HIRSP RFP DOCUMENT
REQUEST FOR PROPOSAL
STATE OF WISCONSIN
DEPARTMENT OF HEALTH AND FAMILY SERVICES
DIVISION OF HEALTH CARE FINANCING
THE HEALTH INSURANCE RISK SHARING PLAN (HIRSP)
Administrative Services
RFP # 0428-DHCF-SM
LATE PROPOSALS WILL BE REJECTED
THE STATE RESERVES THE RIGHT TO REJECT ANY OR ALL PROPOSALS
TABLE OF CONTENTS
Page No.
1.0 General Information 1
1.1 Introduction and Background 1
1.2 Overview of HIRSP Eligibility Requirements 1
1.3 Overview of HIRSP Plans 1
1.4 Premium, Deductible and Drug Coinsurance Subsidy Program 1
1.5 Covered and Non-Covered Services 1
1.6 HIRSP Budget and Financing 1
1.7 Current Plan Administrator 1
1.8 Scope of the Project 1
1.9 Definitions and Acronyms 1
1.10 Access to Program Information for Proposers 1
1.11 Overview of Demographics, Statistics and Operations 1
2.0 STATEMENT OF OBJECTIVES 1
3.0 PROCUREMENT AND CONTRACTING INFORMATION 1
3.1 Procuring and Contracting Agency 1
3.2 Clarification or Revisions to Specifications and Requirements 1
3.3 Vendor Conference 1
3.4 Reasonable Accommodations 1
3.5 Calendar of Events 1
3.6 Contract Term 1
3.7 Vendornet Registration 1
3.8 Letter of Intent to Submit Proposal 1
4.0 PREPARING AND SUBMITTING A PROPOSAL 1
4.1 General Instructions 1
4.2 Incurring Costs 1
4.3 Submitting the Proposal 1
4.4 Use of Subcontractors 1
4.5 Proposal Organization and Format 1
4.6 Multiple Proposals 1
4.7 Oral Presentations 1
4.8 Site Visits 1
4.9 Withdrawal of Proposals 1
5.0 PROPOSAL SELECTION AND AWARD PROCESS 1
5.1 Preliminary Evaluation 1
5.2 Proposal Scoring 1
5.3 Right to Reject Proposals and Negotiate Contract Terms 1
5.4 Evaluation Criteria 1
5.5 Award and Final Offers 1
5.6 Notification of Intent to Award 1
5.7 Appeals Process 1
6.0 GENERAL PROPOSAL REQUIREMENTS 1
6.1 Organization Capabilities 1
6.2 Financial Statements 1
6.3 Staff Qualifications 1
6.4 Proposer Client List and References 1
6.5 Oral Presentation and Materials 1
7.0 MANDATORY PROPOSAL REQUIREMENTS 1
7.1 Transmittal Letter 1
7.2 Designation of Primary Contact Person 1
7.3 Location and Staff 1
7.4 Disaster Recovery Plan 1
7.5 Legal Representation 1
7.6 HIPAA Compliance 1
8.0 TECHNICAL REQUIREMENTS 1
8.1 Policyholder and Provider Services 1
Eligibility Determination and Applications Processing 1
Customer Service 1
Communications and Publications 1
Appeal and Grievance Processes 1
8.2 Financial Management 1
Premium Administration 1
Accounting and Financial Services 1
Actuarial Services 1
Auditing Procedures 1
8.3 Claims and Systems Administration 1
Claims Processing 1
Pharmacy Benefit Management 1
Provider Network Maintenance 1
8.4 Medical Management 1
Medical and Other Clinical Consulting Services 1
Cost Containment 1
Disease Management 1
8.5 Detailed Transition Plan 1
8.6 Data Collection and Reporting 1
9.0 COST PROPOSAL 1
9.1 General Instructions and Information on Preparing Cost Proposals 1
9.2 Method of Invoicing and Payment 1
9.3 Formula for Payment 1
9.4 Allocation of Administrative Fees 1
9.5 Format for Submitting Cost Proposals 1
9.6 Fixed Price Period 1
9.7 Inflationary Adjustment 1
10.0 SPECIAL CONTRACT TERMS AND CONDITIONS 1
10.1 Payment Requirements 1
10.2 Independence of Proposer 1
10.3 Performance Review, Liquidated Damages and Other Remedies 1
10.4 Executed Contract to Constitute Entire Agreement 1
10.5 News Releases 1
10.6 Right to Publish 1
10.7 Agreement Revisions and/or Termination 1
11.0 STANDARD/SUPPLEMENTAL STANDARDS TERMS AND CONDITIONS 1
12.0 REQUIRED FORMS 1
ATTACHMENTS 1
A. HIRSP Vendor Information 1
B. Designation of Confidential and Proprietary Information 1
C. Affidavit 1
D. Vendor Information 1
E. Vendor Reference 1
F. Cost Proposal Form 1
G. Business Associate Agreement 1
1.0 General Information
1.1 Introduction and Background
The purpose of this document is to provide interested parties with information to enable them to prepare and submit a proposal for a Plan Administrator to provide administrative services for the Wisconsin Health Insurance Risk Sharing Plan (HIRSP). The State of Wisconsin, as represented by the Department of Health and Family Services (DHFS) or herein referred to as the “Department” intends to use the results of this solicitation to award a contract for the administrative services.
Established in 1980 and administered pursuant to Chapter 149, Wisconsin Statutes, HIRSP provides health insurance coverage to Wisconsin residents who are unable to find adequate health insurance coverage in the private market due to their medical conditions. In addition, since 1997, HIRSP has been Wisconsin’s “state acceptable alternative mechanism” under the Health Insurance Portability and Accountability Act (HIPAA) assuring portability in the individual market. Individuals who lose their employer-sponsored group health insurance coverage and meet certain criteria may enroll in HIRSP without serving a pre-existing condition waiting period.
HIRSP has no marketing staff and incurs no sales commissions. Policy acquisition costs are minimal and expensed as incurred through the payment of one-time referral fees, in the amount of $35 for each policy issued, to insurance agents who assist individuals with the HIRSP application process. All health insurance agents licensed in Wisconsin are required by law to refer individuals to HIRSP if the insurer refuses coverage. Individuals may also apply directly to HIRSP.
As of January 1, 2004, there were 17,447 enrollees in HIRSP residing in nearly every county in Wisconsin.
The Department is responsible for the administration of HIRSP under the oversight of a Board of Governors, herein referred to as the “Board.” The Board consists of (13) representatives with various statutorily mandated affiliations.
The Board is responsible for establishing oversight committees to monitor all aspects of HIRSP operations, including HIRSP financial matters, approving contracts with the Plan Administrator, establishing contractor performance standards, processing grievance requests, and developing public awareness and education materials.
The Department and Board are responsible for overseeing all financial matters related to the plan including; establishing the annual budget, plan operation, annual premium rates, deductible and coinsurance amounts, setting and collecting insurers’ assessments, and adjusting provider payment rates as necessary to meet program funding requirements.
Daily program operations are performed by the Plan Administrator and include eligibility determination, claims evaluation for eligibility and payment, premium billing and collection, accounting, cost and utilization and other statistical reporting, customer service and communications functions.
The Plan Administrator must also provide actuarial, legal and pharmacy benefit management services as specified in this RFP.
HIRSP functions as an insurer with the Plan Administrator maintaining all records necessary to effectively administer the program and prepare annual and semiannual financial statements and HIRSP Monthly Reports.
HIRSP must be administered in conformance with applicable state and federal laws and regulations as well as Department polices and procedures.
HIRSP premium revenue is collected through a bank lockbox operation, contracted by the State of Wisconsin Treasurer. All HIRSP revenue is deposited into a State of Wisconsin account. Records of all revenue transactions must be submitted by the Plan Administrator to the Department. The transactions are reported to the State Treasury and recorded in the Wisconsin Management Accounting and Reporting Tool (WiSMART).
The Plan Administrator submits a weekly accounting of claim expenditures with a request for disbursement of funds to the Department. Upon approval by the Department, funds in the amount of the disbursement request are authorized for transfer to facilitate provider payment for services rendered.
The Plan Administrator submits invoices for its services to the Department on a monthly basis according to the cost and payment structure established in the final contract.
The State of Wisconsin Investment Board (SWIB) manages the investment strategies of all funds in the accounts that are under Treasurer oversight, including HIRSP funds.
1.2 Overview of HIRSP Eligibility Requirements
Eligibility requirements for HIRSP are specified in state law. In general, in order to be eligible for HIRSP, an individual must be a resident of Wisconsin, must not be eligible for employer-sponsored group health insurance or for Wisconsin Medicaid (including BadgerCare) and must meet the requirements described under A or B below:
A. Eligibility Based on Medical Condition: In addition to meeting the general requirements outlined above, an individual must be less than 65 years of age and must either be eligible for Medicare because of a disability, have tested positive for the Human Immunodeficiency Virus (HIV), or in the past nine months, received from an insurer a notice of rejection or cancellation, a substantial limitation in coverage or a premium greater than 50 percent higher than the individual had been paying or that is charged to persons at standard risk, based wholly or in part on medical underwriting.
B. Eligibility for Applicants Who Lost Employer-Sponsored Group Health Insurance (“eligible individual”): In addition to being a resident of Wisconsin, and not eligible for employer-sponsored group health insurance or for Wisconsin Medicaid (including BadgerCare), the individual must:
• Have lost employer-sponsored group health insurance and applied to HIRSP within 63 days of losing employer-sponsored group health insurance.
• Did not voluntarily cancel coverage.
• Exhausted continuation coverage [state continuation coverage or Consolidated Omnibus Budget Reconciliation Act (COBRA)].
• Had continuous insurance coverage for at least 18 months with no gap in coverage greater than 63 days.
• Not eligible for Medicare.
Eligibility for HIRSP is not dependent upon income or assets. However, there are provisions for reduced premium, deductible and prescription drug coinsurance amounts for lower income policyholders. Refer to Section 1.4 for additional information of HIRSP’s premium and deductible subsidy program.
1.3 Overview of HIRSP Plans
Benefits and plans are defined by statute. All HIRSP plans provide coverage for major medical and prescription drug expenses. Policyholders are responsible for paying premiums, annual deductibles, and medical and prescription drug coinsurance amounts.
The successful bidder must be able to effectively administer the HIRSP benefits, which are subject to change. The successful bidder must be able to implement all benefits changes within effective dates established as a result of legislation or as otherwise directed by the Department.
The HIRSP plans, options and cost-sharing requirements are described below. A table summarizing the cost-sharing requirements by plan has also been included.
Plan 1, Options A and B
• For policyholders who are not eligible for Medicare.
• Provide identical coverage. (Option A has a lower deductible and lower drug coinsurance out-of-pocket maximum and premiums that are higher than Option B. