SECTION I - WCPS) Purchasing



SECTION VIII – QUESTIONNAIREInstructions for Completing the QuestionnaireThe questionnaire found in this section will assist WCPS in evaluating the offerors’ proposal. INSTRUCTIONS(1)In addition to the hard copy document, this questionnaire is provided as an embedded file should you receive this RFP electronically; if you download off of the Procurement website, you must request the file via e-mail. This file may be used by each Offeror in completing the responses to this section. A hard copy of each question and response must be provided in TAB IV as instructed.(2)Answer each question fully, clearly, and concisely.(3)Each response must immediately follow the respective question. The question as well as the answer shall be typed. All questions and responses shall be numbered/labeled exactly as in this Questionnaire.(4)If the Offeror is unable to answer a question or the question does not apply, the Offeror shall indicate why.(5)If the Offeror is unwilling to disclose particular information asked in a question, the Offeror shall indicate why.(6)Responses to the Questionnaire should be submitted in written hard copy, Tab IV, per the instructions.(7)Samples of documents requested in the Questionnaire should be labeled with the corresponding question number and submitted in Tabs.GENERAL INFORMATIONType in the following information:Point of Contact:Title: Company:Address:Telephone/Fax:E-Mail:Have the proposal requirements been fully met as requested in this RFP? FORMCHECKBOX Yes FORMCHECKBOX No If not, please summarize all deviations and include the summary in Tabs I and II as requested in Section 5.2.Please fill in the tables below, indicating 1) the number of employees within your organization and 2) the number of group health plan members.Number of employees of your firm in:# of employees WCPS Service AreaNationwideNumber of Enrolled Group Health Plan Members in: PPOPOSHMOWCPS Service AreaNationwidePlease provide pertinent financial data that demonstrates your organization’s ability to successfully perform this contract. Please provide your most recent ratings by each of the following:CompanyRatingDate of RatingLegal Name of Company to Which Rating AppliesFitchStandard & Poor’sMoody’sA.M. BestPlease identify all subcontractors (including consultants, advisors, network managers and suppliers) to be used and describe specific responsibilities, qualifications, and background experience of all key personnel. Include financial ratings for each major subcontractor, consultant, or advisor.Is your organization currently compliant with HIPAA HITECH legislation as it pertains to Private Health Information and EDI Standards? ENROLLMENT/ELIGIBILITY AND ADMINISTRATIONWhat is the location of the claims office that will be processing claims and providing general administration for this account? Indicate if locations are different for medical, prescription drug, and managed mental health. Identify service center locations for each of the following functions:FunctionService Center LocationClaims ProcessingEligibilityBillingClaims Management & ReportingAccountingUnderwritingAccount ManagementContract GenerationID Card GenerationProvide an implementation schedule (in Tab IV of your proposal) Detail specific activities, target dates, data requirements, and responsibilities for completion. Detail any expenses involved and whether these expenses are included in your pricing.Provide information on any electronic communication that would be required from the WCPS systems.Describe your ongoing enrollment procedures and annual open enrollment assistance. Indicate the services you would be willing to provide, such as on-site assistance with employees, etc. Identify any services that would require a separate fee to be paid outside the administrative fees included in the Price Quotations. Please indicate whether you are providing members with uniform explanation of coverage documents, or Summary of Benefits Coverage (SBC). Please indicate the processes in which they will be provided to clients; andTimeline required for generating the documents.Do your systems have the following capabilities? If yes, indicate if there are additional charges for any of these:YESNOCan you accept current eligibility records electronically for initial enrollment?Please list the administrative services that are provided as part of your “standard fees”.Will you issue ID cards directly to plan members? Yes NoPlease explain the process WCPS must follow to add and delete employees to and from your eligibility system. How long does it normally take for your billing department to make requested changes to the bill or monthly accounting statement (additions/deletions) andHow long does it normally take for the proper adjustments in fees or premium? Will you allow the Schools to pay fixed fees based on their internal enrollment records rather than paying your invoice “as billed”? How quickly can your system generate adjusted bills (based on enrollment/eligibility changes)?How long will you allow retroactive changes to be made to the bill?Do you provide automated, interactive telephone service? Yes NoIs there always an option to default to a customer service representative? Yes NoDuring what hours is a customer service representative available to take calls?Do the customer service representatives have the authority to resolve problems immediately? Yes No What is the percentage of problems that are resolved during the initial call?Confirm that your claims processing system can administer separate accumulators for deductible and out-of-pocket maximums.Please provide your performance standards and quarterly results for 2017, 2018 and 2019 in the chart below. The results should include the performance of the service team, which would be responsible for WCPS and Schools. If different units would be responsible for the different plans, provide standards and results separately for each unit. Input your standard on each measure.Product(s):ResultsThe results below include the following service units: 201720182019Q1Q2Q3Q4Q1Q2Q3Q4Q1Q2Timeliness of claims processing:Standard:Results:Claims processing accuracy:Standard:Results:Telephone inquiry/wait time:Standard:Results:Telephone inquiry/ abandonment rate:Standard:Results:Please furnish a copy of the payment explanation form and claim form that would be used by the claimant (for all products). Include in Tab IX of your proposal.Please furnish a copy of the booklets that will be provided to the Schools’ health plan members (for each plan you are proposing). Include in Tab IX of your proposal. Will there be any additional cost to the County for you to prepare and print these materials?Confirm that you will allow WCPS to review and approve all School-specific communication pieces before they are sent to County employees.To what extent will the WCPS be allowed to customize the enrollment and communication materials that will be provided to members? What additional costs will be associated with customization?Will your company accept responsibility for errors and overdraws created by your personnel in processing claims? Yes No Please WORKSHow much advance notice must the provider give you if they wish to cancel their contract with you?What is your process for notifying members when a physician leaves the network? Do you provide on-line tools that allow members to evaluate the quality and/or cost associated with specific hospitals, physicians, and/or medical procedures? If so, please describe.What is your contracting strategy with regard to hospital-based radiologists, anesthesiologists, pathologists, and ER physicians (specify for each network)?What is your standard protocol for processing these types of claims if these providers are not in your network but are utilized by a WCPS member at an in-network facility?Do you have network arrangements for alternative medicine, chiropractic, and acupuncture providers? Explain your credentialing process for these providers.If a physician or hospital cancels or fails to renew their network contract, how would transition of care be handled for an inpatient or critical/chronic case or a maternity case? Confirm your compliance with Maryland continuity of care mandates.How and how often is patient satisfaction measured with providers? What regions/networks are included in the results you are providing?How and how often is provider satisfaction measured? How are member/subscriber grievances against providers handled?Please complete the following information for each hospital/facility you have under contract in the WCPS service area as of October 2019. Also provide anticipated changes for 2020.Name of Hospital/FacilityType of Contract (1)Services not IncludedContract Effective DateLength of ContractTypes of Products Accessing NetworkIncludes All Attending Physicians Yes or NoList Specialists not included (2)Average DiscountMeritus HealthWestern Maryland Hospital CenterWashington County HospitalFrederick MemorialJefferson Medical Center Adventist HealthCareWaynesboro HospitalChambersburg Hospital (Wellspan, Summit Health)UPMC Pinnacle HarrisburgIndicate your average aggregate inpatient hospital discount for the WCPS service area:Indicate your average aggregate outpatient discount for the WCPS service area:(1) Per Diem, Capitation, DRG, Per Case, Discount off Charges, Other - please explain. Indicate inpatient and outpatient reimbursement methods separately.