30 days of initial call).

Telephone Calls Response Time

90.0% within 20 seconds (From the time of selection to speak to a live representative via the IVR system to the time a live person is on the line; calculated automatically via automatic telephone call distribution system).

2% (Calculated automatically via automatic telephone call distribution system)




8. Eligibility/Transfer Accuracy 2.0%

9. ID card distribution (routine) 0.75%

10. 0.25%

11. 1.5%

12. Coordination of Benefits 1.5%

13. Coordination of Benefits 1.5%

14. Data Security 1.0%

15. 1.5%

16. Member Satisfaction Survey 1.5%

17. Enrollment support 2.0%

18. Customer Service 1.0%

Reporting

Category Standard

19. Reporting 1.0%

Account Management

Category Standard

20. 2.5%

Category Standard

21. Credentialing 1.0%

97% within 4 days, 100% within 6 days (measured monthly)99% mailed within 10 days of receipt from the State.

ID card distribution (open enrollment)

99% mailed within 10 days of receipt from the State.

Data Submission to Data Warehouse

Claims by 15th day of each month, Eligibility by 5th day of each month – 95% compliance (measured monthly).

Weekly list of all contract holders/spouses non-compliant with COB policy – 95% (measured weekly).

List of contract holders effective 7/1 non-compliant with COB policy – 100% (measured annually).

Regularly advise State of any changes in status – 100%

Timeliness of Responding to CMS Demands

98% Written response to CMS or third party vendor within 45 days.Positive Response Rate of 85% or higher.

Accurate enrollment materials will be distributed to SEBC employees in advance of open enrollment period.

Customer Service center will be trained and available to respond to employee inquiries and will remain open and available 8:30 a.m. to 7:00 p.m. Monday through Friday, EST.




Complete and Timely Submission of accurate reports, defined as delivery within 45 days of close of reporting period unless agreed to in writing by SEBC and Bidder (measured annually).




Account Management Satisfaction

Score of 3.0 or higher on the State's Account Management Survey Form (attached to this RFP).

Network Management and Development




Every network provider or facility must be recredentialed at least every three years (Written letter from Bidder at the end of each contract year confirming compliance with credentialing requirements).




22. 1.0%

III. Financial Guarantees

Category Standard

1. Discount off Medical Charges Measured Annually 10.0%

2. Measured Annually 5.0%

3. Trend Guarantee Measured Annually 5.0%

4. Disease Management (ROI) Measured Annually

Maintenance and Growth of Network

Actual Growth or status quo (Written letter from Bidder at the end of each contract year documenting size of network from first day of plan year to last day of plan year).

Total Claims Administration / Customer Service / Reporting/ Account Management/ Network Management and Development Fees at Risk

Bidder's Standard and Formula For Measurement (Bidder to

complete this column)Requested Fee at

RiskActual Fees at Risk (Bidder to

complete this column)

In-Network Guarantee (PPO and CDHP)

20% of annual DM fees

Total Financial Guarantees Fees at Risk

TOC for Questionnaire 33 September 26, 2011

Questionnaire - Table of Contents

Section Section TitleI. General Plan InformationII. Use of SubcontractorsIII. Vendor Financial Strength/StabilityIV. Financial ProposalV. Utilization ReviewVI. Access and ManagementVII. Quality AssuranceVIII. Medical ManagementIX. ImplementationX. EligibilityXI. Claims AdministrationXII. ID CardsXIII. CommunicationXIV. Customer ServiceXV. Web CapabilitiesXVI. Account ManagementXVII. ReportingXVIII. Internal Audits and SOD Audit RightsXIX. SystemsXX. Legal/Contractual/ComplianceXXI. Mental Health/Substance Abuse (MH/SA)XXII. Plan DesignXXIII. Financial RequirementsXXIV. Medical Delivery SystemXXV. Administrative and Operational IssuesXXVI. Performance BenchmarksXXVII. Officer CertificationXXVIII. Other InformationXXIX. References


Questionnaire 34 September 26, 2011

MEDICAL RFP Answer Format Format Type Response Explanation


To Vendor: Use Column Q to provide a brief explanation. However if the length of the explanation is greater than 400 characters, you must use the "Explanation" worksheet to provide your detail explanation.

I. General Plan Information Answer Format Format Type Response Explanation

1. Primary Contacta. Name text Text

b. Title text Text

c. Address text Text

d. City text Text

e. State text Text

f. Zip text Text

g. Phone Number text Text

h. Fax Number text Text

i. E-mail Address text Text

2. Secondary Contact a. Name text Text

b. Title text Text


d. City text Text

e. State text Text

f. Zip text Text

g. Phone Number text Text

h. Fax Number text Text

i. E-mail Address text Text

3. Vendor Brand Name text Text

4. Parent Co. Legal Entity Name text Text

5. d/b/a (Name in Marketplace) text Text

6. Year Established/Incorporated mm/dd/yyyy Date

7. Stock Ticker # text Text

8. FEIN (Federal Employer Identification Number) text Text

9. Tax Status drop down box ListBox, ListTaxStatus

10. Public or Privately-Held drop down box ListBox,Listrngpub

11. text Text

12. text Text

13. text Text

14. Home Office Location text Text

Please provide the contact information for this RFP response.

Mergers, acquisitions, spin-off's, significant organizational changes in past 2 years. Include impact to the SEBC.

Anticipated changes in ownership or business developments, including but not limited to mergers, stock issues, and the acquisition of new venture capital.

Organization's core competency(ies), including significant differentiators that the organization delivers to its customers.





a. Address Line #1 text Text

b. Address Line #2 text Text

c. City text Text

d. State text Text

e. Zip text Text

15. Web Address text Text

16. HMO Plan Name (f applicable) text Text

a. Street Address text Text

b. City text Text

c. State text Text

d. Zip text Text

e. Web Address text Text

f. HMO Model Type text Text

g. HMO Operational Date mm/dd/yyyy Date

h. NCQA Accreditation Status text Text

i. Last NCQA Status Date Change mm/dd/yyyy Date

j. HMO Commercial Group Membership number, 0 Number, 0

17. PPO Plan Name (if applicable) text Text


b. City text Text

c. State text Text

d. Zip text Text


f. PPO Operational Date mm/dd/yyyy Date

g. NCQA Accreditation Status text Text

h. Last NCQA Status Date Change mm/dd/yyyy Date

i. PPO Commercial Group Membership number, 0 Number, 0

18. CDHP Plan Name (if applicable) text Text


b. City text Text

c. State text Text

d. Zip text Text


f. CDHP Operational Date mm/dd/yyyy Date

g. NCQA Accreditation Status text Text

h. Last NCQA Status Date Change mm/dd/yyyy Date

i. CDHP Commercial Group Membership number, 0 Number, 0

19. Medicare Supplement Plan Name text Text


b. City text Text

c. State text Text

d. Zip text Text


f. Medicare Supplement Model Type text Text

g. Medicare Supplement Operational Date mm/dd/yyyy Date

h. NCQA Accreditation Status text Text

i. Last NCQA Status Date Change mm/dd/yyyy Date

j. number, 0 Number, 0

20. drop down box

Medicare Supplement Commercial Group Membership

Is your company licensed to conduct business in all 50 states? If not, list which states you are licensed in under "Explanation."

Listbox, ListYNNoExplain





21. How many clients do you cover nationally? number, 0 Number,0

22. How many clients do you cover in Delaware? number, 0 Number,0

23. How many lives do you cover nationally? number, 0 Number,0

24. How many lives do you cover in Delaware? number, 0 Number,0

25.

a. Account service text Text

b. Customer service call center text Text

c. Claims processing center text Text

d. Underwriting text Text

e. Accounting/Finance text Text

f. Case Management text Text

g. Utilization Management text Text

h. Disease Management text Text

26. text Text

27. text Text

28. text Text

II. Use of Subcontractors Answer Format Format Type Response Explanation1. Do you subcontract any services? drop down box ListYesNo

2. Name of Service drop down box Listbox, ListDeliver

a. Text Text

b. drop down box

c. Effective Date of Subcontract mm/dd/yyyy Date

d. Location (City, State) Text Text

3. Name of Service Text Text

a. Text Text

b. drop down box




a. Text Text

b. drop down box




a. Text Text

b. drop down box


Identify the service center locations for each of the following functions:

Are there any services performed at an overseas location? If so, describe.

Provide the attributes of your organization that you believe separate you from your competitors.

Describe your organization's involvement in leading edge health care management initiatives such as pay-for-performance, Leapfrog, tiered networks, Bridges to Excellence, etc.

Name of Contracted Vendor, if outsourced/subcontracted

Exclusive Relationship? (Yes / No) Listbox, ListYNNoExplain













a. Text Text

b. drop down box









III. Vendor Financial Strength/Stability Answer Format Format Type Response Explanation

1.

a. A.M. Best: Financial Rating Status drop down box Listbox, ListRatedNot

Financial Rating (do not report credit rating) drop down box Listbox, ListAMBest

Financial Rating Modifiers (if applicable) drop down box

mm/dd/yyyy Date

b. Standard & Poor's: Financial Rating Status drop down box Listbox, ListRatedNot

Financial Rating (do not report credit rating) drop down box Listbox, ListStPoors

Financial Rating Modifiers (if applicable) drop down box

mm/dd/yyyy Date

c. Moody's: Financial Rating Status drop down box Listbox, ListRatedNot

Financial Rating (do not report credit rating) drop down box

mm/dd/yyyy Date

d. Fitch: Financial Rating Status drop down box Listbox, ListRatedNot

Financial Rating (do not report credit rating) drop down box Listbox, ListFitch

mm/dd/yyyy Date

2. drop down box Listbox,ListAttached

IV. Financial Proposal Answer Format Format Type Response Explanation

1. drop down box

2. drop down box

3. drop down box

4. drop down box

5. drop down box

6. drop down box



For the entity that will be underwriting this coverage, provide your most recent financial ratings or filings and effective dates of the ratings from each of the following agencies:

Listbox, ListAMBestMod

Date Rating Effective (if rated; if not financially rated, leave response cell blank)

Listbox, ListStPoorsMod


Moody's: Financial Rating Status



Provide an electronic copy of your company’s most recent financial statement. If your company will not release this information, provide proof of ongoing financial stability. Name the file: [Your Organization's Name]_Financial Statement.

Initial contract term will be for two (2) years and may be renewed for three (3) additional one-year extensions.


State of Delaware will renegotiate the contract terms after 2 years if they elect to renew.


Confirm that all financial terms are guaranteed for 5 years from the contract effective date.


Confirm that pricing can only change on the contract anniversary date, or sooner if mutually agreed to by Vendor and the State of Delaware.


Confirm that ninety days advance notice will be provided for any pricing change, other than the renewal.


The vendor agrees to provide a renewal proposal to the State of Delaware at least 180 days prior to the contract expiration date.


The vendor will provide a complete description of the methodology inherent in the renewal work up.

The vendor will provide a definition of all terms and an itemization of all assumptions used including projected claims, trend factors and the formula involved, plus a complete explanation of the logic inherent in the final renewal rate/fee package.





9. Vendor will act as plan fiduciary. drop down box

10. drop down box

11. drop down box

12. text Text

13. text Text

14. drop down box

V. Utilization Review Answer Format Format Type Response Explanation

1.

a. Preadmission Certification drop down box

b. Managed Mental Health Program drop down box

c. Organ Transplant Network drop down box

d. Concurrent Review drop down box

e. Discharge Planning drop down box

f. Line Item Hospital Bill Audits drop down box

g. Skilled Nursing Care drop down box

h. Neonatal Program drop down box

i. Bariatric Surgery drop down box

j. IVF Program drop down box

2. drop down box

3. text Text

4. text Text

5. drop down box

6. Hospital bill audit services:


Claim amount paid will be the negotiated amount. In other words, services will pay actual negotiated amount; none of the savings will be retained by your organization or shared with any other organization.


The vendor will agree to invoice the State of Delaware on a monthly basis for the administration fee.


Please provide your major assumptions. Explain any deviations or circumstances under which your proposal and guarantees would not apply.

Are all payment checks printed and mailed from the office that is doing the claims processing? If not, where is the location this would occur? How often are checks printed and mailed?

In the event of a future change in vendors, you agree to administer all run-out claims at no additional fee within 24 months after contract term and provide to SBO to resolve concerns.


Does your quotation include the following utilization controls?











Please confirm that you are able to make specific level of care (room & board) determinations for each and every inpatient day, and having a workable process to assure that level of care determinations are accurately applied during claim adjudication. Management of sub-acute/SNF days should be included.


Provide a list of services which do not require preadmission certification and explain how appeals for these services based on no medical necessity are addressed.

Provide a description of out of network inpatient certification capabilities and utilization management guidelines. How do you handle adverse medical management determinations when the patient is at an out of area non-network provider?

Do you provide on site hospital reviews? If not, why?






a. text Text

b. text Text

7. text Text

a. text Text

b. text Text

8. text Text

9. text Text

10. Psychiatric and substance abuse review:

a. text Text

b. text Text

11. Large Claim/Case Management

a. text Text

12. Describe your large case management program. text Text

13. text Text

14. text Text

Please include an outline of how you proactively manage hospital over-billing (unsubstantiated, inappropriate or up coded charges) through your provider contracts or other means, avoiding the need to pay sub-vendor contingencies.

Also, address whether you are willing to perform hospital bill audits as a core in-house service within your fee structure.

Describe how your precertification process operates. What services do you recommend pre-certifying in-network and out-of-network? What diagnostic services do you pre-certify? What mental health services do you pre-certify?

Will you provide pre-certifications if requested or specific services if not standard such as P.T. and DME?

Do you review inpatient itemized bills to assure that all charges are eligible and appropriate? If so, please explain the process utilized. If not, explain why not.

What guidelines do you use to determine length of stay?How do you report Utilization Review activity and results?

Does the Utilization Review program have a separate component for monitoring mental disorders and substance abuse treatment?

Please describe the outpatient review process for outpatient psychiatric and substance abuse services, including notification and the frequency of review.

When and how is large claim management initiated?

What are the thresholds used to identify cases for case management?

Please provide your methodology for developing “savings” for your Utilization Review, Large Case Management and Disease Management Services. Documentation should be maintained for all individual claims that were utilized to develop global savings representations for inpatient utilization case management, disease management, etc. Please confirm that savings only apply when medical management outcomes are actually applied during claim adjudication.





VI. Access and Management Answer Format Format Type Response Explanation

1. drop down box

2. text Text

3. In terms of your HMO (if applicable):

a. Percent of board certified PCPs percent, 1 Percent,1

b. Percent of board certified specialists percent, 1 Percent,1

c. percent, 1 Percent,1

d. Percent of PCPs that are closed to new patients percent, 1 Percent,1

4. Describe your guidelines for:

a. Emergencies in or out of your service area text Text

b. text Text

c. text Text

d. text Text

e. text Text

f. text Text

g. drop down box

5. text Text

6. text Text

7. drop down box

8.


Will you guarantee that the negotiated prices/fees that you pass on to the State of Delaware are the most favorable fees available and that better prices and/or terms are not negotiated for any other Delaware clients, regardless of the funding arrangement (Administrative Services Only, fully insured, at risk, etc.)?


Please provide a detailed description of how you currently manage/allow ancillary charges for all Delaware facilities, as well as for out of state and out of network facilities. Include how ancillary charges are treated for denied inpatient days.

2010 voluntary and involuntary physician turnover rate (PCP and specialist combined)

Employees or dependents who temporarily reside outside of their service areaCovered services for which no network provider existsHow will you notify plan participants if their selected provider is no longer in the network?

Please indicate which indicators are part of your national standards for initial physician credentialing.

How often are network physicians recredentialed? Annually? Every two years? Other? (Please specify)

Is your organization currently National Committee for Quality Assurance (NCQA) accredited? If not, are you considering plan accreditation? If so, please provider your NCQA report.


Are there specific plans to expand the network to locations not currently covered in State of Delaware? If yes, when?

In areas of relatively poor network access, what initiatives are underway or planned to improve access to participating providers?

Do you own the networks proposed for the State? If not, please specify those locations that are not owned and the vendor with whom you associate.


Complete the disruption reports for the SEBC’s designated utilized providers:

For HMOs, please see the Primary Care Physician list on the provided disks in the file named, “State of Delaware Disruption Report Template.”, tab named "Prof". This worksheet contains a list of current PCPs for which we are requesting you to identify if the provider is in-network or out-of-network. Identify providers accepting new patients separately from those that are not.






