The vendor is required to provide for medical and pharmacy plan administrative services for city employees and their dependents, effective January 1, 2026.
- The city currently employs 416 employees, 341 full-time and 75 part-time / temporary.
- Provide primary administrative services, including:
• Adjudicate medical and pharmacy claims
• Administer selected cost control and member support programs
• Manage coordination of benefits
• Conduct medical necessity and coverage denial determinations
• Conduct utilization review, including internal appeals and coordination of external review
• Subrogation pursuit following appropriate standards of practice
• Open enrollment, benefit administrator, and benefit fair support
• Detect and report on fraud, waste, and abuse
• Monitor provider quality
• Coordinate services with any data management, stop loss, episodes of care, direct primary care, clinic, medical care management, navigation, transparency, expert second opinion, telemedicine or other vendor with whom the city may contract
• Provide standard and agreed-upon ad hoc reports on a timely basis
• Adhere to agreed-upon performance guarantees
• Maintain member-facing website with applicable accruals, tools, and support
• Allow audits of claims, operational, and administrative processes and procedures and systems
• Conduct annual utilization review and make recommendations for improved plan performance
• Conduct bi-weekly or monthly administrative calls
• Advise of any new regulatory compliance issues that may impact the city’s plan
• Offer a comprehensive employee wellness and incentive program that supports physical, mental, and emotional well-being through evidence-based initiatives, health education, digital tools, coaching, and incentive structures aligned with the employer’s health engagement goals.
• Provide thorough provider network covering all specialties
• Provide care coordination with key partners, including employee assistance services (mental health and substance abuse benefits) and the employee health clinic
• Ensure adherence to HIPAA regulations and other relevant healthcare laws
• Provide information to assist the city with effective decisions in developing an employee benefits program that is comprehensive and meets established objectives with respect to cost and competitiveness with the goal of attracting and retaining employees
• Offer early intervention and enhanced management of chronic diseases
• Provide materials for enrollment purposes for all benefit-eligible employees
• Provide member-facing and employer-facing customer service, with a seasoned client service team
• Assist with resolution of specific claims when requested by the city
• Provide timely notification of and assistance with understanding and implementing new, updated or revised benefits, laws, regulations and programs, including alerting the city regarding any employee communication deadlines or communication issues, and providing sample documents that may be used to notify employees of any of these changes
• Provide on-going analysis regarding accuracy of vendor billing, eligibility, claims, benefit research questions, and administration
• Provide information about wellness programs or services offered to support the overall health and well-being of employees, and how these programs integrate with medical insurance offerings
• Provide information about employee assistance programs (“EAP”) offered that integrates with the medical insurance provider network, and what specific resources or services are available to all employees through this integration
• Participate in virtual and in-person meetings as needed or requested
• Provide enrollment and ongoing utilization reporting
• Provide clear and timely communications.
- Contract Period/Term: 3 years
- Questions/Inquires Deadline: May 30, 2025