(2) Anesthesiologists, radiologists, emergency room physicians, etc.Please provide a geographic access report for each network using the zip code listing provided in the census file. Access is defined as: 2 PCPs within 10 miles, 2 specialists within 10 miles and 1 hospital within 15 miles. Do not use other access parameters in your response. Please include reports for detailing zip codes that do not meet access criteria. (Include in Tab V of your proposal.)Do you have Centers of Excellence for specific specialty care, surgery, etc.? If yes, list the facilities by specialty. Describe your program, including how centers are selected and details on services offered to family members when travel and overnight stays are involved. Is your Centers of Excellence program voluntary? Yes NoComplete the table below and explain in detail the coverage options available and how benefits are paid for each of the following members (discuss for each product if different). Indicate how the member would be covered for ongoing treatment for a chronic illness.MembersRoutine CareEmergency/UrgentChronic IllnessCOBRA enrollee outside the service areaRetiree living permanently outside the service areaRetiree living three to six months outside the service areaDependent spouse and/or child of an active employee living permanently outside the service areaDependent attending college outside the service areaIs your HMO/POS NCQA accredited? Yes NoIs your PPO URAC accredited? Yes NoIf accredited, at what level? If no, have you applied for accreditation?For all networks included in your quote, do you own the network? If yes, how long have you owned the network? If no, who owns the network? Explain your responsibility and accountability for the network.Please complete the Hospital, Provider and Drug Checklist (Attachment A) as instructed and include both a hard copy and an electronic copy (in Excel file format) of the completed exhibits in Tab VI of your proposal. PRESCRIPTION DRUG PROGRAM (Indicate if you are bidding separately and if there is additional costs)Do you intend to bid on the prescription drug program as well? Yes NoComplete the chart for any charges that might apply or savings if bundled:$Charges if unbundledMANAGED MENTAL HEALTH PROGRAMDo you administer the program included in your quote or do you subcontract the services? If services are subcontracted, specify the vendor.What are the qualifications of the individuals taking initial calls from members? How are calls handled from the initial contract? How are emergency calls handled? How are after hours calls handled?Is this program NCQA accredited? If not, do you plan to seek accreditation?Is there a Mental Health/Substance Abuse Medical Director on staff? What are his/her credentials?How do you handle situations where a member has an existing relationship with a mental health/substance abuse provider they are seeing on a regular basis who is not in your network?HEALTH MANAGEMENT SERVICESWhich programs are accredited with URAC (American Accreditation HealthCare/Commission)?Who approves medical procedures and services before they are performed?What tools are used to determine medical necessity?Indicate what health management services you provide as part of your coverage and specify A for adult and P for pediatric services for each service provided. (Place an “” in the appropriate box if you provide the service.)Disease Management (defined as proactive telephonic/home based contact to reduce risk, improve adherence to prescribed therapies, improve outcomes and health status, and reduce inappropriate utilization)APDisease Management ProgramsServices included in rate (Y/N)AsthmaHigh CholesterolDiabetesHypertensionCoronary Artery DiseaseCongestive Heart FailureLow back/musculoskeletalOther (Specify)Maternity Management (defined as proactive, telephonic/home based contact to reduce risk, per-term birth rate, low and very low birth weight rates, and infant mortality to increase VBAC rates and improve outcomes, and health status)Demand Management (24-hour nurse triage line)Member health risk and/or health status assessmentWelcome calls to new membersSatisfaction surveyHealth promotion/wellness programs (define)Lifestyle management (defined as smoking cessation, weight management, fitness activities, stress, injury prevention)NewsletterOther (define)Are you willing to guarantee utilization rates/return on investment on your disease management programs in total? Discuss how you would structure the guarantee?How involved are your network physicians in accountability for compliance with wellness, disease management, and pharmacy initiatives to improve quality and cost management?Please describe health promotion or wellness programs that you can offer the County and Schools at no cost (attach program descriptions or other literature to illustrate your program offerings). Do you have the ability to conduct on site wellness seminars, clinical screenings or health risk assessments? Are there additional programs that could be purchased by the County and Schools?DATA MANAGEMENTProvide a sample of your standard management/utilization reports for medical and drug coverages and the frequency of distribution. (Include in TAB VIII of your proposal.)Provide a sample of your standard claims data reports that will be provided to WCPS and Schools. (Include in TAB VIII of your proposal.)Do you offer on-line access to your database