11. text Text

12. text Text

13. text Text

14. text Text

15. Describe your credentialing process. text Text

16. text Text

17. percent, 1 Percent,1

18.

a. text Text

b. The nature of illnesses/conditions text Text

c. text Text

d. text Text

e. text Text

f. text Text

g. text Text

h. text Text

i. text Text

j. text Text

19. Describe any plans to add Centers for Excellence. text Text

20. text Text

21. text Text

22. text Text

In the provided disk, please refer to the file named "State of Delaware Discount Report Template", tab named " Discounts+Disruption_Facility.” The worksheet contains a list of top providers for which we are requesting you to identify if the provider is in-network or out-of-network.

Can your network be customized per client's specification? (i.e. providers deleted or added)? If so, for what criteria?

Please confirm there is no balance billing allowed for network providers.

Do you have multi-year contracts with providers? If yes, describe the typical terms of the contract. Describe caps or controls on reimbursement increases from year to year.

What services (if any) are capitated in your network?

Describe your recredentialling process, including the frequency at which your recredentialling.

What percentage of your contracting is done with individual providers versus provider groups?

Describe any special national networks that are utilized, such as National Centers of Excellence; specifically identify:Each special network facility with which you contract

Treatments/services and providers covered by the contractIf only selected providers are covered by the terms of the contractThe selection criteria used in identifying each of these facilities

Types of payment arrangements, such as discounted fee-for service, per diem or global fee (encompasses facility and provider charges.)

How are cases selected for Centers of Excellence?

How do you communicate to members, their families, and their providers the member’s ability to take advantage of care at a Center of Excellence?

Does Vendor’s Center of Excellence program include provision of services, such as discounts at hotels or lodgings, to close relatives who accompany a member to a Center of Excellence?

Do you use an organ transplant network? If so, describe this network.

Do you have any type of risk-sharing (withhold, etc.) or pay-for-performance bonus arrangements with Providers? If yes, describe in detail and include sample contract language.

Describe your network’s activities and requirements with regards to profiling of network physicians. What do you do with the results?

Describe all efforts that your organization takes to negotiate directly or indirectly to obtain discounts with out-of-network providers.





23. text Text

24. drop down box

25. drop down box

26. drop down box

27. text Text

28. drop down box

VII. Quality Assurance Answer Format Format Type Response Explanation

1. text Text

2.

a. Require that treatment protocols be used? text Text

b. text Text

c. text Text

d. text Text

e. text Text

3.

a. text Text

b. text Text

c. text Text

d. text Text

e. text Text

4. text Text

5. text Text

How are Outpatient out-of-network facility charges determined? For example, is a schedule used or are reasonable and customary charges used?

Has the Geo-Access reporting been completed using the requested parameters?


Will the vendor maintain a satisfactory number of providers (hospitals and physicians) in all implemented locations?


Will the vendor actively pursue physicians nominated by the State employees to participate in network?


Describe any experience your organization has with HD network plans.The vendor will accept the State's authorization to pay claims or provide a service.


How do you determine physician cost-effectiveness? How is quality of care determined? What measurement units are used for each?

Describe Vendor’s ongoing quality assurance procedures for hospitals and other health care facilities. With respect to hospitals, do you:

Investigate whether changes to quality controls are made after adverse outcomes? Monitor nosocomial infection and anesthesia death rates?

Monitor re-admission rates after inpatient discharge or outpatient treatment (e.g., surgery)?

Validate patient satisfaction with telephone or written surveys?

Describe Vendor’s ongoing quality assurance procedures for physicians. With respect to physicians, do you: Share physicians' practice patterns with the respective physicians?

Monitor a surgeon's frequency of surgery by procedure and total surgeries performed during the year?

Monitor emergency room treatment approvals and specialist referral rates?Monitor the frequency and type of diagnostic and laboratory tests?

Monitor re-admission rates after inpatient discharge or outpatient treatment (e.g., surgery)?

What guidelines and protocols are used for determining appropriate lengths of stay? Have the guidelines and protocols been peer reviewed? Who at the vendor has the authority to make the initial determination to deny payment for a confinement or stay? What is the appeal process?

Are second level appeals reviewed by a Provider with training in the appropriate specialty for the claim being contested? How does Vendor determine what specialty to use for second level appeals peer review?





6. text Text

7. text Text

8. text Text

VIII. Medical Management Answer Format Format Type Response Explanation

1. text Text

a. text Text

b. text Text

c. When and how often do you perform chart review? text Text

2. text Text

a. Utilization review text Text

b. Case Management text Text

c. Centers of Excellence text Text

d. Disease Management text Text

3. text Text

4. text Text

a. Any qualitative and quantitative results. text Text

b. text Text

c. text Text

d. text Text

5. text Text

6. text Text

7. text Text

8. text Text

IX. Implementation Answer Format Format Type Response Explanation

What is Vendor’s criteria for concurrent inpatient on-site review? What percentage of in-network cases are concurrently reviewed? Is concurrent review performed for out-of-network admissions?

What guidelines do you use to determine appropriate mental health services? Do you use a subcontractor?

What guidelines do you use for managing outpatient treatment?

Describe the methods your Medical Management program(s) uses to target areas where you believe you can make a difference in managing health care utilization and costs. Include the following:

Do you target cases based on dollar thresholds, diagnoses, volume, provider profile, etc.?

How often do you conduct on-site reviews for: (i) inpatient hospital facilities; (ii) outpatient facilities; (iii) physician offices; (iv) outpatient labs, x-ray, and testing facilities, and (v) other (specify)?

How do you see your Medical Management programs evolving over the next 3-5 years? As appropriate, provide responses specific to:

Do you offer a 24-hour Nurse line service? If so, describe the program and utilization results.Describe your case management program, including:

What enhancements have been made to your case management program within the last year and what changes are being planned for implementation within the next year?

What are the qualifications of the case managers? What is the ratio of case managers to covered members?

How are the cases identified for case management?

Are the case management services provided by the Vendor or by a subcontractor? If by a subcontractor, is the subcontractor part of a national organization? (as listed earlier)

How does Vendor identify members who would benefit from early interventions through this program?

Identify those conditions and circumstances that would trigger case management.

Bidder will perform pre-determination on any service as requested by physician, member or the SBO.





1. drop down box

2. drop down box

3. drop down box

4. drop down box

5. text Text


7. drop down box

8. text Text

a. text Text

9. text Text


10.


Note: Incumbent vendors are subject to the same implementation criteria. If you feel a criteria does not apply, so state and explain.

You agree to provide an implementation allowance of $40,000 to pay for implementation expenses for items such as communications to members in your proposed administrative fees.


Payment of the implementation allowance does not require the State of Delaware to submit receipts for services; instead, the payment will be provided automatically 60 days after implementation.


Please confirm that you will provide a designated implementation team for the State of Delaware that will include an implementation manager and the account manager; they will provide assistance during the transition/implementation process and participate in regularly scheduled status meetings (at least weekly) with the State of Delaware. Also, both managers must appear in person at the kick-off meeting.


Please confirm that you will maintain an implementation project plan and issue log documenting all implementation issues, actions, due dates and responsible parties.


Describe key factors to a successful implementation based on your experience.

Provide a detailed description of the process you will use to monitor and audit implementation of the program. Be sure to include the resources and responsibilities required of the SBO.

Vendor confirms that Account Manager will be part of the team at award date (so they are part of the implementation process).


Indicate whether the team will be dedicated full-time to the Statewide Benefits Office, and, if not, the nature of their other responsibilities during the Statewide Benefits Office implementation.

Please indicate the nature and amount of involvement you will require from the Statewide Benefits Office.

What are the most critical steps that you and/or the State must take to ensure a smooth transition by the effective date?

Indicate your willingness to provide network service area zip codes and electronic directories, if requested by the SBO.

Indicate your willingness to provide the following pre-implementation services:

The State will conduct a quality review of the plan design to be loaded in the claims system(s) prior to implementation (or as soon thereafter as reasonably possible). As the selected carrier or administrator, you agree to pay the cost of this review, up to $25,000. You will provide all necessary support to enable the State to review claims in a test environment that mirrors the plan information present in the "live" claims processing system. If this review cannot be supported remotely and requires an on-site review, you will be responsible for travel costs. Costs for these services must be included in your proposed administrative fees.





X. Eligibility Answer Format Format Type Response Explanation

1. drop down box

2. drop down box

3.

a. drop down box

b. drop down box

c. drop down box

d. drop down box

4. text Text

5. text Text

6. text Text

7. text Text

8. text Text

a. text Text

b. text Text

c. text Text

d. How do you identify cases of duplicate coverage? text Text

9. text Text

Can the vendor provide immediate on-line real-time manual eligibility updates for urgent requests by the SBO staff?


The vendor agrees to receive paper enrollment and changes for all non-payroll groups.


Based on the eligibility files you receive, you will:

Add coverage for members who have joined the plan within 48 hours of receipt of eligibility data


Update member information (e.g., address changes) within 48 hours of receipt of eligibility data


Terminate coverage for members leaving the plan within 48 hours of receipt of eligibility data.


Notify prescription vendor of updates within 48 hours.


What assurances can the Vendor, and all subcontractors, provide that its claims files will be reconciled with the State's enrollment files? If separate systems are used for enrollment and claim processing, how are changes in enrollment data updated on the system used to pay claims?

Describe how dependent information is stored. Is it part of the subscriber record, or a separate record? If separate, how are the two linked so that changes or termination on the subscriber record update the dependent record?

If a member has another group health benefits policy with the Vendor, will the Plan’s eligibility record be separate or shared? If common data is shared (e.g. SSN, DOB, name), describe how this information can be protected from changes made by other plans or groups. Describe how HIPAA related data is also treated across multiple plans.

Describe how the Vendor will notify the SEBC if it receives information relevant to, but not indicated on, our enrollment records, such as death, divorce, or Medicare entitlement.

Describe how your system handles eligibility changes for employees and dependents. What resources are required of the State? Include the following:

How do you identify dependents exceeding or nearing a plan’s limiting age?How do you administer lapses and/or overlaps in coverage?

Number of eligibility changes the system can accommodate per employee: i.e. can you process marriage, birth and termination on the same day?

How frequently can eligibility information be updated? How soon is the eligibility system updated on-line after receipt of the new information?





10. Confirm that you have VDSA capabilities. text Text

11. Confirm that you have HICN tracking capabilities. text Text

12. text Text

13. text Text

14. text Text

15. text Text

XI. Claims Administration Answer Format Format Type Response Explanation

1. drop down box

2. drop down box

3. drop down box

4. drop down box

5. drop down box

6. drop down box

7. drop down box

8. COB data is updated annually. drop down box

9. drop down box

10. drop down box Listbox, ListRCInfo

11. drop down box Listbox,ListCompleted

12. text Text

Do the customer service representatives have on-line access to the eligibility system? Can they make changes to the system?

How do your systems integrate with those of your subcontractors (if any) being used to administer the plans?

Confirm that you will provide the State with access to an on-line eligibility system through which authorized State benefits staff can add emergency updates to the eligibility "real time".

Confirm that you will accommodate eligibility, claims and provider file layouts utilized by other vendors doing business with the State. The Bidder will need to transmit electronically to these other vendors as frequently as needed at no cost to the State.

We encourage you to explain any "No" responses using the "Explanation" column. If you need more space, please use the "Explanation" worksheet. Explanations should be numbered to match with "No" responses and must be brief. They cannot exceed 1,000 characters in the worksheet.

Your company can provide claims adjudication at varying R&C percentiles beginning with the 50th percentile.


Network physicians routinely submit claims to the network and the claims administrator electronically.


Network members never have to submit claim forms for in-network services.


Each of your networks serving the members is supported by a computerized, on-line direct access claims processing system containing plan/claim information storage and retrieval.


Does your system require manual operations at any point during the claims process?


Plan summaries are stored in the computer memory for screening purposes.


The claims system maintains on-line eligibility files for all members that are updated at least weekly.



The claims system automatically screens for duplicate bills.


Please note the source of your R&C information (e.g., HIAA, PHCS, internally developed, other)

Please complete the table shown on the tabs "Discounts+Disruption_Facility" and "Discounts_Professional" in the file named "State of Delaware Discount Report Template" on the provided disk.

List the locations of all claims offices that you propose to process claims for the State of Delaware. If you need more space, please use the "Explanation" column and/or worksheet. Indicate the question answered.





13. percent, 1 Percent,1

14. What is your average claims backlog (in days)? number, 0 Number,0

15. drop down box

16. text Text

17. text Text

18.

a. Maximum draft amount drop down box

b. Maximum service charge drop down box

c. Maximum claim limit drop down box

19. drop down box

20. drop down box

a. drop down box

21. drop down box

What percentage of your in-network claims were automatically adjudicated in the last calendar year?

The State requires fully dedicated customer service representatives, claim processors, and supervisors to process claims. Will the claims unit dedicated to the State process claims for other clients?


Who in your claim office would be the claim service representative responsible for responding to the State's questions? Include their experience and length of employment with you. Describe your supplemental staffing plans to resolve possible claim backlogs and identify the average tenure of your claims processors.

What are your minimum education and experience requirements for claim processors? Briefly describe the training program.

Do you have authority limits for each examiner including:




The State current utilizes a Spousal Coordination of Benefits Policy form. Please confirm that you will reconcile receipt of this required form with the State at each open enrollment period, assuring claims are processed at secondary level of 20% for applicable subscriber’s dependents until an updated form has been secured. The forms are received electronically and in hard copy.


The Bidder must provide staff to proactively monitor claims for "disabled" members.


The Bidder must provide written notice to "disabled" members or members with ESRD that enrollment in Medicare A and B is mandatory. The Bidder will provide notice to the Pension Office and SBO.


Participants who are eligible for Medicare part A or B (for whatever reason they qualify) must enroll. Please confirm that if a subscriber who is not actively employed full-time has Medicare Part A and failed to enroll for part B, related claims should be denied and the State should be contacted in writing and the status maintained. Vendors who do not have procedures in place to accurately enforce this requirement shall accept liability for any overpayments that cannot be timely recovered.






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Describe procedure for identifying and investigating claims involving subrogation. If you are sub-contracting this service, please identify the sub-vendor, explain how the subcontractor was selected and your specific ability to manage this vendor for the State. Whether you present an in-house or outsourced solution, provide your capabilities to identify and recover third party mass tort, malpractice claims. If the State decides to carve out this service, you will be expected to professionally interface with the selected vendor. You will also be expected to work with the State to craft optimal plan language for the recovery of claim dollars that are the liability of other parties.

Describe your disabled dependent certification procedures.

Vendors are expected to accept accountability/liability for interest owed and/or discounts lost due to failure to process claims timely per prevailing statutes, per provider agreement timely pay provisions willfully entered into, and when failing to take optimal advantage of prompt pay and differential opportunities. Please confirm your agreement.


What are your guidelines for "medical necessity" or "appropriateness"?Describe what controls are in place to pay claims only for eligible members.

Describe the organization(s) that will be established to process claims (i.e., for each plan design) and indicate whether there will be a dedicated unit for the State.

Which other major accounts are processed in the designated claim office(s)?

If claims are adjudicated in multiple claim offices, how does the Vendor ensure consistency in claims administration?

Describe your claim processing system(s) – its architecture, platforms, features (e.g., automated links between claims system and eligibility system; percentage of auto adjudication for in-network and out-of-network claims; handling of unbundled charges).

Are in-network and out-of-network claims processed on the same system? If not, explain how Vendor coordinates the systems.

How are overcharges, medically inappropriate or unnecessary care or provider abuse detected?

What steps will Vendor take to remedy conditions that are uncovered during utilization review for claims that appear aberrant, excessive or fraudulent?

Describe overpayment recovery procedures (including any thresholds).

Describe the process you propose for transitioning with the predecessor Vendor to obtain history of claims towards benefit accumulators and maximums.





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42. text Text

43. Describe your COB payment processing. text Text

44. text Text

XII. ID Cards Answer Format Format Type Response Explanation

1. drop down box

2. drop down box

3. text Text

4. text Text

a. text Text

Does the Vendor employ any protocols in its claims adjudication process that limit treatment modalities by providers such as chiropractors, physical therapists, or occupational therapists whether the treatments modalities occur during a single outpatient visit or over a course of treatment? If yes, what peer-reviewed protocols are employed for which treatments, and if no, explain why not.

The plan will contain the birthday rule and will have group to group coordination of benefits provision.

To the extent permitted under state law, no fault auto insurance, governmental plans coordination and negligent third party subrogation will be administered.

All claim records and eligibility data used by the carrier in its role as claim administrator shall remain the property of the State as Plan Sponsor and Plan Administrator.

The vendor will be responsible for tracking IVF participant expenses (both medical and prescription) for both grandfathered and non-grandfathered participants to ensure members do not exceed limits. For grandfathered members, this includes coordination or experience with PBM.

Describe the External Appeals process you propose or currently have in place. Confirm if there is a separate charge for this process.

