Loading...
HomeMy WebLinkAboutRFP - P985 BENEFITS1 REQUEST FOR PROPOSAL CITY OF FORT COLLINS Proposal Number P985 Benefits The City of Fort Collins is seeking proposals from firms reflecting fees for providing a Preferred Provider Organization (PPO) network, Point-of Service (POS) network, Exclusive Provider Organization (EPO) network, third party administration services, utilization review services, stop loss insurance, transplant insurance and prescription drug coverage. Single service as well as multiple service providers are encouraged to respond. Proposers may be on one or multiple services. The City currently provides all eligible employees and their dependents medical benefits on a self-funded basis. Prescription drug coverage is provided to employees and their dependents through a carve-out card program. Proposals are being solicited by the City to obtain the most competitive benefits for its employees and their eligible dependents. Current plan designs are to be replicated. Plan documents are available upon request. Written proposals, six (6) will be received at the City of Fort Collins' Purchasing Division, 215 North Mason St., 2nd floor, Fort Collins, Colorado 80524. Proposals will be received before 2:00 p.m. (our clock), April 22, 2005. Proposal No 985. If delivered, they are to be sent to 215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80524. If mailed, the address is P.O. Box 580, Fort Collins, 80522-0580. Questions concerning the scope of the project should be directed to Katey Tarkington, Benefits Administrator, (970) 221-6828. Questions regarding proposals submittal or process should be directed to David Carey, C.P.M., Buyer, (970) 416-2191. Sales Prohibited/Conflict of Interest: No officer, employee, or member of City Council, shall have a financial interest in the sale to the City of any real or personal property, equipment, material, supplies or services where such officer or employee exercises directly or indirectly any decision- making authority concerning such sale or any supervisory authority over the services to be rendered. This rule also applies to subcontracts with the City. Soliciting or accepting any gift, gratuity favor, entertainment, kickback or any items of monetary value from any person who has or is seeking to do business with the City of Fort Collins is prohibited. Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be rejected and reported to authorities as such. Your authorized signature of this proposal assures that such proposal is genuine and is not a collusive or sham proposal. The City of Fort Collins reserves the right to reject any and all proposals and to waive any irregularities or informalities. Sincerely, James B. O'Neill II, CPPO, FNIGP Director of Purchasing & Risk Management CITY OF FORT COLLINS REQUEST FOR PROPOSAL P985 BENEFITS PROPOSAL DATE: 2:00 p.m. (our clock) APRIL 22, 2005 1 REQUEST FOR PROPOSAL CITY OF FORT COLLINS Proposal Number P985 Benefits The City of Fort Collins is seeking proposals from firms reflecting fees for providing a Preferred Provider Organization (PPO) network, Point-of Service (POS) network, Exclusive Provider Organization (EPO) network, third party administration services, utilization review services, stop loss insurance, transplant insurance and prescription drug coverage. Single service as well as multiple service providers are encouraged to respond. Proposers may be on one or multiple services. The City currently provides all eligible employees and their dependents medical benefits on a self-funded basis. Prescription drug coverage is provided to employees and their dependents through a carve-out card program. Proposals are being solicited by the City to obtain the most competitive benefits for its employees and their eligible dependents. Current plan designs are to be replicated. Plan documents are available upon request. Written proposals, six (6) will be received at the City of Fort Collins' Purchasing Division, 215 North Mason St., 2nd floor, Fort Collins, Colorado 80524. Proposals will be received before 2:00 p.m. (our clock), April 22, 2005. Proposal No 985. If delivered, they are to be sent to 215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80524. If mailed, the address is P.O. Box 580, Fort Collins, 80522-0580. Questions concerning the scope of the project should be directed to Katey Tarkington, Benefits Administrator, (970) 221-6828. Questions regarding proposals submittal or process should be directed to David Carey, C.P.M., Buyer, (970) 416-2191. Sales Prohibited/Conflict of Interest: No officer, employee, or member of City Council, shall have a financial interest in the sale to the City of any real or personal property, equipment, material, supplies or services where such officer or employee exercises directly or indirectly any decision- making authority concerning such sale or any supervisory authority over the services to be rendered. This rule also applies to subcontracts with the City. Soliciting or accepting any gift, gratuity favor, entertainment, kickback or any items of monetary value from any person who has or is seeking to do business with the City of Fort Collins is prohibited. Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be rejected and reported to authorities as such. Your authorized signature of this proposal assures that such proposal is genuine and is not a collusive or sham proposal. The City of Fort Collins reserves the right to reject any and all proposals and to waive any irregularities or informalities. Sincerely, James B. O'Neill II, CPPO, FNIGP Director of Purchasing & Risk Management 2 TABLE OF CONTENTS Business Associate Agreement – Security Standards .............................................. 3 I. Background......................................................................................................... 4 II. Health Care Objectives and Proposal Evaluation Criteria ............................. 4 III. Proposal Process Information and Requirements .......................................... 6 A. Confidentiality ................................................................................................................... 6 B. Timetable ........................................................................................................................... 6 C. Response Format.............................................................................................................. 7 E. Miscellaneous.................................................................................................................... 8 IV. Services To Be Provided.................................................................................... 8 A. Current Services ............................................................................................................... 8 B. Specific Requirements ..................................................................................................... 9 V. Proposal Submittal........................................................................................... 11 A. Proposal Requirements.................................................................................................. 11 B. Proposal Instructions ..................................................................................................... 11 C. Proposal Checklist.......................................................................................................... 12 VI. Plan Design Confirmation Checklist............................................................... 13 VII. Questionnaire ................................................................................................... 19 VIII. Performance Guarantees................................................................................. 25 IX. Financial Exhibits............................................................................................. 26 X. Appendices ....................................................................................................... 32 Appendix A: Monthly Claims and Enrollment .......................................................................... 32 Appendix B: Employee Census (Active and Retired).............................................................. 32 Appendix C: Transplant Insurance Contract, Medical Plan SPD’s ........................................ 32 Appendix D: Large Claims Report............................................................................................. 32 3 To participate in the RFP process vendors need to sign and return this Business Associate Agreement. This agreement must be signed and returned prior to the City of Fort Collins providing Appendices A – D. BUSINESS ASSOCIATE AGREEMENT – SECURITY STANDARDS This agreement is entered into between ___________________________ (Business Associate) and the City of Fort Collins. Business Associate agrees that it will implement policies and procedures to ensure that its creation, receipt, maintenance, or transmission of electronic protected health information (“ePHI”) on behalf of the City of Fort Collins complies with the applicable administrative, physical, and technical safeguards required to protect the confidentiality and integrity of ePHI under the Security Standards 45 CFR Part 164. Business Associate agrees that it will ensure that agents or subcontractors agree to implement the applicable administrative, physical, and technical safeguards required to protect the confidentiality and integrity of ePHI under the Security Standards 45 CFR Part 164. Business Associate agrees that it will report security violations to the City of Fort Collins, Security Manager. By: _________________________________ Date: ________________ ____________________________________ PRINT NAME ____________________________________ TITLE Please return to: City of Fort Collins Attn: Purchasing-RFP P985 PO Box 580 Ft. Collins, CO 80522 4 City of Fort Collins Request for Proposal P985 Benefits I. BACKGROUND The City of Fort Collins (“The City”) currently provides medical benefits to approximately 1,350 active employees and 25 retired employees. The City offers its employees and retirees a choice between four medical plans, a Health Maintenance Organization (“HMO”), a Point of Service (“POS”), and two preferred provider (“PPO”) plans. The plans’ prescription drug coverage is administered through our current Healthcare TPA. Approximately 640 active employees are enrolled in the HMO plan, 410 employees in the POS plan, and 300 employees in the two PPO plans. All medical benefit plans, including HMO coverage, are provided on a self-insured basis. Great West Healthcare administers all four plans and also provides the $120,000 specific stop-loss. The City’s current transplant insurance is being separately administered by The Segal Company through Western Cost Management Trust. The City is requesting proposals to administer its current HMO, POS, and PPO plan designs, as well as separate specific prescription, transplant insurance, and/or stop-loss proposals from independent carriers. Based on the proposals received, the City may select one administrator for all medical plans and include prescription coverage, stop-loss coverage and/or transplant insurance. At their discretion, the City may opt to provide separate contracts for the administration of prescription coverage, stop-loss coverage and/or transplant insurance. The City believes that an essential factor in managing the cost/service/quality balance is the relationship with each of its business partners. The City will view the selected vendor as an active partner in assuring employee satisfaction. II. HEALTH CARE OBJECTIVES AND PROPOSAL EVALUATION CRITERIA The City has adopted the following health care objectives as part of its health care strategy to address medical care benefit needs: ∗ The City strongly desires to provide employees access to managed care plans which minimize disruptions to existing patient-physician relationships. ∗ The City strives to provide employees with managed care options that offer a wide selection of health care providers. ∗ Managed care vendors will be selected that can provide an array of on-line administrative services to the City including provider directories, billing and eligibility, claims reports and claim status review, etc. As a result of these objectives, The City has developed selection criteria to evaluate managed care proposals. These objectives will be used heavily in the proposal process. 5 Parameter Main Criteria Weight Access to Providers How does the network fit and serve The City’s employees? 20% Member and Customer Service How well does the plan service its members and clients? How satisfied are members with the health care they receive? 20% Care Management How well does the plan treat sick members? 15% Wellness and Disease Management How effective is the plan in keeping members healthy? How does the plan handle Disease Management? 10% Program Management How thorough is the managed care plan in selecting providers and managing health care programs? 15% Cost / Financial Effectiveness How competitive are the managed care plan’s costs and contracts with area providers? 20% Mercer Human Resources Consulting (“Mercer”) may be assisting The City in evaluating its medical RFP’s. This Request for Proposal (RFP) is intended to assess which organizations have the ability to meet The City’s long-term goals and objectives as previously defined. Together with Mercer, The City will evaluate competing proposals considering: ∗ proposal adherence to the services requested and described in the RFP; ∗ quality of care and customer service; ∗ plan cost and rate guarantees; and ∗ responses to the RFP's Questionnaire section. Based on results of the initial evaluation, The City will select finalists for consideration. Any or all proposals may be rejected by The City. The finalists may be asked to make formal presentations of their proposals, as well as to demonstrate their systems and procedures for administering The City’s HMO, POS, and PPO medical plans. Site visits may take place at the finalists' home offices and/or the claims and administrative facility/facilities each finalist indicates will provide service to The City. Please note that the selection of the claims administrator will not be based solely on cost considerations. The City believes strongly in first assuring itself that the successful proposer can provide the scope and intensity of services required. Once those issues are confirmed, The City is prepared to pay a fair, competitive price for services rendered. 