Request for Proposals For Medical and Prescription Drug · Medical & Prescription Drug RFP 6...

Request for Proposals

For

Medical and Prescription Drug

Issued by:

Conrad Siegel Actuaries

Issue Date: March 2, 2015

Response Date: March 31, 2015

1:00 PM

Harrisburg Area Community College

Medical & Prescription Drug RFP

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Table of Contents

Page

Program Background & Overview ............................................................................................................. 1

Objective ................................................................................................................................................. 3

Information Required From Vendors ....................................................................................................... 3

Data for RFP ...................................................................................................................................... 3

Exhibit A – Benefit Summaries

Exhibit B – Census*

Exhibit C - PPO Plan - Top 250 Providers*

Exhibit D – Prescription Drug – Top 100 Providers*

Exhibit E – Claims and Enrollment Data*

Exhibit F – High Claimant Reports*

Exhibit G – Summary of Changes in Benefits*

* This information will be provided via secure e-mail once the vendor has registered and

completed the intent to bid.



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Program Background & Overview Current Program

HACC currently contracts with HealthAmerica for their Medical and Prescription Drug coverage.

HACC offers the plans listed below to full-time active employees and part-time employees who work at least 30 hours per week.

HACC has a very small number of retirees that are offered a Medicare Advantage Plan through HealthAmerica.

Eligible dependents are also eligible for coverage in each of the plans.

The current financial arrangement between HACC and HealthAmerica is a fully-insured prospective funding arrangement.

There are approximately 800 actives covered under the PPO plans.

Active Employees PPO Premium Plan (Current Enrollment 300):

HealthAmerica Premium PPO

Medical In Network Out of Network

Deductible $250/$500 $500/$1,000

Coinsurance 10% 20%

Out of Pocket Max $500/$1,000* $3,000/$6,000

Total OOP Max: $6,350/$12,700 n/a

UC/ER Visit $50 Urgent Care / $125 Emergency

OV Copay (PCP/Specialist) $20/$30 20%

Prescription Drug Retail Mail Order

Copayments $5/$40/$60 $10/$80/$120

*Out-of-Pocket Max does not include deductible or copayments

PPO Core Plan (Current Enrollment 500):

HealthAmerica Core PPO

Medical In Network Out of Network

Deductible $500/$1,000 $1,000/$1,500

Coinsurance 10% 30%

Out of Pocket Max $750/$1,500* $3,000/$6,000

Total OOP Max: $6,350/$12,700 n/a

UC/ER Visit $50 Urgent Care / $125 Emergency

OV Copay (PCP/Specialist) $25/$30 30%

Prescription Drug Retail Mail Order

Copayments $5/$40/$60 $10/$80/$120

*Out-of-Pocket Max does not include deductible or copayments



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Retirees – Medicare Advantage Program (Current Enrollment 32)

Active Employee and Retiree Contributions Employees and retirees are required to contribute to the cost of their health care and prescription coverage based upon the plan (Premium or Core) and tier (Single, Employee/Child, Employee/Children, Employee/Spouse & Family). The percentage of contributions shown in the following chart is based upon total expected plan costs (vendor premiums).

Active Employees Contributions (Approximate)

Salary Tier PPO Core PPO Premium

< $35,000 1% 8%

$35,000 - $65,000 5% 12%

> $65,000 11% 18%

Retirees pay 100% of the premium



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Objective HACC desires to obtain a qualified vendor(s) to provide health care and prescription drug coverage for benefit eligible employees, retirees, and dependents. The contract(s) entered into as a result of this RFP will be effective January 1, 2016, through December 31, 2018. In addition, the contract should provide for two one-year extensions. A minimum of a three (3) year rate guarantee (preferably five (5)) on the administration rate or premium rate, depending on funding method, should be provided. The contract should contain no termination penalty if HACC desires to terminate the contract early.

Information Required From Vendors Plan Specification – Medical & Prescription Drug Program

1. We are requesting that the quotes provided match the current plan designs. If HACC’s current benefits cannot be matched, please provide a plan design that is as close to their current plan design as possible. If there are benefit areas that you cannot match to the current design, please list and provide ideas on how to address these differences.

2. The contract will cover all full-time employees and part-time employees who work at least

30 hours per week. The contract will also cover eligible dependents. There is no actively-at-work requirement.

3. HACC will reserve the right to audit, either directly or through its authorized agent(s), the

vendor’s compliance with the terms of the contract.

4. The vendor must maintain an employee, retiree, and dependent eligibility system and handle coverage verification procedures. Initial enrollment/eligibility file will be furnished electronically from HACC/Bswift. The vendor must accept weekly updates containing additions, deletions, and status changes affecting enrollment from an electronic file produced by HACC/Bswift. The vendor must furnish a proposed file format and agree to work with HACC/Bswift on a file format and transmission that is acceptable to both parties.