The State of Delaware currently provides a Medicare Supplement health plan for Medicare eligibles (the plan design summary is included in the RFP). However, it is possible that the plan design and or the method of coordination of benefits (COB) will change in the future. Please confirm that your organization is able to administer all potential methods of COB with Medicare including but not limited to standard COB, non-duplication of benefits, and government exclusion at no additional cost and with no charge to your proposed administrative fees.

Describe your appeals process for a grandfathered verses a non-grandfathered plan.

If related to vendor errors or vendor initiated charges, you will be responsible for cost to reproduce ID cards (including priority shipping).


Do you have the on-line capability to have an employee print an ID card?


Describe Vendor's identification card distribution process. Include details such as the card creation locations, distribution methods, use of subcontractors, third party involvement, etc.

If a member requests a replacement ID card, what is the charge to the State (including postage, if any)?

Vendor will send the first set (two) of ID cards to the members at no cost to the State.





XIII. Communication Answer Format Format Type Response Explanation

1. Text Text

2. drop down box

3. drop down box

4. text Text

5. drop down box

6. text Text


8. text Text


10. Will the health plan pay for printing costs for?

a. ID Cards drop down box Listbox,ListYesNo

b. SPDs drop down box Listbox,ListYesNo



13. drop down box

14. text Text

15. text Text

Please provide a proposed timetable for availability of electronic SPD’s.

The communication materials must be customized at no additional cost. (For example, the State's logo)


State of Delaware Seal: the State of Delaware may wish to have the State seal appear on various printed materials. The designated vendor must agree to this at no additional cost and must ensure that seal placement and color requirements are met.


You must agree to request written permission from the Secretary of State to use the seal.

Confirm your ability to send materials to multiple groups via electronic media and email to members.


Describe your distribution strategy including whether or not you track what materials participants are requesting for reporting purposes.

Please provide examples of other communications that may be sent to members. Are printing and mailing of these communications included in the ASO fees? Name the file: [Your Organization's Name]_Standard Communications.

List the location of your fulfillment center for participant mailings.

When customized printing is required, the health plan must present a proof to the State for approval.

The health plan must provide SPDs in an electronic format.

The health plan agrees that no external communications material that mentions the State's benefit plans may be circulated without written approval from the State.

You will ensure communications sent to participants are specific to the State of Delaware's plan designs.


Confirm your willingness to provide an annual employee communication allowance. Specify the amount and the permitted uses for this allowance per plan year.

Confirm that a Summary Plan Description for each health care plan will be modified as changes occur throughout the plan year and a final copy for each plan year will be provided to the State at least 10 business days prior to the annual open enrollment.





XIV. Customer Service Answer Format Format Type Response Explanation

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8. number, 0 number, 0

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If "yes," provide the following statistics:

a. percent, 1 Percentage, 1

b. percent, 1 Percentage, 1

c. Definition of turnover Text Text

12.

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You will provide the State of Delaware a dedicated toll-free telephone line with live caller support through a designated member service team (Including supervisors) who is available 8:30 a.m. to 7:00 p.m. Monday through Friday, EST. Please confirm an automated voice mail system shall be available on the same dedicated toll-free line 24-hours a day, 7-days a week.


IVR and web support will be available through the dedicated toll-free telephone line 24 hours a day, seven days a week, 365 days a year.


The member service team will be knowledgeable of the State of Delaware's specific medical benefit programs to respond to member questions.


Your customer service representatives will offer the name and phone number of the "manager/supervisor" for escalated issues.


You (or your designee at your expense) will perform a client-specific (versus book-of-business) member satisfaction survey at least once annually.


You will have a backup call center available to handle roll-over calls or calls in the event of a disaster.


You are able and willing to customize messaging for the State of Delaware-specific plan design issues.


How many languages does your call center support?

Do you currently provide versions of your member website in multiple languages that offer the same functionality as the English version?


Will you provide plan summaries and other materials to all members in Spanish, if requested?


Do you measure the turnover of your Customer Service staff? If not, why not?


Percentage of turnover during last six months (include turnover due to promotions, resignations and terminations).

Percentage of turnover during last 12-month period (include turnover due to promotions, resignations, and terminations.

We encourage you to explain any "No" responses using the "Explanation" column. If you need more space, please use the "Explanation" worksheet. Explanations should be numbered to match with "No" responses and must be brief. They cannot exceed 1,000 characters in the worksheet.

Each new member receives a SPD or other relevant member materials that describes appeal procedures.


Respond to member appeals, complaints and grievances and report quarterly to the SBO to be compliant with PPACA.






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20. A fax line that is operational 24 hours a day. drop down box

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25.

a. E-mail drop down box

b. Live web chat drop down box

c. drop down box

d. Assistance for hearing impaired drop down box

26.

a. Provider locations drop down box

b. Check eligibility drop down box

c. Plan coverage drop down box

d. How to use the plan drop down box

e. Past service claim history drop down box

f. HRA Balances drop down box

g. Plan Design Information drop down box

h. drop down box

27. drop down box

a. Does the system show:

b. Date of initial call drop down box

c. Date inquiry closed drop down box

There is a single toll-free, customer service telephone number for addressing claims payment, member services and any appeals.


You provide a dedicated individual or staff responsible for resolving claim disputes or other issues.


During 2010, the member services telephone abandonment rate was 5% or less for the vendor's call center proposed for the State of Delaware.


During 2010, at least 90% of telephone calls to member services were answered within 20 seconds for the vendor's call center proposed for the State of Delaware.


During 2010, 90% or more of new members received their ID cards by the effective date of coverage in each metropolitan area you served the members for the vendor's service center proposed for the State of Delaware.



Vendor confirms that customer call center is located in the United States.


Are all of your customer service representatives employees of your organization?


How many customer service employees do you have?How many hours of new hire training do your customer service representatives receive?Are the following currently available to access your customer services employees?



Automated Interactive Voice Response (IVR) system available 24/7



Indicate the information your automated IVR system offers to callers:








Current status (in deductible, deductible satisfied, etc.)


Does the member services area use a dedicated on-line call-tracking and documentation system to log inquiries by type and ensure the timeliness of follow-up activities?








d. Representative who handled the call drop down box

e. Call status drop down box

f. If and where issue was referred for handling drop down box

g. Reason for call (issue) drop down box

h. What was communicated to member drop down box

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29. text Text

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XV. Web Capabilities Answer Format Format Type Response Explanation

1.

a. Claims history. drop down box

b. Cost of Care estimators drop down box

c. Provider Locator drop down box

d. Quality Measures drop down box

e. Educational Materials drop down box

f. drop down box

2. drop down box

3. Indicate your web site's capabilities for members.

a. drop down box

b. Link to provider's web site (if applicable) drop down box

c. In-network savings information drop down box

d. Link to contact customer service drop down box

4. Indicate your website's capabilities for the SBO:

a. Tools to manage eligibility drop down box

b. Access to reports drop down box

c. Link to account team members drop down box

d. text Text






Can the member services representative access claims status on-line?


What methodologies (e.g. silent call monitoring) are employed to monitor and control the quality of service provided?

Are CSRs authorized to make claim adjustments? If yes, describe any limitations.

Do you tape all customer calls and if not, what percentage are taped? How long are the tapes kept?

Participants will have access to a web-based application, which allows them to review:






Explanation of Benefits (EOBs) -- current and historical


Vendor will have the ability to develop and maintain custom websites for the State of Delaware plan members, as well as pre-member websites for prospective members.


Provider information (languages spoken, special services, etc.)








Describe your additional internet capabilities with respect to services for plan sponsors. Address billing, eligibility maintenance and reporting, management reporting, plan design information, claim status, provider directories, claim forms, CDH-HRA statements, provider report cards, a link to labs to see test results, etc.





XVI. Account Management Answer Format Format Type Response Explanation

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5. Text Text

6. Text Text

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10. drop down box Listbox, ListProvideNA

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Describe the account team you are proposing for the State of Delaware. For each team member, include years of experience servicing similar types of organizations.

The team must promptly respond to all communication from the State.


The team must attend all quarterly meetings in person.


The team must conduct and summarize for the State legislative research regarding any proposed plan modifications


Describe each team member’s current client base and work load. How will other responsibilities be transitioned?

Describe how the account team will provide customer service to the members of the Plan and actions they will take to handle any issues that may arise.

Describe the customer service the account management team will provide to SBO and actions they will take to handle any issues that may arise and manage on a daily basis.

You will coordinate with the SBO for development of the SPD. This includes, but is not limited to, reviewing changes to the SPD, making sure that you administer the plan as reflected in the SPD, and communicating any plan/clinical program changes to the SBO for inclusion in the SPD. The SPD for the upcoming plan year would be available for Open Enrollment in May and available to members via a website.


Bidder will maintain an "Issue Log" to track the status of all concerns/issues between the bidder and SBO. This log will be used as an agenda item for Monthly Conference Calls. A copy of the "Issue Log" will be provided to the State three (3) business days prior to Monthly Conference Calls. An updated "Issue Log" will be provided no later than three (3) business days following the conference call.


If requested by the State of Delaware, the State shall have the ability to participate in the hiring and interview process for the State's account executive or manager.

Using the "Acct Management Plan" Worksheet, describe your plan for managing the account, including periodic reviews of cost and utilization and recommendations for plan design changes from the State of Delaware's representatives.


Confirm that the Bidder will proactively provide administrative and management services to the State.


Confirm that the Bidder will proactively advise in advance or as soon as reasonably possible, the State of potential problems that would impact on the State's account.






XVII. Reporting Answer Format Format Type Response Explanation

1.

2.

a. drop down box

b. Cost Share Reporting drop down box

c. Customer Service Statistics drop down box

d. Contract Forecasting and Utilization drop down box

e. Trend Analysis of Appeals, etc. drop down box

f. Executive Summary drop down box

3.

a. Financial Overview drop down box

b. Early Retiree Cost/Utilization Reporting drop down box

c. Cost/Utilization per program and member group drop down box

4.

a. drop down box

5.

a. drop down box Listbox,ListAttached

b. drop down box

c. drop down box

6.

a. Paid Claims drop down box Listbox,ListYesNo

b. Capitation (if applicable) drop down box Listbox,ListYesNo

c. Administrative/Network Fees (if applicable) drop down box Listbox,ListYesNo

d. Premiums (if applicable) drop down box Listbox,ListYesNo

e. Monthly enrollment counts by plan and tier drop down box Listbox,ListYesNo

f. Enrollment by group drop down box Listbox,ListYesNo

g. OPEB and non-OPEB actives drop down box Listbox,ListYesNo

h. Retired non-Medicare eligible drop down box Listbox,ListYesNo

You will provide to the State the reports at the frequency, in the method, and at the target date stated at no cost to the State. All reporting must be done via numerous groups - departments, agencies, school districts, and non-state groups, retirees - pre & post. Please see the attachment - "Required Reports List To/From Medical Vendor".

You will provide the following administrative / analysis / statistical reporting to the State at no charge. All reporting must be done via numerous groups - departments, agencies, school districts, and non-state groups, retirees - pre & post.

For any ad-hoc reports, what would the range of charges be? Please describe examples of ad-hoc reports and the associated charges.







You will provide the following financial reports on a Quarterly and Annual basis to the State at no charge.




You will provide the following invoicing report to the State at no charge.Invoicing for claims with detail breakdown and legends in user-friendly format. Format to be discussed and agreed upon by the State.


Sample reports available to the State at no charge:

Attach a sample management and utilization report(s) that would be prepared for the State of Delaware. Name the file: [Your Organization's Name]_MgmtRptgPkg.

Are these reports available in real-time and on-line via the internet?


Can these reports be customized to further meet the State's needs?


Monthly reporting containing the following information:





i. Medicare eligible drop down box Listbox,ListYesNo

7.

a. Electronic eligibility listing drop down box Listbox,ListYesNo

b. Claims paid by dollar amount increments drop down box Listbox,ListYesNo

c. Reconciliation of claim drafts to paid claims drop down box Listbox,ListYesNo

8.

a. Claims submitted drop down box Listbox,ListYesNo

b. Claims eligible drop down box Listbox,ListYesNo

c. Deductible and coinsurance application drop down box Listbox,ListYesNo


e. R&C cutbacks and savings drop down box Listbox,ListYesNo

f. COB savings drop down box Listbox,ListYesNo

g. Ineligible expenses drop down box Listbox,ListYesNo

h. Net benefits paid by major line of coverage drop down box Listbox,ListYesNo

i. Claims incurred report drop down box Listbox,ListYesNo

9.

a. Employees drop down box Listbox,ListYesNo

b. Dependents drop down box Listbox,ListYesNo

c. Retirees 65 and over and their dependents drop down box Listbox,ListYesNo

d. Retirees under 65 and their dependents drop down box Listbox,ListYesNo

e. COBRA Participants drop down box Listbox,ListYesNo



12. Claim lag report. drop down box Listbox,ListYesNo

13. Network savings reports for each network offered. drop down box Listbox,ListYesNo

14. Most-utilized hospitals and physicians reports. drop down box Listbox,ListYesNo





XVIII. Internal Audits and SOD Audit Rights Answer Format Format Type Response Explanation

1. text Text

2. text Text

3. text Text

Quarterly reporting containing the following information:

General claim utilization reports by major line of coverage identifying:

Payment reductions due to network negotiated rates

Claim utilization report will show separate experience for:

Confirm your abilities to provide your claim utilization reporting above as per group structure to be provided by the State.

Employee contested claims separated by denial reason.

A year-end financial accounting for the program within 90 days of the fiscal year end.

You will analyze the State of Delaware's utilization and claims data and meet with the State on at least a semi-annual basis to review emerging trends and account servicing.

The Bidder agrees to pay for any reprocessing fees that are directly due to the Bidder sending an unusable file to the State's vendors.

Please confirm that your organization will support the State of Delaware in filing for all Early Retiree Reimbursement Program payments including but not limited to providing all required documentation at no additional cost.

What percentage of claims are audited pre-disbursement? Post-disbursement?

Describe internal audit procedures including the number of claims audited per Claims Examiner; how frequently each Claims Examiner is audited and how results are reported.

Are there any special audits (e.g. high dollar claims) or reviews? If yes, describe.





4.

a. drop down box

5. drop down box

a. drop down box

b. Right to audit post termination. drop down box

c. drop down box

d. drop down box

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10. text Text

XIX. Systems Answer Format Format Type Response Explanation

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3. drop down box

The State of Delaware reserves the right to conduct audits as follows. Confirm you agree with each of the following:

Based on audit findings, Bidder shall be required to re-process claims for payment or modify adjudication process to correctly process future claims.


Right to audit any data necessary to ensure your organization is complying with all contract terms, approved and denied utilization management reviews; clinical program outcomes; appeals; information related to the reporting and measurement of performance guarantees; etc.


Right to audit at no charge except at a direct pass-through of any data retrieval fees, which may be required if data requested has already been stored.



Right to audit more than once per year if the audits are different in scope or for different services


Right to perform additional audits during the year of similar scope if requested as a follow-up to ensure significant/material errors found in an audit have been corrected and are not recurring or if additional information becomes available to warrant further investigation.


You agree to provide reasonable cooperation with requests for information, which includes but is not limited to the timing of the audit, deliverables, data/information requests and your response time to SBO's questions during and after the process. Your organization will also provide a response to all “findings” it receives within 30 days, or at a later date if mutually determined to be more reasonable based on the number and type of findings.


Your organization agrees to pay the Plan 100% of any overpayments made by the Plan as determined from an audit by a organization that the Plan chooses, and no later than 30 days after both parties have agreed to the recoveries.


You will permit any other party selected by client, to audit claims at any time.


The State reserves the right to conduct a third party audit of the clinical performance of each program at least once annually


Please explain the process of auditing providers for compliance with your contracts to ensure correct charges and correct employee utilization of benefits and out of pocket charges to the participants.

If requested, you will accept from the incumbent a claims file that you can use to transfer data, as required.


You will deliver enrollment and claims data to our data mining vendor no less frequently than once a month.


You will deliver enrollment and claims data to our PBM vendor weekly within 48 hours of eligibility updates.






4. text Text

5. text Text

6. text Text

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XX. Legal/Contractual/Compliance Answer Format Format Type Response Explanation

1. text Text

2. drop down box

3. drop down box


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Describe how historical information is maintained in the system. For how long?

Describe your disaster recovery protocols, procedures and backup systems. Are claim files and hard copy and electronic claim files stored off site? Can you rapidly shift phone service to another center, if needed? Can you rapidly shift claim processing to another center, if needed?

Will all of the eligibility information the SEBC provides to support its plans be handled by one system?

You agree to provide periodic electronic data feeds at no additional cost to a minimum of four unique vendors. Each data feed could be unique in nature and would range from real time to weekly to quarterly transmission intervals.


You agree to provide a mailing address file each quarter to the SBO.