6 III. PROPOSAL PROCESS INFORMATION AND REQUIREMENTS The intent of this RFP is to confirm key information about specific proposers, receive financial proposals and identify network access compatibilities with The City’s employees. The following describes the anticipated proposal process, including confidentiality, timing, expected response format, and requirements for interaction regarding questions. Please note that The City reserves the right to accept or reject any and all proposals, to waive any technicalities or irregularities therein, to award contracts, or to withdraw the request for proposal without awarding a contract. Your response to this RFP and any subsequent correspondence related to this proposal process will be considered part of the contract, if one is awarded to you. Under no circumstances are commissions related to The City’s medical benefits payable to anyone in conjunction with this request. A. Confidentiality All data included in this RFP and accompanying appendices, as well as any census data and attachments, are proprietary to The City. It is for your exclusive use in preparing a proposal and must not be shared with any other firm or used for any other purpose. The use of The City’s name in any way as a potential customer is strictly prohibited. B. Timetable The following is a proposed timetable developed for this project. You will be notified of any significant changes which might occur: The City releases RFP to vendors March 4, 2005 Appendices sent to organizations that have returned Business Associate Agreements As agreements are returned to the City of Fort Collins Written questions due to The City March 25, 2005 Proposals due to The City April 22, 2005, 2:00 p.m. (our clock) Finalist vendors notified May 13, 2005 Onsite evaluations of finalists (if necessary) By June 3, 2005 Finalist negotiations (completed) June 10, 2005 Selection of recommended vendor(s) June 24, 2005 Plan effective date January 1, 2006 7 C. Response Format Your proposal must clearly indicate the name of the responding organization, as well as the name, address and telephone number of the primary contact at your organization for this proposal. Your proposal must include the contact name for local service and account management whom The City can call directly. Please submit your proposal no later than 2:00 p.m. (our clock) on April 22, 2005. Submit six (6) copies of your proposal to: If delivered: City of Fort Collins, Purchasing Reference: P985 215 North Mason, 2nd Floor Fort Collins, Colorado 80524 If mailed: City of Fort Collins, Purchasing Reference: P985 PO Box 580 Fort Collins, CO 80522-0580 Questions regarding this RFP are due to The City no later than March 25. A written response to substantive questions will be provided to all proposers. The City assumes no responsibility or liability for any costs you may incur in responding to this RFP, including attending meetings, site visits or negotiations. D. Deviations from RFP Specifications All responses to the Request for Proposal must be prepared in accordance with the Proposal Requirements set forth in Section IV of this RFP. The City reserves the right to refuse any proposal not prepared according to the Proposal Requirements of Section VI. The City retains the right to directly negotiate the finer points of your proposal that comply in spirit with this RFP and that satisfy The City’s objectives for effective, interactive and proactive claims and network administration. The City may, at its discretion, authorize Mercer to negotiate with any proposer on its behalf. The City shall not be bound to accept the proposal with the lowest price. The RFP may be amended or revoked at anytime prior to final execution of an Agreement by The City. Any deviations from this RFP must be clearly explained in your proposal. These deviations are to be delineated as instructed in the Proposal Requirements as set forth in Section IV of this RFP. It is intended that you should conform to these specifications as much as possible. Do not quote alternative plan designs unless absolutely necessary. Please quote the requested financial arrangements only. Your company will be bound to comply with the provisions set forth in this RFP unless any and all deviations are explicitly stated in your proposal. 8 E. Miscellaneous The City shall not infringe upon any intellectual property right of any vendor, but specifically reserves the right to use any concept or methods contained in the proposal. Any desired restrictions on the use of information contained in the proposal should be clearly stated. Responses containing your proprietary data shall be safeguarded with the same degree of protection as The City’s own proprietary data. All such proprietary data contained in your proposal must be clearly identified. The City may use Mercer to review the proposals. Neither The City nor Mercer shall be under any obligation to return any materials submitted in response to this RFP. The City expects to enter into a written Agreement (the “Agreement”) with the chosen vendor (“Chosen Vendor”) that shall incorporate this RFP and your proposal. The anticipated terms and conditions of the Agreement are set forth in this RFP; however, The City may include additional terms and conditions in the Agreement as deemed necessary. IV. SERVICES TO BE PROVIDED A. Current Services 1. Overview The City currently offers full-time and part-time active employees, COBRA participants and retirees a choice between an HMO, POS, and two PPO medical benefit plans. The current administrator of all four of our healthcare plans is Great West Healthcare. 2. Funding/Stop Loss All medical plans are self-funded. The plans have specific stop loss protection currently provided by Great West Healthcare. The specific stop-loss deductible is $120,000. Please quote $120,000 and $150,000 specific stop-loss protection. Stop-Loss coverage is to be quoted on a 15/12 or 24/12 basis in the first year and on a “paid” basis in subsequent years. Organ transplants will not be covered under the stop-loss coverage since this coverage is “carved-out” of the plans. However, transplant insurance may be quoted as a separate coverage item under this request. 3. Employee Contributions The City provides employees with sufficient contributions to purchase PPO Plan 1 for themselves and their dependents at no cost to the employee. If employees choose the HMO, POS, or PPO Plan 2, they must contribute towards the cost of the medical coverage. Employee contributions for these plan options are currently at 15% of the equivalent premium cost over and above the employer contribution. 9 B. Specific Requirements The City has specific vendor requirements needed to support its day to day operations. 1. Account Management The account executive and service representative(s) will deal directly with The City. This environment requires the account management team to: • Be able to devote the time necessary to the account, including being available for frequent telephone and on-site consultations with The City. Proposers who are not committed to account service will not receive serious consideration; • Be extremely responsive; • Be comprised of individuals with specialized knowledge of the proposing company’s: − managed care networks, − claims and eligibility systems, − systems reporting capabilities, − claims adjudication policies and procedures, − administrative services contract wording, − standard and non-standard banking arrangements and − relationships with third parties; • Be thoroughly familiar with virtually all of the proposing company’s functions that relate directly or indirectly to the account; and • Act on behalf of The City in “cutting through red tape.” This facet of account management cannot be emphasized enough--the account management team must be able to effectively advance the interests of The City through the vendor’s corporate structure. • Be flexible. During 2005, the City will enter into collective bargaining with the Fraternal Order of Police. At the end of that bargaining, it is possible that the City’s health plans may differ from what is currently being quoted in this RFP. It is extremely important that we have a healthcare vendor that will work with us to achieve a positive outcome from all perspectives. 2. Enrollment/Eligibility The City may, at their discretion, provide initial enrollment forms on paper. The eligibility updates will be provided electronically. The initial enrollment and updates will be provided directly to the selected vendor(s) by The City. The selected vendor(s) will perform direct eligibility certification to providers and verify coverage as part of the claims management and adjudication process. A quarterly reconciliation between payroll and eligibility will also be required of the selected vendor(s). 10 3. Fee Administration All administrative fee statements will be self-billed by The City. The City will calculate the fees payable on a monthly basis and will submit these fees directly to the selected vendor(s). 4. COBRA Administration The COBRA Administration will be conducted by the chosen vendor(s) and eligibility information will be provided by The City. Supportive services required by the selected vendor(s) will be as follows: • accept information from The City on COBRA participants; • send COBRA notifications to plan participants at termination; • send HIPAA certifications to plan participants at termination; • claims adjudication inquiries; and • COBRA member service inquiries related to benefits and claims. 5. Customer Service The selected vendor(s) must have, as its primary focus, efficient and effective processing of all inquiries. Satisfactory customer service will include prompt, courteous and accurate responses to The City and employee inquiries regarding claim submissions, provider networks, utilization review, plan design, etc. A toll-free number should be available for eligibility certification and claim submission inquiries. 6. Financial Accounting On a monthly basis, the selected vendor(s) must provide an accounting reconciliation of any “central bank” accounts utilized. The selected vendor(s) must provide a quarterly written report detailing all administrative expenses charged outside the Administrative Services Agreement. The selected vendor(s) must present a report detailing and justifying proposed fees for the coming year by September 1st of the preceding year. 7. Right to Audit The selected vendor(s) must agree to allow The City, or its representative, the right to audit all claims, medical/utilization management files, provider credentialing, financial data, and other information relevant to The City’s account. 8. Data and Management Information Reporting The selected vendor(s) must provide monthly paid claim summaries and detailed claim listings, preferably in Excel format. The vendor(s) must also provide its standard reporting package. Ad hoc reports will periodically be requested. Enrollment, claims and premium/fee information must be accurate and supplied in a timely manner upon request. Please describe your on-line claim reporting and look-up capabilities that will be available to The City. 9. “No Loss No Gain” for Covered Employees It is critical that there will be no loss of coverage (including medical, transplant insurance or stop-loss) for any employees. Therefore, it is required that your proposal waives any “actively at work”, “dependent non-confinement”, or any other rules that would prevent 100% continuity of coverage for any employees or dependents, COBRA participants, or retirees who are currently covered under the plans. 11 V. PROPOSAL SUBMITTAL A. Proposal Requirements Your response should be organized into the following sections: Section I Executive Summary Section II Proposal compliance letter (A letter signed by an authorized officer of your organization signifying your proposal’s complete compliance with the RFP specifications, except as specifically noted in the appropriate sections) Section III Checklist of Items included with Proposal Section IV Plan Design Confirmation Checklist Section V Confirmation Section Section VI Questionnaire Responses Section VII Performance Guarantees Section VIII Financial Exhibits Section IX Items Included with Proposal (as indicated on the Checklist included in Section III - these items should be indexed in the order listed on the checklist, with a copy of the index included in this section) B. Proposal Instructions 1. Please do not deviate from the requested formats. Your proposal should include the financial exhibit from Section IX of the RFP. Please provide your proposed rates and fees using the financial exhibits included in this RFP. 2. Assume an “incurred claims” basis (i.e. all claims incurred on or after 1/1/2006). 3. The City is seeking an initial premium/administration cost that runs for at least 24 months (January 1, 2006 - December 31, 2007) with three (3) additional one (1) year renewals. Please confirm the time period applicable to your proposed rate/fee guarantees. After that time, the City has the option of renewing the contract for three one-year periods. 4. Please quote all medical plans on a self-funded basis and transplant insurance and stop-loss coverage on a fully-insured, non-participating basis. If you are quoting transplant insurance and/or stop-loss coverage only, please only respond to the “Account Management” and “Stop-Loss” sections of the questionnaire or to the “Account Management” and “Transplant” sections of the questionnaire. 5. Define specifically what services are included in the fees your company has quoted. 6. Please specify any charges for services that your company has not included in the fees quoted above, including any start-up fees. 7. Please adhere to the instructions in this section when organizing your proposal. 