medical administration fsa/hra administration care management stop loss the health care partnership

106 Pages·2016·0.91 MB·English

DRAFT
MEDICAL ADMINISTRATION
FSA/HRA ADMINISTRATION
CARE MANAGEMENT
STOP LOSS
THE HEALTH CARE PARTNERSHIP
DATE
FORM H: Questionnaire
Project Number: 16-01-07
FORM H: QUESTIONNAIRE 16-01-07
MERCER 1
FORM H: QUESTIONNAIRE 16-01-07
I. SCOPE OF SERVICES
1.1 MEDICAL ADMINISTRATION
· Onshore (U.S.) administration of claims processing, member services, provider services and all aspects of
medical administration
· Benefit determination, coordination of benefits and appeals (including external review)
· Managed care network services
· Provider contractual negotiations, including pay for performance
· Custom network development, maintenance and operation
· Full claims fiduciary
· Acceptance of electronic eligibility file from district or its third party designate
· Health care medical management services
· Disease management services
· Transplant benefit management services including transplant access program (Transplant
Centers of Excellence Network)
· Specialty resource centers – Cancer, Neonatal, Reproductive resource services, Kidney resource,
Maternity, and outline others as applicable
· Enhanced clinical review/hi-tech radiology
· Claim recovery services (overpayments and adjustment services due to coordination of benefits,
retroactive termination, audits [hospital, DRG, high cost drugs], duplicate bills and contract
compliance)
· Escheat services
· Subrogation services
· 24/7 nurseline resource center
· Claim abuse and fraud management services
· Assistance with general plan administration
· Claim accounting, draft reconciliation and provider 1099 reporting
· Claim systems production and development
· Account Management Services:
o On-site support
o Enrollment meeting support
o Enrollment kits
o Administration of account structure (premium and claims accounts for reporting purposes)
o Administration of employer site to review billing, enrollment and claims
o ID card production
o Administration of alternate ID’s
o Electronic eligibility processing both manual and tape processing
o Ability for employer or designated third party to make online eligibility updates
o Underwriting services (including projections and reserve estimates)
o Customer reporting system administration
o Access to customized ad-hoc reporting and provision of ad-hoc hours bank
MERCER 2
FORM H: QUESTIONNAIRE 16-01-07
o Claims processing, medical claim review, coordination of benefits
o Access to member services toll free 800# as well as member portal to access claim
status, eligibility, plan features, physician/facility look up, transparency tools and online
health information, including web based & mobile
o Preparation and communication of annual accounting package
· Production of Summary Plan Descriptions and Summary of Benefits & Coverage (SBC’s)
· Shared services and facility Reasonable & Customary R&C) payment schedules – out of network
contractual discount negotiation services – or carve out of such services
· Administration of a fee schedule based on Medicare allowable for out-of-network claims
· Administration of online participant website, enabling access to online providers, member claims,
member explanation of benefits (EOBs), personal health records
· Development of customized explanation of benefits (EOBs)
· Access to stop loss management services, including reporting to a third party vendor, if selected
· Billing and eligibility services
· Billing reconciliation services
· Administration, including payout if applicable, of plan performance guarantees
· Administration of allowances including but not limited to communication, MWBE, investment
dollars, audits
· Plan sponsor reporting, including quarterly “stop light” dashboard as well as annual reporting
· Plan sponsor banking services (self-funded only)
· Run out administration services
· Plan audit services, including internal audits and cooperation with external audits
· SOC 1/ SSAE administration audit reports
· Wellness incentive support and administration
· Medicare secondary payer reporting
· Provider network management reporting (including premium designation)
· Predictive modeling services
· Mental health network management services
· Precertification, utilization review and case management services
· Large claims review support
· Integration of pharmacy third party claims data to support benefit accumulators as well as
predictive modeling
· Access to online discount program
· Reporting to designated data warehouse
· Implementation and ongoing support of single sign on (SSO)
· Compliance with current and evolving legislation including but not limited to, the Patient Protection
and Affordable Care Act, HIPAA, GINA, Mental Health Parity, ERISA
1.2 FSA/HRA ADMINISTRATION
FSA ADMINISTRATION
· Section 125 Flex plan administration
MERCER 3
FORM H: QUESTIONNAIRE 16-01-07
· Creation of FSA plan documents
· Record keeping for FSA transaction and overall plan sponsor accounting
· Administration of plan reimbursements to plan participants (claims processing)
· Employer plan sponsor reporting including banking, transactions etc.