Communication and data exchange between health management and PBM will be at no cost to the State.


Please describe any pending indictment, court order or investigation that your company or any of its officers, directors, partners, or principals. Include any investigation or regulatory action by a state or federal agency.

The vendor maintains executed contracts with all providers participating in the network.


The vendor provider contracts do not provide for any type of remuneration to your organization, such as commission, finder's fee or other financial benefit.


Please provide a copy of your company’s standard forms that State of Delaware will be required to sign prior to the notice to proceed (e.g. HIPAA, Business Associate Agreement). Along with the forms, please include the specific law or regulation that mandates the form. Name the file: [Your Organization's Name]_Standard Forms.

Your organization is not a creditor of any provider in the network.


By submitting a proposal, the proposing organization agrees that in the event it is awarded a contract, it will indemnify and otherwise hold harmless the SEBC, its agents and employees from any and all liability, suits, actions, or claims, together with all costs, expenses for attorney’s fees arising out of the organizations, its agents’ and employees’ performance of work services in connection with the contract, regardless of whether such suits, actions, claims or liabilities are based upon acts or failures to act attributable, in whole or in part, to the SEBC, its employees or agents. The SEBC is prohibited by law from providing indemnity by contract and therefore, the contract will not provide for indemnity by the SEBC.






7. drop down box

8. drop down box

a. text Text

9. Vendor is bonded. drop down box Listbox,ListYesExempt

a. If not, please explain amount of coverage. text Text

10. Liability insurance covers:

a. Medical management decisions. drop down box

b. Professional malpractice drop down box

c. Provider contracting drop down box

11. text Text

12. drop down box

13. drop down box

By submitting a proposal, the proposing organization agrees than in the event it is awarded a contract, it will indemnify and hold harmless the State of Delaware, its agents and employees, from any and all liability, suits, actions or claims, including any claims or expenses with respect to the resolution of any data security breaches/ or incidents, together with all reasonable costs and expenses (including attorneys’ fees) directly arising out of (A) the negligence or other wrongful conduct of the Contractor, its agents or employees, or (B) Contractor’s breach of this Agreement, provided as to (A) or (B) that (i) Contractor shall have been notified promptly in writing by the State of Delaware of any notice of such claim; and (ii) Contractor shall have control of the defense of any action on such claim and all negotiations for its settlement or compromise.


Vendor has complied with all state insurance department filing requirements for all plans/products being offered in this quote in each state in which the State has employees.

Listbox,ListYNNANoExplain

Comment: Be sure to review the census file submitted with this RFP.

If the answer to the preceding question is "no", for all plans/products quoted in this RFP for which the required state insurance department filing requirements have not been met, please specify the applicable plan/product and corresponding state




Contractor shall provide a written report no later than forty-five (45) days following the close of each quarter which shall describe any judgment or settlement or pending litigation involving Contractor that could result in judgments or settlements in excess of One Hundred Thousand Dollars ($100,000).

If self-funded option is offered, vendor will act as plan fiduciary, if requested.


The vendor selected during this proposal process will be responsible for processing all incurred claims up to the termination date of the contract, regardless of paid date, in the event the contract awarded during this marketing is subsequently terminated. The replacement vendor will have the responsibility pay claims incurred after the termination date of the contact.






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The vendor selected during this proposal process must agree to transfer to the State of Delaware, at no cost to the State, within a mutually agreed time of notice of termination, all required data and records necessary to administer the plan(s)/program(s), subject to state and federal confidentiality considerations. The transfer may be made electronically, in a file format to be determined based on the mutual agreement between the State of Delaware and the vendor.


Vendor agrees to prepare and file all legal documents necessary to implement and maintain the plan, including policies, amendments, contracts, and required state filings, including any additional states that may be required to administer the plan at no cost to the State.


Vendor agrees to provide necessary legal defense in the event of litigation, including all costs inuring thereto.


In performing the services subject to this RFP the organization agrees it will not discriminate against any employee or applicant for employment because of race, creed, color, sex, or national origin. The successful organization will comply with all federal and state laws, regulations, and policies pertaining to the prevention of discriminatory employment practice. Failure to perform under this provision constitutes a material breach of contract.


The State of Delaware reserves the right to terminate the agreement, with or without cause and without termination charges, with 30 days written notice. The State of Delaware will be the only party to have termination for convenience rights. Should the vendor terminate for cause, the State of Delaware will require 180 days written notice.


The RFP and the executed Contract between the State and the successful organization will constitute the Contract between the State and the organization. In the event there is any discrepancy between any of these contract documents, the following order of documents governs so that the former prevails over the latter; Contract and RFP. No other documents will be considered. These documents contain the entire agreement between the State and the organization.


The successful organization warrants that no person or selling agency has been employed or retained to solicit or secure this contract upon an agreement of understanding for a commission or percentage, brokerage or contingent fee excepting bona-fide employees or bona-fide established commercial or selling agencies maintained by the Vendor for the purpose of securing business. For breach or violation of this warranty the State will have the right to annul the contract without liability or its discretion to deduct for the contract price or otherwise recover the full amount of such commission, percentage, brokerage or contingent fee.






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28. The contract will be issued in Delaware. drop down box

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If the scope of agreement of any provision of this Contract is too broad in any respect whatsoever to permit enforcement to its full extent, then such provision will be enforced to the maximum extent by law, and the parties hereto consent and agree that such scope may be judicially modified accordingly and that the whole of such provisions of the contract will not thereby fail, but the scope of such provision will be curtailed only to the extent necessary to conform to the law.


In performance of this contract the organization is required to comply with all applicable federal, state, and local laws, ordinance, codes, and regulations. The cost of permits and other relevant costs required in the performance of the contract will be borne by the successful organization. The Laws of the State of Delaware shall apply, except where the Federal Law has precedence. The successful organization consents to jurisdiction and venue in the State of Delaware.


Do you agree to the terms of the Business Associate Agreement? (See attachment) If no, please provide a redline version.


Do you agree to the terms of the Professional Services Agreement? (See attachment) If no, please provide a redline version.


The vendor understands that in the event that the General Assembly fails to appropriate the specific funds necessary to continue the contractual agreement, in whole or in part, the agreement shall be terminated, as to any obligation of the State requiring the expenditure of money for which no specific appropriation is available, at the end of the last fiscal year for which no appropriation is available or upon the exhaustion of funds.


The vendor must submit a contract (electronically) to the SEBC within 20 days after award and commit to a fully executed agreement prior to the effective date of the contract.


July 01, 2012 is to be the contract effective date or a January 1, 2013 effective date if the SEBC decides to defer implementation.



July 1 will be the first contract anniversary date or January 1 if the SEBC decides to defer implementation.


The vendor agrees not to appoint any agent, general agent, or broker, nor authorize payment of any kind to a party not approved in writing by the State.


We understand that terminology and contract provisions may vary among the involved vendors. We will permit such alternative language provided benefit payment levels are not adversely impacted.


There will be no restrictions or benefit limitations for pre-existing conditions applied to any members enrolled in the plan/program at any time.






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No Loss/No Gain Provision: The insurer must provide coverage on a discontinuance and replacement basis (sometimes referred to as a "no loss/no gain" basis) for eligible employees (and dependents) participating in the current plans on the effective date and to unconditionally provide continuous coverage to all participants enrolled on the program effective date.


Waiver of Actively at Work Provisions: Any participants not actively at work due to disablement on the program effective date will be covered.


You and your subcontracted vendors will comply with all HIPAA, DOI, and DOL regulations, concerning member services, complaints, appeals, timeliness of responses and confidentiality. Any fines related to non-compliance will be your sole responsibility.


You maintain a dedicated individual or staff responsible for resolving HIPAA issues.


Your processes, systems and reporting will be in full compliance with federal and state requirements, and compliant with HIPAA for acceptance of claim transactions in the applicable industry standard NCPDP format. Any fines related to non-compliance will be your sole responsibility.


Vendor agrees that it will honor repayment demands or requests for reimbursement that are made within the 3-year period for Medicare to recover improper payments.


The vendor agrees to comply with the U.S. Department of Labor's final claims procedure regulations, including the appropriate timeframes for adjudicating claims and notice of appeal decisions.


Please confirm that, in the course of its business, the Vendor has not experienced any breaches/data security incidents in the past seven years. If you have, please describe the incident and the steps taken to prevent such a breach or incident in the future.


The vendor agrees to promptly notify the State of Delaware in the event Vendor experiences any breaches/data security incidents during the term of the contract.


The vendor agrees to make internal practices, books, and records relating to the use and disclosure of PHI received from, or created or received by organization available to the United States Secretary of the Department of Health and Human Services for purposes of the United States Secretary of the Department of Health and Human Services determining organization’s compliance with the privacy rules.


The vendor adopts and implements written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose.


The vendor will not use or further disclose protected health information (PHI) other than as permitted or required by the Business Associate Agreement or as required by law.






45.

drop down box

46.

drop down box

47.

drop down box

48.drop down box

49.drop down box

50.

drop down box

51.

drop down box

52.

a. drop down box

b. drop down box

c. drop down box

d. drop down box

XXI. Mental Health/Substance Abuse (MH/SA) Answer Format Format Type Response Explanation

The vendor agrees to use appropriate safeguards to prevent the unauthorized use or disclosure of the PHI. Vendor agrees to report to the plan sponsor any unauthorized use or disclosure of the PHI.


The vendor agrees to mitigate, to the extent practicable, any harmful effect that is known to vendor of a use or disclosure of PHI by vendor in violation of the requirements of the federal privacy rule.


The vendor agrees to ensure that any agent, including a subcontractor, to whom it provides PHI received from, or created or received by the vendor agrees to the same restrictions and conditions that apply to vendor with respect to such information.


The vendor agrees to provide access to PHI in a "designated record set" in order to meet the requirements under 45 CFR §164.524.


The vendor agrees to make any amendment(s) to PHI in a "designated record set" pursuant to 45 CFR §164.526.


The vendor agrees to document such disclosures of PHI and information related to such disclosures as would be required to respond to a request by an individual for an accounting of disclosures of PHI in accordance with 45 CFR §164.528.


The vendor agrees to (i) implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that it creates, receives, maintains, or transmits, (ii) report to the plan sponsor any security incident (within the meaning of 45 CFR § 164.304) of which vendor becomes aware, and (iii) ensure that any vendor employee or agent, including any subcontractor to whom it provides PHI received from, or created or received by the vendor agrees to implement reasonable and appropriate safeguards to protect such PHI.


Vendor certifies that it will comply with the interim final rules on nondiscrimination in the group health market, including:

Vendor certifies that it reports to the national Healthcare Integrity and Protection Databank (HIPDB) as required and, as may be necessary, submits inquiries to the HIPDB to determine whether any final adverse legal actions have been taken against its member providers.


Vendor certifies that, if it conducts Standard Transactions, it is in full compliance with HIPAA's administrative simplification standards relating to electronic data interchange (EDI).


Vendor will not require that enrollment and eligibility information electronically transmitted by Client to Vendor comply with EDI.


Confirm that you will be compliant with interim final rules issued June 30, 2011, implementing Section 1104 of PPACA by the January 1, 2013 deadline. Describe the actions your organization is taking to achieve compliance.






1. text Text

2. text Text

3. text Text

a. text Text

b. The hours of operation text Text

c. The staffing of the service center text Text

XXII. Plan Design Answer Format Format Type Response Explanation

1. drop down box



4. Consumer Directed Healthcare Plans (CDHP)

a. How long has your organization provided CDHPs? text Text

b. number, 0 Number,0

c. number, 0 Number,0

d. text Text

e. text Text

f. percent, 1 Percent,1

g. number, 0 Number,0

h. number, 0 Number,0

i. text Text

j. text Text

Is your MH/SA network owned by your organization, a subsidiary, or do you contract with another MH/SA provider?

If so, confirm that you are able to accept data from an external EAP provider. If not, please explain why this is not part of your service offering.

Is there a separate service center that handles customer service issues relating to MH/SA? If so:

Describe how calls are routed to that center from other call centers

Adhere to the proposed plan designs shown in the worksheets, in preparing the quote.

The proposal is issued in accordance with the specifications, assumptions and information included in this Request for Proposal, the accompanying worksheets and standard services addressed in the Request for Information previously submitted. If "No", indicate deviations in "Explanation" column and/or worksheet.

Listbox,ListYesNoSeeExplain

Review and detail deviations from the proposed plan(s) design shown in the worksheet(s), "Plan Design." Note that deviations due to plan administration limitations will be the only deviations the State will consider as part of this proposal evaluation. Examples of such deviations include: coverage for current benefits only available as a rider versus embedded within the plan design, tracking of visit limits. etc. Please indicate if the deviation is firm, or if it can be accommodated by other means, such as manual intervention.

Identify any features of the current plan which you plan to duplicate which will involve manual processes.

How many employer groups offer CDHPs with HRAs?How many employer groups offer CDHPs with HSAs?List any public sector clients that you offer CDHPs.List any large DE based employers that you offer CDHPs.What is your typical enrollment percentage in CDHPs when offered as a choice?How many covered employees are enrolled in your HRAs?How many covered employees are enrolled in your HSAs?Describe your HRA administrative capabilities and fees.Describe the web-based tools that are available to promote "consumerism"





k. text Text

l. Provide your largest public sector CDHP client. text Text

5. drop down box


XXIII. Financial Requirements Answer Format Format Type Response Explanation

1. Please attach your financial quotation. drop down box Listbox,ListCompleted

2. text Text

3. drop down box Yes,No

4. drop down box


b. If yes, indicate bank name. text Text

XXIV. Medical Delivery System Answer Format Format Type Response Explanation



XXV. Administrative and Operational Issues Answer Format Format Type Response Explanation

1.

a. HMO

Offered/Not Offered? drop down box

Name of Insuring Entity text Text

b. Medicare Supplement


Describe the communication materials that are available to the State to help educate employees about CDHP and HRA/HSA options. Identify any costs associated with these materials.

Confirm that vendor will collaborate with PBM at the request of the State to determine if prescriptions that have historically been processed through the medical plans will be processed through the Rx plan administrator and cooperate with such change should it be determined to be more cost effective.


If applicable, include information on Medicare Advantage plans that would service State retirees and be beneficial for the Group Health Program. Name the file: [Your Organization's Name]_MedicareAdvantage.

Describe the terms and conditions under which you have the right to modify the rates or administrative agreement and/or its fees. If you need more space, please use the "Explanation" column and/or worksheet.

Confirm that vendor will defer the proposal from a 7/1/2012 effective date to a 1/1/2013 effective date if the SEBC decides to defer implementation. Further, confirm that all subsequent renewals and associated rate guarantees are also deferred to the corresponding renewal year based on a calendar year.

The Bidder must accept payments by automated clearing house (ACH).


Use of a specific bank is required for self-insured coverages.

List participating Acute Care Hospitals for the geographic locations as shown for each of the worksheets in the file named "State of Delaware Eligibility Census" on the provided disk.

Provide the number of participating physicians by specialty for the geographic locations shown for each of the worksheets in the file named "State of Delaware Eligibility Census" on the provided disk.

Indicate which conversion plans are offered post-COBRA coverage; if offered, indicate the name of insuring entity.

Listbox,ListNameInsureEntity







c. Port Authority Plan



d. PPO



e. CDHP





XXVI. Performance Benchmarks Answer Format Format Type Response Explanation

1.

a. Service Center #1

Financial Dollar Accuracy was 99% or greater. drop down box Listbox,ListMetNotMet

Procedural Accuracy was 98% or greater. drop down box Listbox,ListMetNotMet

drop down box Listbox,ListMetNotMet


b. Service Center #2





c. Service Center #3








Attach a description of premium or administrative fee billing procedures. Include information on the timing of billing, billing-payment reconciliations and ability to provide for client self-billing. Name the file: [Your Organization's Name]_PremiumBilling.

Vendor agrees to monitor federal and state legislation affecting the delivery of medical benefits under the plan and to report to the State on those issues in a timely fashion prior to the effective date of any mandated plan changes.

Focusing specifically on the claim office(s) that would be used for the State, indicate if performance from July 2010 through July 2011 did or did not meet the specified standards below. If more than three Service Centers proposed, provide requested data in "Explanation" column and/or worksheet.

90% of claims were processed in 10 business days or less.At least 90% of telephone calls to member services were answered within 20 seconds.







XXVII. Officer Answer Format Format Type Response Explanation

1. drop down box Listbox,ListOffWksheet

XXVIII. Other Information Answer Format Format Type Response Explanation

1. drop down box

2. text Text

3. drop down box

4. drop down box






XXIX. References Answer Format Format Type Response Explanation

1.

a. Reference #1Company Name text Text

Contact Person text Text

Title text Text

Phone Number text Text

City, State text Text

E-mail Address text Text

Network Name text Text

Members Enrolled number, 0 Number,0

Vendor's completed proposal contains the form (included in the worksheet, "Officer Certification"), signed by a company officer, attesting to compliance with RFP specifications and the accuracy of all responses.

