REQUEST FOR PROPOSAL
FLEX BENEFITS HEALTH PLANS City of Los Angeles Flex Benefits Program Personnel Department - Employee Benefits Division Joint Labor-Management Benefits Committee
Date Issued:
February 12, 2016
TITLE:
FLEX BENEFITS PROGRAM MEDICAL PLANS: NATIONAL PROVIDER NETWORK: PREFERRED PROVIDER ORGANIZATION (PPO) STATEWIDE PROVIDER NETWORK: STAFF MODEL HEALTH MAINTENANCE ORGANIZATION (HMO) STATEWIDE PROVIDER NETWORK: FULL NETWORK MODEL HEALTH MAINTENANCE ORGANIZATION (HMO) STATEWIDE PROVIDER NETWORK: NARROW NETWORK MODEL HEALTH MAINTENANCE ORGANIZATION (HMO) ALTERNATIVE PROVIDER NETWORK AND CARE MODELS - REGIONAL/LOCAL PROVIDER NETWORK HEALTH MAINTENANCE ORGANIZATION (HMO) - ACCOUNTABLE CARE ORGANIZATIONS (ACO) - PATIENT CENTERED MEDICAL HOME (PCMH) - OTHER ALTERNATIVE NETWORK OR CARE MODELS
CONTRACT TERM: A period of three years with a City option for up to two additional years from the contract effective date as provided for by the final contract. PRE-PROPOSAL CONFERENCE: MARCH 2, 2016 1:00 p.m. – 2:00 p.m. Personnel Department Training and Testing Center 520 E. Temple Street Los Angeles, CA 90012 Training Room A/B PROPOSAL DELIVERY ADDRESS: City of Los Angeles Attention: Maria Koo City Hall 200 North Spring Street, Room 867 Los Angeles, CA 90012 1
DEADLINE FOR SUBMITTING PROPOSAL: MARCH 25, 2016 at 3:00 p.m. DEADLINE FOR OUTREACH TO SUBCONTRACTORS (pursuant to the City’s Business Inclusion Program outreach requirements): MARCH 10, 2016 at 11:59 p.m. RFP ADMINISTRATOR: Maria Koo, Senior Personnel Analyst Phone (213) 978-1597 Email:
[email protected]
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PART A TABLE OF CONTENTS
PAGE NUMBER
Section 1: Introduction/Background
4
Section 2: Plan Profile & Scope of Services
11
Section 3: Proposal Questionnaire
25
Section 4: Submission Requirements
58
Section 5: Evaluation of Proposals
67
Section 6: General Terms and Conditions
70
PART B City of Los Angeles General Contracting Requirements (Rev. 6/14)
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SECTION 1
INTRODUCTION/BACKGROUND 1.0
INTRODUCTION
The City of Los Angeles is seeking proposals for fully insured health plan benefits for its Civilian Flex Benefits Program. The mission of this procurement is to identify the service provider(s) who can best support the Flex population in its health and wellness efforts by: Providing a broad range of quality choices for members in delivery model and benefit levels; Providing access to services and care across the Los Angeles region and surrounding communities; Communicating and assisting members in navigating benefit and service complexity; Providing effective member self-service tools; Effectively engaging members in the prevention, diagnosis, and treatment of disease; and Producing and improving upon measurable member outcomes. It is the City’s intent to approach this procurement from a “member-based” perspective focused first and foremost on addressing the support services, quality of care, access to care, and communications efficacy that Flex members are most concerned with and which directly impact their health and wellbeing. The City currently contracts with service providers who provide Flex members with broad geographic access to care across the Los Angeles region and surrounding communities, as well as with an option that provides national access to providers. The current providers are Kaiser Permanente, which offers a Staff Model HMO plan; and Blue Shield, which offers a Network Model HMO (Narrow/Full Network) as well as a PPO plan. Pursuant to this RFP, the City is soliciting proposals for a National Provider Network Preferred Provider Organization (PPO); a Statewide Provider Network Staff Model Health HMO; a Statewide Provider Network Full Network Model HMO; and a Statewide Provider Network Narrow Network HMO. These plans comprise the core menu of offerings presently offered to the City’s Flex Benefits population. In addition, the City will also consider proposals for alternative provider network and care models which may be offered as part of the core menu of offerings and could include more narrowly tailored regional local provider network HMOs; Accountable Care Organizations (ACOs); Patient Centered Medical Homes (PCMHs); and/or other alternative network or care models. Further details regarding each model type included within this RFP are provided as follows:
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CORE MENU Statewide Provider Network Staff Model Health HMO A Staff Model involves an insurance company providing a fully insured Health Maintenance Organization (HMO) whereby doctors, hospitals and other healthcare providers are combined within a fully integrated system. Participants must access covered services as directed by a Primary Care Physician (PCP). Benefits include physician, hospital, prescription drug, and vision services.
Statewide Provider Network Full & Narrow Network Model HMO A Network Model involves an insurance company providing a fully insured Health Maintenance Organization (HMO) that provides care through a network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP). Benefits include physician, hospital, prescription drug, and vision services.
National Provider Network Preferred Provider Organization (PPO) A Preferred Provider Organization model involves an insurance company providing a fully insured network of medical doctors, hospitals and other health care service providers offering medical care at reduced rates to the insurer's or administrator's clients. Benefits include physician, hospital, prescription drug, and vision services.
OPTIONAL SUPPLEMENTARY MODEL(S) ALTERNATIVE PROVIDER NETWORK AND CARE MODELS Alternative Care Providers include alternative delivery models such as Regional/Local Health Maintenance Organization (HMO), Accountable Care Organizations (ACOs), PatientCentered Medical Homes (PCMH), and other models that may be more narrowly tailored by region, provider risk sharing structures, networks, or philosophy of care.
Proposal Options: A vendor may submit a proposal or proposals for any or all of the service provider categories indicated above. Proposals for each plan type will be evaluated separately. The City reserves the right to contract with multiple vendors pursuant to this RFP and to select more than one vendor within any provider category. Fully insured premium proposals for each medical plan category must be separately provided. 1.1
DEFINITIONS OF TERMS
The following terms used in the RFP documents shall be defined as follows:
“Agreement” or “Contract” will mean the contract to be entered into between the City and proposer(s). “Alternative Provider Network or Care Model” will mean alternative delivery models such as Regional or Local Health Maintenance Organizations (HMOs), Accountable Care 5
1.2
Organizations (ACOs), Patient-Centered Medical Homes (PCMH), and other models that may be more narrowly tailored by region, provider risk sharing structures, networks, or philosophy of care. “Bidder” or “Proposer” will mean the entity that responds to the Request for Proposal. “City” will mean the City of Los Angeles. “Contractor” will mean the individual, partnership, corporation or other entity to which a contract is awarded, and will be synonymous with the term “vendor”. “Department” will be considered synonymous with the City’s Personnel Department. “Flex Benefits Program” will mean the City’s benefits program for its Civilian and other eligible employees. “JLMBC” will mean the City of Los Angeles Joint Labor Management Benefits Committee. “MOU” will mean a Memorandum of Understanding, or collective bargaining agreement, to which an employee labor organization and the City of Los Angeles are both parties. “Non-Represented” will mean an employee who is not represented by a City of Los Angeles employee bargaining unit. “Network Model HMO” will mean a fully insured Health Maintenance Organization (HMO) that provides care through a network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP). “PPO” will mean a fully insured network of medical doctors, hospitals and other health care service providers offering medical care at reduced rates to the insurer's or administrator's clients. “Represented” will mean an employee who is represented by a City of Los Angeles employee bargaining unit. “RFP” will mean this Request for Proposal for contracted services issued by the City of Los Angeles. “Staff Model HMO” will mean a fully insured, fully integrated Health Maintenance Organization (HMO) that provides care through an integrated network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP). CONTRACT TERM
The term of any contract(s) awarded pursuant to this RFP shall be for a period of three years with a City option for renewal of up to two additional years from the contract effective date as provided for by the final contract. The service agreements resulting from this RFP will at maximum length cover the period January 1, 2017 through December 31, 2021. 1.3
RFP CONTENTS
The contents of this RFP are as follows: PART A – Request for Proposal, including the Plan Profile & Scope of Service, Proposal Questionnaire, Submission Requirements, Evaluation of Proposals, and General Terms and Conditions. PART B – General Contracting Requirements and Attachments, which includes the City of Los Angeles Standard Provisions for City Contracts (Rev. 6/14) and other general contracting requirements that must be reviewed and completed by proposers as specified in order for a proposal to be deemed responsive. 6
1.4
RFP CONTACT INFORMATION
The Personnel Department and JLMBC are committed to ensuring that all Flex Benefits business transactions, including procurement processes, are based strictly on integrity, competence, merit and benefit to Flex members and their dependents. As a matter of policy, JLMBC members and staff will not communicate with current or prospective vendors or their representatives, or any other person or organization, for the purpose or intent of having a particular vendor secure or maintain a contract or business with the Flex Program, or otherwise realize financial gain from the Flex Program, whether during or outside of a procurement process. In support of this, and to ensure the transparency and objectivity of this procurement process, all communications and questions regarding or related to the services included in this RFP should be directed as follows: PART A Contact Information All questions regarding this RFP PART A must be in writing and should be directed to the RFP Administrator as follows:
Personnel Department, Employee Benefits Division Maria Koo
[email protected] (213) 978-1621
PART B Contact Information All questions regarding this RFP PART B must be in writing. Questions may be directed to the Personnel Department’s Administrative Services Division staff as follows:
Personnel Department, Administrative Services Division Roberta (Bobbi) Jacobsen
[email protected] (213) 473-9148
Questions regarding certain General Contracting Requirements may also more appropriately be directed to the City department responsible for the particular requirement, as specified within the Part B materials. 1.5
GENERAL INFORMATION AND PRE-PROPOSAL CONFERENCE
The City intends to award a contract, in a form approved by the City Attorney, to the selected proposer. Written proposals submitted to the City constitute a legally binding contract offer and shall remain open for twelve (12) months. It is requested that proposals be prepared simply and economically, avoiding the use of unnecessary promotional material.
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Proposal Timeline The following is the current timeline for the RFP process. The City reserves the right to adjust this schedule. Changes to the timeline, if any, will be posted online as an RFP Addendum. Proposal Timeline Dates
Event
February 12, 2016
Request for Proposal Released
February 24, 2016
Deadline for receiving written questions for the PreProposal Conference is 4:00 p.m.
March 1, 2016
Deadline to register to participate in Pre-Proposal Conference by telephone is 4:00 p.m.
March 2, 2016
Pre-Proposal Conference at 1:00 p.m. Pacific Standard Time
March 9, 2016
General Contracting Requirements Preliminary Submission Deadline
March 16, 2016
_______________
March 18, 2016
City Review of General Contracting Document Due to Vendor by This Date Deadline for vendors to issue written solicitations to subcontractors via www.labavn.org website. This step must be completed by ______________ Pacific Standard Time to avoid risk of late submission. Deadline for receiving written questions regarding the RFP is 4:00 p.m.
March 25, 2016
RFP responses due by 3:00 p.m. Pacific Standard Time
March 26, 2016
BIP Summary Sheet Submission on LABAVN – 4:30 p.m. Pacific Standard Time
March 25-April 30, 2016 May-June, 2016 December 31, 2016 January 1, 2017
RFP evaluations City makes selection and begins contract negotiation with successful proposer Deadline for executing contract Commencement of Services
Pre-Proposal Conference A Pre-Proposal Conference will be held to provide information regarding the RFP requirements and answer questions from prospective proposers regarding this RFP. The Pre-Proposal Conference will also give proposers and potential subcontractors the opportunity to network. City staff will not provide assistance regarding a proposer’s individual RFP response. The conference has been scheduled pursuant to the schedule noted in the Proposal Timeline. Potential proposers may participate by physically attending or by calling in to the conference. Participants will be asked to identify themselves by name and firm. 8
If you intend to participate by telephone, please pre-register by contacting the RFP Administrator by the deadline noted in the Proposal Timeline. The City will provide a call-in number at that time for those interested in participating by telephone. It is to your benefit to bring your own copy of the RFP, particularly the City’s General Contracting requirements, to the conference. No copies will be provided at the conference. Questions Regarding the RFP To maximize the effectiveness of the conference, to the extent possible, proposers should provide questions in writing prior to the conference in accordance with the deadline noted in the Proposal Timeline. This will enable the City to prepare responses in advance. Specific questions concerning the RFP should be submitted in writing via e-mail to the RFP Administrator. Please identify the RFP title on the subject line of your message. All questions should identify the RFP section and page number, or the relevant General Contracting provision, for each question submitted. Additional questions may be accepted and addressed at the conference. However, certain responses may be deferred and posted online as addenda to the RFP at a later date. All questions regarding the RFP should be in writing and sent via e-mail to the RFP Administrator. The City will make every effort to respond to all written questions as soon as practical. All questions and responses to questions, or any other changes to or interpretation of the RFP, will be posted on the Plan’s website at www.labavn.org. Any such changes or interpretations shall become a part of this RFP and may be incorporated into any Contract awarded pursuant thereto. 1.6
GENERAL CONTRACTING SUBMISSION DEADLINES
REQUIREMENTS
PRE-SUBMISSION
OPTION
AND
The City’s General Contracting Requirements are included in Part B, which is attached hereto. Part B contains the Standard Provisions for City Contracts and a variety of documents and forms with which prospective City vendors must demonstrate compliance in order to be awarded a City contract. Within Part B is a list of requirements that must be fully met, including forms to be completed and submitted and details regarding certain processes which must be followed by prospective vendors as part of their RFP response. Failure to meet any of these requirements to the satisfaction of the City by the RFP Proposal Submission Deadline will result in disqualification of the vendor’s proposal as being non-responsive. The City will provide vendors an opportunity to demonstrate responsiveness to the City’s General Contracting Requirements at a date prior to the Proposal Submission Deadline. Vendors are not required to complete and submit their General Contracting Requirements forms/processes by the Preliminary Submission Deadline; however, it may be to their advantage to do so. If a vendor utilizes this option, City staff will identify whether the documents as submitted are or are not responsive to the City’s requirements. If deemed non-responsive, the vendor will have time to demonstrate responsiveness with its proposal at the RFP Proposal Submission Deadline. Following the Proposal Submission Deadline, there will be no further opportunity for demonstrating responsiveness to the City’s General Contracting Requirements. Failure to adequately demonstrate responsiveness to the City’s General Contracting Requirements, or a rejection by the vendor of those 9
requirements or the Standard Provisions for City Contracts, will result in disqualification of the proposal. The relevant dates with respect to this process are included in the Proposal Timeline. 1.7 PROPOSAL SUBMISSION DEADLINE Response to this RFP must be submitted on paper and electronic copy must be received by the RFP Administrator by the Proposal Submission Deadline noted in the Proposal Timeline. Electronic portions, as specified further in this RFP, must be received no later than this date/time as well. Late responses will not be considered. The City reserves the right to extend the Proposal Submission Deadline should this be in the interest of the City. 1.8 CONSULTANT RESPONSE INFORMATION Responses to this RFP must also be submitted at the same time on paper and electronic copy to the consultants used by the City in the evaluation of responses to this RFP. Delivery should be provided to: Segal Consultants Attention: Stephen E. Murphy Vice President, Benefits Consultant 330 N. Brand Blvd., Suite 1100 Glendale, CA 91203-2337
[email protected] Keenan Consultants Attention: Laurie Lofranco Vice President Municipalities 4204 Riverwalk Parkway, Suite 400 Riverside, CA 92505
[email protected]
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SECTION 2 MEDICAL PLANS PROFILE & SCOPE OF SERVICES A. FLEX BENEFITS PLAN OVERVIEW The City of Los Angeles Flex Benefits Program is offered to eligible full-time and half-time employees of the City of Los Angeles Civilian employee population. The City offers its Civilian Flex Benefits Program (“Flex Benefits”) under Internal Revenue Code (IRC) Section 125. The Flex Benefits Program includes approximately 24,000 City employees and their 32,000 dependents. In 2016 the Flex Program will spend approximately $297 million in combined employer and employee contributions to health insurance premiums to its medical service providers, along with an additional $41 million on combined premiums for other Flex Benefits service providers (dental, life, disability, & AD&D). B. FLEX PROGRAM GOVERNANCE & CONTRACTING AUTHORITY The City’s Joint Labor-Management Benefits Committee (JLMBC) and the Personnel Department's Employee Benefits Division administer the Flex Benefits Program for active City civilian employees and their qualified dependents. The JLMBC is composed of five management and five labor representatives and makes recommendations to the General Manager Personnel Department for Flex Benefits service provider selections. The General Manager Personnel Department is the contracting authority for Flex Benefits service providers. The JLMBC will be reviewing the findings of a designated review panel for this RFP in generating its recommendations to the General Manager Personnel Department. C. CORE MISSION The core mission of the Flex Benefits Program is to promote employee health/wellness with competitive benefits at a reasonable level relative to the City's financial capacity. Promoting employee health/wellness involves delivering the support services, quality of care, access to care, and communications efficacy that directly impact the health and wellbeing of Flex members. D. KEY SUCCESS METRICS The key metrics for evaluating the success of the City’s medical plans in meeting the Flex Benefits Program’s core mission include the following:
Member Satisfaction Quality of Care Access to Care Wellness, Prevention & Disease Management Cost & Affordability 11
E. FLEX BENEFITS PROGRAM DESIGN The Flex Benefits Program presently offers employees a menu of medical, prescription drug, vision, dental, life, disability, employee assistance and tax-advantaged savings programs, detailed with incumbent service providers as follows: MEDICAL Statewide Staff‐Model HMO
LIFE INSURANCE
DENTAL
Kaiser Permanente Statewide Narrow Network HMO Statewide Full Network HMO National PPO Blue Shield
Preventive Only
Basic life
DHMO
Supplemental life (1‐5 times pay)
PPO
Dependent life
Delta Dental
The Standard Insurance Company
All Medical plans include vision
DISABILITY INSURANCE Basic disability
ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Voluntary AD&D
Supplemental disability The Standard Insurance Company
Dependent AD&D The Standard Insurance Company
TAX‐ADVANTAGED SAVINGS ACCOUNTS Flexible Spending Dependent Care Reimbursement Transportation Spending Parking Spending Wageworks
EMPLOYEE ASSISTANCE PROGRAM Managed Health Network
F. SUMMARY MEDICAL DATA Indicative statistical data regarding the City’s health plans is provided in Attachment A, and includes the following:
Current enrollment information Current and historical premium information Access to the City’s most recently published Evidence of Coverage documents Historical plan experience Benefit Summary Data
G. ELIGIBILITY Full-Time Employees - The eligible population includes all Civilian full-time employees who are contributing members of the City’s Los Angeles City Employees’ Retirement System (LACERS) and who are working a minimum of 40 hours per pay period1. In addition, eligible employees must also meet at least one of the following requirements:
1
Or alternate number of hours specified in a Memorandum of Understanding 12
Eligible for membership within one of the employee representation units where the Flex Program has been negotiated through a Memorandum of Understanding (MOU). A “Non-Represented” Civilian employee. A Port Police Officer (MOU 27 or MOU 38) and a member of Tiers 5 or 6 of the Fire & Police Pension System. An elected official of the City of LA or a full-time member of the Board of Public Works. Half-Time Employees – The eligible population includes all Civilian half-time employees who are contributing members of LACERS and who are working a minimum of 20 hours per pay period. Employees in part-time, temporary or seasonal positions who are not LACERS members are not generally eligible for Flex Benefits unless pursuant to requirements of the Affordable Care Act (ACA) and any negotiated provisions for ACA-compliant health care as provided for in the applicable MOU. Employee Family Member Eligibility – Flex members may also enroll eligible dependents including a spouse, domestic partner, biological or step child, child of a domestic partner, grandchildren for whom the member has legal custody, and grandchildren of children who are up to age 26, unmarried, and financially dependent on the member. H. HEALTH INSURANCE COVERAGE TIERS Flex members may elect from one of the following four coverage tiers for health insurance:
Employee Employee + Spouse/Domestic Partner Employee + Child(ren) Employee + Family
I. PREMIUM COST-SHARING Premium Cost-Sharing Models - The Flex Benefits program has three primary cost-structure arrangements which are determined by applicable MOU provisions: Flex Plan - has no required percent of premium contribution from the member towards the member’s health insurance, but a member will pay the difference between the negotiated maximum subsidy and the full premium. Flex Pay 1 - has a required 5% percent of premium contribution from the member towards the member’s health insurance, plus a member will pay the difference between the negotiated maximum subsidy and the full premium. Flex Pay 2 - has a required 10% percent of premium contribution from the member towards the member’s health insurance, plus a member will pay the difference between the negotiated maximum subsidy and the full premium. In addition, beginning January 1, 2017, certain current “Flex Plan” employees in certain bargaining units representing approximately 65% of the Flex member population will pay 1.5% of their base salary towards the aggregate cost of health care premiums for their members. These individuals will simultaneously receive a 1.5% salary bonus. On a per-member basis, the contributions of 1.5% of pay will not alter the fundamental structure of the “Flex Plan, Flex Pay 1, and Flex Pay 2” premium structure models. All premium cost-sharing provisions are subject to change in future MOUs. 13
In 2016 the City will pay approximately 96.2% and members will pay approximately 3.8% of total health insurance premiums. 73% of members do not have a contribution towards their premiums, while 27% do have a contribution. Please refer to Attachment B (Census File) for details. Maximum Subsidy – For full-time employees, the maximum subsidy provided by the City for the Flex Plan for all medical plan models (excluding the HMO Full Network) is 100% of the Kaiser full family premium. The maximum subsidy provided by the City for Flex Pay 1 for all medical plan models (excluding the HMO Full Network) is 95% of the Kaiser full family premium. The maximum subsidy provided by the City for Flex Pay 2 for all medical plan models (excluding the HMO Full Network) is 90% of the Kaiser full family premium. With respect to the HMO Full Network, the City pays the subsidy up to the subsidy amount paid by the City for HMO Narrow Network coverage as applicable within Flex Plan, Flex Pay 1, and Flex Pay 2. Regular Half-Time Employees: The City’s maximum subsidy for those categorized as Regular HalfTime employees and hired after July 20, 1989 is the Kaiser single party premium less applicable cost sharing of 10% as provided for under Flex Pay 2. Regular Half-Time Employees hired prior to July 20, 1989, are eligible for 100% of the Kaiser full family premium. J. THIRD-PARTY-ADMINISTRATION The City presently contracts with Mercer Benefits Administration to provide third-party-administrator (TPA) services for the Flex Benefits Program. The TPA is responsible for administering eligibility and benefit elections. Relative to health insurance, the TPA recordkeeps employee eligibility through a data exchange with the City’s payroll system, as well as employee elections of providers, coverage tiers, dependents, family status changes, etc., as a result of either Open Enrollment (held in October of each year) or family status or employment status changes which occur throughout the year. Data updates are provided to the health insurance carriers on a bi-weekly basis.
