HR Medical Plan Admin and Pharmacy Benefit Management Services

The Vendor is required to provide the administration of medical benefits and/or pharmacy benefits for the State approximately 13,400 enrolled employees and non-Medicare retirees (or approximately 29,600 total covered members - employees and dependents)
- A medical benefit partner that will meet the following objectives:
•    Provide nationwide coverage to eligible state employees, non-medicare retirees, and their dependents (note that the state’s intent is that all participants enrolled in each of the plans offered by the state are enrolled in the same plan/product, regardless of whether they reside within or outside of the service area);
•    Administer and support a wellness/health program and initiatives for the active population; 
•    Provide a high level of accountability around the member experience both in terms of quality care and administration;
•    Manage the finances of the medical benefit program to optimize the cost/value;
•    Improve the health of state employees and their dependents; and
•    Contribute to the state’s health policy goals around care transformation and payment reform to improve health care quality and reduce costs.
- Provide medical benefit services including:
•    Provision of a comprehensive national provider network with uniform quality;
•    Provision of cost-effective contracting arrangements that can be demonstrated to represent direct savings to the state and plan participants;
•    Provision of a comprehensive set of medical management services;
•    Effective, efficient, and accurate claim processing;
•    Payment of claims on a scheduled basis including issuance of reimbursement checks;
•    Provision of explanation of benefits (EOB) statements (available online in addition to print copies) to patients;
•    Level 1 and 2 internal claims appeals for plan members, as well as willingness to cooperate and provide necessary documentation in the case of an external appeal;
•    Provision of best-in-class member services and customer support;
•    Accessible current coverage reports;
•    An active third-party liability (TPL) coordination of benefits (COB) function encompassing identification of TPL, cost avoidance, and collections;
•    HSA accounts administration;
•    Cobra administration;
•    Superior level of account management and service;
•    Sophisticated web-services for plan participants;
•    Capability to integrate with the state’s enrollment and open enrollment functionality;
•    Assistance in ensuring compliance with new laws and regulations;
•    Willingness and ability to provide the communication, tracking, reporting, and administrative services necessary to support the state’s customized current wellness program and calendar, including aggregating data received from the state’s other vendors (i.e., prescription drug, dental, vision, etc.) For the purposes of tracking the state’s rewards for wellness program, as well as to adopt any changes to the program;
•    Ability to provide customized communication materials;
•    Point solution programs;
•    Commitment to successful implementation;
•    Demonstrated commitment to supporting and building a strong system of primary care in the State.