The State of Delaware is considering changing the plan year start date from 7/1 to 1/1. Please indicate that you will be able to accommodate this change whether in 2013 or at a later date, and identify any impact on fees.


What "value add" programs and services would be available to State enrollees?

Please confirm your commitment to attend and conduct presentations at annual Employee Health Fairs, SEBC meetings, and other meetings as requested. The locations vary statewide and number approximately fifteen per plan year, not to exceed twenty. Fees should be included in the overall price.


You must agree to abide by any exceptions required by the State.


Please provide the following information in electronic format and name the file as specified:

A description of the health plan's conversion plan(s) and associated costs. Name the file: [Your Organization Name]_Conversion Services.

A copy of the health plan's appeal policies, if not specified in the Suggested Employer Contract. Name the file: [Your Organization Name] _Appeal_Policies.

Sample ID Card and description of elements that may be customized. Name the file: [Your Organization Name]_IDCard.

Current member enrollment materials that the health plan feels would be of assistance to the State in evaluating your program. Name the file: [Your Organization Name]_EnrollmentMaterials.

The Bidder will provide Customer Services staff to Senior Centers and Pension Office on a routine schedule when there are significant changes to retiree benefits. The Bidder will advertise these opportunities and provide all members with opportunity to use services.

Please provide three of your largest public sector client references with similar services as outlined in your quote.





b. Reference #2Company Name text Text


Title text Text






c. Reference #3Company Name text Text


Title text Text






2.

Company Name


Title text Text






3.



Title text Text






b. Reference #2Company Name text Text


Title text Text






c. Reference #3

Please provide one of your largest terminated public sector client references with similar services as outlined in your quote.

Please provide three of your Large National Account references of similar size with similar services as outlined in your quote.





Company Name text Text


Title text Text






4.



Title text Text






5. text Text

Please provide one of your terminated Large National Account clients of similar size.

Provide a list of your largest 25 current clients you administer with covered members residing in the State of Delaware. Indicate approximate Delaware membership by Client.

Disease Mgt Questionnaire 71 September 26, 2011

Disease Management Questionnaire

DISEASE MANAGEMENT Answer Format Format Type Response Explanation


Note to Vendor: This is a required section. You are required to bid on Disease Management if bidding on any of the health plans other than the Medicare Supplement plan. This is an optional program that the SEBC may not award effective 7/1/2012.

I.CONTACTS Answer Format Format Type Response Explanation

1.Primary Contact

a.Name text Text

b.Title text Text

c.Address text Text

d.City, State, Zip text Text

e.Phone Number text Text

f.Fax Number text Text

g.E-mail Address text Text

II.VENDOR EXPERIENCE Answer Format Format Type Response Explanation

1.

2. text Text

3.text Text

4.text Text

5. text Text

III.PROGRAM DESCRIPTION Answer Format Format Type Response Explanation

Please indicate the primary contact for this section of your proposal.

Vendors who submit bids for the Health Insurance program or any of the plans other than the Medicare Supplement, must bid on the disease management services on this sheet. Disease management includes the Condition Care Programs and Physician Care Alerts. Wellness services are an optional program and should be bid on the separate sheet. Vendors may use subcontractors for either program.

Comment: You may use the response cells that correlate to each of the questions below to provide your answers. However, you are limited to 100 characters in your response. If your response exceeds the specified character length, please use the worksheet "Disease Management Explanation" to provide your response.

Describe your experience delivering disease management to public entities.

Discuss imminent plans to change your existing disease management services. This should include expansion in scope of current programs.

Discuss your willingness to provide a dedicated disease management account manager who is local to the service area.

List any disease management accreditations such as NCQA or URAC.






1.

text Text

2.

text Text

a.Health plan network providers text Text

b.Utilization Management programs text Text

c.Case management text Text

d.Behavioral Health Care (MH/CD) text Text

e.Wellness text Text

f.EAP text Text

g.PBM text Text

h.Worker’s Compensation text Text

i.Non-Occupational Disability text Text

j.Disability management text Text

3.text Text

4.text Text

5.text Text

6.text Text

7.text Text

8.

text Text

9. text Text

Describe how your disease management programs could be integrated with any wellness program to provide a seamless user experience. Provide an example participant experience for a participant who has a chronic disease.

Describe how your organization collaborates to provide integrated delivery of the programs (e.g., data sharing, coordination of care procedures, warm transfers) with an employer’s other health care initiatives or existing vendors, including but not limited to the following:

Identify the source of the clinical protocols/evidence based guidelines used to guide interventions, the processes for updating them, and who is responsible for updates when protocols are modified.Detail how your programs focus on patient empowerment strategies.

Describe how your programs emphasize prevention of complications.

Do your disease management models account for regional or other medical practice variations? If so, please explain how.

Describe how your program design enhances quality of care, including improvements in health status and clinical outcomes.

Describe the systems in place to provide cross referrals to and from wellness and disease management programs. If not bidding on the wellness programs, your response should assume wellness services will be contracted to another vendor.

Detail how your company supports the physician/patient relationship and plan of care.






10. text Text

IV.SUBCONTRACTOR INFORMATION Answer Format Format Type Response Explanation

1.text Text

Outsourced Service #1 text Text

Outsourced Partner #1 text Text







2.text Text

V.COACHING Answer Format Format Type Response Explanation

1. text Text

2. text Text

3.text Text

4. text Text

5.text Text

6.

text Text

7.text Text

Detail how complaints would be resolved in your proposed disease management programs.

List any of your services that would be subcontracted and the name of the corresponding outsourced partner.

Comment: If none, leave the following section blank.

Describe your willingness to subcontract with local vendors on an as needed basis to provide program components.

How long has your company been providing disease management coaching services?Do your disease management coaches accept in-bound calls and place out-bound calls?

What are your hours of operation and days of operation for member outreach and in-bound calls?

Discuss the role of licensed (clinical) or non-licensed (non-clinical) staff and their training.

If a participant has multiple health risks, how do your disease management coaches prioritize which risks to address first?

Describe how you assign participants to phone-based coaches (e.g. is a participant assigned a primary coach). Also describe how specialized coaches (e.g. dietician) are assigned.

Can your disease management coaches "warm transfer" participants to other program services (e.g. case management, wellness, EAP)?






VI.SERVICES Answer Format Format Type Response Explanation

1.

a.Medical claims drop down box

b.Pharmacy claims drop down box

c.HRA results drop down box

d.Referrals drop down box

e.Other drop down box

2.text Text

3.text Text

4.

a.text Text

b.text Text

c.text Text

5.

a.Asthma number, 0 Number, 0

b.CAD number, 0 Number, 0

c.CHF number, 0 Number, 0

d.COPD number, 0 Number, 0

e.Diabetes number, 0 Number, 0

f.Low Back Pain/Musculoskeletal number, 0 Number, 0

g.Other Diseases number, 0 Number, 0

Individuals are identified for disease management outreach using:






Indicate the frequency of data analysis and identification of potential program participants.

Detail any predictive modeling software is used to identify and risk stratify individuals.

For the active and non-Medicare eligible populations please provide:

Of those identified with the targeted medical condition, % that are successfully contacted.

On average, what % of the targeted population agrees to participate initially.

On average, what % of those who agree to enroll initially, remain enrolled in the program after 12 months.For our non-Medicare eligible population, provide the following enrollment statistics (as of 1/1/2011) for each disease state program that you are proposing for the State.






6.

text Text

7. text Text

8.

drop down box

9.

text Text

10. text Text

11.

text Text

12.Do you have a Gaps in Care patient safety program? text Text

a.For pharmacy gaps? text Text

b.For medical gaps? text Text

c.For preventative screening? text Text

13.text Text

a.text Text

b.text Text

14.text Text

a.text Text

15.What is the frequency of Gaps in Care cycle? text Text

a.

text Text

b.text Text

Please address how your organization would identify members as potential disease management candidates through risk stratification. Please address which risk groups receive telephonic coaching versus mail only (e.g. low risk asthmatic receive mail only versus all asthmatics receive telephonic coaching) and the duration and frequency of telephone contact.

Describe your enrollment model (e.g. opt-in or opt-out) and why it is the best approach.

Is your organization willing to coordinate a disease management program with multiple vendors in instances where an employer offers various health plan options or wants to coordinate disease management with disability management vendors, wellness programs or existing data management relationships?


Describe your experience coordinating your program with value-based benefits (e.g. free diabetic supplies to diabetics participating in disease management) including, but not limited to, the exchange of data.

Describe the role of the medical director in the disease management program.

Describe how you collaborate with treating physicians including the nature and frequency of feedback to physicians on individual participant's progress.

Do you provide compliance/gaps messaging to members?

Is gap messaging available to members in Spanish? Other languages?

What is the delivery method to members for gap communications? Please list (paper based mail, email, phone, etc.).

Do you provide compliance/gaps messaging to physicians?

What is the delivery method to physicians? Please list (paper based mail, email, fax, phone, etc.).

Describe the specific data feeds (medical, Rx, lab, health risk questionnaire, PHR, biometrics, client benefits information, other - please explain) that are supporting Gaps in Care.

Describe future enhancements to data feeds (disability, dental, vision, behavioral health, other - list).






VII.WEB-BASED INTERACTIVE TOOLS Answer Format Format Type Response Explanation

1. drop down box

2.text Text

3.

text Text

4.text Text

5.text Text

VIII.TECHNOLOGY AND DATA EXCHANGE Answer Format Format Type Response Explanation

1.text Text

2. text Text

3.

text Text

4.text Text

5.

text Text

IX.COMMUNICATION Answer Format Format Type Response Explanation

Is a logon and password required for access to web-based tools?


Describe how you keep participants engaged in these types of programs. Also detail how you would increase utilization.

Describe any web-based interactive programming capabilities including the incorporation of readiness to change theory and client customization.

Describe any plans to expand web-based information technology that will be effective within the next 12 months.

Please provide information necessary to access your web site (sufficient to experience the web site like the participants would).

What is the current system platform used to support the delivery of your disease management programs?

Comment: Address the following in your response: tools used to facilitate the delivery of your programs, including data management, program monitoring, tracking and reporting.

Describe your system security protocols and the measures you take to ensure data integrity.

If awarded disease management administration and services as part of this RFP, describe how you would propose extending services to any portion of the population whose medical plan was administered by another third party vendor. This should include the requirements of other third party vendors that are necessary in order for you to have seamless information linkages. The response should address: specific data element groupings, data transfer processes, legal issues, implementation plans and processes and requirements for liaisons from each third party.

Is all data collected for use in your proposed systems maintained only within your company facilities?

Do you utilize third party systems or subcontractors for technical support or to provide core applications and/or programming? If yes, describe how and to what extent.






1.

text Text

2.

drop down box Listbox,ListAttached

3. text Text

4. text Text

5.text Text

X.INCENTIVES Answer Format Format Type Response Explanation

1.

a. Reduced premium contribution drop down box

b. Lower prescription drug co-payments drop down box

c. drop down box

2.

a. Glucometers for diabetics drop down box

b. Peak flow meters for asthmatics drop down box

c. Home blood pressure monitors for hypertensives drop down box

3.

text Text

4.text Text

XI.REPORTING Answer Format Format Type Response Explanation

Provide a description of the standard approach for communicating with the key stakeholders (e.g., Participants, Physicians, Health Professionals, Health Plan, Other Third Party Vendors, Primary Client Contact, etc.) during the delivery of the disease management program(s).

As an attachment, provide samples of the standard communication and health education materials for each of the referenced target audiences above. Name the file: [Your Organization's Name]_Sample DM Communication Materials.

Can the State of Delaware's own "branding" be added to communication materials?Can communication materials be customized? If so, is there an additional cost?

Are the standard communications attached available at no additional cost? If not, detail extra costs.

Are you able and willing to report information on active program participants to the SEBC and the claims payer that permits administration of the following:



Different co-payments/co-insurance for medical services.


Are you able and willing to directly distribute to active program participants equipment such as the following:




Are you able to track individuals by their type of engagement/participation in the program & report this information back to the SEBC for incentive purposes? Please describe the processes/applications used to report this information to the SEBC on at least a monthly basis.

Do you currently offer any vendor sponsored incentive programs for disease management? If so, please give details on the programs.






1.

text Text

2.

text Text

3.

a. Standard Report Names text Text

b. Standard Report Descriptions text Text

c. Standard Report Frequencies text Text

d. Standard Report Format/File Types text Text

4.

a. Coronary artery disease/hypertension

Beta-blocker treatment post-MI drop down box

drop down box

Reduction in rates of myocardial infarction drop down box

drop down box

b. Diabetes

Comprehensive diabetes care drop down box

Improved diet and weight control drop down box

Lowered cholesterol drop down box

Improved quality of life drop down box

Annual retinal exams drop down box

Annual foot exams drop down box

HgbA1c monitoring twice annually drop down box

c. Patient satisfaction drop down box

5.

text Text

6.

text Text

7.

text Text

Please indicate your willingness to provide samples of your organization's standard reports. Each report must reflect data for the client's groups: (1) Total population; (2) Actives; (3) Early Retirees; and (4) at a department/division level if requested.

Attach one sample of all standard reports that would be provided to the SEBC. Name the file: [Your Organization's Name]_Sample DM Reports.

For each report included in the sample reporting package provided, indicate the name of the report, describe the information reported and the frequency of the issuance of the report.

As an example of SEBC reporting, will you track, monitor and report at least annually on the following outcome measures:


Percentage of eligible members on anti-lipemic medication



Admission rate reductions for ischemic heart disease










Describe how you will measure success of the disease management program. Explain how it is similar or different from your company's standard approach to measuring program success.

Cite any evidence of the effectiveness of your disease management programs including the existence of any web-based interactive programming to improve health and impact measured economic outcomes.

Describe your ability to report separately on active and passive engagement in the disease management program(s) as well as the impact each population's engagement upon meeting program goals and objectives to improve health and return on investment.






8.

text Text

XII.PERFORMANCE GUARANTEES Answer Format Format Type Response Explanation

1.

drop down box

2.

drop down box

3. drop down box

4.

a. Health status

drop down box

Performance Guarantees text Text

Percent of Fees at Risk percent, 1 Percent, 1

b. Participant Participation

drop down box



c. Return on investment

drop down box



d. Participant Satisfaction

drop down box



e. Administrative Performance

Describe the biostatistical validity of reported program outcome impact. Be sure to address how your evaluations take into consideration regression to the mean, selection bias, motivation bias, demographic differences, presence or absence of comorbid conditions, etc.

Complete the worksheet “Disease Management Financial_Non-Financial Guarantees Year 1 and Year 2” to describe any guaranteed improvements in health status, clinical outcomes, utilization, member satisfaction, absenteeism, and administrative performance.

Listbox, ListNotCompletedExpl

ain

Complete the worksheet “Disease Management Financial _Non-Financial Guarantees” to describe return on investment (ROI) guarantees. Provide details of how ROI will be calculated. Be sure to address if ROI analysis is based on total claims dollars or is specific to disease-related claims dollars. Describe if you compared an enrolled versus an unenrolled population in the calculation. Describe any case mix adjustment techniques used. Describe how your ROI calculation conforms to the DMAA standards for measuring ROI. All trend, prevalence, and savings assumptions should be clearly delineated.


ain

Offer Performance Guarantees with at least 20% of administrative fees at risk.


It is expected that the selected vendor will place a portion of its fees at risk based upon any or all of the following categories listed below. Please describe the proposed risk arrangement and the methods used in determining performance standards.

Performance Standards (included or excluded from risk arrangement)

Listbox,ListIncludedNAExplain












drop down box



5.drop down box

6.drop down box

XIII.PRICING/FINANCIALS Answer Format Format Type Response Explanation

1.

drop down box

2.drop down box

3.If yes, indicate the length of time. drop down box

4.drop down box Listbox, ListConfirmed

XIV.IMPLEMENTATION AND INTEGRATION Answer Format Format Type Response Explanation

1. drop down box

2.drop down box

3.text Text

a. Please indicate your fees if willing to visit. dollar, 0 Dollar, 0

4. text Text

5.text Text



Confirm that all performance guarantees will be measured on a Plan-specific basis rather than your book of business (BOB).


Confirm that ROI and the performance guarantees will be subject to final negotiation regarding terms, definitions and amounts.


Guided by the census data provided along with this RFP, complete the worksheet “Disease Management Pricing” to propose program pricing. Be sure to address any implementation fees, data exchange fees with wellness vendors or PBMs (initial and any potential ongoing fees), per member/participant fees, reporting fees, data formatting fees, and any other fees that your organization would assess. Provide disease management pricing two ways: PEPM and Per Participating Disease Member Per Month. Please describe who is considered a participant.


ain

Is your organization willing to guarantee the proposed fees for more than a 12-month period of time?