ORGANIZATIONAL STRENGTH, RECORDKEEPING & PLAN SPONSOR SERVICES K. ORGANIZATIONAL QUALIFICATIONS AND RELIABILITY (1) Organizational Background, Financial Strength, Experience The City will be evaluating each proposer’s organizational experience, stability, financial strength, experience in administering medical plans, staff qualifications and turnover, and other factors related to determining the degree to which an organization can be a long-term viable partner with the City in executing the Flex Program’s mission, goals and strategies. (2) References The City will be evaluating references provided by the proposer, including governmental plan sponsors who are currently utilizing the provider’s services as well as those who have terminated those services in the recent past.
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(3) Regulatory and Compliance Services The City relies on the medical provider’s regulatory and compliance services to ensure that administrative functions are conducted in accordance with Internal Revenue Code rules and guidelines. The City will be reviewing each proposer’s organizational resources for enforcing, monitoring and providing updates to plan sponsors regarding regulatory processes and changes. (4) HIPAA Compliance The City will be evaluating each proposer’s Health Insurance Portability and Accountability Act (HIPAA) compliance plans and member communication processes to ensure that the Flex Benefits program meets all requirements. (5) Rating Agency Financial Ratings The City will be evaluating each proposer’s rating agency financial ratings as a means of assessing organizational stability and reliability. L. ADMINISTRATION SUPPORT & ACCOUNT MANAGEMENT (1) Claims Processing The City values service provider attention to organizational efficacy with respect to the claim administration process. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to the timely and accurate processing of claims, and effectively communicating with members regarding their benefits and how to successfully navigate the claims process. (2) Billing & Eligibility The City seeks to ensure that each proposer can work with the City’s TPA with respect to data file transfers, and will also evaluate each vendor’s billing and payment requirements. (3) Plan Sponsor Services The City will be evaluating the plan sponsor services provided by each proposer, including its electronic and written reporting capabilities, new member processing requirements and timeframes, processing of ID cards, and other services in support of City membership. (4) Imaging & Document Storage The City will evaluate the provider’s resources for imaging and storing member records, documents, and forms related to the administration of member accounts.
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(5) Security Protocols, Disaster Recovery & Guarantees The service provider is responsible for maintaining the confidentiality and security of participant records relative to its administration of the Plan. “Confidential Information” includes participant data, records and personal information such as social security numbers, dates of birth, marital status, home addresses, contribution and account balance information, investment information, transaction histories, and other information related to participation in the Plan. The provider will need to execute, as part of its contract, a Confidentiality Agreement providing that all confidential information provided to the provider by or on behalf of City and/or City Personnel, or accessed or reviewed by the provider during the performance of the Contract, is and will remain the confidential property of the City. The provider will be required to further agree not to provide or divulge confidential information to any other person or entity except as authorized in writing by the City. The provider will also be responsible for protecting the confidentiality and maintaining the security of all confidential information in its possession by implementing and maintaining adequate and necessary security systems, along with policies and protocols, to provide the highest reasonable level of safety and security of the confidential information. In the event of a security or data breach, the provider must have in place an emergency response plan. The provider must, if there is a breach of its security system and confidential information is accessed or believed to have been accessed, include the information in Civil Code Section 1798.82(d)(3) in the required notification of a breach and indemnify the City against any losses in connection with the data breach. In addition, the provider will also be required to demonstrate its participant protection and remediation plan, including but not limited to the purchase of credit protection services for impacted participants. Finally, the provider is responsible for establishing contingency plans for emergencies, disasters, and disaster recovery. These plans should include redundant processing centers and plans for activating the necessary participant support services in the event a primary processing center is, for emergency reasons, not available. These plans should also address backup systems and records in the event of damage or disaster impacting the storage and maintenance of the recordkeeping system and its records. M. INNOVATIONS & ADVOCACY RESOURCES (1) Advocacy Resources The City will consider vendor resources for member advocacy. Member advocates would act as resources for members to navigate the complexity of the provider’s benefits and services and applicable rules/regulations/policies. The City is interested in having its healthcare providers provide dedicated member advocates who would be available onsite at City facilities and/or via a local service center to address member questions and assist members with receiving services. (2) Value Added Services Proposers are provided the opportunity, pursuant to this RFP, to propose innovative programs, tools, plan design concepts, or other ideas that would improve quality, choice and efficiency for the City’s Flex Program health benefits.
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MEMBER SERVICES N. DIRECT SERVICES The City values service provider attention to the quality and responsiveness of its member services team. The City will evaluate each provider’s member service support operation to include the staffing, resources, hours of operation, training, and tenure applicable to the team which would service the City’s account. The City will further evaluate the process and timelines for issuing eligibility ID cards, and whether medical/vision cards are bundled or separately issued. Finally, the City will evaluate each proposer’s resources, policies and practices for monitoring, assessing and improving upon the service quality of the member services team. Generally, the City expects that member service representatives be available to assist our members minimally between the hours of 7:00 a.m. and 5:00 p.m. Pacific Standard Time (PST) each business day; and that these calls will be recorded to the extent allowed by and in accordance with applicable law. If an automated line is used, the City will assess its responsiveness and ease of access for members who need to speak with a member service representative. (1) Quality Control: Appointments, Wait Times, Consultations, etc. The City values service provider attention to interactions between physicians and other health service providers and Flex members. The City will evaluate each provider’s resources, policies and practices for monitoring and creating positive outcomes on essential service criteria such as setting appointments, appointment wait times, length of consultations with physicians, updating provider directories, etc. The City will also closely evaluate each provider’s resources, policies and practices with respect to measuring and creating goals around improving upon member satisfaction. (2) Quality Control: Referrals The City values service provider attention to the referral process from a member’s perspective. The City will evaluate each provider’s resources, policies and practices for monitoring and creating positive outcomes with respect to timely specialist referrals. (3) Quality Control: Appeals Process The City values service provider attention to the medical appeals process from a member’s perspective. The City will evaluate each provider’s medical appeals process as well as the resources, policies and practices for monitoring and creating positive outcomes with respect to member appeals. (4) Vision Provider Benefits The City values service provider attention to the accessibility and ease of use of vision benefits offered as part of the services arrangement with the City from a member’s perspective. The City will evaluate the transparency, communications, and resources offered to members with respect to vision benefits. The City is reserving the option of unbundling vision benefits from any or all of its primary medical service provider relationships and offering a stand-alone and uniform vision benefit to Flex members.
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(O) PROVIDER QUALITY OF CARE (1) PCP Continuity & Provider Turnover The City values service provider attention to the continuity of medical personnel, including especially those primary care physicians with whom its members interact on an ongoing basis. The City will evaluate the resources devoted by your organization to promoting continuity and stability among primary care physicians and assessing your efforts to acquire feedback from your physicians to determine their satisfaction and assess what factors are impacting the stability of where they provide service and what kind of service they provide. (2) Quality Control: PCP, Specialist and Other Providers The City values service provider attention to the quality of care provided by treating physicians and provider groups. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to providing quality care to its members. (3) Quality Control: Prevention, Adherence, Follow-Up Care The City values service provider attention to the efficacy of your organization and its treating physicians and provider groups with respect to prevention, adherence and follow-up care. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to preventive, adherence and follow-up care services. (4) Prescription Options & Availability The City values service provider attention to the efficacy of your organization and its internal or contracted prescription drug providers with respect to availability and member-based engagement on the use of formulary/non-formulary and generic/brand-name drugs. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to the use of prescription drugs. The City will further evaluate service provider effectiveness in communicating changes to formularies and generic/brand-name drugs and working with patients to address specialized considerations that may apply thereto. (5) Health Plan External Agency Ratings The City will be considering the National Committee for Quality Assurance (NCQA) Accreditation and Health Plan Employer Data and Information Set (HEDIS) Rating. The National Committee for Quality Assurance (NCQA) is a private, 501(c) (3) not-for-profit organization founded in 1990. The NCQA develops quality standards and performance measures for a broad range of health care entities, and produces reports of performance against such measures measured in the form of statistics that track the quality of care delivered by the nation’s health plans. Accredited health plans are evaluated on more than 60 standards and must report on their performance in more than 40 areas in order to earn NCQA’s seal of approval. Health plans in every state, the District of Columbia and Puerto Rico are NCQA Accredited. These plans cover 109 million Americans or 70.5% of all Americans enrolled in health plans. In addition to its accreditation program, the NCQA has developed a Health Plan 18
Employer Data and Information Set (HEDIS) Rating, which is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Each provider’s accreditation and HEDIS ratings will be considered pursuant to this RFP. (P) COMMUNICATIONS The Flex Benefits Program places the highest priority on member communications because they fundamentally represent the touch-points at which members engage with the resources provided by the medical provider to maintain their health and well-being. All of the communications resources provided by the health insurance provider are evaluated relative to their effectiveness in communicating, translating and providing education regarding the services and resources available to members. In addition, the City contracts with a separate communications consulting firm to assist the City in designing its communications strategy and objectives, and to help develop and execute specific communications initiatives. In 2016 the City will initiate a project in which it will work with its consultant to conduct a communications audit and define a long-term, outcomes-based communications strategy that will align all member communications and communications metrics with the Flex Program’s core mission. An important value for the City is ensuring that its health insurance providers be able to communicate a high-level, accessible and coherent framework for participants to conceptualize the most fundamental objectives and aspects of their medical benefits. The City will look to ensure that communications/features/services “overload” does not come across as overwhelming to members or distract them from the most important and critical information they require to be successful in navigating their benefits. (1) Website Facility and Content The vendor shall administer a member website which will provide members with the ability to access contact information, provider directories, and other resources for managing their needs. The City will assess each proposer’s core website template and functions to evaluate their relative success in effectively organizing categories of information for members. The City will also evaluate each proposer’s website functionality for user-friendliness, opportunities for/limitations to customization, interactive features, planned enhancements, and speed/facility in generating and adapting messaging and content. The website should be compliant with the Americans with Disabilities Act (ADA) and other applicable law/regulation related to accessibility. (2) Self-Service Tools The City will review the self-service tools that vendors make available to members such as verifying enrollment status, locating physicians, reviewing and processing claims, reviewing and managing pharmacy/prescription benefits, obtaining health advice, making payments, scheduling appointments, and other tools for members to efficiently access information and services. (3) Electronic, Print, Video, & Other Media Technology The City is interested in reviewing other communications media technology that vendors may offer such as videos, mobile applications, social media tools, etc. The City is additionally interested in the vendor’s capabilities for communicating with its membership via email. Additional and alternative 19
means of engaging participants is important as continued fragmentation occurs with respect to how participants prefer to or are willing to receive information. (Q) WELLNESS, PREVENTION & DISEASE MANAGEMENT (1) Resource Support & Alignment w/Flex Wellness Program A long-standing and important objective of the City has been the creation of a comprehensive and robust Wellness Program for the Flex Benefits population. On November 12, 2015, the JLMBC adopted a resource and implementation plan for a Flex Benefits Wellness Program. The mission of the Flex Wellness Program is to support our members in making progress on a continuum of improving health, with a particular focus on behaviors impacting the prevention, treatment and incidence of chronic disease. Progress in fulfilling this mission would be measured by outcomes in some or all of the following broad measurements: Increasing utilization of personalized educational and support services Increasing member awareness of personal health and biometric data Improving outcomes in a variety of key health indicators related to metabolic syndrome, body mass index, nutrition, tobacco use, stress impact, etc. The City intends to proceed strategically with a focus on building the necessary infrastructure to establish, sustain and grow the Wellness Program over time. By creating and reinforcing a strong base of support, the Wellness Program can demonstrate to Flex members a clear mission, communications coherence and effectiveness, and the credibility of the City’s commitment to member health and well-being. This infrastructure can be thought of as a pyramid of resources (see visual). A crucial objective is to establish a service delivery resource model that can incorporate but “sit above” the City’s health plans, rather than being primarily structured around each health plan’s independent wellness resources. The City believes this is important in order to meet several critical objectives: Establishing and aligning a universal mission, goals, strategies and tactics; Ensuring consistency of communication content and messaging; Providing a common platform for disseminating information and providing gateway access to multiple resources; and Creating universal benchmarks and data management. This service delivery model will incorporate service providers into the program specializing in Wellness administrative or counseling services, as well as providers specializing in assisting with designing goals, benchmarking outcomes, and measuring success. Following is a brief discussion of each layer of the resource and implementation plan adopted by the JLMBC: 20
Organizational Commitment – Organizational commitment involves the commitment of the City’s elected officials, the JLMBC, the Personnel Department, and all City departments in supporting the objectives of the Wellness Program. This commitment manifests in the dedication of resources, modeling a culture of wellness, communicating the goals and resources of the program, and otherwise supporting Flex members on their unique health journeys.
Securing City Staffing – Dedicated City staffing is necessary to drive the program forward, interact with stakeholders and gatekeepers, and direct the use of contracted resources.
Strategic Planning – In consultation with the Personnel Department, the JLMBC will work with its consultant to create a detailed strategic plan for developing, implementing and administering the Wellness Program. The strategic plan will cover multiple years and include defining the program’s mission, goals, objectives, strategies, and measurements of success, including objectives related to engagement (employee participation in various Wellness-related programs), awareness (employee knowledge of certain essential information that is a prerequisite for changing behavior), and outcomes (measurable health-related outcomes in areas such as chronic disease incidence, adherence to treatment protocols, etc.).
Communications Strategy/Branding – This will involve branding the program and developing a communications strategy at the Flex Program level (rather than by health plan provider), such that all Wellness-related communications are consistent, coherent, and aligned with the Flex Program’s and the Wellness Program’s mission and strategy.
Communications Distribution Channels/Content – This will involve development of commonplatform distribution channels and content. This will likely include creation of a Flex-branded wellness portal and educational content designed to engage members and raise their awareness of information promoting behaviors conducive to positive health outcomes. This information must necessarily be provided through resources possessing the expertise and qualifications to communicate around complex and personalized topics such as nutrition, exercise, stress management, etc.
Wellness Education/Counseling – This will involve identifying and utilizing a contracted inperson educational/counseling services provider which would have the objective of engaging, educating, and raising awareness among the City’s population as part of creating a “culture of wellness” and helping members successfully access all of the Flex Program’s health and wellbeing resources.
Benchmarking/Data Management – This will involve identifying and utilizing a contracted resource for benchmarking and data management services, so that the Flex Plan can track and benchmark certain aggregate data related to a variety of data points including employee engagement, awareness, and health outcomes. As with the local counseling service, this would be done at the Flex Program level rather than the level of the individual medical plan providers, to assure data consistency.