12 C. Proposal Checklist The following information is requested as part of the proposal process. Please indicate your included attachments by duplicating this checklist and marking the appropriate column (Yes or No): Yes No Description of Item _____ _____ Intent to Propose _____ _____ Signed Proposal Compliance letter _____ _____ Signed Plan Design Confirmation _____ _____ Completed and Signed Questionnaire _____ _____ HMO Network Access Analysis _____ _____ POS Network Access Analysis _____ _____ PPO Network Access Analysis _____ _____ A proposed Implementation timeline for The City _____ _____ Audited financial statements and/or Department of Insurance filings for the past two years _____ _____ Provider “report cards” used to provide feedback on clinical and non-clinical performance measures _____ _____ A copy of your policy assuring member satisfaction in receiving medical care _____ _____ Your latest HEDIS report _____ _____ A copy of your EOB for in-network and out-of-network Services. Samples of all standard & optional reports you are proposing to provide on a health plan and account specific basis: _____ _____ - Utilization and Claims reports _____ _____ - Financial plan indicators _____ _____ - Member Service/Performance Standard Reporting _____ _____ - Member complaints/grievances reports _____ _____ A copy of your banking services agreement _____ _____ A copy of your member satisfaction survey _____ _____ A copy of your Administrative Services Agreement Signature of Authorized Representative:________________________________________ 13 VI. PLAN DESIGN CONFIRMATION CHECKLIST The following pages describe The City’s current HMO, POS, and PPO plan designs. Please quote your standard plans that most closely match the current plans. We realize there may be differences between the current and your proposed plans. However, it is our goal to keep these differences to a minimum. Please complete the column labeled “Your Plan” and “Differs Because” only where your plan differs from the standard described. Your quoted rates and fees should reflect your plan design as indicated in this checklist. The key for completing the “Differs Because” column is as follows: S - Systems limitations C - Corporate Policy L - Legal limitations I - State Mandated Insured Benefit O - Other (please describe) There are some design changes being considered for our medical plans. Although we expect to know what those changes are prior to the finalization of this RFP process, the City expects that, if these changes take place after the selection of a Healthcare TPA, the TPA will be able to accommodate such changes without any significant reduction in service or without any increase in fees. Changes being considered include, but may not be limited to: • Adding preventative care to our PPO plans • Changing the way our HMO and POS plans cover Lab, X-ray, and other diagnostic services from a flat fee to a percentage of charges. • Changing the way our HMO and POS plans cover outpatient surgery from a flat fee to a percentage of charges • Changing the prescription drug formulary for the HMO and POS plans to emulate the PPO plan formulary without the deductible. • Increase the in-network deductible for the PPO plan from $200 to $400 • Increase the In network “Out-of-pocket” maximum for the PPO 2 plan from $1,450 to $2,000 and the Out of Network “Out-of-pocket” maximum from $2,000 to $2,500 14 HMO Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of- Network Benefits Annual deductible $0 N/A Physician office visit $15 PCP $30 specialist N/A Inpatient Hospital Co-pay $500 N/A Outpatient Hospital Co-pay $100 N/A Emergency Room $100 N/A Mental Health/Substance Abuse Inpatient Outpatient $50/day; 45 days/ yr. MH; 21 days/yr. SA $0 visits 1-5, then $30 N/A Maternity $100 for pre-natal and post-natal care N/A Preventive Care (periodic physical exams, health screenings, immunizations, well baby/child care) $15 N/A Prescription Drugs Retail Mail Order $8/$15/$30 $16/$30/$60 N/A Annual Out-of- Pocket Limit 15 POS Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step- children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of-Network Benefits Annual deductible $0 $200/$400 Physician office visit $15 PCP $30 Specialist 70% R&C after deductible Inpatient Hospital Co-pay $500 70% R&C after deductible Outpatient Hospital Co-pay $100 70% R&C after deductible Emergency Room $100 50% R&C after deductible Mental Health/Substance Abuse Inpatient Outpatient $50/day; 45 days/ yr. MH; 21 days/yr. SA $0 visits 1-5, then $30 50% R&C after deductible; 45 days per year 70% R&C after deductible Maternity $100 pre-natal & post-natal care 70% R&C after deductible Preventive Care (periodic physical exams, health screenings, immunizations, well 16 PPO Plan 1 Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of-Network Benefits Annual deductible $750 $1,500 Coinsurance 80% 60% R&C Physician office visit 80% after deductible 60% R&C after deductible Inpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Outpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Emergency Room 80% after deductible 60% R&C after deductible Mental Health/ Substance Abuse Inpatient Outpatient 80% after deductible 80% after deductible 60% R&C after deductible 60% R&C after deductible Maternity 80% after deductible 60% R&C after deductible Preventive Care 80% after deductible 60% R&C after deductible Prescription Drugs $50 deductible, then greater of $8/$15/$30 or 10%/20%/30% (mail order – 2 co- pays for 90 day supply) N/A Annual Out-of- Pocket Limit $2,000 $2,750 PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in- and out-of-network out of pocket maximums do not cross apply and count towards the 17 PPO Plan 2 Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step- children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of- Network Benefits Annual deductible $200 $500 Coinsurance 80% 60% R&C Physician office visit 80% after deductible 60% R&C after deductible Inpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Outpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Emergency Room 80% after deductible 60% R&C after deductible Mental Health/Substance Abuse Inpatient Outpatient 80% after deductible 80% after deductible 60% R&C after deductible 60% R&C after deductible Maternity 80% after 18 Transplant Insurance Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) Coverage Please see attached SPD for coverage descriptions. Use this chart to explain any differences in the coverages you are quoting. 19 VII. QUESTIONNAIRE Instructions: This section is to request additional information for evaluating which health care plans best meets The City’s needs. All explanations should be labeled and tabbed in the response to the RFP. If you are unable to answer a question, please indicate why you cannot. If you are unwilling to disclose particular information asked in a question, please indicate why you will not respond. General 1. Who will be the Account Executive and Service Representative assigned to this account? From what office will these individuals provide service? 2. What are the background and experience of the account team members? 3. Will you allow The City or its agent to perform clinical and/or financial audits of your plan(s)? Will you provide on-line access to claims data? 4. Are you willing to protect, defend, indemnify and hold The City free and harmless from any and all losses arising from clerical, professional or administrative decisions made by or on behalf of your organization? 5. Please confirm that your company is and will continue to be compliant with both the DOL claims regulations and HIPAA administrative simplification. Please provide a copy of your compliance plans. 6. Will you agree to a contract provision requiring your organization to provide at least a 120-day written notice to the City prior to the renewal dates of the contract of a change in rates? 7. Will you agree to the following contract provision for termination of agreement? Termination of Agreement. This Agreement may be terminated at any time by mutual consent of both parties. This Agreement may be terminated by either party at any time upon sixty (60) days written notice to the other party. 8. It is required that proposals assume that all participants (including COBRA) presently covered will be covered under a successor plan regardless of medical condition, disabled status, or whether they are actively at-work or on a no-loss, no-gain basis for both the City and the participant. Is your proposal written in accordance with this requirement? 9. In the event of termination of this contract, are you willing to provide utilization data, including unique patient identifier, service codes, dates of service, and file format on commonly used magnetic media? 10. Are directories available on-line? Are practices identified as “open” or “closed?” Can employees make PCP elections on-line? 20 11. What services are available on-line for use by The City? Billing? Eligibility? Claim reports? 12. Please provide a copy of your standard medical claims utilization reports package. How often will these reports be provided to The City at no charge? What are your costs for ad hoc reports? 13. Provide samples of your standard prescription drug reports that permit analysis of the retail drug program and of the mail order drug program and which display the results of your drug utilization review program. Is there a charge for your standard reports? Are ad hoc reports available? Is there an extra fee? 14. Can you provide management reports that can isolate the components of cost increases in the prescription drug benefit? For example, leading drugs dispensed, increases in utilization, development of trends, physician outliers, high patient utilizers and/or possible abusers? Is there an extra fee for any of them? 15. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid, by line of coverage, showing the information separately for active, COBRA participants, and retirees; and separately for employees and dependents? 16. Do you have physician and patient profiling/reporting capabilities? If so, please describe the standard reports available and ad hoc capability. Provide sample reports. Provider Access 17. Please attach a network access report, separately for HMO, POS, and PPO, using the criteria outlined below and the census diskette included with this RFP. Please list the number of employees not meeting these criteria, including the city and zip code within which they reside. a. Number of employees with two adult primary care physicians (Family Practice, General Practice, Internists) within 10 miles of the employees’ zip code (open practices only). b. Number of employees with two obstetricians within 10 miles of the employee's zip code. c. Number of employees with two pediatricians within 10 miles of the employee's zip code. d. Number of employees with one hospital within 20 miles of an employee's zip code. 18. Please complete the following for your proposed Fort Collins and Denver HMO and POS networks (separately for HMO and POS and location): Number Hospitals Number PCPs Number Specialists Number Lab Facilities Number Pharmacies 21 19. How is the adequacy of a physician panel determined? What measures will be taken if the physician network is weak in a given geographic area? 20. What ratio of physicians to participants do you maintain? What is the ratio currently in Larimer County? Provider Contracting 21. Do you screen the cost effectiveness of each HMO/POS/PPO network provider? How? What actions are taken if a provider does not appear to be operating cost- effectively? 22. Do you measure the quality of care provided by your participating physicians? How often? How is quality measured? 23. What criteria are used to select hospitals and other health care facilities? How are the hospitals monitored for cost efficiency and quality of care on an ongoing basis? How often is this review conducted? Have any hospitals been terminated or dropped from the managed care program? Please describe circumstances. 24. May an employee nominate his or her physician for inclusion in the HMO/POS/PPO networks? Please describe the process, including the anticipated timing to add a physician. 25. What percentage of HMO/POS plan physicians were terminated in the past year? Indicate what percentages were terminated as a result of: Issue Percentage of total plan physicians Quality of care problems Over/under utilization Customer complaints Voluntary termination Other (please list) Total 26. Briefly describe any plans for changes to your HMO/POS/PPO physician or hospital financial arrangements. Is it likely that these changes could result in smaller hospital or physician networks or increased costs? 27. Are there any plans to increase or decrease your networks’ size over the next 12-18 months? 28. Do you subcontract any services (e.g., mental health) to another vendor or network? Please describe. 29. If your reimbursement to a physician is based on a fee schedule, what is the basis for the fee schedule? What is the target reimbursement level as a % of RBRVS for each managed medical product? • Family Practice, • Internal Medicine, • Pediatrician, • OB/GYN, 22 • Cardiologist, • Orthopedist, • Oncologist, • Neurosurgeon, and • Other Specialists. Medical Management 30. If you were reviewed by an accrediting agency and did not receive full accreditation, please summarize the key reasons. 31. Please describe at least two quality improvement activities initiated recently as a result of member satisfaction surveys. 32. Please describe the disease management programs that you currently offer as part of your medical benefit plans. Is the cost for these programs included in your premium rates and/or administrative fees? What enhancements to your Disease Management Program does your organization have planned for the next 12 – 18 months? 33. Describe any Wellness Program that you currently offer as part of your medical plans? What enhancements to your Wellness Program do you have planned for the next 12 – 18 months? Are the costs for these programs included in your premium rates or fees? 34. Does the managed care program have a formal procedure for addressing member grievances? If so, please explain. 35. Please describe your prescription drug utilization review program separately for pharmacy network and mail order claims. In addition to a description of the program and how it functions, please advise how your drug utilization review program addresses the following issues: • quality and cost of patient's recommended therapy • physician prescribing patterns • pharmacy dispensing practices • therapeutic and dosing regimes • generic monitoring • member education 35. Is utilization review performed on all prescriptions? If not, what criteria are used to select the prescriptions reviewed? 36. Please provide a copy of your prescription drug formulary. Will you inform employees directly regarding formulary changes that may impact them? 23 Member and Customer Service 37. What actions are you taking to improve average telephone responsiveness? 38. Are employee satisfaction surveys routinely performed? How often? Please provide a copy of the survey and the results for the most recent two years. 39. What are the standard customer service unit operating hours for toll-free telephone access? 40. Please indicate below your average for the most recent twelve months, and specify the reporting frequency you are proposing for The City. Also please provide copies of available reports. Tracked? (Yes/No) Monitoring Frequency Last 12 Month Average # of members # of calls Call wait time Abandonment rate Complaint call log Administration 41. When were your current claims, eligibility, member services and data reporting systems last updated? When are the next upgrades/ enhancements scheduled? Do you anticipate changes in the claims system prior to January 1, 2006? 42. Do you have any plans to move, close, or consolidate your claims or member services offices? If so, please describe. 43. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid, by line of coverage, showing the information separately for active, COBRA participants, and retirees; and separately for employees and dependents? 44. Are you able to administer on-line, electronic transfer, and tape-to-tape eligibility transfers? How does this impact your cost proposal? 45. Do you agree to provide COBRA administration? 46. In addition to COBRA, describe your support services in complying with the issuance of HIPAA certifications. Is there an additional charge for these services? 47. What was the employee turnover rate in the proposed claim payment office(s) in the past 36 months by year? 48. Please provide three current and two terminated references. Include name and phone number of contacts. 24 49. Confirm that your system will accept named dependent eligibility data. Can your system accept ongoing (after conversion) dependent eligibility? Please detail your audit process for eligibility verification. 50. What percentage of your claims was adjudicated manually in the last 12 months? What steps have you taken to reduce manual claims adjudication? 51. In the event of termination, what is your guaranteed fee to provide for payment of run-out claims? Include all data processing charges. 52. How do you pay out of network claims? Which R&C tables do you use? 1) 53. Is there an aggregate annual or lifetime limit on your stop-loss liability for a given claimant? 54. Please confirm that you will not “laser” or exclude any employees or dependents at issue or at renewal. 55. What special reports, if any, would you require from the current medical carrier for the stop-loss coverage? 56. How soon after a claim is submitted to your company can reimbursement be expected by the City? 57. Please confirm that you will accept The City’s definition of “investigational” procedures as defined in The City’s current contracts and SPDs, so that all claims approved for payment under the medical plan will be eligible for stop-loss reimbursement. These definitions can be found in the SPDs in Appendix D. 58. Does the proposed stop-loss coverage include any “inside” limits (e.g., mental health cap, etc.)? 59. Please provide a copy of your standard renewal disclosure form. 25 VIII. PERFORMANCE GUARANTEES The City expects its managed care partners to demonstrate an exemplary level of customer service to The City. The attached performance standards are indicative of the levels of customer service expected from The City’s managed care vendors. Please specify the current performance of the office where The City’s claims will be processed and member services provided next to the proposed standard. In the far right column please state your acceptance of The City’s standard or your alternative proposed guarantees, as well as the amount you are willing to put at risk. In total, we would expect 10%-15% of the ASO fee to be “at risk.” EPO/POS/Catastrophic The City Minimum Standard Actual Vendor Performance – 2003 Vendor Proposal I.D. Card Mailing Mailed within 10 days of receipt of complete enrollment information from The City Network Directories Requested supply delivered to The City prior to open enrollment Employee Booklets Booklets will be printed and mailed to participants within 15 working days from receipt of approval of final draft Financial Accuracy Total paid dollars errors divided by total paid dollars 99% or higher Coding Accuracy Number of claims without coding errors divided by total number of audited claims 98% or higher Perfect Claims Number of claims without any errors divided by number of audited claims 97% or higher Claims Turnaround Time 90% within 14 calendar days; 98% within 21 calendar days Telephone Response Time 90% of all calls answered within 30 seconds Time on Hold Average monthly hold time will not exceed 20 seconds 26 IX. FINANCIAL EXHIBITS Please complete the following exhibits in full. If you are an incumbent, please complete both the client specific and book of business exhibits. If you are not an incumbent, please return only the book of business exhibits with your proposal. Exhibit A: Self-Insured Administrative Fee and Fully-Insured Premium Rates Stop-Loss Rates Transplant Insurance Exhibit B: Prescription Drug Fee (Retail and Mail Order) Exhibit C: Services Included in Self-Insured Administrative Fee EXHIBIT A Page 1 of 2 27 EXHIBIT A SELF-INSURED ADMINISTRATIVE FEE AND FULLY-INSURED PREMIUM RATES STOP-LOSS RATES TRANSPLANT INSURANCE Self-Insured Active HMO 2006 2007 Number of Employees - HMO Number of Claims/EE - HMO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Self-Insured POS 2006 2007 Number of Employees - POS Number of Claims/EE - POS Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Self-Insured PPO Plan 1 2006 2007 Number of Employees – PPO Number of Claims/EE - PPO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE EXHIBIT A Page 2 of 2 28 EXHIBIT A (Cont.) Self-Insured PPO Plan 2 2006 2007 Number of Employees – PPO Number of Claims/EE - PPO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Stop-Loss Insurance (January 1, 2006 – December 31, 2007) Section 1.02 Specific Stop-Loss (Monthly Rate): # of $120,000 $150,000 Employees Deductible Deductible Employee (15/12) _______ $________ $_______ Employee (24/12) _______ $________ $_______ Transplant Insurance Plan Benefit Period Riders ______________________ _____________ ______________________ ________________________ _____________ ______________________ EXHIBIT B Page 1 of 2 29 EXHIBIT B PRESCRIPTION DRUG FEE QUOTATION Retail Only Generic Dispensing Fee Brand Dispensing Fee Generic Discount Below AWP* (AWP based on quantities of 30) Brand Discount Below AWP** (AWP based on quantities of 30) Administration Fees (per prescription) Other Fees Identification Cards DUR Program MAC Pricing Other Fees (List in detail) $___________/Rx $___________/Rx ____________% ____________% $__________/Rx $__________/ee $__________/ee $__________/ee $__________/ee * If MAC, please indicate the average discount % ** Indicate Source of AWP. EXHIBIT B Page 2 of 2 30 Mail Order Only Generic Dispensing Fee Brand Dispensing Fee a. Generic Discount Below AWP* (AWP based on quantities of 90) Brand Discount Below AWP** (AWP based on quantities of 90) Administration Fees (per prescription) Other Fees Identification Cards DUR Program MAC Pricing Other Fees (List in detail) $___________/Rx $___________/Rx ____________% ____________% $__________/Rx $__________/ee $__________/ee $__________/ee $__________/ee * If MAC, please indicate the average discount % ** Indicate Source of AWP. 31 EXHIBIT C SERVICES INCLUDED IN SELF-INSURED ADMINISTRATIVE FEE Using the table below, specifically define the services included in your proposed fees. Please specify any items included or excluded from your proposed fees that are not specifically listed in the table in the “Other” section of the table. Service Yes No Additional Charge Development of Plan Document and Amendments Drafting and Printing of Employee Booklets Other Communications (Please Specify) Employee I.D. Cards Preparation of Government Forms Legal Services Legislative Services Establishment of Banking Arrangements and Banking Fees Verification of Eligibility Assistance Actuarial Services (determination of liabilities, estimate of cost of benefit changes, and pricing for additional benefits) Renewal Services (development of COBRA rates, determination of reserve requirements, determination of total plan costs) Set Up Fees (Please specify the amount if not included) Travel Expenses Other (Please specify) 32 X. APPENDICES Appendix A: Monthly Claims and Enrollment Appendix B: Employee Census (Active and Retired) Appendix C: Transplant Insurance Contract, Medical Plan SPD’s Appendix D: Large Claims Report NOTE: Appendices A – D are available on disc and will be sent after the receipt of the Business Associate Agreement listed on page 3. HIPAA Security measures will be in effect on April 10, 2005 and the City of Fort Collins requires this Agreement prior to the release of information that could be ePHI. Agreements should be signed by an authorized official and returned to: David Carey Attn: Purchasing City of Fort Collins PO Box 580 Fort Collins, CO 80522-0580 CITY OF FORT COLLINS REQUEST FOR PROPOSAL P985 BENEFITS PROPOSAL DATE: 2:00 p.m. (our clock) APRIL 22, 2005 1 REQUEST FOR PROPOSAL CITY OF FORT COLLINS Proposal Number P985 Benefits The City of Fort Collins is seeking proposals from firms reflecting fees for providing a Preferred Provider Organization (PPO) network, Point-of Service (POS) network, Exclusive Provider Organization (EPO) network, third party administration services, utilization review services, stop loss insurance, transplant insurance and prescription drug coverage. Single service as well as multiple service providers are encouraged to respond. Proposers may be on one or multiple services. The City currently provides all eligible employees and their dependents medical benefits on a self-funded basis. Prescription drug coverage is provided to employees and their dependents through a carve-out card program. Proposals are being solicited by the City to obtain the most competitive benefits for its employees and their eligible dependents. Current plan designs are to be replicated. Plan documents are available upon request. Written proposals, six (6) will be received at the City of Fort Collins' Purchasing Division, 215 North Mason St., 2nd floor, Fort Collins, Colorado 80524. Proposals will be received before 2:00 p.m. (our clock), April 22, 2005. Proposal No 985. If delivered, they are to be sent to 215 North Mason Street, 2nd Floor, Fort Collins, Colorado 80524. If mailed, the address is P.O. Box 580, Fort Collins, 80522-0580. Questions concerning the scope of the project should be directed to Katey Tarkington, Benefits Administrator, (970) 221-6828. Questions regarding proposals submittal or process should be directed to David Carey, C.P.M., Buyer, (970) 416-2191. Sales Prohibited/Conflict of Interest: No officer, employee, or member of City Council, shall have a financial interest in the sale to the City of any real or personal property, equipment, material, supplies or services where such officer or employee exercises directly or indirectly any decision- making authority concerning such sale or any supervisory authority over the services to be rendered. This rule also applies to subcontracts with the City. Soliciting or accepting any gift, gratuity favor, entertainment, kickback or any items of monetary value from any person who has or is seeking to do business with the City of Fort Collins is prohibited. Collusive or sham proposals: Any proposal deemed to be collusive or a sham proposal will be rejected and reported to authorities as such. Your authorized signature of this proposal assures that such proposal is genuine and is not a collusive or sham proposal. The City of Fort Collins reserves the right to reject any and all proposals and to waive any irregularities or informalities. Sincerely, James B. O'Neill II, CPPO, FNIGP Director of Purchasing & Risk Management 2 TABLE OF CONTENTS Business Associate Agreement – Security Standards .............................................. 3 I. Background......................................................................................................... 4 II. Health Care Objectives and Proposal Evaluation Criteria ............................. 4 III. Proposal Process Information and Requirements .......................................... 6 A. Confidentiality ................................................................................................................... 6 B. Timetable ........................................................................................................................... 6 C. Response Format.............................................................................................................. 7 E. Miscellaneous.................................................................................................................... 8 IV. Services To Be Provided.................................................................................... 8 A. Current Services ............................................................................................................... 8 B. Specific Requirements ..................................................................................................... 9 V. Proposal Submittal........................................................................................... 11 A. Proposal Requirements.................................................................................................. 11 B. Proposal Instructions ..................................................................................................... 11 C. Proposal Checklist.......................................................................................................... 12 VI. Plan Design Confirmation Checklist............................................................... 13 VII. Questionnaire ................................................................................................... 19 VIII. Performance Guarantees................................................................................. 25 IX. Financial Exhibits............................................................................................. 26 X. Appendices ....................................................................................................... 32 Appendix A: Monthly Claims and Enrollment .......................................................................... 32 Appendix B: Employee Census (Active and Retired).............................................................. 32 Appendix C: Transplant Insurance Contract, Medical Plan SPD’s ........................................ 32 Appendix D: Large Claims Report............................................................................................. 