Listbox, ListPropFeeLenTime

Comment: The proposed fees shall remain in effect for your guarantee period, unless vendor stipulates in its proposal an alternative schedule. If vendor wishes to retain the right to modify fees for whatever reason (e.g., enrollment, disease prevalence changes, etc.), all considerations associated with the fee changes must be clearly defined in this proposal. Use the worksheet "Disease Management Pricing" to explain in detail.

Confirm that your proposal reflects the compensation arrangement as requested in the "Disease Management Pricing" worksheet.

What is the minimum lead-time needed to implement a disease management program?

Listbox, ListMinLeadTim

In the worksheet "Disease Management Implementation", include a proposed implementation plan for the client.


ain

Would you be willing to send your staff to visit as many as 10 of the largest client locations to explain the program to employees?


Describe the resources and responsibilities required of SEBC and/or its vendors during the implementation process.






6.

text Text

7.drop down box

Explain how your program coordinates and integrates with SEBC's internal and external resources to achieve optimal program impact. Give specific examples and explain unique program aspects.

Provide a detailed description of the process you will use to monitor and audit implementation of the program.

Listbox,ListProvideNAExplain

DM Pricing 82 September 26, 2011

Disease Management Pricing

[XIII. 1.] Fees/Costs Year 1 Year 2 Additional Year 3 Additional Year 4 Additional Year 5Implementation Fee:Data Exchange Fees:

Party #1Party #2Party #3

Reporting Fees:Reporting Fee #1Reporting Fee #2Reporting Fee #3

Other: Other: SpecifyOther: SpecifyOther: Specify

Year 1

DiabetesCoronary Artery DiseaseHeart Failure

AsthmaBack Pain & OsteoarthritisDyspepsiaOther:

Other: SpecifyOther: SpecifyOther: SpecifyOther: Specify


The proposed fees shall remain in effect for your guarantee period, unless vendor stipulates in its proposal an alternative schedule. If vendor wishes to retain the right to modify fees for whatever reason (e.g., enrollment, disease prevalence changes, etc.), all considerations associated with the fee changes must be clearly defined in this proposal. Use this sheet to explain in detail below the pricing tables.

Data Mapping Fees if Required

Assumed Employees #

Per Employee Per Month Basis

Assumed # Participating

Disease Members

Per Participating Disease Member Per

Month Basis

Chronic Obstructive Pulmonary Disease

DM Pricing 83 September 26, 2011

Disease Management Pricing


The proposed fees shall remain in effect for your guarantee period, unless vendor stipulates in its proposal an alternative schedule. If vendor wishes to retain the right to modify fees for whatever reason (e.g., enrollment, disease prevalence changes, etc.), all considerations associated with the fee changes must be clearly defined in this proposal. Use this sheet to explain in detail below the pricing tables.

Year 2

DiabetesCoronary Artery DiseaseHeart Failure



Year 3 Year 4 Year 5DiabetesCoronary Artery DiseaseHeart Failure



Assumed Employees #

Per Employee Per Month Basis

Assumed # Participating

Disease Members

Per Participating Disease Member Per

Month Basis


Renewal - Additional Years -- Percentage


DM Financial_NonFinancial Guar 84 September 26, 2011

Disease Management Financial and Non-Financial Guarantees

[XII. 2.]


Use the spaces below to describe the information requested. Each cell has been formatted to wrap the text you enter. The row heights should adjust for the amount of text you enter, as well.

Describe any guaranteed improvements in financial outcomes

and return on investment and the amount of the fees at-risk for each year

of the contract. You must include a description of the ROI methodology.

We understand that this will be a preliminary guarantee based upon

demographics.

DM Financial_NonFinancial Guar 85 September 26, 2011

Disease Management Financial and Non-Financial Guarantees


[XII 1.]

Specific Targets Fee at Risk (%)Health Status

Clinical Outcomes

Utilization

Member Satisfaction

Functional/Quality of Life Improvement

Absenteeism

AdministrativeOther: SpecifyOther: SpecifyOther: Specify

Describe any guaranteed improvements in health status, clinical outcomes, utilization, member satisfaction, absenteeism, and administrative performance. Be sure to list the portion of your fees that will be placed at risk for each performance guarantee component for each year of the contract. The State of Delaware reserves the right to renegotiate guarantees after the first 2 years based on actual experience.

DM Implementation 86 September 26, 2011

Disease Management Implementation Plan

Post the Implementation Plan on this worksheet or include as an appendix


Wellness Questionnaire 87 September 26, 2011

Wellness Questionnaire

WELLNESS PROGRAM Answer Format Format Type Response


Note to Vendor: This is an optional section. You are not required to bid on Wellness.

I. CONTACTS Answer Format Format Type Response

1. Primary Contacta. Name text Text

b. Title text Text


e. Phone Number text Text

f. Fax Number text Text

g. E-mail Address text Text

II. VENDOR EXPERIENCE Answer Format Format Type Response1.

2. text Text

3.

text Text

text Text

4.text Text

III. PROGRAM DESCRIPTION Answer Format Format Type Response1.

text Text

2.

text Text

a. Health plan network providers text Text

b. Utilization Management programs text Text

c. Case management text Text

d. Behavioral Health Care (MH/CD) text Text

e. EAP text Text

f. PBM text Text

g. Worker’s Compensation text Text

h. Non-Occupational Disability text Text

i. Disability management text Text

Please indicate the primary contact this section of your proposal.

Vendors who submit bids for any of the Health plans other than the Medicare Supplement, must bid on the disease management services on the separate sheet. Wellness services are an optional program that the SEBC may not award and must be bid on this sheet. Vendors may use subcontractors for either program.

Comment: You may use the response cells that correlate to each of the questions below to provide your answers. However, you are limited to 100 characters in your response. If your response exceeds the specified character length, please use the worksheet "Wellness Explanation" to provide your response.

Describe your experience providing wellness programs to public entities.

Discuss imminent plans to change your existing wellness services. This should include expansion in scope of current programs.

Discuss your willingness to provide a dedicated wellness program account manager who is local to the service area.

List any wellness accreditations such as NCQA or URAC.

Describe how your wellness program could be integrated to provide a seamless user experience. Provide an example participant experience for a participant who is healthy, at risk, and has a chronic disease.

Describe how your organization collaborates to provide integrated delivery of the programs (e.g., data sharing, coordination of care procedures, warm transfers) with an employer’s other health care initiatives or existing vendors, including but not limited to the following:






j. Disease Management text Text

3.

text Text

4. text Text

5. text Text

6.text Text

7.

text Text

8.

text Text

9. text Text

10. text Text

IV. SUBCONTRACTOR INFORMATION Answer Format Format Type Response1.

text Text









2.text Text

V. WELLNESS Answer Format Format Type Response1.

2. text Text

3. text Text

4. text Text

5. text Text

Identify the source of the clinical protocols/evidence based guidelines used to guide interventions, the processes for updating them, and who is responsible for updates when protocols are modified.

Detail how your programs focus on patient empowerment strategies.Describe how your programs emphasize prevention of disease.

Do your wellness management models account for regional or other medical practice variations? If so, please explain how.

Describe how your program design enhances quality of care, including improvements in health status and clinical outcomes.

Describe the systems in place to provide cross referrals to and from wellness and disease management programs. Your response should also include the assumption that disease management will be contracted to another vendor as well.

Detail how your company supports the physician/patient relationship and plan of care.Detail how complaints would be resolved in your proposed wellness programs.

List any of your services that would be subcontracted and the name of the corresponding outsourced partner.

Comment: If none, leave the following section blank.

Describe your willingness to subcontract with local vendors on an as needed basis to provide program components.

Please provide the information requested on each wellness product, program and service that the organization provides. Use the "Wellness_Services" worksheet.

How is your wellness program personalized for the individual user?Is individual use by participants tracked? If so, please describe.Describe the level of customization that is allowed with your wellness programs.Detail your definition for low, moderate and high risk members.






6.

text Text

a.

text Text

b.


VI. HEALTH RISK ASSESSMENTS Answer Format Format Type Response1.

text Text

2.

text Text

3.

text Text

4.text Text

5.

a.

text Text

b.

text Text

6.

text Text

Does your company have the capability and experience to provide onsite health seminars at numerous State of Delaware locations? If a third party is used, provide the partnered vendors' name and describe your experience and relationship with them, how long the agreement has been in place, and provide contact information. Include any certification or licensure held by your partner and have the partner address the following questions:

Please describe the approach you would use to provide seminars at numerous State of Delaware locations to obtain the best level of attendance. Include participant notification approach, registration notification, registration changes and estimated number of seminar topics.

Please provide any health seminar topics, materials, and resources that are available to participants and name the file: [Your Organization's Name]_Wellness Resources.

Provide the name and a copy of the HRA you propose to use. How long has your organization been providing this HRA? Name the file: [Your Organization's Name]_Wellness_Risk Assessment.

Describe how the HRA was developed including the background of people involved, philosophy behind the instrument and validation methodologies and results. Provide citations of any peer reviewed publications if applicable and name the file: [Your Organization's Name]_Wellness_HRA Citations.

Describe how your proposed HRA instrument is offered (online, hard copy, or both)? If paper is available, please describe the process for survey submission and analysis. Describe the quality control procedures with the paper instrument, especially as it pertains to results processing.

For online versions provide a direct link, login, and password that offers full access to view and complete the HRA as part of your proposal.

Give information regarding the types of services provided to respondents for the following:

Summary reports immediately upon completion of the online survey. Describe how the report is personalized and if a "wellness score" or "health age" is provided in the report. If not, is something comparable provided?

Hyperlinks to Intranet or Internet resources as part of their risk reports. Describe the method used for employees to enter the site (e.g. passwords, user names, etc.)

If multiple HRAs are completed by a participant over a defined time period, is there a single report they can view that shows previous and current results? Can HRA results be compared year to year and can that information be accessed by employees?






7.

text Text

8.drop down box

9.

text Text

10.drop down box

VII. BIOMETRIC SCREENINGS Answer Format Format Type Response1.

text Text

2.text Text

3.

text Text

4.text Text

5. text Text

6.

text Text

VIII. COACHING Answer Format Format Type Response1. text Text

2. drop down box

3.text Text

4. text Text

5.text Text

6.

text Text

7.text Text

IX. Answer Format Format Type Response

Can identifiable information and HRA responses for participants at high risk be forwarded to a third party for follow-up? Please describe your procedures for forwarding this information, including policies with regards to confidentiality and privacy.

Provide sample reports and name the file: [Your Organization's Name]_Wellness_HRA Reports.


Describe the capability of your HRA to model the impact of changes on health risk (e.g. "Losing 20lbs will do what to my health risk score?").

Does your HRA have the capability to total all members' health risks into a single aggregate numeric score?


Describe your recommended approach to having participants obtain biometric screenings.

Would you accept biometric information directly from physicians of the participants? If so, describe how this would be done.

Describe your approach to conducting health screening sessions at various worksite locations for the participants. Include information regarding participant notification, scheduling including appointment changes, emergency procedures, staffing, maximum number of recommended participants per session, and costs associated with multiple sites.

Indicate the specific health elements (blood pressure, blood glucose, etc.) recommended in your proposed biometric screenings.

Describe post-event reporting provided to the State and to the individual participant.

Are biometric results automatically populated in a participant's HRA? If so, please explain how long it takes from biometrics completion to HRA population of values.

How long has your company been providing health coaching services?Do your health coaches accept in-bound calls and place out-bound calls?


What are your hours of operation and days of operation for member outreach and in-bound calls?

Discuss the role of licensed (clinical) or non-licensed (non-clinical) staff and their training.

If a participant has multiple health risks, how do your health coaches prioritize which risks to address first?

Describe how you assign participants to phone-based coaches (e.g. is a participant assigned a primary coach). Also describe how specialized coaches (e.g. dietician) are assigned.

Can your health coaches "warm transfer" participants to other program services (e.g. case management, disease management)?

IDENTIFICATION AND COORDINATION OF SERVICES






1.

a. Health risk appraisal (HRA) drop down box

b. Medical claims data (in and outpatient) drop down box

c. Behavioral health claims (MH/CD) drop down box

d. Pharmacy claims drop down box

e. Referrals drop down box

f. Other drop down box

2.text Text

3.text Text

4. text Text

5.text Text

6.

text Text

7.text Text

8.text Text

9. text Text

10.

text Text

11.

text Text

X. Answer Format Format Type Response

1.

text Text

2.

text Text

XI. WEB-BASED INTERACTIVE TOOLS Answer Format Format Type Response

Indicate which of the following methods are used to identify individuals with health risks or conditions:







Describe the utilization of data (claims, pharmacy, other) to maximize participation in wellness programs.

Describe the criteria and/or hierarchy used to stratify members for the various program elements.

Describe your enrollment model (e.g., opt-in or opt-out) and why it is the best approach.

Detail how the program will facilitate access to timely and accurate patient information at the point of care.

Describe how you plan to engage Delaware physicians and other health care providers in the State's wellness programs. Include examples of how you successfully engaged providers in similar programs.

Do you have a medical director in the wellness program, and if so, describe the director's role.

Indicate the frequency of data analysis and identification of potential program participants.

Detail any predictive modeling software that is used to identify and risk stratify individuals.

For the active and non-Medicare eligible populations, can you provide of those identified by low risk, medium risk or high risk, the % that are successfully contacted, the % who agree to participate initially, and the % of those who agree to enroll initially and remain enrolled in the program after 12 months?

Please address how your organization would identify members as potential candidates through risk stratification and describe the types and frequency of program interventions they would be offered based on risk.

WELLNESS PROGRAM COORDINATION SERVICES

Is your organization willing to coordinate with multiple vendors in instances where an employer offers various health plan options or wants to coordinate wellness services with disease management and disability management vendors or existing data management relationships?

Describe your experience coordinating your program with value-based benefits (e.g. free diabetic supplies to diabetics participating in wellness program) including, but not limited to, the exchange of data.






1. drop down box

2.text Text

3.

text Text

4.

text Text

5.text Text

XII. Answer Format Format Type Response

1. text Text

2.text Text

3.

text Text

4.text Text

5.

text Text

XIII. COMMUNICATION Answer Format Format Type Response1.

text Text

2.


3.text Text

Is a logon and password required for access to web-based tools?


Describe how you keep participants engaged in these types of programs. Also detail how you would increase utilization.

Describe any web-based interactive programming capabilities including the incorporation of readiness to change theory and client customization related specifically to the wellness program.

Describe any plans to expand web-based information technology specific to the wellness program that will be effective within the next 12 months.

Please provide information necessary to access your web site (sufficient to experience the web site like the participants would).

TECHNOLOGY AND DATA EXCHANGE - "REQUIRED"What is the current system platform used to support the delivery of your wellness program?

Comment: Address the following in your response: tools used to facilitate the delivery of your programs, including data management, program monitoring, tracking and reporting.

Describe your system security protocols and the measures you take to ensure data integrity.

If awarded the wellness program administration and services as part of this RFP, describe how you would propose extending services to any portion of the population whose medical plan was administered by another third party vendor. This should include the requirements of other third party vendors that are necessary in order for you to have seamless information linkages. The response should address: specific data element groupings, data transfer processes, legal issues, implementation plans and processes and requirements for liaisons from each third party.

Is all data collected for use in your proposed systems maintained only within your company facilities?

Do you utilize third party systems or subcontractors for technical support or to provide core applications and/or programming? If yes, describe how and to what extent.

Provide a description of the standard approach for communicating with the key stakeholders (e.g., Participants, Physicians, Health Professionals, Health Plan, Disease Management Vendor, Other Third Party Vendors, Primary Client Contact, etc.) during the delivery of the wellness program(s).

As an attachment, provide samples of the standard communication and health education materials for each of the referenced target audiences above. Name the file: [Your Organization's Name]_Sample Wellness Communication Materials.

Can the State of Delaware's own "branding" be added to communication materials?






4.text Text

5.text Text

XIV. INCENTIVES Answer Format Format Type Response1.

a. Reduced premium contribution drop down box

b. Lower prescription drug co-payments drop down box

c. drop down box

d. Lump Sum Payments drop down box

2.

a. Pedometers drop down box

b. Glucometers for diabetics drop down box

c. Peak flow meters for asthmatics drop down box

d. Home blood pressure monitors for hypertensives drop down box

3.

text Text

4.text Text

XV. REPORTING Answer Format Format Type Response1.

text Text

2.

drop down box

3.

a. Standard Report Names text Text

b. Standard Report Descriptions text Text

c. Standard Report Frequencies text Text

d. Standard Report Format/File Types text Text

4.

a. Wellness Maintenance drop down box

Can communication materials be customized? If so, is there an additional cost?