5. The vendor must process eligibility updates (new enrollments, demographic changes,

coverage terminations, etc.) within 48 hours of receipt of an electronic file from HACC.

6. Eligibility forms that are faxed (including COBRA enrollments) to the vendor from authorized HACC representatives will be processed within 24 hours for emergency and urgent cases and within 48 hours for non-urgent cases.

7. Designated HACC personnel must have access to the vendor’s on-line enrollment system

and be able to input data in emergency situations.

8. The vendor will be required to provide a complete renewal each August 1 for the plan year effective the following January 1.



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9. For an insured arrangement, the vendor will be required to provide monthly reports showing incurred claims vs. income, lag reports, high claimants for the various group numbers.

10. For a self-funded arrangement, the vendor will be required to provide monthly individual

claims data. 11. The vendor must produce a SPD/Certificate of Coverage describing benefits coverage to be

made available no later than 90 days after the effective date. 12. The vendor must have the ability to process prescription drug overrides to maximum

quantities, refills too soon, etc., for employees in a traveling status. Technical Response – Medical and Prescription Drug General

1. State your ability to totally comply with the plan design specifications outlined above in the Plan Specifications section. Note any variations from the program specifications in your proposal, explain the variation, provide the reason you are not able to comply with the specification, and provide ideas on how you could address these differences.

Implementation 1. Provide an implementation time line identifying each task and target date for a January 1,

2016, effective date. On the time line, indicate HACC’s involvement in each phase, from initial response through implementation.

2. Provide copies of communication materials that you distribute to employees to announce

the HACC’s plan of benefits. Include a sample letter to employees announcing that your organization will be responsible for program administration effective January 1.

3. Indicate the flexibility HACC will have in communication materials. Is there a charge for

personalization?

4. Indicate if you would be willing to conduct open enrollment meetings at all HACC sites. Access

1. For the PPO plans, provide a GeoAccess study using the standards defined below and the employee residence zip code data provided on the census.

Two primary care physicians within 10 miles of an employee’s zip code.

Two specialty physicians within 10 miles of an employee’s zip code. Include all specialties. Be sure to include a list of the types of specialties.

One hospital within 15 miles of an employee’s zip code.

2. For the PPO plan, complete a network disruption analysis using the top 250 providers.

3. For the Prescription Drug Plan, complete a network disruption analysis using the top 100 pharmacies.



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4. Describe the process that allows HACC and its employees to recommend providers for

addition to the network. How difficult is this process? How long does this process take?

5. Complete the following chart to indicate provider activity in your networks.

Provider Activity Vendor Response

PPO Plan

Number of large physician group contracts that will expire within the next twelve (12) or twenty-four (24) months (please identify)

Number of hospital contracts that will expire within the next twelve (12) or twenty-four (24) months (please identify)

Number of physicians involuntarily terminated in 2013

Number of physicians involuntarily terminated in 2014

Percentage of PCPs accepting new patients

6. Do you expect any difficulty with renegotiating any expiring contracts for large physician

groups and hospitals? If so, what contingency plans are in place? Value-Driven Program Components

1. Describe any tools or applications available through your organization for the purposes of improving quality and engaging consumers.

2. Describe any incentives for high-value health care.

Service

1. Describe in detail your claims and appeal processes including the names of the companies you contract with to conduct the external review?

2. Are any of your customer service functions outsourced? If yes, please list. 3. Complete the chart below to provide information on your organization’s customer service.

Customer Service Area Vendor’s Response

Average hold time in seconds and average abandonment rate for calls in 2013 and 2014

Hours of operation of customer service unit

Will there be a dedicated toll free customer service unit for HACC employees?

Average length of service of the customer service representatives

Customer service employee turnover rate for 2013 and 2014

Member satisfaction rating in most recent member satisfaction survey



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4. Is your organization willing to establish a dedicated customer service unit?

5. Will your organization provide a dedicated account representative for HACC’s Human

Recourses Department? In addition, will your organization provide direct access to this person’s superior in the event they cannot access or are having issues with their dedicated account representative?

6. Describe the training process for your customer service representatives.

7. Does your organization perform client specific customer service satisfaction surveys? If yes,

how frequently and what guidelines are followed? 8. Do you have a website where members can view personal insurance information such as

whether claims have been processed or how much of their deductible has been used? 9. Does your website explain how the insurance plan works to educate members who are

attempting to understand co-pays, deductibles, co-insurance, limits, prior auth, procedures, etc.?