· Administration of forfeited funds
· Administration of plan audits
· Administration of member communication materials
· Administration of plan compliance and plan sponsor legislative updates
· Administration of plan overpayments
· Administration of non-discrimination testing
· Administration and distribution of FSA debit cards
· Establishment of employer sponsored plan asset accounts
· Administration of plan set up, web enrollment maintenance, administration of deposits
· Administration and support of non-discrimination testing
HRA ADMINISTRATION
· Record keeping for HRA transaction and overall plan sponsor accounting
· Administration of fund allocation and health incentives
· Administration of plan reimbursements to plan participants (claims processing and order of
reimbursement account, i.e. HRA, FSA.)
· Employer plan sponsor reporting including available funds, transactions etc.
· Administration of plan audits, and cooperation with third party audits
· Administration of member communication materials
· Administration of plan compliance and plan sponsor legislative updates
· Administration of plan overpayments
· Creation of HRA plan document
· Administration of plan set up, including rollover to next plan year
1.3 CARE MANAGEMENT
For the purposes of this RFP “Care Management “includes Disease Management (DM), Custom
Care Management (CCM), and Case Management. Disease Management services consists of
interactive communication between an individual and a health professional or expert system
through various modalities (e.g., telephonic, email, online, face-to-face, etc.), to address individuals
with chronic conditions, typically those who are moderate to low chronically ill. Conditions
addressed might include (but are not limited to) asthma, COPD, CHF, CAD, depression, diabetes,
maternity, obesity, etc. Custom Care Management is defined as a customized program that
proactively outreaches and manages the highest risk/cost patients. Expertise in conditions such as
cancer care, neonatology, maternal health, renal disease & behavioral/mental health are useful.
Includes a dedicated nurse for employees, addresses gaps in care, consists of an integrated
medical team, has extended phone hours and measurable referrals and/or warm transfers to other
vendor partners. CCM utilizes evidence based best practices in counseling and support. Case
management is the process of assessment, planning, facilitation, care coordination, evaluation,
MERCER 4
FORM H: QUESTIONNAIRE 16-01-07
and advocacy for options and services to meet an individual’s health needs, promoting cost-
effective treatments and quality outcomes.
1.4 STOP LOSS
· Administration of individual excess risk benefit level (specific stop loss/ISL) which includes all
services as outlined in the Summary Plan Description
· Reimbursement of stop loss triggers above the ISL level
· Tracking and payment of individual/specific stop loss claims
· Administration of aggregate stop loss factors (ASL) inclusive of the same benefits as listed in the
first bullet
· Administration of annual aggregate attachment point and tracking
· Underwriting services for annual renewal of stop loss and factors
· Payment of ISL and/or ASL stop loss claims
· Clinical evaluation of large claimants
· Option to include prescription drug benefits in both specific (individual) and aggregate stop loss
coverage
· Development of policy that outlines coverage and premiums in effect during any given policy year
MERCER 5
FORM H: QUESTIONNAIRE 16-01-07
II. INTRODUCTION TO QUESTIONNAIRE
2.1 EXPLANATION TO PROPOSERS
Any Proposer who desires an explanation or interpretation of the RFP and its related documents, or who
discovers any discrepancies or omissions in the RFP or related documents, shall notify the designated
HISD Project Manager in writing. Each notification must make specific reference to the applicable section
of the RFP (e.g., Section, Page Number, and quote from RFP document) to be considered by HISD. HISD
reserves the right to reject any request that does not conform to these instructions. Oral explanations or
instructions provided will not be binding. Any information given to a Proposer concerning the RFP may be
furnished in writing promptly to all other potential Proposers as an addendum to the RFP, if that
information is necessary in submitting offers, or if the lack of it would be prejudicial to any other
Proposers.
All communications regarding this RFP must be coordinated through the HISD Project Manager named in
Section 1.1.4/1.1.5 – Instruction Submission Requirements and Procedures. Failure to do so may result in
disqualification of the Proposer from further consideration.
Addenda
The only method by which any requirement of this RFP may be modified is by written addendum issued
by the Procurement Services Department. All addenda will be posted on the HISD Procurement
Services’sProposal Solicitations Download website. For more information go to www.houstonisd.org and
find the link under Community > Do Business with HISD > Bid Opportunities
http://www.houstonisd.org/Page/68148.