Are the standard communications attached available at no additional cost? If not, detail extra costs.

Are you able and willing to report information on active program participants to the SEBC and the claims payer that permits administration of the following:



Different co-payments/co-insurance for medical services.



Are you able and willing to directly distribute to active program participants equipment such as the following:





Are you able to track individuals by their type of engagement/participation in the program by department/division & report this information back to the SEBC for incentive purposes? Please describe the processes/applications used to report this information to the SEBC on at least a monthly basis.

Do you currently offer any vendor sponsored incentive programs for wellness? If so, please give details on the programs.

Please indicate your willingness to provide samples of your organization's standard reports. Each report must reflect data for the client's groups: (1) Total population; (2) Actives; (3) Early Retirees; (4) Spouse and Dependents; and (5) at a department/division level if requested.

Attach one sample of all standard reports that would be provided to the SEBC. Name the file: [Your Organization's Name]_Sample Wellness Reports.

Listbox, ListAttachedNAExplain

For each report included in the sample reporting package provided, indicate the name of the report, describe the information reported and the frequency of the issuance of the report.

As an example of SEBC reporting, will you track, monitor and report at least annually on the following outcome measures:







b. Patient satisfaction drop down box

5.

text Text

6.

text Text

7.

text Text

8.

text Text

XVI. PERFORMANCE GUARANTEES Answer Format Format Type Response1.

drop down box

2.

drop down box

3. text Text

4.

text Text

5.

a. Health status

drop down box



b. Participant Participation

drop down box


Describe how you will measure success of the wellness program. Explain how it is similar or different from your company's standard approach to measuring program success.

Cite any evidence of the effectiveness of your wellness program including the existence of any web-based interactive programming to improve health and impact measured economic outcomes.

Describe your ability to report separately on active and passive engagement in the wellness programs as well as the impact each populations engagement upon meeting program goals and objectives to improve health and return on investment.

Describe the biostatistical validity of reported program outcome impact. Be sure to address how your evaluations take into consideration regression to the mean, selection bias, motivation bias, demographic differences, presence or absence of comorbid conditions, etc.

Complete the worksheets “Wellness Financial _Non-Financial Guarantees Year 1 and Year 2” to describe any guaranteed improvements in health status, clinical outcomes, utilization, member satisfaction, absenteeism, and administrative performance. Be sure to list for each performance guarantee component the portion of your fees that will be placed at risk for Year 1 when no incentives/disincentives will be in place compared to Year 2 when the SEBC plans to provide program incentives/disincentives.


ain

Complete the worksheet “Wellness Financial_Non Financial Guarantees” to describe return on investment (ROI) guarantees. Provide details of how ROI will be calculated. All trend, prevalence, and savings assumptions should be clearly delineated.


ain

Offer Performance Guarantees with at least 20% of administrative fees at risk.

Is it necessary (in your organization's opinion) to utilize HRAs on an employee population every year in order to guarantee ongoing savings?

It is expected that the selected vendor will place a portion of its fees at risk based upon any or all of the following categories listed below. Please describe the proposed risk arrangement and the methods used in determining performance standards.












c. Return on investment

drop down box



d. Participant Satisfaction

drop down box



e. Administrative Performance

drop down box



6.drop down box

7.drop down box

XVII. PRICING/FINANCIALS Answer Format Format Type Response1.

text Text

2.drop down box

3.If yes, indicate the length of time. drop down box

4.drop down box Listbox, ListConfirmed

XVIII. IMPLEMENTATION AND INTEGRATION Answer Format Format Type Response1. text Text

2.drop down box

3.text Text







Confirm that all performance guarantees will be measured on a Plan-specific basis rather than your book of business (BOB).


Confirm that ROI and the performance guarantees will be subject to final negotiation regarding terms, definitions and amounts.


Guided by the census data provided along with this RFP, complete the worksheet “Wellness Pricing” to propose program pricing. Be sure to address any implementation fees, data exchange fees with disease management vendors or PBMs (initial and any potential ongoing fees), per member/participant fees, reporting fees, data formatting fees, and any other fees that your organization would assess. Provide wellness pricing two ways: PEPM and Per Participant Per Month. Please describe the definition of participant.

Is your organization willing to guarantee the proposed fees for more than a 12-month period of time?


Listbox, ListPropFeeLenTime

Comment: The proposed fees shall remain in effect for your guarantee period, unless vendor stipulates in its proposal an alternative schedule. If vendor wishes to retain the right to modify fees for whatever reason (e.g., enrollment, prevalence changes, etc.), all considerations associated with the fee changes must be clearly defined in this proposal. Use the worksheet "Wellness Pricing" to explain in detail.

Confirm that your proposal reflects the compensation arrangement as requested in the "Wellness Pricing" worksheet.

What is the minimum lead-time needed to implement a wellness program?In the worksheet "Wellness Implementation", include a proposed implementation plan for the State of Delaware.


ain

Would you be willing to send your staff to visit the largest client locations to explain the program to employees?






a.dollar, 0 Dollar, 0

4.text Text

5.text Text

6.

text Text

7.drop down box

Confirm that cost or site visits in Question 3 above are included in the PEPM and Per Participant Per Month pricing.


Describe the resources and responsibilities required of SEBC and/or its vendors during the implementation process.

Explain how your program coordinates and integrates with the State's internal and external resources to achieve optimal program impact. Give specific examples and explain unique program aspects.

Provide a detailed description of the process you will use to monitor and audit implementation of the program.



Explanation

Explanation

Explanation

Explanation


Explanation

Explanation

Explanation


Explanation

Explanation


Explanation

Explanation

Explanation

Explanation


Explanation

Explanation

Explanation


Explanation

Explanation


Explanation

Explanation

Explanation


Explanation

Wellness Services WS 107 September 26, 2011

Wellness Services

[V. 1.]

Modes of Delivery Subcontractors Program Components (Provide answers in appropriate box)

Wellness Service

Direct Mail Online Telephone Worksite Sub-Contracted

Back Care

Hypertension

Nutrition

Physical Activity

Smoking Cessation


Please provide the information requested on each wellness product, program and service that the organization provides. Use the chart below.

(Using the drop down box in each cell, indicate if these services are included in the basic package, available for an additional cost or neither included in the basic package or

available for an additional cost)

(Check if subcontracted by entering a "P" in the box and provide name of subcontractor)

Name of Subcontractor

Number of Stages/Levels to

Program

Length of Time to Complete Program

Length of Time Providing Program

Health Risk Assessment

Individualized HRA Response

Biometric Screenings

1-800 Health Information Line

Targeted Behavior Change Programs

Cholesterol Reduction


Wellness Services

[V. 1.]


Wellness Service









Program



Others (Please list)

On-line Newsletter

Promotional Email

Health Challenges

Stress Management

Weight Management

Articles or Other Requested Information via Email

Automatically Generated Emails Based on Pre-Identified Criteria

Live On-Line Interaction (Chat Room)

Health Related Incentive Programs


Wellness Services

[V. 1.]


Wellness Service









Program



Symptom Advisor

Client Specific Resource Referral

Community Resource Referral

Interactive tools such as BMI calculators

On-line Trackers (e.g. for program completion)

Wellness Pricing 110 September 26, 2011

Wellness Pricing

[XVI. 1.] Provide fees for on-site health promotion activities such as health fairs, lunch and learn, and targeted educational sessions.

Worksite Programs Hourly Fee Hourly Fee Hourly Fee

On-site CoachPer attendee not enrolledOther (describe)

Year 1Services (Describe each service provided) Set-up Fees Total Annual Cost Set-up Fees

Online Services:HRAHealth EducationBehavior Change Modules

Employee Customer Service Toll Free #80024 Hour Access to Registered NurseHRA Questionnaire:

PaperOnline

HRA Individual Results:PaperOnline

Mailing Costs:QuestionnaireResults

Communication and Promotion Materials:

StandardCustomized

Management Report(s)Other (describe)


The proposed fees shall remain in effect for your guarantee period, unless vendor stipulates in its proposal an alternative schedule. If vendor wishes to retain the right to modify fees for whatever reason (e.g., enrollment, prevalence changes, etc.), all considerations associated with the fee changes must be clearly defined in this proposal. Use this sheet to explain in detail below the pricing tables.

Year 1 - Annual Cost (Please identify how

you develop this number)

Year 2 - Annual Cost (Please

identify how you develop this

number)

Additional Year Annual Cost

Assumed # of Employees

Per Employee Per Month Pricing

Assumed # of Participants

Per Participant Per Month

Pricing

Total Annual Cost

Health Risk Assessment and Online Services


Wellness Pricing




Telephonic Lifestyle Coaching

Mailing Costs

Management Reports


StandardCustomizedOther (describe)

Client Management ReportingAccount ManagementIT/ISCustom CommunicationsCustom ReportsIncidentals:

Travel ExpensesExpress mailOther (describe)

Implementation FeesImplementation Fees

Year 2Services (Describe each service provided)



PaperOnline




Individual Targeted Lifestyle Modification Programs

Mail-Based Health Management Interventions

Assumed # of Employees

Per Employee Per Month Pricing

Total Annual Cost

Assumed # of Participants

Per Participant Per Month

Pricing

Total Annual Cost



Wellness Pricing




StandardCustomized



Wellness Pricing





Mailing Costs

Management Reports





Implementation CreditImplementation Credit

Renewal - Additional YearServices (Percent increase) Year 3 Year 4 Year 5



PaperOnline




StandardCustomized






Wellness Pricing





Mailing Costs

Management Reports





Implementation CreditImplementation Credit



Wellness Financial NonFin Guar. 115 September 26, 2011

Wellness Financial and Non-Financial Guarantees

[XVI. 2.]



Describe any guaranteed improvements in financial outcomes and return on investment and the amount of the fees at-risk for each year of the

contract. You must include a description of the ROI methodology. We understand that this will be

a preliminary guarantee based upon demographics.





[XVI. 1.]

Specific Targets Fee at Risk (%)Health Status

Clinical Outcomes

Utilization

Member Satisfaction

Functional/Quality of Life Improvement

Absenteeism

AdministrativeOther: SpecifyOther: Specify

Describe any guaranteed improvements in health status, clinical outcomes, utilization, member satisfaction, absenteeism, and administrative performance. Be sure to list the portion of your fees that will be placed at risk for each performance guarantee component for each year of the contract. The State of Delaware reserves the right to renegotiate performance guarantees after the first 2 years based on actual performance.





Other: Specify

Wellness Implementation 118 September 26, 2011

Wellness Implementation Plan

Post the Implementation Plan on this worksheet or include as an appendix


GEO Access HMO 119 September 26, 2011

Geo Access HMO

Practice Specialty

2 8 15 25

Specialists (excluding OB/GYN) 1 30 35 45Pediatricians 2 8 15 25Obstetricians/Gynecologists 2 8 15 25

Acute Care Hospitals 1 10 15 25

Mental Health Providers 1 30 35 45

Psychiatric Hospitals 1 30 35 45

Zip Code Employees Matched Employees Not MatchedNumber Percent Number Percent


Number of Providers Available

Miles from Employees Residence

Urban

Miles from Employees Residence Suburban


Rural

Adult Physicians (Family Practice, General Practice, General Internal Medicine)

Provide the following report format for each type of provider listed in RFP (Adult Physicians, Pediatricians, OB/GYN and Hospitals):

Average Distance to Providers

Total Number of Employees

GEO Access PPO_CDHP 120 September 26, 2011

Geo Access PPO/CDHP

Practice Specialty

2 8 15 25

Specialists (excluding OB/GYN) 1 30 35 45Pediatricians 2 8 15 25Obstetricians/Gynecologists 2 8 15 25

Acute Care Hospitals 1 10 15 25

Mental Health Providers 1 30 35 45

Psychiatric Hospitals 1 30 35 45





Urban



Rural





GEO Access Medicare 121 September 26, 2011

Geo Access Medicare

Please complete this exhibit only if your organization is bidding on a network based Medicare product.

Practice Specialty

2 8 15 25

Specialists (excluding OB/GYN) 1 30 35 45

Pediatricians 2 8 15 25Obstetricians/Gynecologists 2 8 15 25Acute Care Hospitals 1 10 15 25Mental Health Providers 1 30 35 45Psychiatric Hospitals 1 30 35 45





Urban



Rural





GEO Access Medicare 122 September 26, 2011

Financial Exhibit 123 September 26, 2011

Medical Enrollment AssumptionsRating Tiers PPO HMO CDHP

Employee Only

Employee & Spouse

Employee & Child(ren)

Family

<Total>

Financial Quotation Proposed Program Costs (Fees and Claims)All quotes must be on a mature basis, whereby the Bidder accepts responsibility to process runout claims in the event of termination at no

additional cost to State of Delaware

Reminder: PPO is the collective term for the PPO, First State Basic and Port Authority plans.

Fees are effective for the initial two year contract term, 7/1/2012 - 6/30/2014

Fees Per Employee Per Month Enrollment Under 7,500 Subscribers Enrollment 7,500 - 14,999 Subscribers Enrollment 15,000 - 29,999 Subscribers Enrollment 30,000 - 44,999 Subscribers Enrollment 45,000+ Subscribers

PPO CDHP HMO PPO CDHP HMO PPO CDHP HMO PPO CDHP HMO PPO CDHP HMO

Proposed PEPM Fee

Claim Administration

HRA administration NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Utilization Review Fees

Network Access Fees

Account Management

Actuarial Services

Underwriting

MHSA Claims Administration

Claims Fiduciary

Standard Reports

Specific Reports

Reporting

Large Case Management

Paper EOBs

Banking charges

ID cards (printing and mailing)

COB Administration

Other

Other


Medicare Supplement

Fees are to be based on final enrollment within your plan offerings in aggregate (not plan by plan).

Medicare Supplement

Medicare Supplement

Medicare Supplement

Medicare Supplement

Medicare Supplement

Confirm the following are included in your proposed fees:

Eligibility maintenance and support, including manual updates as needed

Dedicated implementation team and supportPlan design set-up and maintenance

Dedicated Customer Service Team and Toll-Free number

MHSA Network and Non-Claims Administration

800 Telephone Links (installation and usage)

Initial cards at time of enrollment

Replacement cards at employee request

Financial Exhibit 124 September 26, 2011

Medical Enrollment AssumptionsRating Tiers PPO HMO CDHP

Employee Only

Employee & Spouse

Employee & Child(ren)

Family

<Total>


Medicare Supplement

Rate Guarantees

Plan Year

Third Year Rate Guarantee 7/1/2014 - 6/30/2015

Fourth Year Rate Guarantee 7/1/2015 - 6/30/2016

Fifth Year Rate Guarantee 7/1/2016 - 6/30/2017

Additional Allowances/Credits

Plan Year

First Year 7/1/2012-6/30/2013Second Year 7/1/2013-6/30/2014Third Year Rate 7/1/2014 - 6/30/2015Fourth Year Rate 7/1/2015 - 6/30/2016Fifth Year Rate 7/1/2016 - 6/30/2017

Claims Assumptions Per Employee Per Month

Expected Paid Claims Excluding Capitations - Vendor Provided

Capitation Amounts (if applicable)

Fee Cap (% increase from prior year)

Implementation Allowance

Communication Allowance

Pre-implementation Audit Allowance

Plan Design(1) - HMO 125 September 26, 2011

HMO

TYPE OF SERVICE Current Aetna HMO Current BCBS HMO

DELIVERY OF SERVICESDeductible/Calendar Year None NoneOut-of-pocket limit None NonePrimary Care office visit $10 copay per visit $10 copay per visitSpecialist office visit $20 copay per visit $20 copay per visitPREVENTIVE MEDICALPeriodic Physical Exams $10 copay per visit $10 copay per visitWell-child checkups (to 19) $10 copay per visit $10 copay per visitRoutine vision exams

Hearing Exam

Routine immunizations $10 copay per visit $10 copay per visitDiabetes Education 100% covered

Routine Gynecological Exams

Routine Mammogram $15 copay per visit $15 copay per visitTREATMENT OF ILLNESS/INJURYOutpatient Surgery - Ambulatory Center $30 copay $30 copayOutpatient Surgery - Doctor's Office Visit $20 copay $20 copayOutpatient Surgery - Hospital $75 copay $75 copayInpatient Room & Board

Inpatient Physicians' and Surgeons' Services 100% 100%Allergy Testing $20 copay per visit $20 copay per visitAllergy Treatment $5 copay per visit $5 copay per visitEMERGENCY SERVICESEmergency Room

Ambulance $50 copay per trip $50 copay per tripUrgent Care $20 copay $20 copayOTHER SERVICESHospice 100% up to 365 days 100% up to 365 daysHome Health Care

Skilled Nursing Facility 100% 100%Durable Medical Equipment 80%

MATERNITY SERVICESPrenatal and postpartum care


ADMINISTRATIVE PLAN DEVIATIONS

100% after $15 copay (one exam every 24 months)

100% after $15 copay (one exam every 24 months)

By specialist/audiologist, $20 copay.

