Medical Third-Party Administration Services

The Vendor is required to provide professional services to enter for the purpose of administering its medical insurance benefit (hereafter “medical third-party administrators (“TPA”) services”).
- All carriers or third-party administrators necessary to provide coverage to State employees and non-Medicare and Medicare retirees, enters into contracts for the purpose of general administration of employee benefits, determines if/whether contracts are to be fully insured or self-insured, and adopts rules and regulations for the general administration of the employee benefit coverage.
- These programs include, but are not limited to, health with wellness and disease management programs, prescription drug, dental, vision, disability, life, flexible spending account program, pre-tax commuter program, employee assistance program, third-party network of surgeons of excellence and supplemental critical illness and accident benefits.
- Because the State utilizes multiple electronic human resources programs, such as PeopleSoft, and vendor databases at separate locations in various formats to collect and store participant data, the medical TPAs serve as the medical plan enrollment systems of record and share enrollment and claims data for all medical plans with the PBM, the third-party network of surgeons of excellence (currently administered by Lantern), and the GHIP data warehouse vendor, Merative.
- Competitive provider reimbursement rates and administrative fees;
- Solutions that reduce costs for targeted conditions, including diabetes, musculoskeletal conditions, and behavioral health.
- Support the State with communication to all eligible employees and retirees about the medical insurance program;
- Provide support for all program-related member communications including open enrollment, direct mailings, and other types of media;
- Provide excellent account management services to the SBO, including superior implementation support and dedicated, expert, and accessible account management staff;
- Distribute member ID cards, benefit information and education for patients and providers;
- Process and pay claims in a timely manner;
- Provide excellent customer service to participants;
- Possess the capability to accept electronic transfer of enrollment according to the State’s existing schedule.