Medical Insurance and Disease Management Services

The vendor is required to provide medical insurance and disease management services for consisting of a group self-funded medical and pharmacy with specific stop loss coverage, reinsurance, pharmacy, wellness and disease management.
- To provide employees with a quality, affordable health insurance program responsive to the diverse needs of employees;
- To ensure employees and their dependents are provided with the highest quality of care by providers and superior customer service;
- To ensure plans are managed effectively by taking advantage of cost and utilization management opportunities available in the marketplace while increasing quality;
- To provide employees access to consumer enhancing technology that assist in education and communication on provider choice, quality, transparency, personal health care, and cost;
- To assist the city in building a community/culture of wellness, accountability and responsibility.
- To ensure the city’s human resources, benefits, and billing departments have resources / mechanisms in place that allow for ease of plan administration.
- Medical, pharmacy, and population health management program financials:
• Quote a self-funded program (administrative services only for medical and pharmacy claims administration and medical management)
• Include 100% pass through of pharmacy rebates.
• Please provide 12 month mature claims projection for current plan design, proposed plan options (chart in appendix) and current RX plan design for medical and pharmacy
• The city also provides a chronic disease management program where copayments for certain prescription drugs are eliminated for those with chronic conditions.
- Medical and pharmacy network design and access:
• Offerors are invited to propose HMO, POS, PPO, ACO networks.
• Provide networks of providers, which are broad enough to ensure that all members (active and retired) have “reasonable access” to an adequate number of highly qualified primary care and specialist providers.
- Technology requirements:
• Enrollment, changes and terminations processed on electronic file transfers provided by the city from their HRIS system; agency implementation in process with the effective date to be determined.
• Member and employee websites with access to claims, tools and resources
• Education materials
• Mobile app
• Provide internet access to claims and to the claim reporting system to the city’s benefits personnel and to the city’s benefit consultants.
- Administrative and service issues:
• The city requires a dedicated billing and eligibility representative and a dedicated account management team.
• The city requires monthly “paid” claim data, accounting statements outlining all fees and large claims.
• The city requires vendors to provide quarterly and annual claims utilization data.
• The city requires quarterly vendor led meetings throughout the year on medical, pharmacy and disease management claims and services review.
• Carrier/administrator is expected to provide an electronic version of all summary plan descriptions and summary of benefits coverage documents
• The city extends coverage to “retirees” under age 65
• Dependents are eligible to the end of the calendar month age 26
• Ideally, the city wishes to have access to a reporting tool in “real time”
• the city may periodically request basic “ad hoc” reporting in order to analyze certain aspects of the program; outline additional cost and timeframes to provide these reports.
• It is assumed that all ongoing administrative costs associated with meeting these proposal specifications are included in the proposed administrative fees.
• The city requires claim processing lag reports.
• Support the city’s current and future wellness initiatives, to include providing, at no cost, direct data feeds to captivity (3d), use’s data mining partner.
- Contract Period/Term: 2 years