By PCP as part of a routine physical, 100% covered. By

specialist/audiologist, $20 copay.

$20 copay for each unit for up to six in three years

Exam: $10 copay / Pap smear: $5 copay

Exam: $10 copay / Pap smear: $5 copay

$100 copay/day with max of $200/admission

$100 copay/day with max of $200/admission

$135 copay per visit (waived if admitted)

$135 copay per visit (waived if admitted)

100% for up to 240 visits per plan year

100% for up to 240 visits per plan year

80%; limited to $5,000 per member per plan year

100% after $20 initial copay (inpatient room and board

copays do apply to hospital deliveries/birthing centers)

100% after $20 initial copay (inpatient room and board

copays do apply to hospital deliveries/birthing centers)

Plan Design(1) - HMO 126 September 26, 2011

HMO

TYPE OF SERVICE Current Aetna HMO Current BCBS HMO



Delivery 100% 100%

DIAGNOSTIC AND THERAPEUTIC SERVICESX-Ray $15 copay per visit $15 copay per visitLaboratory $5 copay per visit $5 copay per visitMRI, CAT, and PET Scans $25 copay per visit $25 copay per visitPhysical Therapy

Speech and Occupation Therapy80% for 60 consecutive days

Chiropractic Care

Inpatient

Outpatient $20 copay per visit $10 copay per visit

Infertility treatment * Note: For IVF "Grandfathered" members retain a lifetime maximum of $30,000 for combined medical and prescription services.

75% covered;$10,000 lifetime maximum for

medical services, $15,000 lifetime maximum for prescription services

75% covered;$10,000 lifetime maximum for medical

services, $15,000 lifetime maximum for prescription

services

80% for 45 visits per condition



Lesser of either PCP copay or 80% of the allowable

charges

Lesser of either PCP copay or 80% of the allowable

charges for up to 60 days per condition

MENTAL HEALTH (as defined by Delaware Code Title 18, Chapter 33, Section 3343 and Substance Abuse Care)

$100 copay per day; $200 copay maximum per

admission

$100 copay per day; $200 copay maximum per

admission

Plan Design(2) - PPO 127 September 26, 2011

PPO

First State Basic Plan (BCBSD) Comprehensive PPO (BCBSD) BCBSDE (Port Authority)TYPE OF SERVICE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK IN-NETWORK

DELIVERY OF SERVICESDEDUCTIBLE None None

None

Primary Care office visit 90% after deductible 70% after deductible $15 copay 80% after deductible $10 copayment Not coveredSpecialist office visit 90% after deductible 70% after deductible $25 copay 80% after deductible 90% covered 70% coveredPREVENTIVE MEDICALPeriodic Physical Exams 100% after $15 copay 80% after deductible $10 copayment Not covered

80% after deductible $10 copayment Not covered

Vision Care Not covered Not covered Not covered Not covered $10 copayment Not coveredHearing Tests 80% after deductible $10 copayment Not covered

Hearing Aids 100%, under age 24 Not Covered Not covered

Routine immunizations 100% after $15 copay 80% after deductible $10 copayment Not covered

Routine Mammogram $15 copay per visit 80% after deductible 100% covered 70% covered

TREATMENT OF ILLNESS/INJURY

Outpatient Surgery 90% after deductible 70% after deductible 100% 80% after deductible 90% covered 70% coveredAllergy Testing and Treatment 90% after deductible 70% after deductible 80% after deductible 70% covered

X-Ray 90% after deductible 70% after deductible $15 copay per visit 80% after deductible 90% covered 70% coveredLaboratory 90% after deductible 70% after deductible $5 copay per visit 80% after deductible 100% covered 70% covered

90% after deductible 70% after deductible $15 copay per visit 80% after deductible 90% covered 70% covered

90% after deductible 70% after deductible 85% 80% after deductible

Chiropractic Care

Urgent Care 100% after $25 copay 100% after $25 copay $25 copay 80% after deductible 100% covered

HOSPITAL CAREInpatient Room & Board 90% after deductible 70% after deductible 80% after deductible 90% covered 70% covered

90% after deductible 70% after deductible 100% 80% after deductible 90% covered 70% covered

Emergency Room Visit 90% after deductible 90% after deductible

Emergency Ambulance 90% after deductible 70% after deductible 100% 100%, no deductible

MATERNITY SERVICESPrenatal and Postpartum care 90% after deductible 70% after deductible 80% after deductible 90% covered 70% covered



OUT-OF-NETWORK

OUT-OF-NETWORK

$500 Individual, $1,000 Family

$1,000 Individual, $2,000 Family

$300 Individual, $600 Family

$300 Individual, $900 Family

ANNUAL OUT OF POCKET MAXIMUM




$500 Individual, $1,500 Family

$1,500 Individual,

$4,500 Family

100% covered, no deductible


Routine Gynecological, Pap Smears (one per year)



Exam: $15 copay Pap Smear: $5 copay



100% after office visit copay

90% after deductible, under age 24





100% covered; no deductible


Testing: $25 copay Treatment: $5 copay

Testing : 90% covered

Treatment : PCP - $10 copay per visit; Specialist - 90% covered per

visit

MRI's, CT Scans, PET Scans, and Other Diagnostic ServicesShort-Term Therapies: Physical, Speech, Occupational

90% covered from first day of treatment up to

60 days

70% covered from first day of treatment up to

60 days

90% after deductible for up to 30 visits per

plan year


plan year

85% covered, up to 30 visits per plan year

80% after deductible, 30 visits per plan year

90% covered, up to 30 visits per

year


year100% covered, no deductible

$100 copay with max of $200/admission

Inpatient Physicians' and Surgeons' Services

$125 copay (waived if admitted)

$125 copay (waived if admitted)

$50 copayment per visit (waived

if admitted)

$50 copayment per visit (waived

if admitted)$25 copayment per occurrence

$25 copayment per occurrence

100% (inpatient room and board copays do

apply to hospital deliveries/birthing

centers)

Plan Design(2) - PPO 128 September 26, 2011

PPO

First State Basic Plan (BCBSD) Comprehensive PPO (BCBSD) BCBSDE (Port Authority)TYPE OF SERVICE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK IN-NETWORK



OUT-OF-NETWORK

OUT-OF-NETWORK

Delivery 90% after deductible 70% after deductible 100% 80% after deductible 90% covered 70% covered

OTHER SERVICESHospice 100% up to 365 days

Home Care Services 100%

Durable Medical Equipment 90% after deductible 70% after deductible 100% 80% after deductible 90% covered 70% coveredSkilled Nursing Facility

Inpatient 90% after deductible 70% after deductible 80% after deductible 90% covered Not covered

Outpatient 90% after deductible 70% after deductible 100% after $15 copay 80% after deductible Not covered


75% after deductible; $10,000 lifetime

maximum for medical services, 75% after deductible, $15,000 lifetime maximum for prescription services




maximum for medical services, $15,000

lifetime maximum for prescription services



75% covered; $10,000 lifetime

maximum for medical services; $15,000 lifetime

maximum for prescription

services

55% covered; $10,000 lifetime

maximum for medical services; $15,000 lifetime

maximum for prescription

services

90% after deductible for up to 365 days

70% after deductible for up to 365 days

80% after deductible up to 365 days

90% covered, up to 365 days

70% covered, up to 365 days

90% after deductible for up to 240 plan

days per year

70% after deductible for up to 240 days per

plan year


plan year


plan year


plan year

90% for up to 120 days per confinement

70% for up to 120 days per confinement

100% up to 120 days per confinement

80% after deductible up to 120 days per

confinement

90% covered, up to 120 days per

plan year

70% covered, up to 120 days per

plan yearMENTAL HEALTH (as defined by Delaware Code Title 18, Chapter 33, Section 3343 and Substance Abuse Care)

$100 copay with max of $200/admission

$5 copayment per office visit

Plan Design(3) - CDHP 129 September 26, 2011

CDHP

Aetna CDH Gold Plan BCBSD CDH Gold PlanTYPE OF SERVICE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK

DELIVERY OF SERVICES

DEDUCTIBLE

COINSURANCE 90% 70% 90% 70%

Primary Care office visit 90% after deductible 70% after deductible 90% after deductible 70% after deductibleSpecialist office visit 90% after deductible 70% after deductible 90% after deductible 70% after deductiblePREVENTIVE MEDICALRoutine Physical Exams 100%, no deductible 70% after deductible 100%, no deductible 70% after deductible

100%, no deductible 100%, no deductible 70% after deductible

Vision Care Not covered Not covered Not covered Not coveredHearing Tests

Hearing Aids

Routine immunizations 100%, no deductible 70% after deductible 100%, no deductible 70% after deductibleRoutine Mammogram 100% covered 70% covered 100% covered 70% coveredTREATMENT OF ILLNESS/INJURY

Outpatient Surgery 90% after deductible 70% after deductible 90% after deductible 70% after deductibleAllergy Testing and Treatment 90% after deductible 70% after deductible 90% after deductible 70% after deductibleX-Ray 90% after deductible 70% after deductible 90% after deductible 70% after deductibleLaboratory 90% after deductible 70% after deductible 90% after deductible 70% after deductible

90% after deductible 70% after deductible 90% after deductible 70% after deductible


Chiropractic Care

Urgent Care 90% after deductible 70% after deductible 90% after deductible 70% after deductibleHOSPITAL CAREInpatient Room & Board 90% after deductible 70% after deductible 90% after deductible 70% after deductible


Emergency Room Visit 90% after deductible 90% after deductible 90% after deductible 90% after deductibleEmergency Ambulance 90% after deductible 70% after deductible 90% after deductible 70% after deductibleMATERNITY SERVICESPrenatal and Postpartum care 90% after deductible 70% after deductible 90% after deductible 70% after deductibleDelivery 90% after deductible 70% after deductible 90% after deductible 70% after deductible



OUT-OF-NETWORK

HEALTH REIMBURSEMENT ACCOUNT (HRA)

$1,250 Employee/$2,500

Family

$1,250 Employee/$2,500

Family

$1,250 Employee/$2,500

Family

$1,250 Employee/$2,500

Family$1,500 Single/$3,000




Family

ANNUAL OUT OF POCKET MAXIMUM

$3,000 Single/$6,000 Family




Routine Gynecological, Pap Smears (one per year)

70% covered, after deductible




70% covered after deductible





MRI's, CT Scans, PET Scans, and Other Diagnostic ServicesShort-Term Therapies: Physical, Speech, Occupational


plan year


plan year


plan year


plan year

Inpatient Physicians' and Surgeons' Services

Plan Design(3) - CDHP 130 September 26, 2011

CDHP

Aetna CDH Gold Plan BCBSD CDH Gold PlanTYPE OF SERVICE IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK



OUT-OF-NETWORK

OTHER SERVICESHospice 90% after deductible 70% after deductible 90% after deductible 70% after deductibleHome Care Services

Durable Medical Equipment 90% after deductible 70% after deductible 90% after deductible 70% after deductibleSkilled Nursing Facility

Inpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductibleOutpatient 90% after deductible 70% after deductible 90% after deductible 70% after deductible


75% covered, $10,000 lifetime













plan year


plan year


plan year


plan year


confinement


confinement


confinement


confinementMENTAL HEALTH (as defined by Delaware Code Title 18, Chapter 33, Section 3343 and Substance Abuse Care)

Plan Design(4) - Medicare Suppl 131 September 26, 2011

Medicare Supplement

TYPE OF SERVICE ADMINISTRATIVE PLAN DEVIATIONS


Current Medicfill Medicare Supplement Plan

INPATIENT HOSPITALDays 1-60 Covers the Part A deductibleDays 61-90

Days 91-120

Days 121-365

EMERGENCY SERVICESEmergency Services

Emergency Ambulance

PREVENTIVE MEDICALPhysician Home & Office Visits

Routine Gyn Exam, Pap Smear

Routine Mammogram

Prostate Cancer Screening Exams (age 50 & over)

Periodic Physical Exams

Covers the specified dollar amount of the coinsurance

Covers care in a general hospital (except mental & nervous). These

days may be used before Medicare's 60 lifetime reserve days.

Covers coinsurance amount

Covers care in a general hospital (except mental & nervous). These

days may be used before Medicare's 60 lifetime reserve days.

Covers coinsurance amount

Covers Part B deductible and 20% of the reasonable charges



When Medicare pays, balance up to 100% of allowable charge. When

Medicare does not pay, 100% of the allowable charge when preventive

benefits are done according to frequency and age.










Plan Design(4) - Medicare Suppl 132 September 26, 2011

Medicare Supplement

TYPE OF SERVICE ADMINISTRATIVE PLAN DEVIATIONS


Current Medicfill Medicare Supplement Plan

Pneumococcal Pneumonia Vaccine

Flu Vaccine

Routine Vision Care Not coveredDIAGNOSTIC AND THERAPEUTIC SERVICES

Specialist Care/Chiropractic Care

OTHER SERVICESProsthetics & Durable Medical Equipment

Hospice

Pneumonia - once at age 65 and up. When Medicare pays, balance

up to 100% of allowable charge. When Medicare does not pay, 100%

of the allowable charge when preventive benefits are done

according to frequency and age.

Once per calendar year for age 65 and over. When Medicare pays, balance up to 100% of allowable

charge. When Medicare does not pay, 100% of the allowable charge when preventive benefits are done according to frequency and age.

Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech Therapy)


X-ray, Lab, Radiation Therapy, and other Diagnostic Services




Balances paid up to the Medicare reasonable charge

Explanation_Minimum Qual. 133 September 26, 2011

Explanation Minimum Qualifications

This worksheet should be used to provide additional explanations for any questions for which a "See Explanation" response was given. Explanations must be numbered to correspond to the question to which they pertain and they must be brief.

State the number of questions you addressed with further explanation:

Worksheet/Section/Question # Question and Explanation


Explanation_Minimum Qual. 134 September 26, 2011

Explanation Minimum Qualifications



Worksheet/Section/Question # Question and Explanation


Explanation_Questionnaire 135 September 26, 2011

Explanation Questionnaire



Worksheet/Section/ Question # Question and Explanation


Explanation_Questionnaire 136 September 26, 2011

Explanation Questionnaire





Explanation_Disease Management 137 September 26, 2011

Explanation Disease Management





Explanation_Disease Management 138 September 26, 2011

Explanation Disease Management





Explanation_Wellness 139 September 26, 2011

Explanation Wellness





Explanation_Wellness 140 September 26, 2011

Explanation Wellness





fmNumPlan 3fmPlanType HMO/PPO/POSfmPlanTypePhrase

fmPlanNamePhrase HMO, PPO and POS

fmSingleProduct 0fmMultiProduct 1fmSingleSIOnly 1fmSingleFullOnly 0fmSingleCombo 0fmMultiSIOnly 0fmMultiFullOnly 0fmMultiCombo 0fmSIOnly 1fmFullOnlY 0fmSingle 1fmMultiple 0fmHMO 1fmSIHMO 1fmFullHMO 0fmPPO 1fmSIPPO 1fmFullPPO 0fmPOS 1fmSIPOS 1fmFullPOS 0fmMFullHMO 0fmSFullHMO 0fmMSIHMO 0fmSSIHMO 1fmMFullPPO 0fmSFullPPO 0fmMSIPPO 0fmSSIPPO 1fmMFullPOS 0fmSFullPOS 0fmMSIPOS 0fmSSIPOS 1

Single Location: SI HMO, SI PPO, SI POS

Officer Certification 142 September 26, 2011

Officer Certification

Please have an Officer review and sign this worksheet to confirm the information is valid.Please include the completed form with your proposal.

OFFICER'S STATEMENTMedical Vendor Legal NameMedical Vendor Marketing NameStreet AddressCityStateZipPhone NumberFax NumberWeb AddressName of Officer completing statementTitle of Officer completing statementPhone Number of Officer completing statementEmail Address of Officer completing statement

Officer's Signature

Date Signed


I certify that our response to the State of Delaware's RFP (Request for Proposal) is complete and accurate to the best of my knowledge and contains no material omissions or misstatements. I acknowledge that the State of Delaware will rely upon the information included in our response to make decisions concerning the medical services that are offered to their employees.

[XLS]Medical RFP - Delawarebidcondocs.delaware.gov/OMB/OMB_11003HealthIns.xls · Web viewProvide...

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Transcript of [XLS]Medical RFP - Delawarebidcondocs.delaware.gov/OMB/OMB_11003HealthIns.xls · Web viewProvide...