If an addendum to the proposal document is a result of a pre-proposal conference, the District will post the
addendum, within a reasonable time, following the conference to the HISD Proposal Solicitations
Download website. The District is not responsible if a Proposer does not receive the proposal revision in
time to include the information with the proposal submission. Proposals may not be considered if they do
not include written information additionally requested in addenda that may be issued regarding the project.
If a Proposer does not have access to the internet, a copy of the addenda may be secured in the
Procurement Services Department. The department is located in the Hattie Mae White Educational
Support Center, 4400 West 18th Street, Level 2NE, Houston, Texas 77092. Department business hours
are 8 AM to 5 PM Central Time, Monday – Friday (excluding District holidays).
Copies of any Addenda will be cross posted on ProposalTech.
Exceptions
If any exceptions are taken to any portion of this RFP, the Proposer must clearly indicate the exception
taken and include a full explanation as a separate attachment to the proposal. The failure to identify
exceptions or proposed changes will constitute acceptance by the Proposer of the RFP as proposed by
the District. The District reserves the right to reject a proposal containing exceptions, additions,
qualifications, or conditions.
Information to Be Requested from Proposer
To achieve a uniform review process and obtain the maximum degree of comparability, it is required that
proposals be organized in the manner specified.
MERCER 6
FORM H: QUESTIONNAIRE 16-01-07
The table below provides a listing of all parts of this RFP. You will need to ensure that you received each
of these parts to confirm that your proposal is complete and meets all submission requirements.
Proposers must submit one copy of FORM H: Questionnaire, and any referenced supplemental
material online through ProposalTech. Failure to include supplemental material, where requested
within the questionnaire, could negatively impact your score.
Each proposer must submit hardcopies/binders including their questionnaire and supplemental
material along with the other required attachments to the addresses listed in Section 2.3. Form H
questions must be submitted electronically through Proposal Tech (www.proposaltech.com). Paper
only copies of the RFP questionnaire will not be accepted.
If electronic submissions are password protected, please provide the password for access in
bound proposal marked “ORIGINAL”, on the inside cover. Please respond to requests for
information by submitting your responses in a binder with tabs labeled as indicated in the
following table. A demonstration of how to use Proposal Tech will be presented at the Pre-
proposal Conference onFebruary 15, 2016; 1-3pm, Hattie Mae White Educational Support Center
Room 2E26, 4400 West 18th Street, Houston, Texas 77092. Should you need further support on
the Proposal Tech software during the RFP process,please contact Proposal Tech support at
[email protected] or 877-211-8316 option 4 for the support team.
Please see the table below for a list of items and their required submission format:
Description Exhibit
(Letters)
Census Data A
Claims Data B
Disruption Request C
Geo Access Request D
Current Fees E
(HISD, AISD, KISD)
Top 25 Conditions F
(HISD, AISD, KISD)
Plan Designs G
(HISD, AISD, KISD)
Stop Loss Designs H
(HISD, AISD)
HISD HIPAA Business Associate Agreement I
Proposer’s Order of Submission Mode
Description
Documents
Title Page - Transmittal Letter & Executive Summary
Table of Contents Tab 1 Paper Copy ONLY
Proposal Submission Forms (HISD FORMS A-G) Tab 2
Company Information Form A Paper Copy ONLY
MWBE Attachment Form B Paper Copy ONLY
Addendum for Agreement Funded by US Federal Grant Form C Paper Copy ONLY
Pricing and Service Affirmation Form D Paper Copy ONLY
Exception Form Form E Paper Copy ONLY
Price Schedule Form F Electronic submission via
Proposal Tech
Supplier Relations Form G Paper Copy ONLY
MERCER 7
FORM H: QUESTIONNAIRE 16-01-07
Profile of Proposer Tab 3 Paper copy AND
Electronic submission
via Proposal Tech
Scope Section Tab 4 Paper copy AND
Electronic submission
via Proposal Tech
Questionnaire and all Attachments as Requested In Questionnaire Tab 5 Form H Paper copyAND Electronic
submission via Proposal
Tech
Invoice Procedure Tab 6 Paper Copy ONLY
Price – Pricing related to Scope submitted through Form H in Tab 5) Tab 7 Paper copyAND Electronic
submission via Proposal
Tech
Addenda Tab 8 Paper copyAND Electronic
submission via Proposal
Tech
Executive Acknowledgement Signature/Date Form Paper Copy ONLY
2.2 GENERAL INFORMATION
Houston Independent School District (HISD)
According to 2014 Facts and Figures, HISD, located in Harris County, Texas, is among the largest
employers in Houston with a 2014 – 2015 budget exceeding $1.7 billion. It operates as the largest public
school system in Texas and the seventh-largest in the US. HISD serves a population of approximately
215,000 students covering 283 campuses including elementary schools, middle schools, high schools,
charter schools, and community-based alternative programs.
