The vendor is required to provide medical benefits for employee’s services for include:
• Provide and make available necessary, appropriate and high-quality medical services to the eligible employees, retirees, and their dependents.
• Any proposed health care plan must be capable of providing coverage to all eligible employees, retirees, and their dependents of agency.
• Provide necessary and appropriate program administration and services, including but not limited to, maintaining central claims and membership files (including social security numbers, dates of coverage, type of coverage, etc.) for each covered member, by account/division number; maintaining payment record; capable of the wire transferring of funds; capable of making payment to providers directly; capable of providing state-of-the-art data tracking and claims paying services; furnish monthly accounting statements by benefit plan and employer showing enrollment, premiums/revenues received, amount of claims paid, capitation expenses charged, detailed list of expenses charged, network discounts earned, claims exceeding the specific stop-loss limit and an estimate of incurred but not reported claims
• Furnish to each employee enrolled in the plan a benefit booklet outlining and defining all covered services, limitations and exclusions, procedures for receiving services, schedule of benefits, cobra and other plan information requirements
• Prior to the effective date of the plan (January 1, 2026) and subsequent to verification of enrollment by the agency, provide to all covered participants an identification card
• The remainder of the contract period, provide an identification card to new enrollees within fifteen (15) calendar days of their enrollment date if outside an open enrollment period or prior to January 1, if enrollment occurs as a result of the annual open enrollment period.
• Provide agency a complete detailed renewal underwriting analysis
• Provide agency with quarterly utilization and savings reports specific to the benefits paid and services rendered to covered members.
• Provide agency with a detailed analysis showing all expenditures and claims on a monthly basis.
• Provide to agency a full financial disclosure of any and all applicable medical rebates on a quarterly basis
• Provide a single point of contact responsible for quality control, resolving problems, and expediting services related to the overall performance of the contract.
• Maintain a local or toll-free customer service number for employees and dependents.
• Provide a systematic procedure for appeal of claims
• Accept the no gain or loss provision and waive any actively-at-work provisions
• No gain or loss provision:
a. No participant (employees, retirees and dependents) currently covered by any of agency health care programs, shall suffer a loss of health benefit coverage as a result of changing insurance carriers
b. All pre-existing conditions and waiting periods shall be waived for those employees and dependents currently enrolled in each of agency health care programs.
c. deductible and out-of-pocket expenses applied toward the current health care program contract are to Be applied to the deductible and out-of-pocket expenses of the new health care program contract, if applicable.
• Mirroring language on stoploss: vendor selected agrees to mirror current plan language in new contract.
• No new lasers on stoploss: vendor selected agrees to no new laser contract
• Rate cap on stoploss: vendor selected agrees to a 40% rate cap each year on the stoploss
• Maintenance of benefits (mob):
a. The health care program is secondary, mob shall be provided to the extent that the coordination of primary and secondary coverage does not exceed the value of covered charges that would have been provided if it were the primary plan
b. The “birthday rule” (defined as “the guideline used to determine which health insurance plan is considered primary when a dependent child is covered by both parents' health insurance plans.
c. The birthday rule, the plan of the parent whose birthday (month and day, not year) falls earlier in the calendar year is designated as the primary plan.
• Cost containment services:
a. The contractor must provide cost containment services
b. Cost containment services may include but need not be limited to: pre-certification of hospital admissions, utilization review services, large case management for hospital inpatient services, and review of high-cost outpatient services.
c. Offeror must also be able to provide cost containment services for psychiatric, substance abuse, and prescription drug utilization.
• Provide agency with the annual service organization controls (soc) 1 and 2 reports from your organization and any third parties that perform claims process and have access to agency personally.
- Contract Period/Term: 3 years
- Pre-Proposal Conference Date: April 10, 2025
- Questions/Inquires Deadline: April 11, 2025