Programs & Events – Under the direction of City staff, this would involve promotional eventbased behavioral programs (such as walking programs, smoking cessation programs, HRA promotion, biometric screening, etc.) that are coordinated within the communications branding, long-term plan, and defined goals/objectives/strategies/metrics. 21
Funding resources for these services in 2016 are available under the City’s current contract with one of its medical services providers. This provider allocates $900,000 annually for Wellness related services. Pursuant to this RFP, the City is requesting that each of its medical service providers commit specific and minimally restricted dollars for use by the City in funding its contracted Wellness-related service provider relationships, educational programs and events, and other expenses related to the City’s administration of the Wellness Program. In addition, the City will be evaluating proposers with respect to their ability to otherwise align their resources and organizational commitment to the City’s vision of Wellness for the Flex Benefits population. (2) Disease Management Programs In connection with the focus of its Wellness Program on chronic conditions, the City will be looking to identify and evaluate each proposer’s Disease Management Programs insofar as they are designed to improve the health of persons with specific chronic conditions and to reduce health care service use and costs associated with avoidable complications, such as emergency room visits and hospitalizations. The City will evaluate the degree to which a provider is able to:
Identify specific populations with specific chronic conditions; Successfully enroll members in the program; Utilize evidence-based practice guidelines to assure consistency of service; Coordinate services among a multi-disciplinary team of providers including physicians, nurses, pharmacists, dieticians, respiratory therapists, and psychologists; Provide educational services such as counseling, home visits, 24-hour call centers, appointment reminder systems, etc.; and Measure outcomes. (3) Coordination w/Utilization/Case/Disease/Rx Management
The City will also evaluate vendor capabilities with respect to the coordination of their Wellness and Disease Management Programs with overall utilization, case management, disease management and prescription drug management. The City values providers who are able to demonstrate a comprehensive and integrated approach to empowering patients to be proactive in not merely treating disease once it has manifested, but preventing disease and progressing across a continuum of improving health.
ACCESS/CONTINUITY OF CARE (1) Provider Groups & Networks & Geographic Access The City will be evaluating accessibility and the potential for disruption of each proposer’s provider groups/networks relative to the provider groups/networks of the incumbent providers. The City’s objective is to minimize and mitigate disruption, such that 85-90% at maximum will be able to retain access to their current providers. The City is providing census data regarding its membership (please refer to Attachment B). Proposers will be required to submit a GeoAccess study for all proposed plans based on the City’s current plans/populations that would be served by the vendor’s proposed network. For example, incumbent PPO members should be separately compared to 1) each PPO 22
proposed network(s) and 2) each HMO proposed network(s). The same should be done for the current Blue Shield HMO and Kaiser HMO plans. Proposers will need to identify the number of participants that meet the network access standard by utilizing the zip code information provided in the census file, including all valid zip codes in which participants reside, including those not in the proposer’s service area, and the total number of provider practices available to each zip code, as well as the number of open practices (i.e., those providers accepting new patients). However, the access studies should be based on open practices only. With respect to disruption analysis, the City will provide reports for each plan type (e.g., HMO, PPO) detailing historic utilization statistics (e.g., total amount paid, total number of services rendered, etc.) by provider type (e.g., hospital, physician, etc.) to assess the alignment between your provider network and participant utilization patterns. For each plan type, proposers will be required to confirm whether the individual provider is currently a contracted network provider. If, after award of the contract, the actual disruption proves to be greater than that identified in the proposal, the successful bidder must provide accommodations to address the deviation. Further details regarding obtaining the necessary reports from the City are provided in Attachment B. (2) Extended Hours, Emergency and Urgent Care Access The City will review the extended hours, emergency and urgent care resources available from each provider, and the resources provided by the health plan to assist and effectively communicate to members where and how to access care when and where it is needed. (R) FINANCIAL COST (1) Provider Reimbursements For the PPO plan, the City will evaluate the non-network equivalent Reasonable & Customary Percentile used for non-network reimbursement and source of non-network Reasonable & Customary Allowances. (2) Hospital and Outpatient Facility Charges The City will evaluate how network hospitals are reimbursed for each plan that you are proposing. The City will further evaluate how network outpatient facilities such as surgicenters, imaging centers and laboratories are reimbursed, as well as any special arrangements that may exist with “Cultures of Excellence.” (3) Underwriting Terms & Conditions The City will be evaluating all aspects of the underwriting terms and conditions of your proposal, including the rate development to support the proposed rates. The rate development includes the claims cost, trend, pooling point and charges, reserves, and ACA fees. The City will also evaluate how the vendor will calculate subsequent renewals and any underwriting provisions that you will impose on the City. (4) Retention Levels 23
The City will be evaluating the retention levels included in developing the rates. The City will review the way in which the retention is developed each year and the reasonableness of the retention charges. (5) Rate Guarantees & Risk Sharing The City values proposals that include multiple year rate guarantees or rate caps for future renewals. The City is requesting fully insured, non-participating and participating rates at this time. (6) Premium Rates and Rate Adequacy for Plan Design Options The City values proposals that include cost effective premiums based on plan design options that match closely to the current plans offered by the City. The City will be evaluating the proposed rates and benefits and the impact any changes will have on the participants.
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SECTION 3 PROPOSAL QUESTIONNAIRE
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QUESTIONNAIRE INTRODUCTION AND INSTRUCTIONS i.
Introduction
The RFP questions included in this RFP are intended to solicit important background information about your firm and fully disclose the data points upon which proposers will be evaluated. The City is not evaluating firms using any information other than what is outlined within this RFP. Responses to this section along with documents required to be submitted pursuant to Part B of this RFP are necessary for the proposal to be considered responsive. ii.
Instructions
Do not alter the questions or question numbering. Complete all appropriate sections of the questionnaire. To obtain an electronic version of the questionnaire, please contact the RFP Administrator. Provide an answer to each question even if the answer is “not applicable” or “unknown.” Answer the question as directly as possible. o If the questions asks “How many…” provide a number o If the question asks, “Do you…” indicate Yes or No followed by any additional brief narrative explanation to clarify. Be concise in your response. Use bullet points as appropriate. Excluding the Problem Resolution Essay Questions, consider how to word any response that exceeds 200 words in length so that the response contains the most important points you want displayed. Referring the reader to attachments for further information should be avoided or used on a limited basis. Any response that does not directly address the question, but only contains marketing information, will be considered non-responsive.
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A. ORGANIZATION BACKGROUND Items 1-9 are required in order for your proposal to be considered responsive but will not be rated. 1. Cover Letter and Proposal Declaration - Provide a cover letter and Proposal Declaration to include the following:
Title “City of Los Angeles Flex Benefits Health Plans RFP” and submission date Contact name of person authorized to bind the proposer to the proposal Contact Name/Title: Mailing Address: Location of Business (if different from mailing address): Type of legal entity (corporation, limited liability company, joint venture, partnership, etc.) A short description of your organization, the businesses in which it engages and the services it provides. Telephone Numbers (Office, Cell, and 24-hour lines): Fax Number: E-mail Address: Date entity was established and location of entity when established Location of headquarters (full address) and, if your firm has more than one office location, which of your firm’s offices will service this account. Annual revenues Total number of employees Total number of employees in the City of Los Angeles Total number of employees in the County of Los Angeles Number of employees reported in whose exclusive, primary work location is in the County of Los Angeles Number of employees providing services for this contract The following statement:
“The undersigned hereby offers and agrees to furnish the goods and/or routine services in compliance with all the service level requirements, instructions, specifications, and any amendments contained in this RFP document and any written exceptions in the offer accepted by the City. This proposal is genuine, and not sham or collusive, nor made in the interest or in behalf of any person not herein named; the proposer has not directly or indirectly induced or solicited any other proposer to put in a sham proposal, or any other person, firm or corporation to refrain from submitting a proposal; and the proposer has not in any manner sought by collusion to secure for itself an advantage over any other proposer.”
A signature submitted on behalf of the proposer by an officer authorized to bind the proposer to the proposal, acknowledging: i. Receipt of and agreeing the submitted Proposal is based on the RFP and any identified addenda. ii. Failure to indicate receipt of addenda may result in the proposal being rejected as nonresponsive iii. To constitute a responsive proposal all pages of the proposal questionnaire and required forms must be submitted. iv. Under penalty of perjury under the laws of the State of California that the proposal is true and correct and the proposer agrees to the terms and conditions in the proposal.
2. City Business License Number or Vendor Registration Number - Indicate your City Business License Number or Vendor Registration Number if available. A license or registration number is not required for your proposal but will be required prior to execution of a contract. To obtain a Business Tax Registration Certificate (BTRC) or Vendor Registration Number call the Office of Finance at (213) 473-5901 and pay the respective business taxes. The address is as follows: City of Los Angeles, City Hall, Room 101, Office of Finance, 201 North Main Street, Los Angeles, CA 90012 – http://www.lacity.org/finance/).
3. State of California Board of Equalization Permit - Indicate your company’s State of California Board of Equalization permit number. If you do not have this permit, please make a statement to this effect. 27
4. California Revenue and Taxation Code - Fill out and submit the appropriate California Revenue and Taxation Code form, if applicable (for out of state vendors).
5. Compliance with Standard Provisions - Provide a statement indicating that your firm will comply with the City of Los Angeles General Contracting Provisions attached to this RFP in Part B, including the Standard Provisions for City Contracts (Rev. 6/14). Please note that your statement does not relieve you from providing all of the documents required pursuant to the “Proposal Response Checklist.”
6. Insurance - The City is estimating that the following insurance coverage types will apply to this contract:
Workers Compensation ($1,000,000) General Liability ($1,000,000) Professional Liability ($10,000,000)
Please verify that you will be able to meet the required coverage levels and that you will submit proof of such pursuant to Part B, “General Contracting Requirements - Insurance Requirements,” as a condition of execution of any final contract (see Part B, “Standard Provisions – Insurance Requirements” for further details). Note that if the proposer is a sole owner company with no employees, the proposer can sign the City’s waiver of workers compensation. General Liability can also be obtained through the City’s SPARTA program for small contractors. Links to the City’s waiver form and SPARTA program from the City’s Risk Management website are provided as follows: http://www.2sparta.com/ http://cao.lacity.org/risk/waivewc.pdf
7. Lobbyist Disclosure – Disclose any (1) arrangements your company has with any lobbyists and/or agents representing your company, and (2) any arrangements your company has with an unrelated individual or entity with respect to the sharing of any compensation, fees, or profit received from or in relation to the proposing company being awarded a Contract with the City. If any such arrangements exist, describe the nature of the relationship and the manner in which compensation or fees would be shared.
8. Endorsement Disclosure – Disclose any financial relationship your company has with any union, organization or association in conjunction with an endorsement. Provide details regarding the relationship, including any benefit that will be recognized by the union, organization or association in the event your company is awarded a Contract with the City.
9. Subcontracting - If any portion of the Contract is to be subcontracted, it must be clearly set forth as to the part(s) to be subcontracted, the reasons for the subcontracting and a listing of subcontractors. For each subcontractor proposed, provide the following information: i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi.
The specific service being subcontracted Name of Subcontractor Subcontractor’s Contact Name Contact Title Contact Phone Number Mailing Address Location of Business (if different from mailing address) Business Telephone Number Subcontractor’s registration # and/or license #, if applicable Description of Work to be Subcontracted Reason for Subcontracting Percent of Total Contract to be Subcontracted & Dollar Amount Relevant work experience in years and level of responsibility Experience in number of years that your firm has worked with the Subcontractor providing these services If subcontractor is a MBE, WBE, LBE, SBE, EBE, DVBE, or OBE If subcontractors will not be utilized, so indicate here.
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QUALIFICATIONS The questions in the following sections will be rated.
QUESTIONNAIRE #
Question
Response
ORGANIZATIONAL STRENGTH & PLAN SPONSOR SERVICES Organizational Qualifications and Reliability Organizational Background, Financial Strength, Experience Please provide an overview of your organization and organizational structure, to include the name of your parent company (if you have one), the nature of its business, the name 1 of your company, the length of time your firm has been providing the broad range of services included within this procurement, headquarters, number of clients and covered lives, and geographic service area. Please provide your organization’s revenues and net profits for 2 2013, 2014, and 2015. Is your company a subsidiary or affiliate of another company? 3 If yes, describe the nature of the business of the parent firm. Provide full disclosure of all direct or indirect ownership. Describe any pending agreements to merge or sell your company or any portion thereof, or your parent company; or 4 any pending or anticipated plans to reorganize your company within itself or as part of the larger organization of which your company is a part. Describe any change in senior management (including CEO, CFO, CIO, or other executive management) in the last five 5 years. Indicate the average tenure (in years) of senior management. For the work unit(s) that you would propose servicing the City's Plan, what was total staff turnover for 2013, 2014, & 2015? 6 Number of full‐time employees Percent Please provide an overview of the proposed health plan model 7 (e.g. Staff model HMO, Network Model HMO, PPO, ACO, PCMH, etc.) that you are proposing pursuant to this RFP. Please indicated by checking the box if, in the last 12 months, your firm has: Closed any network services areas (if yes, please list the centers). 8 Combined/consolidated member service or claims service centers. If yes, please list the centers. Closed/consolidated or relocated any claims offices. If yes, please list the offices. Please complete the following applicable membership profile/client base information for calendar years 2014 and 2015: Annual PPO Membership ‐ National 9 Annual PPO Membership ‐ California. Please break down the percentages for Commercial, Medicare, Covered California, Medi‐Cal, and other membership categories. Annual HMO Membership ‐ National
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Annual HMO Membership ‐ California. Please break down the percentages for Commercial, Medicare, Covered California, Medi‐Cal, and other membership categories. Annual Alternate Care Model Membership ‐ National Annual Alternate Care Model Membership ‐ California. Please break down the percentages for Commercial, Medicare, Covered California, Medi‐Cal, and other membership categories. Please complete the following client retention rate information for group accounts only for calendar years 2013, 2014, and 2015. Client Retention Rates
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HMO
Alternative Provider Network or Care Model
Client Termination Rates
PPO
HMO
Alternative Provider Network or Care Model
Phone, Email and Location
Number of Employees Covered
Contract Start Date
Provide three terminated (within the past five years) public sector client references in the following format:
Client Name
Contact Name
Phone, Email and Location
Number of Employees Covered
Contract Start Date
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Contact Name
Regulatory Compliance Has your company been the subject of any complaint filed with any state or federal regulatory agency or office In the past five years? Has your company ever had a license to do business, an 13 agent/broker license or any other insurance license revoked or suspended? Has your company ever been reprimanded or otherwise cited by a licensing agency? If any of these apply, please describe fully. Are there any outstanding legal actions pending against your organization? If so, please explain the nature and current 14 status of the action(s). What guarantees can you provide that these actions will not disrupt your business operations or impact the City’s account if you were awarded a contract?
PPO
References Provide three current public sector client references in the 11 following format: Client Name
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Identify and describe any past, pending or threatened judicial or administrative litigation (including lawsuits or protests) in which you have litigated against a client or prospective client, 15 within the past five years, related to the type of services you are proposing. Indicate the reasons for the lawsuit/protest and the outcome. Provide contact information for the entity sued or challenged. Describe any incident within the past ten years in which your business has had a contract terminated for default. Termination for default is defined as notice to stop performance due to your organization's non‐performance or poor performance and the issue was either not litigated, or litigated and such litigation determined your organization to be in default. Submit full details of all termination for default experienced by your firm 16 during the past five years including the other party’s name, address, telephone number and your firm’s position on the matter. The City will evaluate the facts and may, at its sole discretion, reject your firm’s proposal if the facts discovered indicate that completion of a contract resulting from this RFP may be jeopardized by selection of your firm. If your firm has experienced no termination for default in the past ten years, so indicate. Has your company or its subsidiaries ever filed or been petitioned into bankruptcy or insolvency or has your company 17 ever made any assignment for the benefit of your creditors? If so, provide complete details. Describe what procedures and policies you have in place to protect against, and provide disclosure of, any potential or perceived conflict of interest involving relationships your firm 18 may have with the City’s current or prospective service providers, governing authorities, advisors, or other interested parties. HIPAA Compliance Do you have a formal Health Insurance Portability and 19 Accountability Act (HIPAA) compliance plan in place? If yes, attach a copy to your proposal. Do you have a website that details information about your policies and procedures for accepting and sending Electronic 20 Data Interchange (EDI) transactions? If so, please indicate the website. Where does the copy of your Companion Guide for HIPAA EDI 21 transactions reside? 22
Will your organization be issuing Notices of Privacy Practices as required by HIPAA to each new plan enrollee? At what cost?
Rating Agency Financial Ratings Please provide the most recent ratings for your company by the following: ‐ Standard and Poor's ‐ Duff and Phelps 23 ‐ A.M. Best ‐ Moody’s If your firm is not rated, submit documentation of a similar nature, which attests to your firm’s financial stability.
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Indicate if there have been any downgrades in your ratings in the last 2 years, and if so indicate to what they are attributable.
Administration Support & Account Management Claims Processing With regard to the claim offices that will be used, provide the 25 following: a) Location:
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b) Average Claims / Processor / Day:
c) Annual Claim Volume:
d) Staffing: (Complete the following): Processors (# of staff, avg. years claims administration experience, annual turnover %) Supervisors (# of staff, avg. years claims administration experience, annual turnover %) Managers (# of staff, avg. years claims administration experience, annual turnover %) For each of the products that you are proposing, describe the claims payment process from date of receipt to full adjudication of checks to providers or patients. If the process is different for network and non‐network claims please discuss separately. For example, do you batch process checks to network providers? If so, explain. Based upon the latest 24 month period , please indicate the following: Average number of business days to process a claim from date received to date check / EOB issued. Percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check / EOB issued) within 10 business days. Percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check / EOB issued) within 30 business days. Have you been penalized by any state for failing to meet state average claim turnaround requirements? If yes, list states where you were sanctioned in the last 12 months. For the claim office proposed, please indicate the following percentages over the past 12 months: Financial accuracy as a percent of total claims dollars paid (include over / underpayments) Coding accuracy (claims without error) as a percent of total claims submitted What are your procedures for recovery of the overpayments or duplicate payments? Explain your Coverage of Benefit (COB) procedures. Indicate if you pursue COB prospectively or retrospectively to payments, and how often records are updated for new information on other coverage. Please provide the following regarding your fraud detection programs: (a) Describe your ineligible claimant program, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives.