which would allow employers to access certain management reports? Yes NoIf so, please outline the cost to access and run reports, and an outline of what kinds of reports are available. Indicate how frequently the database is updated with real-time information. With the County’s permission, will you allow the consultant access to on-line reporting? Do the employer and/or consultant have the ability to produce ad-hoc reports from your database?List any standard report not available electronically.What is your process for transmitting claims data to a third party reinsurer? Discuss the frequency of such reports. Is there a fee charged to WCPS to send these claims?Confirm that you are willing to provide the Schools at least $75,000 annually to be used in the implementation and administration of wellness programs. Confirm that the dollars can be spent against your wellness programs or can be used on third party programs as desired by the Schools.FINANCIALIndicate your trend factors both rating and actual observed. Label accordingly for your PPO, POS and HMO plans for the last three years for medical and drug. Specify the location/region on which these trend factors are based. If available, provide trends for the WCPS region. PPOPOSHMOObserved Trend 2017Observed Trend 2018Observed Trend 2019Rating Trend 2017Rating Trend 1Q 2018Please describe your proposed shared-risk funding arrangement. Indicate how fees are charged (calculations and timing), monthly cash flow arrangements, escrow requirements, settlement process, terminal liability, etc. Explain the billing process for claims and administrative fees. (Your proposed arrangement should also be explained in Tab III of your proposal.)On what basis will you price your specific stop loss arrangement (i.e., 12/12, 12/15, etc.)? Please describe how this arrangement is administered. How will this arrangement change in year two of the contract?Is your administrative fee developed on a paid claim or incurred claim basis? If it is based on a paid claim basis, explain how the fee will change in year 2 of the contract and what will happen upon termination of the contract.Do you retain any negotiated provider discounts as a source of administrative fees? If so, please explain.Confirm that your organization will accept fiduciary responsibility for claim payments. Outline any fees that would apply.Is specific stop loss reinsurance offered at termination of the contract?How does the specific stop loss arrangement change in the event of termination off of the renewal date?Provide a sample ASO contract and a sample reinsurance contract. (Include in Tab VIII of your proposal.)Provide a copy of a sample annual settlement. What is the timing of the annual settlement at the end of a contract year? (Include in Tab X of your proposal.)Discuss the timing of reimbursements for claims that exceed your stop loss reinsurance limits. Outline any maximum limits or minimum requirements included in your reinsurance contracts. How are these limits developed? List any covered service limitations and/or exclusions.Confirm that you do not and will not laser individuals under your specific or aggregate stop loss insuranceWhat are your notification requirements for changes in eligibility?What is your enrollment fluctuation threshold?Outline any claims/expenses NOT included in your specific reinsurance.Outline your renewal methodology for specific stop loss charge calculations.In the event of termination on the contract anniversary date, are you willing to process claims runout? For how long? What is the cost for this service? How is this cost determined?Explain how your contract addresses coverage for claims expense on any individual in the hospital: (1) on the day your contract becomes effective, and (2) on the day your contract is terminated.Are you willing to provide a guarantee on the percentage of discount to be achieved through your negotiated agreements?Outline your proposed guarantee and explain thoroughly how it would be measured.Outline any financial guarantees offered to WCPS.Are you willing to guarantee a maximum percent or dollar increase in administrative fees and/or reinsurance fees for the second, third, fourth, or fifth year?What guarantees will you offer for overall program performance (i.e., guaranteed trend factors within a certain range, guaranteed utilization targets, network performance and managed care performance)? Identify and describe any conditions and potential cost implications.VISIONAre you only biding on vision? Yes NoAddress any subcontracting involved in your vision plete the provider information below:WCPS Service Area# of participating offices# of participating optometrists# of participating ophthalmologists# of participating laser surgeons# of participating surgery centersDescribe the claims filing process procedures for in and out-of-network services.End Questions ................
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