Third-Party Administration Services

The Vendor is required to provide Third Party Administration (TPA) services to support the delivery, coordination, and ongoing administration of the Program.
- Responsible for performing a wide range of administrative, operational, and coordination functions that are essential to the successful management of the Program and the delivery of benefits to its members.
- Responsibilities include, but are not limited to, enrollment and eligibility administration, billing and financial coordination, customer service and call center operations, Open Enrollment planning and execution, website administration, COBRA and disability program administration, Health Savings Account (HSA) and Flexible Spending Account (FSA) administration, and support for ongoing Program initiatives and strategic efforts.
- The Program serves a large and diverse membership across the State, including urban, rural, and underserved communities, and encompasses medical, pharmacy, dental, vision, life, disability, flexible spending, and related benefit offerings.
- Must maintain sufficient staffing, infrastructure, and operational capacity to meet the demands of the Program, including periods of increased activity such as Open Enrollment.
- Responsible for all system-related activities necessary to support Open Enrollment, including the design, development, testing, validation, and implementation of all data files and interfaces required for enrollment and eligibility processing.
- Conduct and support all phases of system testing, including but not limited to internal testing, carrier testing, and user acceptance testing (UAT).
- This includes maintaining appropriately trained personnel across all functional areas, including eligibility, enrollment processing, billing, customer service, LPB support, systems coordination, and escalation management.
- Provide call center services during standard business hours at a minimum and shall ensure that sufficient staffing is available to handle both routine and peak call volumes.
- Shall ensure that call center staff are fully trained on all aspects of the Program, including plan options, eligibility requirements, enrollment processes, billing, COBRA, HSA, and other benefits.
- Provide bilingual customer service support and shall ensure that language needs are met promptly and effectively.
- Shall administer all enrollment and eligibility functions for the Program and shall ensure accurate and timely processing of all enrollment transactions. This includes initial enrollments, changes, terminations, reinstatements, and any other eligibility-related transactions.