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2014
2015
(b) Describe how you assure that services billed are actually rendered, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives. (c) Describe your overbillings program, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives. Do you retain medical consultants for the review of any unusual claims or charges? If yes, explain the method in which such 33 consultants are used and describe their qualifications and any affiliations. How do you reimburse multiple surgical procedures being 34 performed during one operation? Is a reduced scale used for the 1st and subsequent procedures? Please outline the frequency and duration of any formal 35 training programs for claim processors and claim managers. Describe initial and ongoing training separately. Please indicate your willingness to allow and pay for the cost of an outside auditor to conduct an on‐site, random, annual claims 36 processing audit. Indicate the cost in dollars that you would allocate for this audit. Billing & Eligibility
Indicate whether the City's payment options include electronic fund transfer, manual invoicing, or both. What are your premium billing frequency options (monthly, quarterly, etc.)? What are your specific due dates for receipt of 38 premiums? Do penalties apply for late payments and if so on what schedule and if so how are the penalties calculated? Do you agree to receive and timely and accurately process as indicated in this RFP all of the enrollment and eligibility 39 information in the format as provided by the City's third party administrator? Plan Sponsor Services By checking each box, verify that you will provide the 40 following. If there are exceptions, do not check the box and explain the deviations. Monthly Enrollment Reports by Plan Type and Membership Segment Monthly Claims Reports by Plan Type and Membership Segment Monthly Large Claimant Reports by Plan Type and Membership Segment Quarterly Utilization Reports by Plan Type and Membership Segment Annual Utilization Reports by Plan Type and Membership Segment Notify the City immediately if the network loses any accreditation, licenses, or liability insurance coverage or if there is a change in hospital network contracts. Provide any required health insurer B‐series ACA‐related tax reporting Plan sponsor on‐line claims summary
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Plan sponsor on‐line billing history
Plan sponsor on‐line premium rates
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Plan sponsor on‐line provider directory
Plan sponsor on‐line eligibility summary
Plan sponsor on‐line enrollment counts
Plan sponsor on‐line plan details
Plan sponsor health topics/medical information
Plan sponsor address changes
Forms w/cost included in premium: SPDs and SBC
Forms w/cost included in premium: Claims Forms
Forms w/cost included in premium: EOBs
Forms w/cost included in premium: Network Directory Please describe your account team that will be assigned to the City of LA to include: a) Day to day contact b) Underwriting c) Billing d) Local Overall account management e) Location of your local telephone service office, number of staff, and hours of operation Assuming a contract award of 07/01/16 and beginning service date of 01/01/17, provide a proposed implementation plan and timetable, beginning with the aware of business to effective date of coverage, including the following: a) Steps required to implement the program
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c) Eligibility feed
e) Contacts and personnel assigned to each step of the implementation process f) Establishment of on‐line plan information What is the process and requirements from the City for distributing ID cards as part of annual open enrollment or other enrollment during the plan year? Please indicate whether the participants would receive one ID card or separate ID cards for medical and vision benefits. What is the timeframe for issuing ID cards? Describe your online plan sponsor reporting services which would enable the City to review its aggregate membership data. Provide your plan sponsor website and dummy account access information. Do customer service representatives have on‐line access to real‐time claim status information? From the date you receive eligibility information from the City, describe the length of time involved to add and activate benefit access for a new member. Verify that you will agree to work with the City's Flex Benefits Third Party Administrator to exchange eligibility information. Verify that you will agree to accept eligibility rules as established by the City and in accordance with applicable law/regulation. 34
b) Role played by the plan sponsor/vendor d) Production and distribution of ID cards, directories, and enrollment materials
43
Verify that if a participant has a family status change pursuant to Internal Revenue Code Section 125, the member will be able 50 to change plan elections outside of open enrollment without having to provide evidence of good health. Describe the ACA tax and other reporting services provided by your firm, and if any of those reporting services involve 51 additional fees to the City. Please provide copies of sample reports. Imaging & Document Storage 52
Describe your imaging and document storage capabilities. Will you transfer enrollment cards, claim information, and other administrative records to any carrier that would replace 53 you in the event of termination of this contract? If so, will you do so without charge to the City? Recordkeeping, Security Protocols, Disaster Recovery & Guarantees Describe your recordkeeping software system including: ‐‐When your recordkeeping system was first put into place ‐‐Whether the software was developed internally, leased, or purchased from another provider and if the system is leased or 52 subcontracted ‐‐Who has the ultimate responsibility/authority to make sure the software remains current with respect to laws, regulations, and client needs When was the last major system enhancement and what was 53 the nature of the enhancement? 54 55 56 57 58
With regard to your recordkeeping systems, please describe your record retention and destruction policy, including how long records are retained. Innovations and Miscellaneous Services 59
Advocates and Onsite Services Have you utilized member advocates or other onsite services 60 with other clients? If so, describe the services offered and the client outcomes. Will you provide dedicated advocates to assist plan participants 61 in resolving administrative, clinical, and claim issues associated with your organization and affiliated providers? If yes: (a) Provide the number of proposed advocates, titles, responsibilities, and the aggregate number of annual hours they will be dedicated to the City;
35
Do you foresee any specific problems incorporating the City’s population and plan features into your system? If so, describe in detail. Describe your response plan in the event of a data security breach. Describe what credit protection and other services you provide to participants who may be impacted by a data security breach. Describe your disaster planning/prevention resources and plans, including the frequency with which your data is backed up and redundant processing centers. Describe your disaster recovery resources and plans; indicate how often you test your recovery system.
(b) Confirm whether the advocates will be available to plan participants at City facilities; and,
(c) Confirm whether these resources are included in your proposed fully insured premium rates.
Value Added Services 62
63
64
Do you have the ability to do population risk profiling? If so, what forms of risk scores do you use? Provide any innovative ideas, programs, tools, and/or coverage that would improve quality and cost for the health care program. Describe what they are, how they work, how much they cost, what is the expected savings, and how savings estimates are derived. Are you willing to guarantee the savings through funds at risk and/or performance guarantees? Can your company undertake a Performance Improvement Project (PIP) with providers that are to achieve, through ongoing measurements and interventions, significant improvement, sustained over time, in clinical care and non‐ clinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction. The PIPs shall include the following: • The use of objective, measurable, and clearly defined quality indicators to measure performance; • Valid sampling techniques; • Accurate and complete data collection; • The implementation of appropriate planned system interventions to achieve improvement in quality;
• An evaluation of the effectiveness of the intervention, including sufficient data and barrier analysis; • An achievement of real improvement that is sustained; and • A plan and activities that shall increase or sustain improvement. Are all of the services included in your base quote? If not, indicate the changes on a per capita basis. MEMBER SERVICES Direct Service
Customer Service Staffing/Availability Describe the call center resources you will provide, including 65 the following: Total Customer Service Representatives (CSRs) employed on a year‐round basis Hours of availability (Pacific Time Zone)
Location of primary and backup centers
Member services call center phone number Staffing as a percentage of total covered members covered by that support operation Proposed staffing with description of the types of personnel to be involved Describe the training provided to your CSRs and indicate the average tenure of those member services representatives that would service the City's members. Describe what resources, policies and practices you have in place to monitor, assess and improve upon the service quality
66 67
36
of your CSR team/staff. Please indicate your Call Center's average response speed, average member telephone wait time to speak to a live CSR (not just an operator), in seconds based on the past 12 month 68 period by product type (i.e. HMO, PPO, etc). Also, please provide your percent abandonment rate in the past 12 months by product type. Can your plan provide Interactive Voice Response (IVR) and Live Call reason statistics specific to the City's population? If yes, 69 please provide a sample report of your call statistics report indicating major categories of call reasons and the frequency of the availability for this report. Will a dedicated CSR team serve the City’s covered members? If 70 yes, how many CSRs will be assigned to the City? In staffing CSRs, how many participants do you assume a single 71 CSR can cover? How many calls per day is a CSR expected to cover and what is the average length per call? Describe the policies and procedures in place to ensure CSRs 72 safeguard member’s personal information. What language services other than English are available? Confirm your ability to provide Spanish language services, vision, and hearing‐impaired access services during all hours of 73 telephone customer service availability. Please indicate the total number of your CSR staff that are bilingual that speak 1) Spanish and 2) a language other than Spanish. Do you offer a 24 hour telephone Nurse Triage (nurse advice / demand management) telephone program for enrollees? If so, indicate whether it is staffed by live health professionals and whether additional costs are charged for this service. Please 74 indicate whether Nurseline call statistics and call reasons for your Nurseline can be shared with the City on a regular basis; provide a sample report and indicate frequency of the availability for this report. Please provide a sample member handbook, evidence of 75 coverage, summary plan description, and sample member I.D. card (please provide actual card and not a picture). Please indicate your willingness to allow and pay for the cost of an outside auditor to audit your plan operations, specifically in conducting an on‐site audit of your member services, customer 76 call center department and processes, complaints/grievance/appeals process, and claims processing results and procedures. Indicate the cost in dollars you would allocate for this audit. Quality Control: Appointments, Wait Times, Consultation Length, etc. Please complete the following table on types of calls / complaints received by your member services department in 75 the last 12 months (or latest calendar year available) by product (i.e.. HMO, PPO). Benefit Program Coverage & Administration (regarding Covered Benefits, Exclusions, Limitations, Claim Processing Issues, Member Services Issues, and Communication Materials) Provider Access & Services Issues (i.e.. Appointment Wait Time, Physician/Hospital Customer Service Issues, and Language/Cultural/Interpretive Issues) 37
Types of Complaints
# Per 1,000 Members
Physician Network Choices
Balance Billing Issues
Referral Process
Pre‐Authorization
Claim Resolution
Total Member Complaints
What is your response time goal for which to respond to claims, complaints and other questions? Describe what resources, policies and practices you have in place to monitor and create positive outcomes on essential 77 service criteria such as setting appointments, appointment wait times, and length of consultations with physicians. What is the average wait time (days) for members to schedule a routine appointment with their PCP? Describe what resources, 78 policies and practices you have in place to monitor PCP accessibility and wait times? Please disclose any and all policies, practices or incentives / 79 disincentives related to the length of physician consultations with patients. Describe how frequently you update your provider directories, both the online and print versions. Please indicate what 80 resources, if any, you devote to monitoring the accuracy of directory content. Please provide a copy of your latest health plan members' 81 Annual Satisfaction Survey and results. Please indicate your willingness to include in your scope of services the cost for designing, distribution, compilation, and analysis of a customized annual member health plan 82 satisfaction survey (by product: HMO, PPO) approved by the City for its specific membership population. If so, please indicate the dollar amount you are willing to allocate annually for this project. Problem Resolution Essay Question: As described in the Scope of Services, the City values improving member satisfaction with regards to setting appointments, appointment wait times, length of consultations with physicians, updating provider directories, etc. If you measure member satisfaction, what 83 have your member satisfaction rates been for the last two years? What mechanisms are provided to members to provide feedback? If surveys are conducted, how often is this done and are they administered internally or externally? How are the survey results used and what is done to improve member satisfaction? Quality Control: Referrals What is the average wait time (days) for members to obtain a referral appointment with their specialist? Describe what 84 resources, policies and practices you have in place to monitor specialist referral accessibility and wait times. Quality Control: Grievance & Appeals Process Describe your process and requirements for members to 85 submit complaints, grievances, and appeals for medical services including pharmacy. 76
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86 87 88
What was your average response time to the following medical service appeal categories during 2014 and 2015: Urgent care cases Prior authorization for treatment Services already received What is your process for monitoring member satisfaction regarding member complaints, grievances, and appeals? Do you provide client‐specific HMO or PPO member complaints, grievances, and appeals reports? If so, please include a sample report and indicate frequency of availability for this report.
Vision Provider Benefits & Transparency Please describe the vision benefits you're offering to the City. If bundled with a medical services proposal, indicate whether you 89 manage your own vision program or if it's outsourced, and if the latter to whom it's outsourced and whether any additional fees apply related to the benefit. Describe the composition of your vision provider network (e.g., number of optometrists, total number of locations, percentage of independent optometrist offices compared to retail 90 establishments) and your top 10 providers in Los Angeles County during the last 12 months based on individual members served.
Provider
1)
# Members Served 1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)
7)
7)
8)
8)
9)
9)
10) Describe the vision billing process from the member's 91 perspective, including if it is different from other medical services. Provider Quality of Care
10)
PCP Continuity & Provider Turnover For plans with gatekeepers, describe the different ways in which participants can select PCPs. What is the average wait 92 time (in days) for a participant to schedule a routine appointment with their PCP? Describe the process you have in place to monitor PCP accessibility and wait times. Do you notify members if a network physician terminates their contract during the plan year, at no additional cost? Explain 93 what happens to patients receiving on‐going treatment from a terminated network physician.
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94
95
96
97
98 99
Describe what resources, policies and practices you have in place to monitor and create positive outcomes with respect to the continuity of primary care physicians within or contracted with by your organization. Please indicate if your health plan conducts an annual provider (physician or medical group) survey. If so, what are the results of the latest survey? How do you adjudicate PPO claims when a member inadvertently receives services from non‐PPO providers (e.g., anesthesiologist, emergency room physician, etc.) while confined in a PPO facility? Are you willing to commit to financial penalties should the network of contracted providers change significantly between the time the City notifies you of its intent to contract and June 30, 2017? Are you willing to commit to financial penalties associated with provider accessibility, network referrals, and provider turnover rates? For the Los Angeles county service area provide the number of Network Providers that have terminated their contract:
Unknown
Total # Terms in past 12 mos.
Terms = to what % of your contracted providers?
% of Terms that are Voluntary
Most common reasons for terms
HMO
Hospital
Physicians
PPO
Hospital
Physicians
% of Terms that are Voluntary
Most common reasons for terms
For the Orange county service area provide the number of Network Providers that have terminated their contract:
Provider Type
Total # Terms in past 12 mos.
Unknown
HMO
Terms = to what % of your contracted providers?
Hospital
Physicians
PPO
101
Provider Type
100
Hospital
Physicians
% of Terms that are Voluntary
Most common reasons for terms
For the Riverside county service area provide the number of Network Providers that have terminated their contract:
Provider Type
Total # Terms in past 12 mos.
Unknown
HMO
40
Terms = to what % of your contracted providers?
Hospital Physicians PPO
102
Hospital
Physicians
% of Terms that are Voluntary
Most common reasons for terms
For the San Bernardino county service area provide the number of Network Providers that have terminated their contract:
Provider Type
Total # Terms in past 12 mos.
Unknown
Terms = to what % of your contracted providers?
HMO
Hospital
Physicians
Hospital
Physicians
% of Terms that are Voluntary
Most common reasons for terms
For the Ventura county service area provide the number of Network Providers that have terminated their contract:
Provider Type
Total # Terms in past 12 mos.
Unknown
Terms = to what % of your contracted providers?
HMO
Hospital
Physicians
PPO
104
PPO
103
Hospital
Physicians
% of Terms that are Voluntary
Most common reasons for terms
For the San Diego county service area provide the number of Network Providers that have terminated their contract:
Provider Type
Total # Terms in past 12 mos.
Unknown
Terms = to what % of your contracted providers?
HMO
Hospital
Physicians
PPO
Hospital
Physicians
San Bernardino
Ventura
Network Hospital and Outpatient Facility Profile ‐ Complete the 105 following table(s) for the network within the geographic areas requested. List Number by County
Los Angeles
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Orange
Riverside
Acute Hospitals
Urgent Care Facilities
Urgent Care Facilities – with extended hours
Emergency Rooms
Outpatient Surgical Centers
Clinics
General / Family Practice Physicians
General / Family Practice Physicians – Accepting new patients
General / Family Practice Physicians – with extended hours
OB/GYN Specialists
Other Specialists
Optometrists
Ophthalmologists Based upon the counties listed above, provide the percentages of physicians that are board certified for: 106 ‐ PCP ‐ Specialist Problem Resolution Essay Question: Continuity of and stability of provider care is a primary concern of Flex members. A variety of factors may influence the stability and continuity of individual physicians and group practices. What policies, practices, and metrics does your organization use to promote stability/continuity within your physician provider network? 107 What efforts, if any, do you make to obtain feedback from your physicians or provider groups to determine their satisfaction and assess what factors are impacting the stability of where they provide service and what kind of service they provide? (PPO proposals should specifically address this question from the perspective of maintaining continuity of your in‐network providers). Quality control: PCP and Specialist Options and Availability PPO only ‐ Please indicate which states your PPO network does 108 NOT extend to. Please provide a description of how your narrow and/or tiered 109 networks are structured. Please provide a response for each type of network proposed. ─ Is the selec on based upon Specialist, Hospitals, and/or Primary Care Physicians? 110 ─ Is the selec on criteria quality or cost based? ─ How do you make the assessments of cost and quality? ─ How o en are the providers profiled? Do your alternative networks have the same underlying cost 111 trend increases? What kind of guarantees are you willing to provide around cost and / or trend increases? The City currently provides Out‐of‐Area (OOA) coverage to employees who reside outside of California (e.g. certain employees who live in Washington D.C. and utilize the PPO 112 option. Please describe your proposed out‐of‐area coverage(s). Are you able to administer similar benefit options for the different out‐of‐state employee groups? If not, please describe the differences. 42
How will you handle the following situations: ─ Eligible dependent students residing out‐of‐area ─ Eligible spouse/domes c partner and/or children of employees residing out‐of‐area ─ Eligible employees on a temporary assignment out‐of‐area 113 (including extended assignments out of the country)
─ Eligible employees/dependents while on vaca on in the continental U.S. ─ Eligible employees/dependents injured while on vacation outside the continental U.S. Quality control: Prevention, Adherence, Follow‐up Indicate if you have a mechanism for routinely investigating if a 114 contracted provider has any disciplinary actions imposed by their State licensure medical board. Do you compare individual network provider practice patterns 115 against Best practices or averages on any of the following: (Check all that apply) Referral rates to specialists
Frequency and quality of prescription drug dispensing
Rates of Diagnostic Procedures ordered (Lab/Imaging)
Rates of surgical procedure relative to peers
Repeat Procedures within given timeframes
Hospital Readmission Rates
Unknown/do not track Other than provider directories and access to providers via your website, what quality or practice pattern data about your 116 contracted providers do you make available to plan participants? Please provide an electronic copy or link to your provider and/or hospital profiling information that will be available to 117 members. If this is different for your Full HMO, Narrow Network, or Tiered network, then provide a copy or link for each. Are you willing to commit to financial penalties associated with utilization management including readmission rates, 118 prescription drug treatment adherence, and high risk claimant follow‐up?