32 3 To participate in the RFP process vendors need to sign and return this Business Associate Agreement. This agreement must be signed and returned prior to the City of Fort Collins providing Appendices A – D. BUSINESS ASSOCIATE AGREEMENT – SECURITY STANDARDS This agreement is entered into between ___________________________ (Business Associate) and the City of Fort Collins. Business Associate agrees that it will implement policies and procedures to ensure that its creation, receipt, maintenance, or transmission of electronic protected health information (“ePHI”) on behalf of the City of Fort Collins complies with the applicable administrative, physical, and technical safeguards required to protect the confidentiality and integrity of ePHI under the Security Standards 45 CFR Part 164. Business Associate agrees that it will ensure that agents or subcontractors agree to implement the applicable administrative, physical, and technical safeguards required to protect the confidentiality and integrity of ePHI under the Security Standards 45 CFR Part 164. Business Associate agrees that it will report security violations to the City of Fort Collins, Security Manager. By: _________________________________ Date: ________________ ____________________________________ PRINT NAME ____________________________________ TITLE Please return to: City of Fort Collins Attn: Purchasing-RFP P985 PO Box 580 Ft. Collins, CO 80522 4 City of Fort Collins Request for Proposal P985 Benefits I. BACKGROUND The City of Fort Collins (“The City”) currently provides medical benefits to approximately 1,350 active employees and 25 retired employees. The City offers its employees and retirees a choice between four medical plans, a Health Maintenance Organization (“HMO”), a Point of Service (“POS”), and two preferred provider (“PPO”) plans. The plans’ prescription drug coverage is administered through our current Healthcare TPA. Approximately 640 active employees are enrolled in the HMO plan, 410 employees in the POS plan, and 300 employees in the two PPO plans. All medical benefit plans, including HMO coverage, are provided on a self-insured basis. Great West Healthcare administers all four plans and also provides the $120,000 specific stop-loss. The City’s current transplant insurance is being separately administered by The Segal Company through Western Cost Management Trust. The City is requesting proposals to administer its current HMO, POS, and PPO plan designs, as well as separate specific prescription, transplant insurance, and/or stop-loss proposals from independent carriers. Based on the proposals received, the City may select one administrator for all medical plans and include prescription coverage, stop-loss coverage and/or transplant insurance. At their discretion, the City may opt to provide separate contracts for the administration of prescription coverage, stop-loss coverage and/or transplant insurance. The City believes that an essential factor in managing the cost/service/quality balance is the relationship with each of its business partners. The City will view the selected vendor as an active partner in assuring employee satisfaction. II. HEALTH CARE OBJECTIVES AND PROPOSAL EVALUATION CRITERIA The City has adopted the following health care objectives as part of its health care strategy to address medical care benefit needs: ∗ The City strongly desires to provide employees access to managed care plans which minimize disruptions to existing patient-physician relationships. ∗ The City strives to provide employees with managed care options that offer a wide selection of health care providers. ∗ Managed care vendors will be selected that can provide an array of on-line administrative services to the City including provider directories, billing and eligibility, claims reports and claim status review, etc. As a result of these objectives, The City has developed selection criteria to evaluate managed care proposals. These objectives will be used heavily in the proposal process. 5 Parameter Main Criteria Weight Access to Providers How does the network fit and serve The City’s employees? 20% Member and Customer Service How well does the plan service its members and clients? How satisfied are members with the health care they receive? 20% Care Management How well does the plan treat sick members? 15% Wellness and Disease Management How effective is the plan in keeping members healthy? How does the plan handle Disease Management? 10% Program Management How thorough is the managed care plan in selecting providers and managing health care programs? 15% Cost / Financial Effectiveness How competitive are the managed care plan’s costs and contracts with area providers? 20% Mercer Human Resources Consulting (“Mercer”) may be assisting The City in evaluating its medical RFP’s. This Request for Proposal (RFP) is intended to assess which organizations have the ability to meet The City’s long-term goals and objectives as previously defined. Together with Mercer, The City will evaluate competing proposals considering: ∗ proposal adherence to the services requested and described in the RFP; ∗ quality of care and customer service; ∗ plan cost and rate guarantees; and ∗ responses to the RFP's Questionnaire section. Based on results of the initial evaluation, The City will select finalists for consideration. Any or all proposals may be rejected by The City. The finalists may be asked to make formal presentations of their proposals, as well as to demonstrate their systems and procedures for administering The City’s HMO, POS, and PPO medical plans. Site visits may take place at the finalists' home offices and/or the claims and administrative facility/facilities each finalist indicates will provide service to The City. Please note that the selection of the claims administrator will not be based solely on cost considerations. The City believes strongly in first assuring itself that the successful proposer can provide the scope and intensity of services required. Once those issues are confirmed, The City is prepared to pay a fair, competitive price for services rendered. 6 III. PROPOSAL PROCESS INFORMATION AND REQUIREMENTS The intent of this RFP is to confirm key information about specific proposers, receive financial proposals and identify network access compatibilities with The City’s employees. The following describes the anticipated proposal process, including confidentiality, timing, expected response format, and requirements for interaction regarding questions. Please note that The City reserves the right to accept or reject any and all proposals, to waive any technicalities or irregularities therein, to award contracts, or to withdraw the request for proposal without awarding a contract. Your response to this RFP and any subsequent correspondence related to this proposal process will be considered part of the contract, if one is awarded to you. Under no circumstances are commissions related to The City’s medical benefits payable to anyone in conjunction with this request. A. Confidentiality All data included in this RFP and accompanying appendices, as well as any census data and attachments, are proprietary to The City. It is for your exclusive use in preparing a proposal and must not be shared with any other firm or used for any other purpose. The use of The City’s name in any way as a potential customer is strictly prohibited. B. Timetable The following is a proposed timetable developed for this project. You will be notified of any significant changes which might occur: The City releases RFP to vendors March 4, 2005 Appendices sent to organizations that have returned Business Associate Agreements As agreements are returned to the City of Fort Collins Written questions due to The City March 25, 2005 Proposals due to The City April 22, 2005, 2:00 p.m. (our clock) Finalist vendors notified May 13, 2005 Onsite evaluations of finalists (if necessary) By June 3, 2005 Finalist negotiations (completed) June 10, 2005 Selection of recommended vendor(s) June 24, 2005 Plan effective date January 1, 2006 7 C. Response Format Your proposal must clearly indicate the name of the responding organization, as well as the name, address and telephone number of the primary contact at your organization for this proposal. Your proposal must include the contact name for local service and account management whom The City can call directly. Please submit your proposal no later than 2:00 p.m. (our clock) on April 22, 2005. Submit six (6) copies of your proposal to: If delivered: City of Fort Collins, Purchasing Reference: P985 215 North Mason, 2nd Floor Fort Collins, Colorado 80524 If mailed: City of Fort Collins, Purchasing Reference: P985 PO Box 580 Fort Collins, CO 80522-0580 Questions regarding this RFP are due to The City no later than March 25. A written response to substantive questions will be provided to all proposers. The City assumes no responsibility or liability for any costs you may incur in responding to this RFP, including attending meetings, site visits or negotiations. D. Deviations from RFP Specifications All responses to the Request for Proposal must be prepared in accordance with the Proposal Requirements set forth in Section IV of this RFP. The City reserves the right to refuse any proposal not prepared according to the Proposal Requirements of Section VI. The City retains the right to directly negotiate the finer points of your proposal that comply in spirit with this RFP and that satisfy The City’s objectives for effective, interactive and proactive claims and network administration. The City may, at its discretion, authorize Mercer to negotiate with any proposer on its behalf. The City shall not be bound to accept the proposal with the lowest price. The RFP may be amended or revoked at anytime prior to final execution of an Agreement by The City. Any deviations from this RFP must be clearly explained in your proposal. These deviations are to be delineated as instructed in the Proposal Requirements as set forth in Section IV of this RFP. It is intended that you should conform to these specifications as much as possible. Do not quote alternative plan designs unless absolutely necessary. Please quote the requested financial arrangements only. Your company will be bound to comply with the provisions set forth in this RFP unless any and all deviations are explicitly stated in your proposal. 8 E. Miscellaneous The City shall not infringe upon any intellectual property right of any vendor, but specifically reserves the right to use any concept or methods contained in the proposal. Any desired restrictions on the use of information contained in the proposal should be clearly stated. Responses containing your proprietary data shall be safeguarded with the same degree of protection as The City’s own proprietary data. All such proprietary data contained in your proposal must be clearly identified. The City may use Mercer to review the proposals. Neither The City nor Mercer shall be under any obligation to return any materials submitted in response to this RFP. The City expects to enter into a written Agreement (the “Agreement”) with the chosen vendor (“Chosen Vendor”) that shall incorporate this RFP and your proposal. The anticipated terms and conditions of the Agreement are set forth in this RFP; however, The City may include additional terms and conditions in the Agreement as deemed necessary. IV. SERVICES TO BE PROVIDED A. Current Services 1. Overview The City currently offers full-time and part-time active employees, COBRA participants and retirees a choice between an HMO, POS, and two PPO medical benefit plans. The current administrator of all four of our healthcare plans is Great West Healthcare. 2. Funding/Stop Loss All medical plans are self-funded. The plans have specific stop loss protection currently provided by Great West Healthcare. The specific stop-loss deductible is $120,000. Please quote $120,000 and $150,000 specific stop-loss protection. Stop-Loss coverage is to be quoted on a 15/12 or 24/12 basis in the first year and on a “paid” basis in subsequent years. Organ transplants will not be covered under the stop-loss coverage since this coverage is “carved-out” of the plans. However, transplant insurance may be quoted as a separate coverage item under this request. 3. Employee Contributions The City provides employees with sufficient contributions to purchase PPO Plan 1 for themselves and their dependents at no cost to the employee. If employees choose the HMO, POS, or PPO Plan 2, they must contribute towards the cost of the medical coverage. Employee contributions for these plan options are currently at 15% of the equivalent premium cost over and above the employer contribution. 9 B. Specific Requirements The City has specific vendor requirements needed to support its day to day operations. 1. Account Management The account executive and service representative(s) will deal directly with The City. This environment requires the account management team to: • Be able to devote the time necessary to the account, including being available for frequent telephone and on-site consultations with The City. Proposers who are not committed to account service will not receive serious consideration; • Be extremely responsive; • Be comprised of individuals with specialized knowledge of the proposing company’s: − managed care networks, − claims and eligibility systems, − systems reporting capabilities, − claims adjudication policies and procedures, − administrative services contract wording, − standard and non-standard banking arrangements and − relationships with third parties; • Be thoroughly familiar with virtually all of the proposing company’s functions that relate directly or indirectly to the account; and • Act on behalf of The City in “cutting through red tape.” This facet of account management cannot be emphasized enough--the account management team must be able to effectively advance the interests of The City through the vendor’s corporate structure. • Be flexible. During 2005, the City will enter into collective bargaining with the Fraternal Order of Police. At the end of that bargaining, it is possible that the City’s health plans may differ from what is currently being quoted in this RFP. It is extremely important that we have a healthcare vendor that will work with us to achieve a positive outcome from all perspectives. 2. Enrollment/Eligibility The City may, at their discretion, provide initial enrollment forms on paper. The eligibility updates will be provided electronically. The initial enrollment and updates will be provided directly to the selected vendor(s) by The City. The selected vendor(s) will perform direct eligibility certification to providers and verify coverage as part of the claims management and adjudication process. A quarterly reconciliation between payroll and eligibility will also be required of the selected vendor(s). 10 3. Fee Administration All administrative fee statements will be self-billed by The City. The City will calculate the fees payable on a monthly basis and will submit these fees directly to the selected vendor(s). 4. COBRA Administration The COBRA Administration will be conducted by the chosen vendor(s) and eligibility information will be provided by The City. Supportive services required by the selected vendor(s) will be as follows: • accept information from The City on COBRA participants; • send COBRA notifications to plan participants at termination; • send HIPAA certifications to plan participants at termination; • claims adjudication inquiries; and • COBRA member service inquiries related to benefits and claims. 