10. Does your company offer information for members transitioning to Medicare? 11. Describe your compliance with HIPAA. Include in your response details on your

organization’s policies on privacy, security (including physical safeguards), electronic data interchange requirements, and HiTech.

12. As it relates to HIPAA HiTech, has your company had any breaches?

13. Is your organization currently in any discussions to be purchased by another organization, to

purchase another organization, or to merge with another organization? If yes, provide details.

14. Describe customer services available through your mail-order pharmacy. Can members

reach a pharmacy assistant at your mail-order customer service telephone number?

Program Administration 1. Are any of your claims administration functions outsourced? If yes, please list. 2. Describe your claim payment turnaround time. 3. Provide samples of your standard reports.

4. In addition to your standard reports, are ad hoc reports available to HACC? If yes, are there

charges for these reports. 5. Please confirm your willingness to provide a comprehensive ASO reporting package

including individual claims data and enrollment on a monthly basis.



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6. Describe any and all differences that would impact HACC between a fully-insured arrangement and a self-funded arrangement. Please address wellness, medical/case management, claims and appeals, reporting, availability of communication material, employee meetings/training sessions, utilization review/utilization management, performance guarantees, etc.

7. Are there any services being provided under the insured arrangement that would NOT be

provided in the self-funded arrangement, or are any additional fees imposed under the self-funded proposal?

8. Describe the authorization override process used by your organization. Example: HACC has

a number of faculty members who travel abroad and occasionally have a need to obtain a larger amount of medication on short notice prior to travel. How would they be handled?

9. Do you have a program that offers 90 day prescriptions at the retail pharmacy? If so, does

mail order pricing apply?

Program Management

1. Provide information on how benefits are administered and claim costs determined for employees who reside out-of-area/out-of-state.

2. Provide information on how your organization handles claim payments to out-of-country

providers. Include in your response procedures for both individuals under age 65 and those who are enrolled in Medicare.

3. Describe your utilization review, continued stay review, and discharge planning processes?

Are results measured and quality/efficiency achieved?

4. Describe your organization’s prior authorization process including who initiates, time frames, communications to employees, etc. If denied, what is the appeal process and how long does it take?

5. Provide a list of drugs recommended for prior authorization/step therapy. 6. Provide a description of the process to select drugs for the formulary, the frequency that the

list is reviewed, and what information will be provided to HACC regarding changes that are made to the list. How does your company’s drug formulary compare to other health insurers? Is the formulary the same for all plans offered by your company? Is your company’s formulary available to view?

Wellness

1. List the education and wellness programs offered to employees through your PPO plans. 2. Provide sample material for two General Health Information categories and two Targeted

Condition Programs you have indicated above.

3. Describe any plans to expand or change web-based technology within the next 24 months.



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4. Provide web addresses and user ID/passwords for HACC’S demonstration purposes.

5. Describe in detail the various Health Risk Appraisal (HRA) tools your organization offers.

6. What chronic illnesses may be managed through your disease management program?

7. Does your HRA require results of biometric screenings? If so, which are needed?

8. Does your HRA result in specific recommendations to the employee?

9. Are “readiness to change” questions included in the HRA? If so, are the “readiness to

change” responses used to tailor the feedback in the individual reports, and do the management reports outline “readiness to change” shifts as part of the data reported to the employer?

10. Do you have available health promotion and lifestyle improvement programs that could be

matched with any recommendations made through the HRA?

11. Do you provide health screening and biometric testing services for clients? If so, how are these provided?

12. Indicate which of the following methods are used to identify individuals with health risks or

conditions by completing the chart below.

Method Check if applicable

Health risk appraisal

Medical claims data (in- and out-patient)

Behavioral health claims

Pharmacy claims

Laboratory claims self-reporting

Other (please list)

13. Describe in detail your organization’s approach to providing telephonic health coaching

services for both lifestyle improvement and disease management. Include when clinical and non-clinical personnel are interacting with participants and the activities they support. Include the qualifications for personnel performing both disease management and health coaching services.

14. Are health coaching services provided by employees of your organization, or are they

contracted out? 15. Is an HRA aggregate report assessing the health status of the entire employee/spouse

population automatically prepared for the employer? If yes, does the report provide recommendations for the employer? Can this be broken down by groups, i.e., by university or by employee groupings?

16. Please provide a typical employer report containing summary HRA findings.



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17. Does your company offer a nurse-on-call hotline? Is it available 24/7? 18. Does your company offer health educational material to members?

Case Management 1. How do you identify cases for case management?