Quality control: Mental Health & Addiction Recovery Resources
119
120 121
122
Describe the mental health and chemical dependency services and resources you can provide for adult members and for dependents under the age of 18, and your experience in providing those services, particularly for municipal or public agency clients. Describe any specialized mental health services you provide for victims of violence. What evidence‐based best practices are followed in the provision of your mental health and chemical dependency services? Provide statistics on the utilization and results your clients have experienced for your mental health and chemical dependency services, particularly for municipal or public agency clients. 43
For treatment of chemical dependency, do you require patients 123 to receive out‐patient treatment prior to being admitted to an in‐patient program? How long does it typically take for a patient to get a mental 124 health appointment? What mental health crisis and emergency care services are 125 available to your members? What education/training can you provide to City employees, spouses, and dependents for issues such as dealing with 126 chemical dependency or depression with family members, coping with the mental stress related to elder care, etc. What metrics do you use in your reporting for these services, 127 including performance measures? Provide samples of client reports. Explain how your mental health and chemical dependency services could be coordinated with a client’s wellness and 128 condition management program components, including how you would address mental/physical health co‐morbidities. Provide examples of evidence‐based clinical initiatives you have implemented to ensure members receive appropriate behavioral health and substance abuse treatment. As part of 129 your response indicate the clinical and financial impact of these initiatives (e.g., inpatient admissions, average length of stay, physician services, and psychotropic medications per 1,000 members). Briefly explain any financial incentives established for behavioral health and substance abuse treatment providers to comply with evidence‐based utilization management protocols 130 or treatment benchmarks. Include withholds, bonuses or other arrangements that are tied directly to provider utilization results and/or outcomes. Rx Options and Availability 131
132
133
134 135
Do you manage your own prescription drug program or is it outsourced? If outsourced, to which organization? Describe your process and requirements for members to submit complaints, grievances, and appeals for prescription drug services, including requests for exceptions to generic and formulary prescriptions. Describe your criteria/process for patients to obtain brand name/non‐formulary prescriptions if a medical necessity for such is identified. What was your average response time to the following prescription drug service appeal categories during 2014 and 2015: (a) Urgent care cases (b) Prior authorization for treatment (c) Services already received Please describe any formulary requirements of your proposed plan, and include a copy of your formulary. Describe your pre‐authorization process and the list of drugs to which it applies.
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136
137
138 139
140
141
In cases where members have chronic conditions (diabetes, CAD, COPD, etc.) that are treated by prescriptions, the City is considering having copays reduced or eliminated in order to increase compliance with maintenance drugs. The pairing of a diagnosis with the prescription is required to avoid reducing copays for prescriptions when the diagnosis is not a chronic condition. Please describe your Rx/Dx pairing for maintenance prescriptions. Include diagnosis and maintenance medications that qualify for Rx/Dx pairing. How are members identified? What is the outreach? Describe your drug utilization review features, capabilities, and/or processes. What is the name of the Specialty Pharmacy? Describe your management of Specialty Drugs and the programs offered to members to encourage appropriate utilization. How do you identify and introduce members to these programs? Describe your process for communicating formulary changes. Provide any innovative ideas, tools, and or coverage that would improve the quality and cost of the Rx benefit. Describe what they are, how they work, how much they cost, what the expected savings are, and how savings estimates are derived. Are you willing to guarantee the savings through funds at risk and/or performance guarantees? Describe your pre‐authorization protocols available to the City. Include information on step therapies and other clinical management programs along with any additional costs for such services and credentials of the staff performing pre‐ authorization. What drugs or class of drugs do you recommend be pre‐authorized?
142 What programs do you offer to address potential drug abuse? What programs, tools, and / or coverage do you have available to improve the quality of the Rx benefits or lower Rx costs? 143 What is the expected savings of these programs? Are you willing to guarantee the savings or provide performance guarantees for these programs? Problem Resolution Essay Question: When taking prescription medications, members often experience frustration when either a brand‐name prescription is changed to generic or when a change in Rx providers results in elimination of a prescription 144 from the formulary. What steps would you take to assist members in being better informed of the consequences of such changes and what steps, if any, might you propose to mitigate these types of situations from occurring? National Committee for Quality Assurance (NCQA) Accreditation Provide your organization’s current accreditation status and 145 duration of continuous accreditation (in years) for the National Committee for Quality Assurance (NCQA). Provide your organization’s current NCQA ratings (from 1.0 to 146 5.0) for the following: Consumer Satisfaction
Prevention
Treatment
Overall Rating
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Health Plan Employer Data and Information Set (HEDIS) Results Provide your latest National Committee for Quality Assurance 147 (NCQA) Health Plan Employer Data and Information Set (HEDIS) results for California plans. Please indicate your willingness to provide a City of LA‐specific Health Plan Employer Data and Information Set (HEDIS) study. 148 If so, indicate how frequently you would recommend conducting such a study and at what volume of membership. Please share and summarize your latest Consumer Assessment of Healthcare Provider Survey (CAHPS/HEDIS) results in the following categories for a commercial and adult population: Claims Processing Composite Score; Customer Service 149 Composite Score; Getting Care Quickly Composite Score; Getting Needed Care Composite Score; and How Well Doctors Communicate Composite Score. Indicate the year of your survey, overall response rate, and product type (i.e. HMO, PPO, etc.). Communications Website Facility and Content By checking each box, verify that you will provide the 150 following. If there are exceptions, do not check the box and explain the deviations.
Provider directory including physician office address and phone number, specialty designation, office hours, languages spoken in office, and list of hospitals with admitting privileges
Provider profiles
Plan details
Health information
Claim status
Lab results
Submission of referrals
Request for prior authorization
Submission of RX
Availability of Complaints, Grievances, and Appeals forms How often do you review and update the member and provider information on your website? Is there a 24 hour 1‐800 number to call if there are technical issues related to your website functionality? Can you share the analytics and statistics collected by your health plan regarding areas and links frequently accessed by members? If so, please provide a sample report. Self‐Service Tools Do you have any decision support tools (e.g. provider/facility selection, cost comparison, provider quality, email access, lab results, Rx refills, telemedicine, etc.) available to members? Is it 151 your tool or a third party’s? Describe the kind of information available to members and how they would access it? Provide a link to these tools. Would you offer a dedicated toll‐free number for Flex Plan 152 members?
46
153
Describe other communication tools available for members such as after hour contact capability, chat feature and email.
Please provide your latest reports or statistics indicating the 154 frequency of usage of your decision support tools and the demographics that are likely to use them. Electronic/Print/Video Do you have any tools for members and/or providers to create and maintain an electronic patient record? Is it your tool or a third party’s? How is the information populated? How do members access their information? How do your medical 155 providers use the electronic patient records to ensure quality healthcare is delivered? What are your policies about making this available to other treating providers in the event of an emergency? Mobile Apps/Education Indicate if you have a mobile application or mobile optimized website, what features it includes or may be limited to as compared to the regular member website, and what information (if any) can be customized by the plan sponsor. If 156 you offer one, provide information regarding how to access your mobile application. Indicate whether and how you maintain consistency between your mobile application and website. Can you share the analytics and statistics collected by your health plan regarding members that access your website or 157 information through mobile apps? If so, please provide a sample report. Describe your organization's video educational and marketing content and what specific video content you make available and whether this material requires or does not require 158 customization for the City. Indicate whether you charge your clients for the use of this material in their plans or for customization. If you have produced them, provide five sample videos that 159 could be used by a client for marketing or educational purposes.
Would you be able to offer/host webinars for employees during or outside of Open Enrollment?
Wellness, Prevention and Disease Management Resource Support for & Alignment w/City Wellness Program Please indicate if you would be willing to provide dedicated 160 funding for the City's use in administering its Wellness program, and if so at what annual value. For any dedicated funding resources you would provide to the City for its Wellness program, please verify that the City is able to use those resources to fund its contracted, communication, 161 promotional, incentive, and internal administrative expenses without restriction, regardless of whether those services are provided by your firm. If you have any restrictions, please identify them and provide the basis for your restrictions.
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162
163
164
165
166
167
For any annual funding you're dedicating for Wellness resources, please indicate if you are willing to transmit those funds directly to the City at the beginning of the calendar year. If you are not willing to transmit those funds to the City, please verify that any unused portion of that funding can be rolled over to a subsequent calendar year and will ultimately be retained by the City up to and including the final year of your contract. Indicate if you will provide dedicated or partially dedicated staff to implement and support the City's wellness program, including administrative staff, consulting, and counseling (including onsite) staff. Please provide name, title, responsibility, and number of annual hours or ongoing percent of a full‐time position for the key staff that would be assigned to service the City's account. Indicate if you provide wellness coaching resources for members, and if so what services are included, the qualifications of the individuals delivering those services, the coaching process, whether those services are restricted in any way to only certain members, and whether those resources are offered face‐to‐face or telephone only or both. Indicate if you will support the City's wellness program benchmarking efforts by fulfilling available aggregate (non‐ member identifying) data requests supplied to an external benchmarking/data management firm. In support of the City's Wellness Program, confirm your ability to transfer medical and pharmacy utilization data on a scheduled basis to an independent data warehouse at no additional cost. Provide an overview of the Wellness resources that your firm has developed and your organization's philosophy with respect to Wellness programs generally.
Which of your programs focus on helping patients identify and lessen the following risk factors:
a. Overweight/obesity
b. Tobacco use
c. High cholesterol/triglycerides
d. High blood glucose
e. High blood pressure
f. Lack of physical activity/exercise
e. Stress management
168
Explain how your organization's wellness program resources 169 could be coordinated with those provided by other providers and describe your experience with this coordination. Explain how your organization's wellness program services (e.g., biometric screenings, health risk assessments, wellness 170 challenges, health education classes, etc.) could be offered to members of various health plans, and describe your experience this provision of cross‐member services. What wellness programs/resources are included within your 171 premium pricing and which are available at an additional cost? Explain in detail and include additional cost. 48
Explain your organization's philosophy and beliefs regarding how best to measure the success of Wellness efforts, programs 172 and resources, and the metrics that you believe would serve as the best indicators of success. Explain your organization's philosophy/practice and experiences with respect to the use of incentives to facilitate 173 participation in the wellness programs and for achieving health enhancement goals. Based on your experience, what wellness‐related programs and strategies have the greatest impact on the following: a. Member engagement, participation and utilization of 174 wellness resources b. Improved health outcomes c. Long‐term cost reduction Problem Resolution Essay Question: As described in the Scope of Services, the City is in the process of creating its own plan sponsor directed Wellness program. The City has articulated a unique vision and will be constructing and implementing a 175 highly customized program offered at the broad level of the Flex Benefits program as a whole. Please discuss how your existing wellness resources and services can be administered to align with and support the City's vision and implementation plan. Disease Management Programs Do you perform Disease Management (DM) services? If yes, 176 describe the DM services in detail that are included in the fully insured premium. Do you have a minimum of three (3) years experience in 177 performing disease management services? Are you currently providing DM services to a group of at least 178 10,000 covered employees (not counting dependents)? 179 180 181
182
183
Do you have the ability and are you willing to customize your DM services to meet the needs / desires of the City? How are members identified and stratified for the DM programs? Describe your DM delivery model, including who delivers the DM coaching, their qualifications, the average DM patient load per coach, and the coaching process. Do you agree to provide reports of DM activity at least quarterly and the annual Return on Investment (ROI) within 3 months of the close of the prior year? If the claims data is available, do you agree (that after the award of this contract and during the implementation phase of your services) you will mine the client’s medical claims and prescription drug data and identify those individuals appropriate for your DM services AND provide the City (prior to the start date of the contract) with a short summary report/memo that outlines what you found in their data, including but not limited to the following elements: (a) The total number of patients identified with chronic diseases you will manage in the initial data analysis (b) The number of patients you identified in each of your risk classes/level
49
(c) The metrics you will use to track the patients' condition management engagement and progress
(d) The percent of clinical goals/objectives the population is NOT adhering to in the baseline data search
Which of the following DM programs do you offer for those patients identified as qualifying for DM services? a. Obesity b. Diabetes c. Hypertension d. Coronary Artery Disease e. Congestive Heart Failure f. Chronic Obstructive Pulmonary Disease (COPD) g. Asthma h. Hyperlipidemia i. Back/neck pain j. Depression k. Other: Are your DM services available to be used by participants who 185 live in any of the 50 states? How do you recommend that a client communicate and 186 encourage the use of DM services? 184
187
Indicate the most effective service you believe your DM staff provides to patients with chronic diseases?
188
Explain how your DM staff introduces themselves to patients for the first time (e.g. phone call, letter)?
189
What DM programs are available at an additional cost? Explain in detail and include the additional cost.
Coordination of Care Describe how your programs provide for coordination of a 190 member's care through utilization review, case management, disease management, Rx management, and wellness programs. ACCESS / CONTINUITY OF CARE
Provider Groups/Networks & Geographic Access Please provide a description of how your narrow and/or tiered 191 networks are structured. Are your proposed networks licensed in the State of California? 192 Please indicate the initial/original year and type of license (for HMO and PPO, as applicable). If a member receives services at an in‐network facility (e.g. for emergency services) but is seen by an out‐of‐network physician, 193 please confirm that the member will not be charged for seeing an out‐of‐network physician. Please provide a response for each type of network proposed. ─ Is the selec on based upon Specialist, Hospitals, and/or Primary Care Physicians? 194 ─ Is the selec on criteria quality or cost based? ─ How do you make the assessments of cost and quality? ─ How o en are the providers profiled? Do your alternative networks have the same underlying cost 195 trend increases? What kind of guarantees are you willing to provide around cost and or trend increases? 50
Please provide an electronic copy or link to your provider and/or hospital profiling information that will be available to 196 members. If this is different for your Full HMO, Narrow Network, or Tiered network, then provide a copy or link for each. Provide separate GeoAccess results for each product that is included in your proposal. Please make sure that the GeoAccess reports match the total of participant counts based on current census data provided. Standard for Definition of Access to Network Provider: 197 ‐ PCPs: 2 in 8 miles for urban/suburban areas, 2 in 15 miles for rural areas ‐ Specialists: 2 in 8 miles for urban/suburban areas, 2 in 15 miles for rural areas ‐ Hospitals: 1 in 10 miles for urban/suburban areas, 1 in 15 miles for rural areas
198 Please complete the disruption analysis tables as accessed through information contained in Attachment B. Explain how the member disruption will impact plan members (employees and dependents). Please identify significant areas 199 of concern in your plan disruption results. Explain how you plan to address member disruption and how your plan will ensure continuity of care.
200
201
202
203
204
Describe your proposed transition of care plan. At a minimum, the transition plan must address: − Individuals who are in the course of medical treatment − Transi on of prescrip ons − Communica on to all plan members and stakeholders Do you agree to cover all eligible expenses incurred by a covered participant who is hospitalized on the date of termination until that person is discharged from the hospital? How would the following situations be handled in which eligible employees/dependents are receiving treatment on the plan’s effective date? ─ Member is hospitalized ─ Member is receiving major ongoing treatment (not hospitalized) for an acute condition ─ Member is receiving ongoing chronic care (e.g., asthma, COPD, diabetes) requiring specialized management ─ Member is receiving non‐acute ongoing care ─ Member is pregnant ─ Member is receiving ongoing treatment for outpatient mental health or substance abuse Are you willing to fund a Pre‐Implementation Review/Audit by an auditor of the City's choosing? This would involve running test claims in a test environment utilizing the City's actual plan parameters. Does your plan have the experience and capability to work with onsite or shared wellness clinics in California? If yes, please describe your experience and capabilities.
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Problem Resolution Essay Question: When a provider group or groups within a network is eliminated there can be changes in what is included within the definition of reasonable and customary for certain services, members may not realize the 205 impact of those changes until after the services are incurred. What steps would you take to assist members in being better informed of the consequences of such changes and what steps, if any, might you propose to mitigate these types of situations from occurring?
Extended Hours, Emergency and Urgent Care Access Describe the extended hours, emergency, and urgent care access resources available to your members, and what 206 resources, policies or practices you have developed to ensure that these resources are member responsive and effectively communicated. FINANCIAL COST
Provider Reimbursement and Discounts 204
For the PPO plan, indicate non‐network equivalent Reasonable & Customary Percentile used for non‐network reimbursement.
205
For the PPO plan, indicate source of non‐network Reasonable & Customary Allowances (Ingenix, Medicare, ADP, Other).
For the PPO plan, please indicate if your plan partners have the 206 ability to access other organizations' PPO networks for claims incurred outside of California. When you are the secondary payor in a Coordination of Benefits (COB) situation, do you use your Usual, Customary & 207 Reasonable (UCR) profiles, reduced network fees, or those of the primary carrier in determining your level of reimbursement?
Hospital and Outpatient Facility Charges
211
Describe how network hospitals are reimbursed for each plan that you are proposing. Your answer should be consistent with the fees provided on the proposal sheets provided. If 208 reimbursement varies by geographic location, identify reimbursement arrangements by area for those relevant to the plan sponsor. For each of the products that you are proposing, how are network outpatient facilities such as surgicenters, imaging 209 centers and laboratories reimbursed (on a discounted fee arrangement, percent of Medicare APCs, pre‐paid capitated arrangement)? 210
If a scheduled fee arrangement is the basis for reimbursement, describe how the scheduled fees are derived. Do you have special arrangements with “Centers of Excellence” facilities? a) Describe the illnesses / conditions and services associated with your Centers of Excellence programs. b) Are services bundled with regard to reimbursement?
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c) Is the facility at risk for cost incurred in excess of the negotiated charge? d) Include the actual bundled charge for each condition, AND list the facilities by name and region.
Underwriting Terms and Conditions
214 What experience period(s) will be used for the first renewal?
What credibility will be given to each period of experience 215 used? Provide a copy of the rate development formula to be used during the first and subsequent annual renewal periods.
217
218
219
220
Please provide the detailed rate development to support the rates in the proposal including claims cost, trend, pooling point 212 and charges, retention, reserves, ACA fees, and all other components including the calculation of tiered rates. Explain the methodology and data to be used for the renewal process. How will projected incurred claims and expenses be 213 estimated for these plans? Please include a sample rate renewal development worksheet.
216
Explain your methodology for establishing Incurred but not reported reserve. Indicate the factors used to set rates for the proposal, to include Annual Trend Factor % of expected claims Reserve Factor % of expected claims, and Margin % of expected claims. Explain any other required reserves other than for Incurred But Not Reported (IBNR). Indicate amounts, reason for reserve, is interest credited and whether reserves are refunded to the client upon policy termination. Detail any underwriting provisions if any (rules) you will impose on the City. Please explain in detail any conditions or requirements, if any, that may cause your organization to increase the rates presented to the City. Please indicate if you can provide a refunding or participating fully‐insured HMO or PPO contract. If so, please provide the estimated percentage change in rates and sample contract.
Retention Levels
Are retention charges set based on a percent of premium, 221 percent of claims, per employee amount, or some other methodology?
Multi‐year Rate Guarantees or Rate Caps
All insured rates, contract terms, and provisions must be guaranteed for twelve months and renewable for a minimum of 12 months for subsequent periods. Will you guarantee initial 222 rates for a longer period of time or provide caps on rate increases? If so, please specify all caveats attached to the rate guarantee(s) offered. Performance Guarantees
223 Please describe any proposed performance guarantee for the first year, second year, and third year.
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224 Please include a sample Performance Guarantee Contract.