5. Customer Service The selected vendor(s) must have, as its primary focus, efficient and effective processing of all inquiries. Satisfactory customer service will include prompt, courteous and accurate responses to The City and employee inquiries regarding claim submissions, provider networks, utilization review, plan design, etc. A toll-free number should be available for eligibility certification and claim submission inquiries. 6. Financial Accounting On a monthly basis, the selected vendor(s) must provide an accounting reconciliation of any “central bank” accounts utilized. The selected vendor(s) must provide a quarterly written report detailing all administrative expenses charged outside the Administrative Services Agreement. The selected vendor(s) must present a report detailing and justifying proposed fees for the coming year by September 1st of the preceding year. 7. Right to Audit The selected vendor(s) must agree to allow The City, or its representative, the right to audit all claims, medical/utilization management files, provider credentialing, financial data, and other information relevant to The City’s account. 8. Data and Management Information Reporting The selected vendor(s) must provide monthly paid claim summaries and detailed claim listings, preferably in Excel format. The vendor(s) must also provide its standard reporting package. Ad hoc reports will periodically be requested. Enrollment, claims and premium/fee information must be accurate and supplied in a timely manner upon request. Please describe your on-line claim reporting and look-up capabilities that will be available to The City. 9. “No Loss No Gain” for Covered Employees It is critical that there will be no loss of coverage (including medical, transplant insurance or stop-loss) for any employees. Therefore, it is required that your proposal waives any “actively at work”, “dependent non-confinement”, or any other rules that would prevent 100% continuity of coverage for any employees or dependents, COBRA participants, or retirees who are currently covered under the plans. 11 V. PROPOSAL SUBMITTAL A. Proposal Requirements Your response should be organized into the following sections: Section I Executive Summary Section II Proposal compliance letter (A letter signed by an authorized officer of your organization signifying your proposal’s complete compliance with the RFP specifications, except as specifically noted in the appropriate sections) Section III Checklist of Items included with Proposal Section IV Plan Design Confirmation Checklist Section V Confirmation Section Section VI Questionnaire Responses Section VII Performance Guarantees Section VIII Financial Exhibits Section IX Items Included with Proposal (as indicated on the Checklist included in Section III - these items should be indexed in the order listed on the checklist, with a copy of the index included in this section) B. Proposal Instructions 1. Please do not deviate from the requested formats. Your proposal should include the financial exhibit from Section IX of the RFP. Please provide your proposed rates and fees using the financial exhibits included in this RFP. 2. Assume an “incurred claims” basis (i.e. all claims incurred on or after 1/1/2006). 3. The City is seeking an initial premium/administration cost that runs for at least 24 months (January 1, 2006 - December 31, 2007) with three (3) additional one (1) year renewals. Please confirm the time period applicable to your proposed rate/fee guarantees. After that time, the City has the option of renewing the contract for three one-year periods. 4. Please quote all medical plans on a self-funded basis and transplant insurance and stop-loss coverage on a fully-insured, non-participating basis. If you are quoting transplant insurance and/or stop-loss coverage only, please only respond to the “Account Management” and “Stop-Loss” sections of the questionnaire or to the “Account Management” and “Transplant” sections of the questionnaire. 5. Define specifically what services are included in the fees your company has quoted. 6. Please specify any charges for services that your company has not included in the fees quoted above, including any start-up fees. 7. Please adhere to the instructions in this section when organizing your proposal. 12 C. Proposal Checklist The following information is requested as part of the proposal process. Please indicate your included attachments by duplicating this checklist and marking the appropriate column (Yes or No): Yes No Description of Item _____ _____ Intent to Propose _____ _____ Signed Proposal Compliance letter _____ _____ Signed Plan Design Confirmation _____ _____ Completed and Signed Questionnaire _____ _____ HMO Network Access Analysis _____ _____ POS Network Access Analysis _____ _____ PPO Network Access Analysis _____ _____ A proposed Implementation timeline for The City _____ _____ Audited financial statements and/or Department of Insurance filings for the past two years _____ _____ Provider “report cards” used to provide feedback on clinical and non-clinical performance measures _____ _____ A copy of your policy assuring member satisfaction in receiving medical care _____ _____ Your latest HEDIS report _____ _____ A copy of your EOB for in-network and out-of-network Services. Samples of all standard & optional reports you are proposing to provide on a health plan and account specific basis: _____ _____ - Utilization and Claims reports _____ _____ - Financial plan indicators _____ _____ - Member Service/Performance Standard Reporting _____ _____ - Member complaints/grievances reports _____ _____ A copy of your banking services agreement _____ _____ A copy of your member satisfaction survey _____ _____ A copy of your Administrative Services Agreement Signature of Authorized Representative:________________________________________ 13 VI. PLAN DESIGN CONFIRMATION CHECKLIST The following pages describe The City’s current HMO, POS, and PPO plan designs. Please quote your standard plans that most closely match the current plans. We realize there may be differences between the current and your proposed plans. However, it is our goal to keep these differences to a minimum. Please complete the column labeled “Your Plan” and “Differs Because” only where your plan differs from the standard described. Your quoted rates and fees should reflect your plan design as indicated in this checklist. The key for completing the “Differs Because” column is as follows: S - Systems limitations C - Corporate Policy L - Legal limitations I - State Mandated Insured Benefit O - Other (please describe) There are some design changes being considered for our medical plans. Although we expect to know what those changes are prior to the finalization of this RFP process, the City expects that, if these changes take place after the selection of a Healthcare TPA, the TPA will be able to accommodate such changes without any significant reduction in service or without any increase in fees. Changes being considered include, but may not be limited to: • Adding preventative care to our PPO plans • Changing the way our HMO and POS plans cover Lab, X-ray, and other diagnostic services from a flat fee to a percentage of charges. • Changing the way our HMO and POS plans cover outpatient surgery from a flat fee to a percentage of charges • Changing the prescription drug formulary for the HMO and POS plans to emulate the PPO plan formulary without the deductible. • Increase the in-network deductible for the PPO plan from $200 to $400 • Increase the In network “Out-of-pocket” maximum for the PPO 2 plan from $1,450 to $2,000 and the Out of Network “Out-of-pocket” maximum from $2,000 to $2,500 14 HMO Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of- Network Benefits Annual deductible $0 N/A Physician office visit $15 PCP $30 specialist N/A Inpatient Hospital Co-pay $500 N/A Outpatient Hospital Co-pay $100 N/A Emergency Room $100 N/A Mental Health/Substance Abuse Inpatient Outpatient $50/day; 45 days/ yr. MH; 21 days/yr. SA $0 visits 1-5, then $30 N/A Maternity $100 for pre-natal and post-natal care N/A Preventive Care (periodic physical exams, health screenings, immunizations, well baby/child care) $15 N/A Prescription Drugs Retail Mail Order $8/$15/$30 $16/$30/$60 N/A Annual Out-of- Pocket Limit 15 POS Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step- children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of-Network Benefits Annual deductible $0 $200/$400 Physician office visit $15 PCP $30 Specialist 70% R&C after deductible Inpatient Hospital Co-pay $500 70% R&C after deductible Outpatient Hospital Co-pay $100 70% R&C after deductible Emergency Room $100 50% R&C after deductible Mental Health/Substance Abuse Inpatient Outpatient $50/day; 45 days/ yr. MH; 21 days/yr. SA $0 visits 1-5, then $30 50% R&C after deductible; 45 days per year 70% R&C after deductible Maternity $100 pre-natal & post-natal care 70% R&C after deductible Preventive Care (periodic physical exams, health screenings, immunizations, well 16 PPO Plan 1 Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of-Network Benefits Annual deductible $750 $1,500 Coinsurance 80% 60% R&C Physician office visit 80% after deductible 60% R&C after deductible Inpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Outpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Emergency Room 80% after deductible 60% R&C after deductible Mental Health/ Substance Abuse Inpatient Outpatient 80% after deductible 80% after deductible 60% R&C after deductible 60% R&C after deductible Maternity 80% after deductible 60% R&C after deductible Preventive Care 80% after deductible 60% R&C after deductible Prescription Drugs $50 deductible, then greater of $8/$15/$30 or 10%/20%/30% (mail order – 2 co- pays for 90 day supply) N/A Annual Out-of- Pocket Limit $2,000 $2,750 PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in- and out-of-network out of pocket maximums do not cross apply and count towards the 17 PPO Plan 2 Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step- children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) In-Network Benefits Out-of- Network Benefits Annual deductible $200 $500 Coinsurance 80% 60% R&C Physician office visit 80% after deductible 60% R&C after deductible Inpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Outpatient Hospital Co-pay 80% after deductible 60% R&C after deductible Emergency Room 80% after deductible 60% R&C after deductible Mental Health/Substance Abuse Inpatient Outpatient 80% after deductible 80% after deductible 60% R&C after deductible 60% R&C after deductible Maternity 80% after 18 Transplant Insurance Your Plan (Differences Only) Differs Because Eligible Employee Participants Active full time and part-time employees and retirees. Eligible Dependents Spouse; natural children, step-children, adopted children (from date of placement), legal guardianship, and QMSCO to age 19 (25 if FT student) Coverage Please see attached SPD for coverage descriptions. Use this chart to explain any differences in the coverages you are quoting. 19 VII. QUESTIONNAIRE Instructions: This section is to request additional information for evaluating which health care plans best meets The City’s needs. All explanations should be labeled and tabbed in the response to the RFP. If you are unable to answer a question, please indicate why you cannot. If you are unwilling to disclose particular information asked in a question, please indicate why you will not respond. General 1. Who will be the Account Executive and Service Representative assigned to this account? From what office will these individuals provide service? 2. What are the background and experience of the account team members? 3. Will you allow The City or its agent to perform clinical and/or financial audits of your plan(s)? Will you provide on-line access to claims data? 4. Are you willing to protect, defend, indemnify and hold The City free and harmless from any and all losses arising from clerical, professional or administrative decisions made by or on behalf of your organization? 5. Please confirm that your company is and will continue to be compliant with both the DOL claims regulations and HIPAA administrative simplification. Please provide a copy of your compliance plans. 6. Will you agree to a contract provision requiring your organization to provide at least a 120-day written notice to the City prior to the renewal dates of the contract of a change in rates? 7. Will you agree to the following contract provision for termination of agreement? Termination of Agreement. This Agreement may be terminated at any time by mutual consent of both parties. This Agreement may be terminated by either party at any time upon sixty (60) days written notice to the other party. 8. It is required that proposals assume that all participants (including COBRA) presently covered will be covered under a successor plan regardless of medical condition, disabled status, or whether they are actively at-work or on a no-loss, no-gain basis for both the City and the participant. Is your proposal written in accordance with this requirement? 9. In the event of termination of this contract, are you willing to provide utilization data, including unique patient identifier, service codes, dates of service, and file format on commonly used magnetic media? 10. Are directories available on-line? Are practices identified as “open” or “closed?” Can employees make PCP elections on-line? 20 11. What services are available on-line for use by The City? Billing? Eligibility? Claim reports? 12. Please provide a copy of your standard medical claims utilization reports package. How often will these reports be provided to The City at no charge? What are your costs for ad hoc reports? 13. Provide samples of your standard prescription drug reports that permit analysis of the retail drug program and of the mail order drug program and which display the results of your drug utilization review program. Is there a charge for your standard reports? Are ad hoc reports available? Is there an extra fee? 14. Can you provide management reports that can isolate the components of cost increases in the prescription drug benefit? For example, leading drugs dispensed, increases in utilization, development of trends, physician outliers, high patient utilizers and/or possible abusers? Is there an extra fee for any of them? 15. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid, by line of coverage, showing the information separately for active, COBRA participants, and retirees; and separately for employees and dependents? 