HISD has approximately 29,000 full-time and part-time employees of which approximately 11,600 are
teachers. Total benefits-eligible employees number approximately 24,000. These employees work at
locations in a variety of positions that include teachers, bus drivers, school principals, custodians,
administrators, office support and skilled trades. HISD is seeking proposals in the RFP for a January 1,
2017 effective date.
Aldine Independent School District (Aldine ISD)
Located in North Harris County, Texas, Aldine ISD encompasses 111 square miles and operates as the
eleventh-largest school district in Texas with a budget exceeding $600 million. Aldine ISD serves a
population of more than 70,000 students covering 76 campuses including elementary schools,
intermediate schools, middle schools, ninth grade schools, high schools, magnet schools, and alternative
campuses.
Currently, Aldine ISD has approximately 9,700 benefits-eligible employees, of which approximately 4,800
are teachers. These employees work at 89 locations in a variety of positions that include teachers, bus
drivers, school principals, custodians, administrators, office support, and skilled trades. Aldine ISD is
seeking proposals for all plan requests in this RFP for a January 1, 2017 effective date.
Katy Independent School District (Katy ISD)
Katy ISD is located in Harris, Fort Bend, and Waller Counties, Texas, and is just west of Houston, Texas.
Budget allocations for 2014 – 2015 exceeded $740 million. It operates as the tenth largest public school
system in Texas and encompasses 181 square miles. Katy ISD serves a population of more than 70,000
MERCER 8
FORM H: QUESTIONNAIRE 16-01-07
students covering 60 campuses including elementary, junior high schools, high schools, and alternative
campuses.
Currently, Katy ISD has approximately 9,600 benefits eligible employees. These employees work at 60
locations in a variety of positions that include teachers, bus drivers, school principals, custodians,
administrators, office support and skilled trades. Katy ISD is seeking proposals for all plan requests in this
RFP for a January 1, 2017 effective date.
Current Plan Administration
Each District’s current plan offerings are described and explained in detail on the District’s benefits
websites. The descriptions include summary information as well as full plan descriptions, current provider
information, and helpful links. Please visit each District’s benefits website at. www.hisdbenefits.org,
www.aldinebenefits.org, andwww.katybenefits.org. Plan design summaries are also included in Exhibit G
of this bid package.
Each school district has complete autonomy with their own plan designs, clinical programs, etc. and make
their own decisions which may or may not mirror the other school districts. All Districts are public entities
and, as such, are subject to FOIA.
Note: while not required to comply with ERISA requirements due to the school districts being public
entities, they do closely follow ERISA guidelines.
Mercer Health & Benefits’ Role
Mercer Health & Benefits is the Consultant of Record for HISD, Aldine ISD and Katy ISD and as such,
strives to implement best business practices to ensure that each district’s goals are met. Mercer Health &
Benefits is responsible for management aspects related to employee benefits programs for HISD, Katy
ISD, and Aldine ISD. Mercer has worked with HISD to develop and submit this RFP in compliance with
the “Request for Proposal” procedures set forth in the Texas Education Code 44.031 required for school
districts participating as part of The Program.
If you are an interested proposer, you must register and follow the directions on the HISD Procurement
Services’sProposal Solicitations Download website; for more information go to www.houstonisd.org and
find the link under Community > Do Business with HISD > Bid Opportunities
http://www.houstonisd.org/Page/68148. Electronic copies of the RFP and its supporting documents can
be obtained from this Proposal Solicitation Download website as well.
Goals and Objectives
THCP has retained Mercer Health & Benefits (Mercer) to assist them in requesting proposals for medical
administration, care management and stop loss as identified in the scope. The purpose of this Request for
Proposal (RFP) is for Mercer to assist THCP with identifying solutions and programs for THCP’s medical
benefit programs which provide the systems, processes and capabilities to meet the objectives listed
below.
(cid:127) Offer financial and operational transparency while controlling THCP’s medical benefit costs
(cid:127) Ensure that members have appropriate access to all medically necessary doctors, hospitals and
services and that innovative clinical and wellness programs are in place to ensure patient safety and
enhance outcomes
(cid:127) Utilize plan design incentives that encourages cost-effective and appropriate utilization of medical
programs
MERCER 9