Premium Rates and Rate Adequacy for Plan Design Options
All insured rates, contract terms, and provisions must be guaranteed for twelve months and renewable for a minimum of 225 12 months for subsequent periods. Please confirm your agreement to this requirement. Do you agree that changes in the premium rate may only occur 226 on the anniversary date unless required by mandatory benefit changes or other legislative action? Do you agree to provide written notice of rate changes no later 227 than April 1st of each year (9 months notice), including supporting experience and underwriting rate development? 228
Please complete the following rate tables. Quote rates on a 4‐tier basis for active employees using the current rate tier structure.
a.
Option #1 ‐ Fully Insured, Non‐participating (including vision)
Enrollment Assumption
PPO Plan
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Narrow Network Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Full Network Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Staff Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Alternative Provider Network or Care Model
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Proposed Monthly Premium Rates 1/1/2017 ‐ 12/31/2017
Rate reduction if awarded multiple plans? If yes, provide percentage reduction. 54
b.
Option #2 ‐ Fully Insured, Non‐participating (excluding vision)
Enrollment Assumption
PPO Plan
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Narrow Network Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Full Network Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Staff Model HMO
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
Alternative Provider Network or Care Model
Employee Only
Employee + Spouse / DP
Employee + Child(ren)
Family
c.
Proposed Monthly Premium Rates 1/1/2017 ‐ 12/31/2017
Rate reduction if awarded multiple plans? If yes, provide percentage reduction.
Enrollment Assumption
Option #3 ‐ Fully Insured, Participating (including vision) PPO Plan Employee Only Employee + Spouse / DP Employee + Child(ren) Family Narrow Network Model HMO Employee Only Employee + Spouse / DP
Proposed Monthly Premium Rates 1/1/2017 ‐ 12/31/2017 Benefit Costs
Administra tion and Retention
Total Premium
Employee + Child(ren)
Family
Full Network Model HMO 55
Employee Only
Employee + Spouse / DP
d. e.
Employee + Child(ren) Family Staff Model HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Alternative Provider Network or Care Model Employee Only Employee + Spouse / DP Employee + Child(ren) Family Rate reduction if awarded multiple plans? If yes, provide percentage reduction.
Enrollment Assumption
Option #4 ‐ Fully Insured, Participating (excluding vision) PPO Plan Employee Only Employee + Spouse / DP Employee + Child(ren) Family Narrow Network Model HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Full Network Model HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Staff Model HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Alternative Provider Network or Care Model Employee Only Employee + Spouse / DP Employee + Child(ren) Family Rate reduction if awarded multiple plans? If yes, provide percentage reduction. Rate Development Worksheet ‐ including claims cost, trend, pooling point and charges, retention, reserves, ACA fees, and all other components including the calculation of tiered rates.
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Proposed Monthly Premium Rates 1/1/2017 ‐ 12/31/2017 Benefit Costs
Administra tion and Retention
Total Premium
229
Please provide confirmation of the following stipulations regarding the proposed rates:
a. Confirm that your proposed premiums do not include commissions.
b. All proposals must include fees and taxes mandated under ACA.
c. Confirm that your proposal does not include minimum contributions and / or enrollment levels.
d. Confirm that there will be no adjustments to the proposed fees and/or rates based on actual enrollment or subsequent shifts in enrollment.
e. Other than the quoted premium rates, there should not be any other charges or fees of any kind that will or could apply to the City such as start‐up costs, any required ACA fees, booklets or printing. The rates quoted shall include all services, fees, and supplies that could reasonably be expected to be provided to the City during the course of your administration of the plan. Confirm your agreement to this requirement.
For the participating options, when would you evaluate the annual accounting and when would surpluses be returned to the City? Can you propose a risk sharing contract with surplus refunding only? If not, describe 230 how deficits would be recouped. Would the deficit have to be funded from future rate increases, future surpluses, additional premium calls or some other arrangement? Please describe the annual accounting process. 231 Please complete the "Benefit Summary" table included in Attachment A to this RFP.
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SECTION 4 PROPOSAL FORMAT AND SUBMISSION REQUIREMENTS Proposals must be based only on the material contained in the RFP, Pre-Proposal Conference responses, amendments, addenda and other material published by the City relating to the RFP. The proposer must disregard any previous RFP draft material. Proposals must be submitted in accordance with the requirements set forth in this RFP. 4.0 Addendum(a) The City reserves the right to issue addendum(a) to this RFP, which may add additional requirements which must be met in order for a proposal to be considered responsive. All proposers must acknowledge any addendum(a) issued as a result of any change in this RFP on the Proposer Signature Declaration Page. Failure to indicate receipt of addendum(a) may result in a proposal being rejected as non-responsive. 4.1 In Writing All proposals must be submitted in writing and proposers shall complete and return any and all applicable documents including but not limited to written responses, questionnaires, forms, appendices, spreadsheets, and any electronic files. The City may deem a proposer non-responsive if the proposer fails to provide all required documentation, copies or electronic files. 4.2 Cover Letter Each proposal must include a cover letter limited to two pages. The cover letter must include the title, address, email address, and telephone number of the person or persons who will be authorized to represent the proposer. 4.3 Best Offer The proposal shall include the proposer’s best terms and conditions. Submission of the proposal shall constitute a firm and fixed offer to the City that will remain open and valid for a minimum of 12 months from the submission deadline. 4.4 Authorized Signatures Proposals must be signed by a duly authorized officer eligible to sign contract documents and authorized to bind the company to all commitments made in the proposal. A non-officer individual, with the authority to bind the proposer to a contract, is sufficient to sign all applicable documents for the purpose of this RFP. Consortiums, joint ventures, or teams submitting proposals will not be considered responsive unless it is established that all contractual responsibility rests solely with one proposer or one legal entity. The proposal must identify the responsible entity. 4.5 Number of Copies Required Proposers are required to submit:
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One (1) original written proposal sent to the City of Los Angeles RFP Administrator proposal delivery address which includes all required responses to Part A (see specific instructions in Section 3) and Part B, with all documents signed in ink. Two (2) copies of the written proposal sent to the City of Los Angeles RFP Administrator proposal delivery address which includes all required responses to Part A only. One (1) copy of the written proposal sent to each of the City of Los Angeles consultant proposal delivery addresses which includes all required responses to Part A only. Five (5) electronic (USB drive) copies of your Part A response only: three to the City of Los Angeles RFP Administrator, and one each to the City of Los Angeles consultants for this RFP.
Original and copies should be identified as such. If any proposal contains any trade secrets or other proprietary information that the proposer claims is exempt from disclosure under the California Public Records Act (see Section 6.0 of this RFP), then one (1) redacted copy of the proposal must also be submitted in addition to the original version. Written proposals must be presented in a sealed envelope or box. Proposer must enter the title and proposer’s name on the outside of the envelope or box. Sealed proposals are to be delivered to the address listed in this RFP no later than the stated proposal submission deadline. Certain efficiencies in how proposals are prepared and submitted are requested in order to facilitate the review, storage and recycling processes for proposal materials. Economy in presentation and packaging is preferred over materials which are not easily reproduced, create unnecessary waste, or are awkward to store. Please do not submit materials in plastic binders. Each response should have the bulk of its contents prepared on standard 8½ x 11 paper. Non-essential promotional materials and over-sized materials should be avoided wherever possible except as otherwise requested within the RFP. 4.6 Electronic (USB Drive) Submission In addition to the written copies of the proposal, proposers are required to provide a copy of the proposal in Adobe PDF, Microsoft Word, and (questionnaire only) Microsoft Excel format on a USB flash drive. Redacted versions should be sent separately and identified as such. The USB flash drive containing the proposal versions should be labeled with the firm name and title of this RFP and placed in a sealed envelope with the firm’s name written across the front of the envelope and attached or affixed inside the front cover of the original RFP response. 4.7 Information Requested and Not Furnished The information requested and the manner of submission is essential to permit prompt evaluation of all proposals. Accordingly, the City reserves the right to declare as non-responsive and reject any proposals in which information is requested and is not furnished or when a direct or complete answer is not provided. 4.8 Alternatives The proposer shall not change any wording in the RFP or associated documents. Any explanation or alternatives offered shall be submitted in a letter attached to the front of the proposal documents. Alternatives that do not substantially meet the City’s requirements cannot be considered. Proposals offered subject to conditions and/or limitations may be rejected as non-responsive.
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4.9 Proposal Errors Proposer is responsible for all errors or omissions incurred by proposer in preparing the proposal. Proposer will not be allowed to alter proposal documents after the Proposal Submission Deadline, except as allowed by the City. The City reserves the right to make corrections or amendments due to errors identified in the proposal by the City or the proposer. This type of correction or amendment will only be allowed for typographical errors, transposition, or other obvious error. Any changes will be dated and time stamped, and attached to the proposal. All changes must be coordinated in writing with, authorized by, and made by the Contract Administrator. 4.10 Proposal Clarification The City reserves the right to request proposers at any phase of the evaluation process to clarify information provided in RFP responses including clarification of assumptions used in the RFP response. All clarifications must be coordinated in writing with, authorized by, and made by the Contract Administrator. Clarifications must be submitted in writing by the requested deadline, otherwise the RFP response will be deemed non-responsive or evaluated without the benefit of the clarification requested. If the City determines that all proposers failed to submit requested information or adequately responded to the same RFP question or request for data, the City may, at its discretion, issue an RFP Addendum and provide all proposers with an opportunity to provide a response to the RFP question. Responses to RFP Addendum questions must be submitted in writing by the stated deadline otherwise the RFP response will be deemed non-responsive or evaluated without the benefit of the clarification requested. 4.11 Waiver of Minor Administrative Irregularities The City reserves the right, at its sole discretion, to waive minor administrative irregularities contained in any proposal. 4.12 Interpretation and Clarifications of RFP Requirements The City will consider prospective recommendations or suggestions regarding any requirements before the Pre-Proposal Conference. All recommendations or suggestions must be in writing and submitted to the Contract Administrator (see page 1 of the RFP). The City reserves the right to modify or amend any and all requirements of the RFP. 4.13 Proposal Submission Deadline Timely submission of proposals is the sole responsibility of the proposer. The City reserves the right to determine the timeliness of all submissions. The proposals, including all hard copies, redacted copies and electronic copies of the final proposals and proposal questionnaire must be received by the RFP Administrator at the published location and by the published due date included with this RFP. It should be noted that all persons and materials entering the Employee Benefits Division’s City Hall location must go through a security check. Proposers should allow ample time to clear security in order to meet the deadline listed above. All proposals will be date and time stamped upon receipt. 4.14 Late Proposals Proposals submitted after the Proposal Submission Deadline shall be considered late. Late proposals will not be considered. 4.15
Cost of RFP 60
The City is not responsible for any costs incurred by proposer while submitting proposals. All proposers who respond to the RFP do so solely at their own expense. 4.16 Withdrawal of Proposals Proposer may withdraw a submitted proposal in writing at any time prior to the Proposal Submission Deadline. A written request, signed by an authorized representative of the proposer, must be submitted to the RFP Administrator. After withdrawing a previously submitted proposal, the proposer may submit another proposal at any time up to the Proposal Submission Deadline. 4.17 Selection of Vendor The proposer with the highest score based on the RFP criteria and that satisfies all City contracting requirements will be recommended for selection. Selection is not restricted to the lowest offer or bid. Should contract negotiations not be successful with the selected proposer, the City may, based on its exclusive discretion, negotiate with the next most qualified proposer or cancel the RFP selection process. 4.18 Rejection of Proposals The City reserves the right to reject any or all proposals; to waive any minor informality in proposals received; to reject any unapproved alternate proposal(s); and reserves the right to reject the proposal of any proposer who has previously failed to perform competently in any prior business relationship with the City. The rejection of any or all proposals will not render the City liable for costs or damages. 4.19 RFP Withdrawal, Cancellation, Other Options The City reserves the right to withdraw or cancel the RFP at any time, if it deems such action necessary. If such action is taken, the City may re-issue the RFP. The City also reserves the right to contract with more than one respondent to this RFP. Furthermore, the City may exercise its right to not select any proposer from this RFP, if it determines that there was no responsive proposer. If an inadequate number of proposals are received or the proposals received are deemed nonresponsive, not qualified, or not cost effective, the City may, at its sole discretion, reissue the RFP or award a sole-source contract with a vendor. The award of the contract is subject to the successful negotiation of the terms and conditions of an agreement. The City reserves the right to verify all information in the proposal. If the information cannot be verified, the City reserves the right to reduce the rating points awarded. The City reserves the right to require a pre-award interview and/or site inspection. 4.20 Contract Evaluation Program When the term of the contract pursuant to this RFP has concluded, the City will conduct an evaluation of the Contractor’s performance. The City may also conduct evaluations of the Contractor’s performance during the term of the contract. As required by Section 10.39.2 of the Los Angeles Administrative Code, evaluations will be based on specified criteria, including the quality of the work product or service performed the timeliness of performance, financial issues, and the expertise of personnel that the Contractor assigns to the Contract. A Contractor who receives a “Marginal” or “Unsatisfactory” rating will be provided with a copy of the final City evaluation and allowed fourteen (14) calendar days to respond. The City will use the final City evaluation and any response from the Contractor to evaluate Proposals and to conduct reference checks when awarding future service contracts.
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4.21
Campaign Contributions a) Proposers are subject to Charter Section 470(c)(12) and related ordinances. As a result, proposers may not make campaign contributions to and or engage in fundraising for certain elected City officials or candidates for elected City office from the time they submit the Proposal until either the contract is approved or, for successful proposers, twelve months after the contract is signed. The proposer’s principals and subcontractors performing $100,000 or more in work on the contract, as well as the principals of those subcontractors, are also subject to the same limitations on campaign contributions and fundraising. b) Proposers must submit CEC Form 55, provided as Attachment 11 in Part B, to the awarding authority at the same time the Proposal is submitted. The Form requires proposers to identify their principals, their subcontractors performing $100,000 or more in work on the contract, and the principals of those subcontractors. Proposers must also notify their principals and subcontractors in writing of the restrictions and include such notice in contracts with subcontractors. Proposals submitted without a completed CEC Form 55 shall be deemed non-responsive. Proposers who fail to comply with City law may be subject to penalties, termination of Contract and debarment. Additional information regarding these restrictions and requirements may be obtained from the City Ethics Commission at (213) 978-1960 or http://ethics.lacity.org/
4.22 Business Inclusion Program Requirements (BIP) It is the policy of the City to provide Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Small Business Enterprise (SBE), Emerging Business Enterprise (EBE), Disabled Veteran Business Enterprise (DVBE), and all Other Business Enterprise (OBE) concerns an equal opportunity to participate in the performance of all City contracts. Proposers will assist the City in implementing this policy by taking all reasonable steps to ensure that all available business enterprises, including MBEs, WBEs, SBEs, EBEs DVBEs and OBEs, have an equal opportunity to compete for, and participate in, City contracts. Equal opportunity will be determined by the proposer’s BIP outreach documentation, as described in Part B, Attachment 13, and the Business Inclusion Program for this RFP. Participation by MBEs, WBEs, SBEs, EBEs, DVBEs and OBEs may be in the form of subcontracting. Proposers must refer to Attachment 13 Business Inclusion Program to this RFP for additional information and instructions. BIP outreach must be performed using the Business Assistance Virtual Network (www.labavn.org). A proposer’s failure to utilize and complete their BIP Outreach as described in Attachment 13 may result in their proposal being deemed non-responsive. Please note this RFP’s published deadline for submitting the BIP Summary Sheet on www.labavn.org. 4.23 Local Business Preference Program Ordinance Proposers are advised that any proposal submitted and/or contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.47, Local Business Preference Program (LBPP) Ordinance. The City is committed to maximizing opportunities for local businesses, as well as encouraging local businesses to locate and operate in Los Angeles County. The LBPP Ordinance allows the Department to apply additional points to the Proposal’s final score under certain conditions. Proposers shall refer to Part B, Attachment 12, “Local Business Preference Program” for further information regarding the requirements and application of the Ordinance. If applicable, proposers may choose to complete and upload the Local Business Certification Affidavit of Eligibility available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) 62
residing at www.labavn.org prior to the Proposal Submission Deadline. The City may request supporting documentation to verify qualification for designation as a Local Business. Only those proposers who apply and qualify for a Local Business designation (or otherwise qualify by using a qualified Local Subcontractor) by the Proposal Submission Deadline will be made eligible for additional points that can be awarded under the ordinance. Proposers seeking additional information regarding the requirements of the Local Business Preference Program Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org. 4.24 Confidentiality All documents, records and information provided by the City to the Contractor, or accessed or reviewed by the Contractor, during performance of the services will remain the property of the City. All documents, records, and information provided by the City to the Contractor, or accessed or reviewed by the Contractor and any if its employees during performance of services, are confidential (hereinafter collectively referred to as “Confidential Information”). The Contractor agrees not to provide Confidential Information, nor disclose its content or any information contained in it, either orally or in writing, to any other person or entity. The Contractor agrees that all Confidential Information used or reviewed in connection with the Contractor's work for the City will be used only for the purpose of carrying out City business and cannot be used for any other purpose. The Contractor will be responsible for protecting the confidentiality and maintaining the security of City documents and records in its possession. Any Confidential Information provided by the City to the Contractor, or accessed or reviewed by Contractor, during performance of services, will be made available to its employees, agents, and subcontractors only on a need to know basis. Further, the Contractor will provide written instructions to all of its employees, agents and subcontractors, with access to the Confidential Information about the penalties for its unauthorized use or disclosure. The Contractor must not remove Confidential Information or any other documents or information used or reviewed in connection with the Contractor's work for the City from City facilities without prior approval from the City. At no cost to the City the Contractor will, at the conclusion of services, or at the request of the City, promptly return in an organized manner that preserves and protects the documentation, any and all Confidential Information and all other written materials, notes, documents, or other information obtained by the Contractor during the course of work under the contract. The Contractor will not make or retain copies of any such information, materials or documents. The Contractor and its employees, agents, and subcontractors may have access to confidential medical records information, which access is controlled by statute. Misuse of such information may adversely affect the subject individual’s civil rights and violates the law. The Contractor will implement reasonable and prudent measures to keep secure private medical history information accessed by its employees, agents, and subcontractors during the performance of services. The Contractor will advise its employees, agents, and subcontractors of this confidentiality requirement. The Contractor shall disclose the intent to use any service provider outside the continental United States of America to handle any aspect of the work within the scope of services, and shall describe to the City’s satisfaction the methods, which will be utilized to protect the City’s interests and confidentiality of City records and information in doing so. The City reserves the right to approve any such service provider throughout the term of the contract at its sole and absolute discretion.