16. Do you have physician and patient profiling/reporting capabilities? If so, please describe the standard reports available and ad hoc capability. Provide sample reports. Provider Access 17. Please attach a network access report, separately for HMO, POS, and PPO, using the criteria outlined below and the census diskette included with this RFP. Please list the number of employees not meeting these criteria, including the city and zip code within which they reside. a. Number of employees with two adult primary care physicians (Family Practice, General Practice, Internists) within 10 miles of the employees’ zip code (open practices only). b. Number of employees with two obstetricians within 10 miles of the employee's zip code. c. Number of employees with two pediatricians within 10 miles of the employee's zip code. d. Number of employees with one hospital within 20 miles of an employee's zip code. 18. Please complete the following for your proposed Fort Collins and Denver HMO and POS networks (separately for HMO and POS and location): Number Hospitals Number PCPs Number Specialists Number Lab Facilities Number Pharmacies 21 19. How is the adequacy of a physician panel determined? What measures will be taken if the physician network is weak in a given geographic area? 20. What ratio of physicians to participants do you maintain? What is the ratio currently in Larimer County? Provider Contracting 21. Do you screen the cost effectiveness of each HMO/POS/PPO network provider? How? What actions are taken if a provider does not appear to be operating cost- effectively? 22. Do you measure the quality of care provided by your participating physicians? How often? How is quality measured? 23. What criteria are used to select hospitals and other health care facilities? How are the hospitals monitored for cost efficiency and quality of care on an ongoing basis? How often is this review conducted? Have any hospitals been terminated or dropped from the managed care program? Please describe circumstances. 24. May an employee nominate his or her physician for inclusion in the HMO/POS/PPO networks? Please describe the process, including the anticipated timing to add a physician. 25. What percentage of HMO/POS plan physicians were terminated in the past year? Indicate what percentages were terminated as a result of: Issue Percentage of total plan physicians Quality of care problems Over/under utilization Customer complaints Voluntary termination Other (please list) Total 26. Briefly describe any plans for changes to your HMO/POS/PPO physician or hospital financial arrangements. Is it likely that these changes could result in smaller hospital or physician networks or increased costs? 27. Are there any plans to increase or decrease your networks’ size over the next 12-18 months? 28. Do you subcontract any services (e.g., mental health) to another vendor or network? Please describe. 29. If your reimbursement to a physician is based on a fee schedule, what is the basis for the fee schedule? What is the target reimbursement level as a % of RBRVS for each managed medical product? • Family Practice, • Internal Medicine, • Pediatrician, • OB/GYN, 22 • Cardiologist, • Orthopedist, • Oncologist, • Neurosurgeon, and • Other Specialists. Medical Management 30. If you were reviewed by an accrediting agency and did not receive full accreditation, please summarize the key reasons. 31. Please describe at least two quality improvement activities initiated recently as a result of member satisfaction surveys. 32. Please describe the disease management programs that you currently offer as part of your medical benefit plans. Is the cost for these programs included in your premium rates and/or administrative fees? What enhancements to your Disease Management Program does your organization have planned for the next 12 – 18 months? 33. Describe any Wellness Program that you currently offer as part of your medical plans? What enhancements to your Wellness Program do you have planned for the next 12 – 18 months? Are the costs for these programs included in your premium rates or fees? 34. Does the managed care program have a formal procedure for addressing member grievances? If so, please explain. 35. Please describe your prescription drug utilization review program separately for pharmacy network and mail order claims. In addition to a description of the program and how it functions, please advise how your drug utilization review program addresses the following issues: • quality and cost of patient's recommended therapy • physician prescribing patterns • pharmacy dispensing practices • therapeutic and dosing regimes • generic monitoring • member education 35. Is utilization review performed on all prescriptions? If not, what criteria are used to select the prescriptions reviewed? 36. Please provide a copy of your prescription drug formulary. Will you inform employees directly regarding formulary changes that may impact them? 23 Member and Customer Service 37. What actions are you taking to improve average telephone responsiveness? 38. Are employee satisfaction surveys routinely performed? How often? Please provide a copy of the survey and the results for the most recent two years. 39. What are the standard customer service unit operating hours for toll-free telephone access? 40. Please indicate below your average for the most recent twelve months, and specify the reporting frequency you are proposing for The City. Also please provide copies of available reports. Tracked? (Yes/No) Monitoring Frequency Last 12 Month Average # of members # of calls Call wait time Abandonment rate Complaint call log Administration 41. When were your current claims, eligibility, member services and data reporting systems last updated? When are the next upgrades/ enhancements scheduled? Do you anticipate changes in the claims system prior to January 1, 2006? 42. Do you have any plans to move, close, or consolidate your claims or member services offices? If so, please describe. 43. Will you agree to furnish monthly and year-to-date average enrollment, and total claims paid, by line of coverage, showing the information separately for active, COBRA participants, and retirees; and separately for employees and dependents? 44. Are you able to administer on-line, electronic transfer, and tape-to-tape eligibility transfers? How does this impact your cost proposal? 45. Do you agree to provide COBRA administration? 46. In addition to COBRA, describe your support services in complying with the issuance of HIPAA certifications. Is there an additional charge for these services? 47. What was the employee turnover rate in the proposed claim payment office(s) in the past 36 months by year? 48. Please provide three current and two terminated references. Include name and phone number of contacts. 24 49. Confirm that your system will accept named dependent eligibility data. Can your system accept ongoing (after conversion) dependent eligibility? Please detail your audit process for eligibility verification. 50. What percentage of your claims was adjudicated manually in the last 12 months? What steps have you taken to reduce manual claims adjudication? 51. In the event of termination, what is your guaranteed fee to provide for payment of run-out claims? Include all data processing charges. 52. How do you pay out of network claims? Which R&C tables do you use? 1) 53. Is there an aggregate annual or lifetime limit on your stop-loss liability for a given claimant? 54. Please confirm that you will not “laser” or exclude any employees or dependents at issue or at renewal. 55. What special reports, if any, would you require from the current medical carrier for the stop-loss coverage? 56. How soon after a claim is submitted to your company can reimbursement be expected by the City? 57. Please confirm that you will accept The City’s definition of “investigational” procedures as defined in The City’s current contracts and SPDs, so that all claims approved for payment under the medical plan will be eligible for stop-loss reimbursement. These definitions can be found in the SPDs in Appendix D. 58. Does the proposed stop-loss coverage include any “inside” limits (e.g., mental health cap, etc.)? 59. Please provide a copy of your standard renewal disclosure form. 25 VIII. PERFORMANCE GUARANTEES The City expects its managed care partners to demonstrate an exemplary level of customer service to The City. The attached performance standards are indicative of the levels of customer service expected from The City’s managed care vendors. Please specify the current performance of the office where The City’s claims will be processed and member services provided next to the proposed standard. In the far right column please state your acceptance of The City’s standard or your alternative proposed guarantees, as well as the amount you are willing to put at risk. In total, we would expect 10%-15% of the ASO fee to be “at risk.” EPO/POS/Catastrophic The City Minimum Standard Actual Vendor Performance – 2003 Vendor Proposal I.D. Card Mailing Mailed within 10 days of receipt of complete enrollment information from The City Network Directories Requested supply delivered to The City prior to open enrollment Employee Booklets Booklets will be printed and mailed to participants within 15 working days from receipt of approval of final draft Financial Accuracy Total paid dollars errors divided by total paid dollars 99% or higher Coding Accuracy Number of claims without coding errors divided by total number of audited claims 98% or higher Perfect Claims Number of claims without any errors divided by number of audited claims 97% or higher Claims Turnaround Time 90% within 14 calendar days; 98% within 21 calendar days Telephone Response Time 90% of all calls answered within 30 seconds Time on Hold Average monthly hold time will not exceed 20 seconds 26 IX. FINANCIAL EXHIBITS Please complete the following exhibits in full. If you are an incumbent, please complete both the client specific and book of business exhibits. If you are not an incumbent, please return only the book of business exhibits with your proposal. Exhibit A: Self-Insured Administrative Fee and Fully-Insured Premium Rates Stop-Loss Rates Transplant Insurance Exhibit B: Prescription Drug Fee (Retail and Mail Order) Exhibit C: Services Included in Self-Insured Administrative Fee EXHIBIT A Page 1 of 2 27 EXHIBIT A SELF-INSURED ADMINISTRATIVE FEE AND FULLY-INSURED PREMIUM RATES STOP-LOSS RATES TRANSPLANT INSURANCE Self-Insured Active HMO 2006 2007 Number of Employees - HMO Number of Claims/EE - HMO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Self-Insured POS 2006 2007 Number of Employees - POS Number of Claims/EE - POS Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Self-Insured PPO Plan 1 2006 2007 Number of Employees – PPO Number of Claims/EE - PPO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE EXHIBIT A Page 2 of 2 28 EXHIBIT A (Cont.) Self-Insured PPO Plan 2 2006 2007 Number of Employees – PPO Number of Claims/EE - PPO Monthly Costs per Employee Network Access Fees Utilization Management Fees Claim Administration Other Administration (specify) Total Medical Administrative Fees Expected Monthly Medical Paid Claims/EE Stop-Loss Insurance (January 1, 2006 – December 31, 2007) Section 1.02 Specific Stop-Loss (Monthly Rate): # of $120,000 $150,000 Employees Deductible Deductible Employee (15/12) _______ $________ $_______ Employee (24/12) _______ $________ $_______ Transplant Insurance Plan Benefit Period Riders ______________________ _____________ ______________________ ________________________ _____________ ______________________ EXHIBIT B Page 1 of 2 29 EXHIBIT B PRESCRIPTION DRUG FEE QUOTATION Retail Only Generic Dispensing Fee Brand Dispensing Fee Generic Discount Below AWP* (AWP based on quantities of 30) Brand Discount Below AWP** (AWP based on quantities of 30) Administration Fees (per prescription) Other Fees Identification Cards DUR Program MAC Pricing Other Fees (List in detail) $___________/Rx $___________/Rx ____________% ____________% $__________/Rx $__________/ee $__________/ee $__________/ee $__________/ee * If MAC, please indicate the average discount % ** Indicate Source of AWP. EXHIBIT B Page 2 of 2 30 Mail Order Only Generic Dispensing Fee Brand Dispensing Fee a. Generic Discount Below AWP* (AWP based on quantities of 90) Brand Discount Below AWP** (AWP based on quantities of 90) Administration Fees (per prescription) Other Fees Identification Cards DUR Program MAC Pricing Other Fees (List in detail) $___________/Rx $___________/Rx ____________% ____________% $__________/Rx $__________/ee $__________/ee $__________/ee $__________/ee * If MAC, please indicate the average discount % ** Indicate Source of AWP. 31 EXHIBIT C SERVICES INCLUDED IN SELF-INSURED ADMINISTRATIVE FEE Using the table below, specifically define the services included in your proposed fees. Please specify any items included or excluded from your proposed fees that are not specifically listed in the table in the “Other” section of the table. Service Yes No Additional Charge Development of Plan Document and Amendments Drafting and Printing of Employee Booklets Other Communications (Please Specify) Employee I.D. Cards Preparation of Government Forms Legal Services Legislative Services Establishment of Banking Arrangements and Banking Fees Verification of Eligibility Assistance Actuarial Services (determination of liabilities, estimate of cost of benefit changes, and pricing for additional benefits) Renewal Services (development of COBRA rates, determination of reserve requirements, determination of total plan costs) Set Up Fees (Please specify the amount if not included) Travel Expenses Other (Please specify) 32 X. APPENDICES Appendix A: Monthly Claims and Enrollment Appendix B: Employee Census (Active and Retired) Appendix C: Transplant Insurance Contract, Medical Plan SPD’s Appendix D: Large Claims Report NOTE: Appendices A – D are available on disc and will be sent after the receipt of the Business Associate Agreement listed on page 3. HIPAA Security measures will be in effect on April 10, 2005 and the City of Fort Collins requires this Agreement prior to the release of information that could be ePHI. Agreements should be signed by an authorized official and returned to: David Carey Attn: Purchasing City of Fort Collins PO Box 580 Fort Collins, CO 80522-0580 CITY OF FORT COLLINS ADDENDUM No. 1 P-985 BENEFITS SPECIFICATIONS AND CONTRACT DOCUMENTS Description of Proposal P-985 BENEFITS OPENING DATE: April 22, 2005 To all prospective bidders under the specifications and contract documents described above, the following changes are hereby made. Addendum 1 – P985 Benefits RFP PROSPECTIVE BIDDER QUESTIONS: 1. Please indicate if EAP services are preferred to be included in our proposal? EAP services should not be included in this proposal. If you wish to quote on an EAP plan, the City of Fort Collins will be issuing an RFP towards the end of April for this service. However, please note that the City of Fort Collins does have mental health benefits under our medical plan. Please refer to the Summary Plan Descriptions for information regarding our mental health benefits. 2. RFP Page 23, Question #44: Please describe what media format the City utilizes when you mention ‘tape to tape” format. Any electronic format that is considered secure and HIPAA compliant may be used to transmit data. This may include, but is not limited to, secure e-mail, discs, or wire. 3. RFP Page 25: Is Actual Vendor Performance – 2003 a possible misprint? Would the City prefer 2004 information? If the vendor has 2004 performance information, that is preferable. However, if that information is not available, 2003 is acceptable. 4. Is the monthly enrollment available? Yes. The enrollment for plans effective 3/1/2005 is as follows: POS 1 Employee Only 182 Employee + Spouse 133 Employee + Child(ren) 74 Family 245 POS 2 Employee Only 108 Employee + Spouse 94 Employee + Child(ren) 42 Family 167 PPO 1 Employee Only 41 Employee + Spouse 49 Employee + Child(ren) 9 Family 35 PPO 2 Employee Only 55 Employee + Spouse 49 Employee + Child(ren) 14 Family 49 5. Can we get 1 more prior year of monthly claims and enrollment? Prior to 2003, the City of Fort Collins was with Pacificare and National Health Systems. That data was not is not available without a fee 6. Can we get 1 more prior year of shock loss claimants? See question #5 7. Is it possible to get a list of provider (including FEIN) utilized by the group in order to better analyze the networks? The current provider network utilized by Great West is their One Health network. Providers may be accessed by going to www.mygreatwest.com and clicking on “Providers” and then selecting a network. We are not asking for a disruption analysis at this point. 8. Can we get the current rates, factors and fees? Administrative Fees POS 1 and 2 $33.40 PPO 1 and 2 $28.72 Specific Stop Loss Fees POS 1 and 2 $35.92 PPO 1 and 2 $42.21 Transplant Insurance $9.65/employee/month 9. We typically request 15% reinsurance commission. Is this acceptable? Per page 5 of the RFP, there are to be no commissions paid in relation to this RFP. 10. In RFP Section V, Proposal Submittal, there is a requested Section V labeled Confirmation Section. What is this referring to? This is referring to those five (5) pages immediately following the Plan Design Confirmation Checklist. These pages are where a vendor would confirm that they are able to duplicate our plans or, only in cases where they are not able to duplicate, they will tell us how and why their plan differs. 11. Can you provide carrier history for the past 5 years? 2003 – Present Great West Health Care 2000 – 2002 – National Health Systems for PPO plans and Pacificare for POS plans. 12. Is there any additional information available on the shock claims illustrated in the Large Claim Reports? Are there any lasers currently in place and if yes, can please provide details (i.e., on which claims and the amount of the laser)? There are no lasers in place for any large claims for medical or for transplant insurance. 13. Are the large claims (those in excess of $60K) open or closed? Is the individual actively at work or out on disability? See Attachment “A”. 14. Are the Large Case Manager notes available on the claims in excess of $60K? Can you provide? Case Manager notes are not readily available. We may provide to finalists. 15. Are the police on the plan now? Explain the collective bargaining with the Fraternal Order of Police. Is this a new bargaining entity? Yes, the police are covered by all of our benefits at this time and that is not expected to change in the future. The Fraternal Order of Police will representing our sworn police officers and that may result in some plan changes. This is a new bargaining entity to the City. 16. Can we get updated claims and enrollment? See Questions # 4 and #20. 17. Are the large claims over $100,000 still on the plan? See Attachment “A”. 18. Can we get the current rates and prior year rates? See #8 for current rates. 2004 rates were: Administrative Fees POS 1 and 2 $32.43 PPO 1 and 2 $27.88 Specific Stop Loss Fees POS 1 and 2 $28.51 PPO 1 and 2 $33.50 Transplant Insurance $9.65/employee/month 19. There is an option to change the x-ray and lab benefit. How is it paid today for both hospital services and physician office based services? Currently, x-ray and diagnostic are paid with a $15 copay. 20. We have claims and large claims through December 04. Can we get any more current data for the initial quote? Amounts that have been paid for claims in 2005. 1/11/2005 $ 169,380.56 1/19/2005 $ 171,258.69 1/25/2005 $ 127,519.31 2/2/2005 $ 152,624.50 2/7/2005 $ 244,582.27 2/14/2005 $ 170,591.20 2/22/2005 $ 167,103.58 2/28/2005 $ 212,672.85 3/7/2005 $ 154,801.41 3/14/2005 $ 370,512.29 3/21/2005 $ 257,461.21 3/28/2005 $ 170,722.47 4/4/2005 $ 229,059.27 21. Will you be providing current/renewal fees, Stop Loss Rates, etc? See #8 and #18 22. Will you provide monthly lives to match the monthly claims? See #4. Turnover within the City is approximately 6% so the monthly lives will not change dramatically. 23. Member months by plan as well as experience by month broken out for each plan. See Attachment “B” and Attachment “C” 24. Current GWL pricing (administration, stop loss, and aggregate attachment). See #8 and #18 25. Prognosis for large claimants for last 12 months. Information is not readily available 26. Diagnosis for large claimants for time period 1/03 – 12/03? Information is not available for that. All claims from 2003 that were still open in 2004 are listed with a diagnosis on Attachment A. 27. Contribution levels by plan. For 2005, employees contribute 15% of the market premium for all plans. For 2006, employee only coverage will be set at 15% and employee + dependent coverage will be set at 20% of market premium. These levels exclude the PPO 1 plan. This plan has no employee contributions for 2005. For 2006, the employee only coverage will be free to employees. Employees with dependents will be covered at 5% of market premium. 28. What is the dependent status of the retirees? RETIREES HEALTH INSURANCE PLANS Single Single/Spouse EE/CH/FAM 1 Medicare/ 1Non-medicare Total PPO 1 - Non-medicare 2 1 0 1 4 PPO 1 - Medicare 3 1 0 0 4 PPO 2 - Non-medicare 4 0 0 0 4 PPO 2 - Medicare 4 4 0 0 8 POS 1 - Non-medicare 1 0 0 2 3 POS 1 - Medicare 1 0 0 0 1 POS 2 - Non-medicare 1 0 0 0 1 POS 2 - Medicare 0 0 0 0 0 TOTAL: 25 29. We didn't see that the City of Fort Collins was requesting ASL coverage. We wondering if you could confirm that the City only carries ISL coverage? The City does not have aggregate stop loss, only individual stop loss. 30. Could we provide enrollment by plan by month by coverage for last 24 months? Using the March enrollment (see Question #4), you should have an accurate portrayal of our enrollment. We had a small shift to the PPO 1 plan during Open Enrollment (maybe 20 employees) but other than that, it's good. Also, we only have a 6% turnover so that shouldn't affect it. Please contact the Purchasing office at 970-221-6775 to obtain a copy of Attachments A, B, and C. If you have any questions please contact David Carey, C.P.M., Buyer, at 970-416-2191. RECEIPT OF THIS ADDENDUM MUST BE ACKNOWLEDGED BY A WRITTEN STATEMENT ENCLOSED WITH THE BID/QUOTE STATING THAT THIS ADDENDUM HAS BEEN RECEIVED. Attachment "A" P985 Benefits RFP, Addendum No. 1 Large Claimants (Jan 1 - Dec 31, '03) Large Claimants (Jan 1 - Dec 31, '04) Gender Relationship Plan Dollars Gender Relationship Plan Dollars Diagnosis Female Ee POS1 $334,983 Male Sp POS2 $316,418 Cardiac Arrest Female Ee POS2 $147,933 Male Ch POS2 $228,858 Bone Cancer Female Ch POS1 $139,378 Male Sp PPO2 $161,462 Circulatory/Heart Disease Male Sp PPO1 $130,655 Male Ee POS2 $129,296 Prostate Cancer Male Ee POS1 $107,588 Female Sp POS2 $109,096 Cancer Male Sp PPO2 $106,048 Male Ee POS2 $108,240 Acute respiratory failure Male Ee PPO2 $102,100 Male Ee POS1 $106,569 Pulmonary Embolism Male Ee PPO2 $80,545 Female Sp POS2 $104,847 Heart Disease Female Sp POS2 $77,429 Female Sp POS1 $104,679 Cancer Male Ee POS1 $74,998 Female Sp POS1 $99,401 Aortic Valve Disorder Female Sp POS1 $69,264 Female Ee PPO2 $89,317 Ulcers Male Ch POS1 $63,060 Female Sp POS1 $86,031 Calculus of Kidney Male Ee PPO2 $51,991 Male Ee PPO2 $83,831 Cirrhosis of Liver Female Ch PPO2 $51,695 Female Ee POS1 $82,954 Brain hemorrhage Female Sp POS1 $50,940 Female Sp POS1 $82,807 Breast Cancer Male Ee POS1 $45,534 Male Ee POS1 $81,309 Cancer Female Sp POS1 $42,576 Female Ee PPO1 $79,322 Breast Cancer Female Ee POS1 $41,565 Female Sp PPO2 $78,928 failure of internal mechanical device Female Ee PPO2 $38,961 Female Ee PPO2 $77,037 Neurological disorders Female Ch POS1 $38,862 Male Ee POS2 $76,287 spondylosis (vertebrae disorder) Female Sp POS2 $37,728 Male Ch POS1 $69,059 Heart Disorder Female Sp PPO2 $37,226 Male Ch PPO2 $62,993 Back Surgery Male Ee POS2 $32,316 Female Ee POS2 $60,023 Breast Cancer Female Sp POS1 $32,036 Male Ee POS1 $59,344 Brain Cancer Female Ee PPO2 $31,516 Female Ee POS2 $58,899 Chonic Pulmonary Disease Male Ee PPO2 $30,933 Female Ee POS1 $43,142 Pancreatitis Male Ee POS1 $29,717 Female Ee PPO2 $42,101 Malignant Hypertension Female Ee POS1 $27,761 Male Ee POS1 $41,461 Coronary Artherosclerosis Female Ee POS2 $25,011 Male Ee PPO2 $33,781 Male Ch POS2 $33,433 Female Sp PPO1 $33,264 Female Ee POS1 $32,918 Male Sp POS1 $31,695 Male Ee PPO2 $31,670 Female Ch POS1 $30,279 Female Sp PPO1 $30,273 Female Sp POS2 $30,237 Male Sp POS2 $29,942 Female Sp PPO1 $29,805 Male Sp POS1 $29,486 Male Ee POS2 $28,191 Male Ee POS2 $27,845 Female Sp POS1 $27,112 Female Sp PPO1 $26,989 Female Sp PPO2 $26,374 Female Ee PPO1 $26,013 Female Ee POS2 $25,324 Female Sp PPO2 $25,308 Status Still on Plan? Resolved no Ongoing yes Ongoing yes Ongoing yes Ongoing yes Ongoing yes Ongoing yes Resolved yes Ongoing yes Ongoing yes Resolved yes Ongoing yes Resolved yes Resolved no Resolved no Resolved yes Ongoing yes Ongoing yes Ongoing yes Ongoing yes Resolved no Resolved yes Ongoing yes Resolved no Ongoing yes Ongoing yes Resolved yes Resolved yes PPO1 Month Rx Medical Med SL Vision Total Claims Claims Claims Claims Claims Jan $4,066 $29,656 $0 $0 $33,722 Feb $7,407 $20,867 $0 $0 $28,274 Mar $7,496 $24,872 $0 $0 $32,368 Apr $9,081 $34,341 $0 $0 $43,422 May $6,579 $26,666 $0 $0 $33,245 Jun $8,535 $76,796 $0 $0 $85,331 Jul $5,409 $21,580 $0 $0 $26,989 Aug $6,811 $25,341 $0 $0 $32,152 Sep $10,918 $28,407 $0 $0 $39,325 Oct $6,564 $18,177 $0 $0 $24,741 Nov $6,766 $13,350 $0 $0 $20,116 Dec $6,201 $27,027 $0 $0 $33,228 Total $85,833 $347,080 $0 $0 $432,913 PPO2 Month Rx Medical Med SL Vision Total Claims Claims Claims Claims Claims Jan $33,410 $117,376 $0 $0 $150,786 Feb $27,849 $118,094 $0 $0 $145,943 Mar $34,977 $152,317 $0 $0 $187,294 Apr $52,738 $305,174 $0 $0 $357,912 May $39,181 $124,452 $0 $0 $163,633 Jun $37,448 $121,648 $0 $0 $159,096 Jul $35,686 $150,832 $0 $0 $186,518 Aug $38,661 $190,058 $0 $0 $228,719 Sep $54,896 $93,408 $0 $0 $148,304 Oct $36,648 $152,011 $0 $0 $188,659 Nov $30,998 $103,563 $0 $0 $134,561 Dec $43,635 $96,856 $41,462 $0 $181,953 Total $466,127 $1,725,789 $41,462 $0 $2,233,378 POS1 Month Rx Medical Med SL Vision Total Claims Claims Claims Claims Claims Jan $71,094 $380,328 $0 $1,958 $453,380 Feb $70,664 $414,886 $0 $1,260 $486,810 Mar $75,776 $333,897 $0 $1,859 $411,532 Apr $111,065 $404,363 $0 $1,545 $516,973 May $73,329 $372,750 $0 $1,484 $447,563 Jun $77,972 $340,394 $0 $886 $419,252 Jul $68,125 $361,520 $0 $1,337 $430,982 Aug $67,064 $474,986 $0 $2,042 $544,092 Sep $124,856 $262,699 $0 $1,591 $389,146 Oct $81,207 $319,174 $0 $1,413 $401,794 Nov $81,516 $385,731 $0 $1,641 $468,888 Dec $79,597 $282,337 $0 $1,373 $363,307 Total $982,265 $4,333,065 $0 $18,389 $5,333,719 POS2 Month Rx Medical Med SL Vision Total Claims Claims Claims Claims Claims Jan $31,155 $196,160 $0 $567 $227,882 Feb $39,276 $244,419 $0 $537 $284,232 Mar $38,494 $263,186 $151,812 $840 $454,332 Apr $57,695 $285,572 $22,514 $1,061 $366,842 May $38,425 $139,233 $26,680 $550 $204,888 Jun $41,594 $239,600 $22,148 $495 $303,837 Jul $35,697 $128,112 $4,394 $126 $168,329 Aug $41,335 $207,333 $7,612 $687 $256,967 Sep $54,199 $142,123 $2,890 $178 $199,390 Oct $35,993 $151,661 $11,804 $955 $200,413 Nov $42,924 $144,185 $6,614 $1,334 $195,057 Dec $41,692 $349,794 $57,094 $1,120 $449,700 Total $498,479 $2,491,378 $313,562 $8,450 $3,311,869 POS1 POS2 W/ SL W/O SL Month Rx Medical Med SL Vision Total Month Rx Medical Med SL Vision Total Total Claims Claims Claims Claims Claims Claims Claims Claims Claims Claims Claims Jan $95,647 $254,022 $0 $1,921 $351,590 Jan $67,331 $168,506 $0 $526 $236,363 $236,363 Feb $47,927 $260,700 $0 $1,196 $309,823 Feb $31,069 $231,159 $0 $639 $262,867 $262,867 Mar $0 $0 $0 $0 $0 Mar $0 $0 $0 $0 $0 $0 Apr $0 $0 $0 $0 $0 Apr $0 $0 $0 $0 $0 $0 May $0 $0 $0 $0 $0 May $0 $0 $0 $0 $0 $0 Jun $0 $0 $0 $0 $0 Jun $0 $0 $0 $0 $0 $0 Jul $0 $0 $0 $0 $0 Jul $0 $0 $0 $0 $0 $0 Aug $0 $0 $0 $0 $0 Aug $0 $0 $0 $0 $0 $0 Sep $0 $0 $0 $0 $0 Sep $0 $0 $0 $0 $0 $0 Oct $0 $0 $0 $0 $0 Oct $0 $0 $0 $0 $0 $0 Nov $0 $0 $0 $0 $0 Nov $0 $0 $0 $0 $0 $0 Dec $0 $0 $0 $0 $0 Dec $0 $0 $0 $0 $0 $0 $143,574 $514,722 $0 $3,117 $661,413 Total $98,400 $399,665 $0 $1,165 $499,230 $499,230 Abandonment Rate Less than 2% of calls abandoned deductible 60% R&C after deductible Preventive Care 80% after deductible 60% R&C after deductible Prescription Drugs $50 deductible, then greater of $8/$15/$30 or 10%/20%/30% (mail order – 2 co-pays for 90 day supply) N/A Annual Out-of- Pocket Limit $1,450 $2,000 PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in- and out-of-network out of pocket maximums do not cross apply and count towards the satisfaction of each other. The deductible is waived for mail order PPO RX. satisfaction of each other. The deductible is waived for mail order PPO RX. baby/child care) $15 70% R&C after deductible Prescription Drugs Retail Mail Order $8/$15/$30 $16/$30/$60 In network co- pays plus 30% In network co- pays plus 30% Annual Out-of- Pocket Limit $2,500/$7,500 $2,500/$7,500 N/A N/A Abandonment Rate Less than 2% of calls abandoned deductible 60% R&C after deductible Preventive Care 80% after deductible 60% R&C after deductible Prescription Drugs $50 deductible, then greater of $8/$15/$30 or 10%/20%/30% (mail order – 2 co-pays for 90 day supply) N/A Annual Out-of- Pocket Limit $1,450 $2,000 PPO annual out-of-pocket max requires 2 persons to each satisfy the individual max. Also, in- and out-of-network out of pocket maximums do not cross apply and count towards the satisfaction of each other. The deductible is waived for mail order PPO RX. satisfaction of each other. The deductible is waived for mail order PPO RX. baby/child care) $15 70% R&C after deductible Prescription Drugs Retail Mail Order $8/$15/$30 $16/$30/$60 In network co- pays plus 30% In network co- pays plus 30% Annual Out-of- Pocket Limit $2,500/$7,500 $2,500/$7,500 N/A N/A