2. What are the credentials of your case managers?

3. How would you educate employees as to the services offered through case management?

4. Describe any disease state and large claim management programs and reporting processes.

5. Describe current programs that integrate prescription and medical claims data and

exchange information with medical case managers. List and briefly describe the criteria used to identify patients for case management, and describe how you integrate with the health care vendor case management programs.

6. Describe any disease state management programs, step therapies, or initiatives, and

indicate the value or expected value of these services.

Personnel 1. Provide a list all of the individuals that will be responsible for servicing HACC under this

contract. References

1. Provide references for three current accounts serviced by the same key personnel that will provide service to HACC. The accounts should be comparable in size to HACC with similar geographic location. Public sector and/or higher Education clients are preferred. Provide the following information:

Client Name Length of relationship Number of participants Contact’s name, title, and phone number

2. Complete the chart below to provide references for two accounts comparable in size and

geographic area to HACC that have terminated your services in the last two years for reasons other than merger or acquisition. Provide the following information:

Client Name Length of relationship Reason for termination Number of participants Contact’s name, title, and phone number



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Response to Cost Proposal

1. Please quote on an experience-rated basis and provide details (actual rate calculation) for the calculation of the initial rates, including a breakout of anticipated claims expenses (i.e., pure premium) and non-claims expenses (i.e., retention). Explain simply (verbally and through the numeric example) how the proposed rates were developed from current claims experience including levels of discounts, assumed network utilization, etc. There should be no commissions included in any of the proposed rates.

2. Do not include any commissions in any of the rates.

3. Please provide tiered rates based on the following factors:

Actives Single 1.00 Employee/Child 1.70 Employee/Children 2.63 Employee/Spouse 2.25 Family 2.90

4. HACC is requesting a “Not to Exceed” rate cap for at least the renewals at Jan 1, 2017 and

Jan 1, 2018. Consider providing a cap for the Jan 1, 2019 and Jan 1, 2020 renewal. Please provide this with the RFP.

5. Fully-insured arrangements - Please provide quotes based on the following funding

arrangements:

Prospective

Any other fully-insured arrangement that you may offer (Retro, Min Premium, Loss Ratio arrangement, etc.)

6. Self-funded (ASO) arrangement - Provide a PCPM administration fee for an effective date of

1/1/2016. Provide a 5-year rate guarantee.

7. Self-funded (ASO) arrangement - Please provide budget rates and details of the budget rate development.

8. Under an ASO funding arrangement, is an advance deposit, cash advance, or letter of credit

required? If so, are there any payment options available that would eliminate this requirement?

9. Under an ASO funding arrangement, is there an administrative expense for processing run-

out claims should there be a desire to return to a fully-insured program or switch to another self-funded administrator?

10. For each of the funding arrangements quoted, what is the total retention/administration

charge included in the rates? (Please provide in the form of percentage (%) of premium and a flat PCPM charge).



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11. For each of the funding arrangements quoted, provide a breakdown of the components that make up retention and what percentage each component represents of total retention. How long of a period of time is this retention percentage and PCPM guaranteed?

Component % PCPM

Administration

Premium Tax

Risk

Profit

Commissions

Contingency

Other (provide detail)

Total

12. Describe your current pooling level(s) and how any applicable charge is calculated.

13. What level of pooling and charge has been included in the quote?

14. Please provide quotes for specific and aggregate stop loss coverage for medical and

prescription drug. For the specific, please quote $150,000, $200,000, and $250,000 with a 12/12, 12/15, & 12/24 contract. For the aggregate, please quote 110%, 120%, and 125%. Please provide FINAL stop loss quotes for January 1, 2016.

15. Are first year stop loss premiums discounted to account for “run-in” claims? If so, by how

much? 16. Are there any reinsurers/stop loss carrier you cannot work with? Do you have preferred

reinsurers that you work with? If so, please list them and explain any advantage you see in working with them.

17. Explain in detail the process of claims exceeding the stop loss insurance. Would HACC be

required to fund the claim initially and wait for reimbursement (if so, include the average wait time), or would the stop loss carrier automatically fund the claims?

18. What is the earliest a stop loss renewal can be provided? Guaranteed? 19. For in-network providers, please provide details on your provider-negotiated contracts

(specify percentage difference between negotiated amounts vs. charges). Provide the basis for your in-network reimbursement levels.



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In addition, please provide the average per-service cost for the listed services provided in the following zip codes: 17110, 17404, and 17602.