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Any breach of security that occurs through Contractor’s website, offices or network shall require Contractor to be responsible for notifying City and all applicants affected by such breach. Contractor shall also be responsible for all costs associated with such notification. 4.25 Government Taxation Forms Proposers must submit the following three forms found in Part B, Attachment 3 to the awarding authority at the same time the Proposal is submitted: IRS Request for Taxpayer Identification and Certificate (Form W-9) Evidence of having obtained or applied for a tax registration account number (City of L.A. Tax Registration Certificate number and/or Vender Registration number) State of California Withholding Exemption Certificate (Form 590) or Non-resident Withholding Certification (Form 587), if the proposer is located outside of California. 4.26
On-Line Submission of Required Documents a) Nondiscrimination, Equal Employment Practices and Affirmative Action Program (Non-Construction) Proposers are advised that any contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.8.2., Non-discrimination Clause. Contractors that provide non-construction services to or for the City for which the consideration is $1,000 or more shall comply with the provisions of Los Angeles Administrative Code Sections 10.8.3., Equal Employment Practices Provisions. All proposers shall complete and upload the Non-Discrimination/Equal Employment Practices Affidavit (two (2) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract valued at $1,000 or more. Contractors that provide non-construction services to or for the City for which the consideration is $100,000 or more shall comply with the provisions of Los Angeles Administrative Code Sections 10.8.4., Affirmative Action Program Provisions. All proposers shall complete and upload the City of Los Angeles Affirmative Action Plan (four (4) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract valued at $100,000 or more. Proposers opting to submit their own Affirmative Action Plan may do so by uploading their Affirmative Action Plan onto the City’s BAVN. Both the Non-Discrimination/Equal Employment Practices Affidavit and the City of Los Angeles Affirmative Action Plan Affidavit shall be effective for a period of twelve months from the date they are first uploaded onto the City’s BAVN. Proposers seeking additional information regarding the requirements of the City’s NonDiscrimination Clause, Equal Employment Practices and Affirmative Action Program may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org. b) Equal Benefits Ordinance Proposers are advised that any contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.8.2.1, Equal Benefits Ordinance (EBO). 64
All proposers shall complete and upload the Equal Benefits Ordinance Affidavit (two (2) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract, the value of which exceeds $5,000. The Equal Benefits Ordinance Affidavit shall be effective for a period of twelve months from the date it is first uploaded onto the City’s BAVN. Proposers do not need to submit supporting documentation with their bids or proposals. However, the City may request supporting documentation to verify that the benefits are provided equally as specified on the Equal Benefits Ordinance Affidavit. Proposers seeking additional information regarding the requirements of the Equal Benefits Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org. c) Slavery Disclosure Ordinance Unless otherwise exempt, in accordance with the provisions of the Slavery Disclosure Ordinance, any contract awarded pursuant to this RFP will be subject to the Slavery Disclosure Ordinance, Section 10.41 of the Los Angeles Administrative Code. All proposers shall complete and upload the Slavery Disclosure Ordinance Affidavit (one (1) page) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract. Proposers seeking additional information regarding the requirements of the Slavery Disclosure Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org. d) First Source Hiring Ordinance Unless approved for an exemption, contractors under contracts used primarily for the furnishing of services to or for the City and that involve an expenditure in excess of $25,000 and a contract term of at least three (3) months, and certain recipients of City Loans or Grants, shall comply with the provisions of Los Angeles Administrative Sections 10.44, et seq., First Source Hiring Ordinance (FSHO). Proposers shall refer to Standard Provisions for City Contracts (Revised 06/14), Attachment 7, “First Source Hiring Ordinance”, for further information regarding the requirements of the Ordinance. The First Source Hiring Ordinance Compliance Affidavit shall only be required of the proposer that is selected for award of a contract. 4.27 Bond Assistance Program For those contractors wishing to bid on City projects but are experiencing difficulty obtaining the required bid, performance and payment bonds, the City of Los Angeles provides bonding assistance thru the Los Angeles Bond Assistance Program (BAP LA). For more information regarding the BAP LA please go to the City’s Risk Management website at http://cao.lacity.org/risk. 4.28 Americans with Disabilities Act As covered under Title II of the Americans with Disabilities Act, the City of Los Angeles does not discriminate on the basis of disability and, upon request, will provide reasonable accommodation to ensure equal access to its proposals, programs, services and activities. If an individual with a disability requires accommodations to attend the Pre-Proposal Conference, please contact the Contract Administrator at least five working days prior to the scheduled event. 65
4.29 Iran Contracting Act of 2010 In accordance with California Public Contract Code Sections 2200-2208, all bidders submitting proposals for, entering into, or renewing contracts with the City of Los Angeles for goods and services estimated at $1,000,000 or more are required to complete, sign, and submit the “Iran Contracting Act of 2010 Compliance Affidavit.”
66
SECTION 5 EVALUATION OF PROPOSALS 1. Review Process Proposals received by the Proposal Submission Deadline as specified in this RFP will be evaluated as outlined below. Preliminary Review – Level One Proposals will be reviewed to determine completeness of required documentation and compliance with the City’s administrative and General Contracting Requirements. Proposers that fail to submit or complete required documentation and/or satisfactorily comply with the City’s requirements will be deemed as non-responsive, eliminated from further consideration and will not proceed to the Level Two review process. Proposers will be notified in writing or email regarding the results of the Level One review. Proposal Evaluation - Level Two A Review Committee will be designated by the City to evaluate/score the proposals and generate recommendations for selection to the City. Following the City’s selection, the award of the contract is subject to successful negotiation of the terms and conditions of an agreement. 1) Written Responses – All written responses to the RFP questionnaire will be considered and evaluated. Proposers are not required to submit responses to questions in service model categories for which they are not offering services. 2) Performance Examinations - Proposers will be required to participate in a series of performance examinations. The performance examinations will be narrowly focused on specific topics and will be approximately one hour each in length. The examinations will occur on a date to be determined by the City. The performance examinations will address in more substantive detail certain topics included within the Scope of Services of this RFP. Proposers will receive advance notice of the topics. Proposers will not be permitted at the performance examinations to discuss the qualifications of their firm; clarify or enhance written responses to the written portion of the RFP; or otherwise discuss any other component of their RFP response or interest in securing business with the City. The performance test is a separately scored component of the RFP and its evaluation will not affect the evaluation of any other portion of the RFP response.
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2. Review Criteria Evaluation of submitted proposals will be based on the following factors and the weights associated with each factor. ORGANIZATIONAL STRENGTH & PLAN SPONSOR SERVICES Organizational Qualifications and Reliability Organizational Background, Financial Strength, Experience References Regulatory Compliance HIPAA Compliance Rating Agency Financial Ratings Administration Support & Account Management Claims Processing Billing & Eligibility Plan Sponsor Services Imaging & Document Storage Recordkeeping, Security Protocols, Disaster Recovery & Guarantees Innovations and Miscellaneous Services Advocates and Onsite Services Value Added Services 15% MEMBER SERVICES Direct Service Customer Service Staffing/Availability Quality Control: Appointments, Wait Times, Consultation Length, etc. Quality Control: Referrals Quality Control: Appeals Process Vision Provider Benefits & Transparency Provider Quality of Care PCP Continuity & Provider Turnover Quality control: PCP and Specialist Options and Availability Quality control: Prevention, Adherence, Follow‐up Quality control: Mental Health & Addiction Recovery Resources Rx Options and Availability National Committee for Quality Assurance (NCQA) Accreditation Health Plan Employer Data and Information Set (HEDIS) Results Communications Website Facility and Content Self‐Service Tools Electronic/Print/Video Mobile apps/Education Wellness, Prevention and Disease Management Resource Support for & Alignment w/City Wellness Program Disease Management Programs Coordination with Utilization/Case/Disease/Rx Management 35% 68
ACCESS / CONTINUITY OF CARE Provider Groups/Networks & Geographic Access/Disruption Analysis Extended Hours, Emergency and Urgent Care Access 20% FINANCIAL COST Provider Reimbursement and Discounts Hospital and Outpatient Facility Charges Underwriting Terms and Conditions Retention Levels Multi‐year Rate Guarantees or Rate Caps Performance Guarantees Premium Rates and Rate Adequacy for Plan Design Options 30%
5.2
Proposal Protest Level One - Preliminary Review Proposer may file a protest regarding disqualification at the Level One review. (See Section 5.0, “Preliminary Review – Level One”.) A Notice of Protest must be filed in writing and submitted to the Contract Administrator within five (5) calendar days of the notification of disqualification date. The Notice of Protest must clearly state the grounds for the protest and the facts on which they are based. The Personnel Department will respond to a protest within 15 calendar days of receiving it, and the Department, at its election, may set up a conference call with the proposer to discuss the protest concerns. The decision of the Personnel Department General Manager will be final. Level Two - Award of Contract Recommendation Proposers may file a protest regarding the award of the contract recommendation submitted to the General Manager Personnel Department. A Notice of Protest must be filed in writing and submitted to the Contract Administrator within seven (7) calendar days of the date the City makes its final vendor selections pursuant to this RFP. The Notice of Protest must clearly state the grounds for the protest and the facts on which they are based. A protest based on non-selection alone or disagreement with award of the contract recommendation is not sufficient grounds for a protest. Personnel Department staff will respond to a protest, in writing, within 20 calendar days of receiving it, and the Personnel Department, at its election, may set up a conference call or meeting with the proposer to discuss the protest concerns. Findings and/or recommendations will be submitted to the General Manager Personnel Department and the decision of the General Manager will be final.
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SECTION 6 GENERAL TERMS & CONDITIONS 6.0 Property of City/Proprietary Material All proposals submitted in response to this RFP will become the property of the City of Los Angeles and subject to the California Public Records Act (California Government Code Section 6250 et seq). Proposers must identify all trade secrets or other proprietary information that the proposers claim are exempt from the Public Records Act. The City Attorney will make an independent determination regarding whether the identified information is disclosable. In the event a proposer claims such an exemption, the proposer is required to state in the proposal the following: “The Proposer will indemnify the City and its officers, employees and agents, and hold them harmless from any claim or liability and defend any action brought against them for their refusal to disclose trade secrets or other proprietary information to any person making a request therefore.” Failure to include such a statement will constitute a waiver of a proposer’s right to exemption from this disclosure. 6.1 Pre-Award Negotiations Prior to award of the contract, the successful proposer(s) may be required to attend negotiation meetings that will be scheduled at a later date. The intent of the meeting(s) will be to discuss and negotiate contract requirements, prices/premiums, service level agreements, detailed scope of work specifications, ordering, invoicing, delivery, receiving and payment procedures, etc. in order to insure successful administration of the contract. 6.2 Execution of Contract Unless otherwise stated, proposals submitted will be irrevocable for a period of one-year following the proposal due date. A contract will be developed following action by the Board. Any contract made pursuant to this RFP must be accepted in writing by the Proposer. If for any reason Proposer should fail to accept the contract in writing, then the Proposer may be deemed nonresponsive and the City may commence contract negotiations with another proposer. Please note that the City takes a legal approach whereby all contracts contain an order of precedence. In the event of a discrepancy between the provisions of the Contractor’s documents and the City’s documents, the City’s documents take precedence with respect to resolution of the discrepancy. 6.3 Amendments/Modifications/Change Orders Any amendments, adjustments, alterations, additions, deletions, or modifications in the terms and/or conditions of the resultant agreement must be made by written amendment/change order approved by the Contracting Authority, the Contractor, and signed by the City Attorney. If Contractor performs any modification without a written amendment/change order, the City will neither pay for nor be obligated to accept said modification.
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6.4 Prime Contractor The Proposer awarded the contract must be the prime Contractor performing the primary functions of the contract. If any portion of the contract is to be subcontracted, it must be clearly set forth in the proposal document as to what part(s) are to be subcontracted, the reasons for the subcontracting and a listing of subcontractors. The City reserves the right to reject any proposal wherein use of subcontractors significantly affects the ability of the Proposer to function as the prime Contractor on the awarded contract. The prime Contractor will at all times be responsible for the acts and errors or omissions of its Subcontractors or joint participants and persons directly or indirectly employed by them. 6.5 Subcontractors/Joint Ventures Acceptance or rejection of a Proposer’s request to use subcontractors is at the sole discretion of the City. With approval of the City, the Contractor may enter into subcontracts and joint participation agreements with others for the performance of portions of resultant agreement. The provisions of the resultant agreement will apply to all subcontractors in the same manner as to the Contractor. In particular, the City will not pay, even indirectly, the fees and expenses of subcontractors that do not conform to the limitations and documentation requirements of the resultant agreement. 6.5.1 Copies of Subcontractor Agreements Upon written request from the City, the Contractor will supply the City with all subcontractor agreements at no cost. 6.6 Supplier Performance Feedback Meetings The Proposer awarded the resulting agreement is required to attend periodic performance feedback meetings facilitated by the Contracting Authority. The meetings will focus on the Contractor’s and the City’s performance in fulfilling the service level requirements contained in the contract. The meetings will provide a forum to informally discuss opportunities for improving contract terms and conditions, service level requirements, and cost reductions for both parties. 6.7 Replacement of Contractor’s Staff The City reserves the right to have the Contractor replace any contract personnel with equally or better qualified staff upon providing written notice to Contractor. In addition, the City reserves the right to approve in advance any changes in project personnel or levels of commitment by the Contractor to the project. 6.8 Contractor’s Address The address given in the proposal response will be considered the legal address of the Contractor and will be changed only by written notice to the City. The Contractor will supply an address to which certified mail can be delivered. The delivery of any communication to the Contractor personally, or to such address, or the depositing in the United States Mail, registered or certified with postage prepaid, addressed to the Contractor at such address, will constitute a legal service thereof. Also, telephone numbers, fax numbers and e-mail addresses (if applicable) must be provided. 6.9 Term & Option to Renew The term of any contract(s) established pursuant to this RFP shall be for the period identified in the RFP Introduction. The City reserves the right in its sole discretion to seek an extension of the term of the contract. 71
6.10 Standard Contract Provision Requirements Please carefully review the information contained in the City of Los Angeles Requirements and Checklist (Part B), including the Standard Provisions for City Contracts. Compliance with these requirements and submission of necessary forms is mandatory at the time of submission of a proposal, prior to award of contract, or both. These requirements will be discussed in detail at the Pre-Proposal Conference. Failure to comply with the requirements and accept the contract provisions will render proposals non-responsive and eliminate them from consideration. 6.11 Governing Law All matters relating to the formation, validity, construction, interpretation, performance and enforcement of the RFP and the resultant agreement/contract, must comply with all applicable laws of the United States of America, the State of California and the City. 6.12 California State Sales Tax Do not include California State sales tax in prices quoted unless otherwise requested. If requested, sales tax must be identified as being included in the pricing. 6.13 California State Board of Equalization Permit Proposer must enter the company’s State of California Board of Equalization permit number on the proposal form. If the company does not have this permit, the proposer must sign the proposal form declaring that the company has no California sales tax permit. 6.14 Federal Excise Taxes The City of Los Angeles is exempt from the payment of excise taxes imposed by the Federal Government. Such taxes must not be included in the proposed prices. The Department of General Services, upon request, will furnish Federal excise exemption certificates. 6.15 Periodic Independent Audit The City reserves the right to assign an independent auditor to assess the quality of services being provided and the extent to which the vendor and its subcontractors are conducting City business within generally accepted industry standard practices. Each Contractor will be required to cooperate fully with any external audit. 6.16 Financial Audit Firms providing services to the City will be responsible for the verification of the legitimacy of payments made to service providers and their subcontractors. The City therefore reserves the right for staff of its Office of the Controller or their designee to conduct audits of financial accountability procedures. 6.17 Proposer Background Information Proposers must submit contact information as requested in the Proposal Questionnaire. 6.18 Verification of Prior City Contracts The City Council adopted a resolution requiring vendors to provide a list of all City contracts held within the past 10 years to be included in the response package for all bids and proposals. Performance on past contracts with the City of Los Angeles will be part of the evaluation criteria. Failure to disclose this information will deem the proposal non-responsive.
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6.19 History of Terminated Contracts You must describe any incident within the past ten years in which your business has had a contract terminated for default as requested in Proposal Questionnaire. 6.20 Business Organization Proposer shall provide an overview of the entity submitting this RFP as requested in Proposal Questionnaire. 6.21 Proposed Subcontractor Information If applicable to proposal, information must be provided for each proposed subcontractor as requested in the Proposal Questionnaire. 6.22 Proposer Signature Declaration Proposer shall provide a Signature Declaration as requested in the Proposal Questionnaire.
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ATTACHMENT A
Summary Medical Data 1. Current enrollment information Oct-2015 Enrollment Blue Shield PPO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Total
1,537 351 462 371 2,721
Blue Shield Narrow Network HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Total
2,426 948 803 2,812 6,989
Blue Shield Full Network HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Total
74 17 15 24 130
Kaiser Employee Only Employee + Spouse / DP Employee + Child(ren) Family Total
4,758 1,966 1,549 4,571 12,844
Note: The Full Network HMO counts are understated due to a group of participants that are counted under the Narrow Network HMO due to some issues during transition from Anthem to Blue Shield. The monthly paid claims and employee counts for this group are included in the Full Network HMO report on page 78.
74
2. Current and historical premium information Rate per Employee per Month Blue Shield PPO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Blue Shield Narrow Network HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Blue Shield Full Network HMO Employee Only Employee + Spouse / DP Employee + Child(ren) Family Kaiser Employee Only Employee + Spouse / DP Employee + Child(ren) Family
1/1/2015 – 12/31/2015
1/1/2016 – 12/31/2016
$ 722.74 $ 1,596.58 $ 1,385.34 $ 1,811.04
$ 808.20 $ 1,785.60 $ 1,549.14 $ 2,025.02
$ 480.48 $ 1,055.58 $ 956.54 $ 1,313.14
$ 531.32 $ 1,167.46 $ 1,057.78 $ 1,452.04
$ 732.26 $ 1,609.76 $ 1,457.94 $ 2,001.04
$ 810.00 $ 1,780.84 $ 1,612.74 $ 2,213.42
$ 543.98 $ 1,196.66 $ 1,087.98 $ 1,414.30
$ 569.26 $ 1,252.28 $ 1,138.54 $ 1,480.04
3. Access to the City’s Evidence of Coverage documents The most recently published evidence of coverage documents can be found on the City’s website: http://per.lacity.org/Bens/docforms.htm
75
4. Historical plan experience Blue Shield PPO Employees Jan-14
2,795
Medical Paid*
Members 4,975
$
356,193
Prescription Drug Paid $
177,665
Total $
533,858
Feb-14
2,791
4,963
1,295,067
523,902
1,818,969
Mar-14
2,791
4,983
1,587,255
505,928
2,093,183
Apr-14
2,783
4,975
1,953,431
579,175
2,532,606
May-14
2,783
4,988
1,739,378
547,090
2,286,468
Jun-14
2,767
4,969
1,913,905
451,486
2,365,391
Jul-14
2,761
4,881
2,109,093
481,705
2,590,798
Aug-14
2,751
4,879
3,112,107
536,346
3,648,453
Sep-14
2,742
4,854
2,792,097
493,934
3,286,032
Oct-14
2,750
4,874
2,437,765
512,504
2,950,269
Nov-14
2,748
4,889
3,369,090
550,938
3,920,028
Dec-14
2,747
4,887
2,805,232
597,255
3,402,487
33,209
59,117
$ 25,470,612
$
5,957,929
$ 31,428,541
$
$
2014 Total Jan-15
2,738
4,893
Feb-15
2,727
4,877
1,943,078
3,160,163
582,725
576,728
$
2,525,803
3,736,891
Mar-15
2,739
4,902
3,470,785
598,192
4,068,977
Apr-15
2,747
4,912
2,672,369
612,915
3,285,284
May-15
2,737
4,901
1,679,977
559,276
2,239,253
Jun-15
2,736
4,891
2,041,360
591,350
2,632,710
Jul-15
2,732
4,891
2,203,814
596,979
2,800,793
Aug-15
2,719
4,866
1,705,536
675,035
2,380,571
Sep-15
2,722
4,871
2,518,043
654,374
3,172,417
Oct-15
2,743
4,909
1,709,629
636,173
2,345,802
Nov-15
2,756
4,939
1,730,187
686,754
2,416,941
Dec-15
2,757
4,938
2,969,096
667,499
3,636,595
32,853
58,790
$ 27,804,037
7,438,000
$ 35,242,037
2015 Total
$
*Includes medical, mental health and substance abuse paid claims and capitation. Vision claims are provided in a separate exhibit.
