Health Plan Administrative Services

The vendor is required to provide self-funded group health plan services on an administrative service only (ASO) basis.
- Administrative services
• Contractor shall have accessible hours of customer service and claims administration and demonstrated service results to administer the comprehensive health plan, including all medical and prescription drug benefits for active employees, cobra participants, transportation planning organization (TPO), retirees, and eligible dependents.
• Open enrollment.
o The county’s annual open enrollment sessions, up to five (5) full days. 
o The following areas shall attend medical, pharmacy, employee assistance program (EAP) services; claims administration and customer service; utilization management, and provider networks at no cost to the county,
• An experienced, dedicated account management team assigned to the county to assist with claims, eligibility and day-to-day service issues.
• All customer service support involving interaction with members will be handled within the territorial limits of the country.
• Contractor shall attend quarterly meetings to review plan performance; meet monthly to review ongoing administrative, service, and plan management issues; and make a medical director and pharmacy director available for ongoing involvement in plan performance initiatives.
• Secure web-based administrative tools will be available to the county benefits department to manage eligibility on an ongoing basis.
• Contractor shall make secure web-based informational and educational tools available to members providing information on issues such as claims status, network providers by specialty, health and wellness topics, and provider / treatment cost calculators that are based on the specific plan designs of the county.
• The county with annual enrollment by training the benefits staff on plans; creating county specific enrollment and educational materials; providing secure web portal assistance for annual enrollment; and agreeing to accept the county’s benefits enrollment files electronically on an ongoing basis.
• The claims fiduciary and accept fiduciary responsibility for claims payment decisions and for defense of actions taken for claims adjudicated and related appeals, including legal defense of claims and medical and pharmacy claims decisions.
• Process and adjudicate all medical and prescription drug claims in accordance with the plan document.
• The ability to identify claims that could potentially be subject to third party liability such as workers compensation, auto accident, and coordination of benefits, and seek reimbursements for such services.
• The care, skill, prudence and diligence under the circumstances then prevailing that a prudent claims administrator and fiduciary acting in a like capacity, and familiar with such matters, would use under similar circumstances as the standard of care for medical and pharmacy services.
- Health management
• Include an online health risk assessment (HRA) tool, accessible to members, capable of having biometric screening results loaded into an individual’s HRA, and shall provide an aggregate report on the responses, including the changes in risk factors.
• Provide on-site biometric screenings at convenient times and locations, for members.
• Demonstrate its ability to identify high risk members, and its ability to assist them in managing their health.
• Include a full-time on-site clinical care coordinator (registered nurse or clinical equivalent) within forty-five (45) days at no additional cost other than the established ASO fees.
• Include a full-time on-site health engagement senior analyst within forty-five (45) days based on established ASO fees.
• The analyst’s primary responsibilities are to support and develop health promotion strategies that influence the organization’s overall wellbeing and drive engagement and adoption of healthy behaviors. county will provide, network access, internet access, and workspace
• Disease management programs will have demonstrated success in participation, care outcomes, and include condition specific online health coaching for members.
• The ability to assist the county with customized, targeted initiatives to improve the health of the population. 
• Comprehensive initiatives may include optional programs such as:
o Weight management for overweight, obese and morbidly obese members;
o Diabetes control and prevention;
o Tobacco cessation;
o Comprehensive cardiology program, including hypertension control and prevention;
o Chronic obstructive pulmonary disease (COPD);
o Healthy pregnancy; and
o Compliance with preventive screening guidelines.
- Contract Period/Term: 5 years
- Pre-Proposal Meeting (Non-Mandatory) Date: August 6, 2025
- Questions/Inquires Deadline: August 13, 2025