Procedure Code Description

Zip Code 17110

Zip Code 17404

Zip Code 17602

99213 Office Medical Visit


90806 Individual Psychotherapy

97110 Physical Therapy

J7185 Injection

88305 Surgical Pathology


97140 Physical Therapy

00810 Anesthesia

H2021 Community Based Wrap Around Service

S0612 Gynecological Exam

98941 Chiropractic Manipulative Treatment


99232 Subsequent Hospital Care



99285 ER Visit

66984 Extracapsular Cataract Removal


99396 Preventive Medicine

A0427 Ambulance Service

59400 Routine Obstetric Care

92014 Ophthalmological Services

99284 ER Visit

95165 Professional Services – Antigens

93306 Echocardiography

77418 Intensity Modulated Treatment Delivery

G0202 Screening Mammography

99243 Office Visit

97112 Therapeutic Procedure

00740 Anesthesia

70553 Magnetic Resonance Imaging

99223 Initial Hospital Care – per day

H0032 Mental Health Service

97014 Application of a modality

90801 Psychiatric Diagnostic Interview

59510 Routine Obstetric Care

78452 Myocardial Perfusion Imaging

99233 Subsequent Hospital Care, per day

45380 Colonoscopy



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20. Are there any access fees (i.e., network fees) that you are required to pay to other carriers? If so, please explain in detail and provide fees.

21. Please provide the average hospital and physician discounts as of January 2015 for hospitals

and physicians in the following Pennsylvania counties:

Hospital Physician

Adams

Cumberland

Dauphin

Lancaster

Lebanon

York

22. Performance Guarantees - Provide performance guarantees tied to plan implementation

(first year only), member satisfaction, reporting/recordkeeping, quality assurance and account management. Complete the chart below to propose your performance measures and amount of fee at-risk.

Vendor’s Response

Plan implementation (first year only)

Performance standard

Performance guarantees

Percent of fee at-risk

Member Satisfaction




Reporting/Recordkeeping




Quality Assurance




Account Management




23. Please provide details on your “other party liability” functions including documentation of quantifiable savings.



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24. Please provide details on your subrogation functions including documentation of

quantifiable savings. 25. What is the cost of medical case management and the expected future cost savings? What

are the savings that you guarantee?

26. Please detail your retail pricing formula for the ingredient component. Does the pricing formula include MAC, AWP, formulary, usual, reasonable, and customary charges? Is acquisition cost plus pricing utilized? What overall discount guarantee is applied to generic and brand drugs? What are the dispensing fees? Over what time period is the pricing formula guaranteed? Are there any additional fees charged to the client?

27. Please detail your mail-order pricing formula for the ingredient component. Does the pricing

formula include MAC, AWP, formulary, usual, reasonable, and customary charges? Is acquisition cost plus pricing utilized? What overall discount guarantee is applied to generic and brand drugs? What are the dispensing fees? Over what time period is the pricing formula guaranteed? Are there any additional fees charged to the client?

28. Please provide all rebate guarantees for both retail and mail order. Specify whether the

rebates are per claim, per brand claim, or per rebateable claim. 29. Will HACC receive 100% of the rebates? 30. What other payments do you get from drug manufacturers besides rebates? Are these

payments passed through to HACC? Please explain. 31. Please provide pricing and details relative to any specialty injectable programs. Include a

complete list of specialty drugs along with the pricing of each. 32. Please provide a flowchart of the prescription drug distribution process starting at the drug

manufacturer and ending when the drug is dispensed to the participant. Please include the cost structure at each level.

33. Provide details on pricing for any wellness component that is not included in the price of the

fully-insured medical premium or the self-funded admin rate.



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BID CERTIFICATION

(date)

Procurement and Contracts HACC, Central Pennsylvania’s Community College One HACC Drive Harrisburg, PA 17110

The undersigned certifies that to the best of his/her knowledge: (check one)

( ) There is no officer or employee of HACC, Central Pennsylvania’s

Community College, who has, or whose relative has, a substantial interest in any contract award pursuant to this proposal/bid.

( ) The names of any and all public officers or employees of HACC, Central

Pennsylvania’s Community College, who have, or whose relative has, a substantial interest in any contract award pursuant to this proposal/bid are identified by name as part of this submittal.

The undersigned further certifies that their firm (check one) IS or IS NOT currently debarred, suspended, or proposed for debarment by any state or federal entity. The undersigned agrees to notify the College of any change in this status, should one occur, until such time as an award has been made under this procurement action.

In compliance with Request for Proposal RFP15-16 for MEDICAL & PRESCRIPTION DRUGS and after carefully reviewing all the terms, conditions and requirements contained therein, the undersigned agrees to furnish such goods/services in accordance with the specifications/scope of work.

Firm Address

Signature Required Phone No.

Print Name Fax No.

Title Federal ID #

Request for Proposals For Medical and Prescription Drug · Medical & Prescription Drug RFP 6...

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