76
Blue Shield Narrow Network HMO
Employees
Medical Paid*
Members $
2,363,708
Prescription Drug Paid $
304,893
Total
Jan-14
6,281
16,568
Feb-14
6,276
16,543
3,169,206
819,785
$
3,988,992
2,668,601
Mar-14
6,307
16,552
3,373,613
791,964
4,165,577
Apr-14
6,303
16,532
3,633,646
931,471
4,565,117
May-14
6,312
16,480
3,769,843
817,114
4,586,957
Jun-14
6,323
16,486
3,656,070
792,113
4,448,184
Jul-14
6,352
16,144
4,726,523
799,805
5,526,328
Aug-14
6,368
16,225
4,849,688
852,152
5,701,839
Sep-14
6,386
16,127
4,753,302
853,474
5,606,777
Oct-14
6,417
16,188
4,619,930
876,040
5,495,971
Nov-14
6,416
16,178
4,109,044
917,434
5,026,479
Dec-14
6,408
16,145
3,650,518
990,183
4,640,701
76,149
196,168
$ 46,675,091
$
9,746,431
$ 56,421,522
Jan-15
6,344
16,167
$
$
931,050
Feb-15
6,324
16,097
Mar-15
6,332
16,075
4,337,166
950,434
5,287,600
Apr-15
6,329
16,062
5,387,344
1,146,216
6,533,560
May-15
6,365
16,086
3,989,291
1,057,083
5,046,374
Jun-15
6,344
16,015
4,057,739
1,010,449
5,068,188
2014 Total
3,761,285 4,377,705
1,046,871
$
4,692,335 5,424,576
Jul-15
6,351
16,032
4,790,790
974,442
5,765,232
Aug-15
6,387
16,044
5,701,110
1,030,187
6,731,297
Sep-15
6,425
16,081
4,052,023
1,070,165
5,122,188
Oct-15
6,497
16,199
4,153,059
1,061,071
5,214,130
Nov-15
6,522
16,231
4,199,693
1,111,721
5,311,414
Dec-15
6,525
16,212
4,499,377
1,261,183
5,760,560
76,745
193,301
$ 53,306,582
$ 12,650,872
$ 65,957,454
2015 Total
*Includes medical, mental health and substance abuse paid claims and capitation. Vision claims are provided in a separate exhibit.
77
Blue Shield Full Network HMO
Employees
Medical Paid*
Members $
653,918
Prescription Drug Paid $
68,091
Total
Jan-14
968
2,860
$
722,009
Feb-14
962
2,846
762,617
185,143
947,761
Mar-14
964
2,845
943,247
143,166
1,086,413
Apr-14
957
2,819
970,897
232,923
1,203,820
May-14
951
2,802
776,368
224,164
1,000,532
Jun-14
942
2,772
779,714
204,189
983,903
Jul-14
888
2,606
1,191,924
162,557
1,354,480
Aug-14
881
2,592
715,770
166,474
882,244
Sep-14
874
2,563
686,105
129,157
815,262
Oct-14
865
2,528
754,280
142,240
896,520
Nov-14
864
2,527
679,661
152,894
832,556
Dec-14
863
2,524
699,629
160,235
859,864
10,979
32,284
$
1,971,233
$ 11,585,363
$
2014 Total
9,614,130
$
853,695
$
Jan-15
721
2,096
Feb-15
717
2,086
646,084
139,407
148,304
$
1,001,999 785,491
Mar-15
716
2,090
646,181
132,619
778,800
Apr-15
706
2,065
611,352
140,641
751,993
May-15
704
2,052
608,273
130,468
738,741
Jun-15
700
2,032
542,869
137,171
680,040
Jul-15
692
2,018
718,526
172,999
891,525
Aug-15
692
2,012
836,823
146,634
983,457
Sep-15
692
2,002
816,079
184,137
1,000,216
Oct-15
693
2,003
1,068,730
158,248
1,226,978
Nov-15
693
1,997
709,766
162,725
872,491
Dec-15
693
1,997
890,430
164,117
1,054,547
8,419
24,450
1,817,470
$ 10,766,278
2015 Total
$
8,948,808
$
*Includes medical, mental health and substance abuse paid claims and capitation. Vision claims are provided in a separate exhibit.
78
Blue Shield Vision
Employees
Members
Total Claims Paid
Jan-14
10,154
24,621
$
36,903
Feb-14
10,105
24,554
54,892
Mar-14
10,085
24,461
79,162
Apr-14
10,098
24,465
68,586
May-14
10,122
24,462
68,571
Jun-14
10,091
24,372
67,470
Jul-14
10,104
23,802
71,500
Aug-14
10,069
23,840
73,797
Sep-14
10,072
23,857
77,500
Oct-14
10,081
23,725
69,855
Nov-14
10,081
23,705
67,751
Dec-14
10,070
23,697
67,010
121,132
289,561
$
802,997
$
78,604
2014 Total Jan-15
9,872
23,409
Feb-15
9,865
23,227
68,871
Mar-15
9,824
23,129
69,980
Apr-15
9,841
23,142
72,022
May-15
9,857
23,150
57,569
Jun-15
9,916
23,217
67,071
Jul-15
9,926
23,207
66,755
Aug-15
9,968
23,215
69,445
Sep-15
9,848
22,964
65,447
Oct-15
9,881
23,022
58,127
Nov-15
9,965
23,140
52,334
Dec-15
9,973
23,150
58,788
118,736
277,972
2015 Total
79
$
785,013
Blue Shield Vision (continued)
Procedure Categories Diagnostic
Frames and Tint
Lens
Procedure Count
Procedure Code 90060 92002 92004 92012 92014 Unknown Unknown
92340 92341 92342 92399 BRHAS BRHK BRSAN BRSAS BRSMY V2781
Procedure Code Description 2014 Comprehensive eye exam Comprehensive eye exam Limited Consultation Comprehensive eye exam Comprehensive eye exam Total
23 4,542 241
48 19 3,361 276 1,458
4,806
5,162
Frames Tint
3,119 117
2,842 86
Total
3,236
2,928
Single Vision Lens Bifocal Lens
2,341 234
2,295 203
53 938 2 3 3 4 737
33 989 1 7 4 1 5 701
4,315 361 43
4,239 115 524 40
7
6 11
14 452 2
2 414 11
1,445 113 77 150
1,472 105 80 117
Trifocal Lens Cosmetic CL Unknown Contact Lenses for Keratoconus Unknown Unknown Unknown Progressive Lens, per Lens Total
Custom Services
2015
92250 92310 RIMLS V2410 V2702 V2741 V2744 V2745
Unknown Fitting of Lens Rimless Single Lens Deluxe Lens Tint, Plastic, Other than rose 1-2, per Lens Tint, Photochromatic, Per Lens Special Tint
V2750
Anti-Reflective Coating, Per Lens
V2755 V2760 V2762
U-V Lens, per Lens Scratch resistant coating, per Lens Polaroid Special Tint
V2782
Unknown
V2783 V2784 V2797 V2799
High Index Polycarbonate Unknown Vision Service, Miscellaneous
18 236 1,757 6 263
31 197 1,803 113 226
Total
4,944
5,267
17,301
17,596
Total Procedure Count
80
5. Benefit Summary Data
Current PPO Plan
Calendar Year Deductible (individual/family) Calendar Year Out-of-Pocket Maximum (individual/family) Lifetime Maximum benefit Routine Office Visits
Pediatric Office Visits
In-Network $750/$1,500
Out-of-Network $1,250/$2,500
$2,000/$4,000 (includes deductible) Unlimited 100% after $30 copay/visit 70% of allowed charges*** with no deductible; 90% after deductible after deductible for any procedures as part of visit 100%, no deductible, for 70% of allowed charges*** routine exams and after deductible immunizations up to age 6
Preventive Care*
100%, no deductible
70% of allowed charges*** after deductible
Inpatient Hospitalization
90% after deductible; prior authorization needed****
Outpatient Surgery
90% after deductible
70% of allowed charges*** after deductible, up to $1,500 per day maximum allowed charges, plus all charges in excess of $1,500, must be prior authorized**** 70% of allowed charges*** after deductible, up to $350 per day maximum allowed charges, plus all charges in excess of $350 70% of allowed charges*** after deductible
Maternity Care (office visits) Diagnostic lab work and xrays Emergency room
100% after $30 copay/visit 90% after deductible
70% of allowed charges*** after deductible
90% after $100 copay/visit; copay waived if admitted and regular hospitalization benefits apply
Mental Health and Chemical Dependency Treatment Inpatient**
Outpatient**
Hearing Aid Benefit
90% after deductible
70% of allowed charges*** after deductible, up to $1,500 per day maximum allowed charges, plus all charges in excess of $1,500, must be prior authorized****
90% after deductible for facility-based care; 100% after $30 copay/visit for physician visit
70% of allowed charges*** after deductible, up to $350 per day maximum allowed charges, plus all charges in excess of $350 for facility based care; 70% of allowed charges for physician office visit
Plan pays up to a maximum of $2,000 per member every 24 months for hearing aid and ancillary equipment
81
Proposed PPO Plan Note Deviations Only Out-ofIn-Network Network
Current PPO Plan In-Network
Out-of-Network
Prescription Drug Retail (30 day supply) Generic
$10
$10 + 25% of remaining covered expense
Brand-name
$20
$20 + 25% of remaining covered expense
Non-formulary
$40
$40 + 25% of remaining covered expense
Proposed PPO Plan Note Deviations Only Out-ofIn-Network Network
Mail Order (90 day supply) Generic $20 N/A Brand-name $40 N/A Non-formulary $80 N/A Specialty (30 day supply) Generic $10 N/A Brand-name $20 N/A Non-formulary $40 N/A If a member requests a brand-name drug and a generic equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost between the brand-name drug and its generic drug equivalent. * Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and the federal regulations. ** The mental health inpatient and outpatient benefits shown here are general benefit provisions. Consult with plan for specific information regarding benefits available in your situation. *** When members use non-preferred providers, they must pay the applicable copayment and coinsurance plus any amount that exceeds Blue Shield’s allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or copayment maximum. **** You or your doctor must contact Blue Shield for preauthorization and approval before a hospital stay or you will be responsible for a penalty of $250.
82
Current Narrow Network HMO In-Network None
Calendar Year Deductible (individual/family) Calendar Year Out-of-Pocket Maximum (individual/family) Lifetime Maximum benefit Routine Office Visits Pediatric Office Visits Preventive Care* Inpatient Hospitalization Outpatient Surgery Maternity Care (office visits) Diagnostic lab work and x-rays Emergency room Mental Health and Chemical Dependency Treatment Inpatient** Outpatient**
Hearing Aid Benefit
Proposed Narrow Network HMO Note Deviations Only In-Network
$500/$1,500 Unlimited 100% after $15 copay/visit 100% up to age 5 100% 100% 100% 100% 100% 100% after $100 copay/visit; copay waved if admitted 100% 100% for facility-based care; 100% after $15 copay/visit for physician visits One hearing aid per ear every 24 months after $15 copay/visit
Prescription Drug Retail (30 day supply) Generic $10 Brand-name $20 Non-formulary $40 Mail Order (90 day supply) Generic $20 Brand-name $40 Non-formulary $80 Specialty (30 day supply) Generic $10 Brand-name $20 Non-formulary $40 If a member requests a brand-name drug and a generic equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost between the brand-name drug and its generic drug equivalent. *Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and the federal regulations. **The mental health inpatient and outpatient benefits shown here are general benefit provisions. Consult with your plan for specific information regarding benefits available.
83
Current Full Network HMO In-Network None
Calendar Year Deductible (individual/family) Calendar Year Out-of-Pocket Maximum (individual/family) Lifetime Maximum benefit Routine Office Visits Pediatric Office Visits Preventive Care* Inpatient Hospitalization Outpatient Surgery Maternity Care (office visits) Diagnostic lab work and x-rays Emergency room Mental Health and Chemical Dependency Treatment Inpatient** Outpatient**
Hearing Aid Benefit
Proposed Full Network HMO Note Deviations Only In-Network
$500/$1,500 Unlimited 100% after $15 copay/visit 100% up to age 5 100% 100% 100% 100% 100% 100% after $100 copay/visit; copay waved if admitted 100% 100% for facility-based care; 100% after $15 copay/visit for physician visits One hearing aid per ear every 24 months after $15 copay/visit
Prescription Drug Retail (30 day supply) Generic $10 Brand-name $20 Non-formulary $40 Mail Order (90 day supply) Generic $20 Brand-name $40 Non-formulary $80 Specialty (30 day supply) Generic $10 Brand-name $20 Non-formulary $40 If a member requests a brand-name drug and a generic equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost between the brand-name drug and its generic drug equivalent. *Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and the federal regulations. **The mental health inpatient and outpatient benefits shown here are general benefit provisions. Consult with your plan for specific information regarding benefits available.
84
Current Vision Benefits for Narrow HMO, Full HMO and PPO Plans Vision Care One eye exam every 12 months Lenses Single Vision Bifocal Trifocal Progressive One pair of frames every 24 months Contacts (instead of frame and lens benefits) Non-elective** Elective - conventional Elective - disposable lenses
In-Network
Out-of Network
100% after $10 copay
Up to $49
Proposed Vision Benefits Note Deviations Only In-Network
Out-of Network
One pair of lenses every 24 months: 100% after $10 copay Up to $35 100% after $10 copay Up to $49 100% after $10 copay Up to $74 100% after $10 copay + Up to $49 $65 Up to $130 retail value, Up to $50 then 20% discount* Every 24 months: 100% Up to $130 retail value*** Up to $130 retail value***
Up to $250 Up to $92 Up to $92
*The maximum varies for network providers offering wholesale or warehouse pricing, including Wal-Mart and Costco. **Required as the result of eye surgery or certain eye conditions ***If you reach the maximum, additional discounts are available by ordering through MESvisionoptics.com.
85
Current Staff Model HMO
Calendar Year Deductible (individual/family) Calendar Year Out-of-Pocket Maximum (individual/family) Lifetime Maximum benefit Routine Office Visits Pediatric Office Visits Preventive Care* Inpatient Hospitalization Outpatient Surgery Maternity Care Diagnostic lab work and x-rays Emergency room
In-Network None
Proposed Staff Model HMO Note Deviations Only In-Network
$1,500 / $3,000 Unlimited 100% after $15 copay / visit 100% up to age 5 100% 100% 100% after $15 copay/visit 100% 100% at Kaiser facility
100% after $100 copay / visit; copay waved if admitted Mental Health and Chemical Dependency Treatment Inpatient** 100% Outpatient** 100% after $15 copay / visit; 100% up to age 5 Hearing Aid Benefit Up to $2,000 allowance for one device per ear every 36 months; covers all visits for fitting, counseling, adjustment, cleaning and inspection Vision Benefits One eye exam every 12 months Lenses, frames and contacts
100% Every 24 months, $200 eyewear allowance toward the purchase of covered lenses, frames and/or elective contact lenses at Kaiser Permanente vision centers
Prescription Drug Retail (30 day supply) Generic Brand-name Mail Order (100 day supply) Generic Brand-name
$10 $20 $20 $40
*Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and the federal regulations. **The mental health inpatient and outpatient benefits shown here are general benefit provisions. Consult with your plan for specific information regarding benefits available.
86
Alternative Provider Network or Care Model
Proposed Benefits Note Deviations Only
In-Network None
In-Network
Calendar Year Deductible (individual/family) Calendar Year Out-of-Pocket Maximum (individual/family) Lifetime Maximum benefit Routine Office Visits Pediatric Office Visits Preventive Care* Inpatient Hospitalization Outpatient Surgery Maternity Care (office visits) Diagnostic lab work and x-rays Emergency room Mental Health and Chemical Dependency Treatment Inpatient** Outpatient**
Hearing Aid Benefit
$500/$1,500 Unlimited 100% after $15 copay/visit 100% up to age 5 100% 100% 100% 100% 100% 100% after $100 copay/visit; copay waved if admitted 100% 100% for facility-based care; 100% after $15 copay/visit for physician visits One hearing aid per ear every 24 months after $15 copay/visit
Prescription Drug Retail (30 day supply) Generic Brand-name Non-formulary Mail Order (90 day supply) Generic Brand-name Non-formulary Specialty (30 day supply) Generic Brand-name Non-formulary
$10 $20 $40 $20 $40 $80 $10 $20 $40
If a member requests a brand-name drug and a generic equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost between the brand-name drug and its generic drug equivalent. *Preventive care coverage includes preventive services rated A or B by the U.S. Preventive Services Task Force and the federal regulations. **The mental health inpatient and outpatient benefits shown here are general benefit provisions. Consult with your plan for specific information regarding benefits available.
87
ATTACHMENT B The following items will be provided upon receipt of a signed mutual confidentiality agreement:
Census data Disruption analysis tables Large claim data for 2014 and 2015 Detailed prescription drug data for 2015
Please contact Segal Consultants to receive a copy of the confidentiality agreement: Segal Consultants Attention: Stephen E. Murphy Vice President, Benefits Consultant 330 N. Brand Blvd., Suite 1100 Glendale, CA 91203-2337 Fax: 818-484-2697
[email protected]
88
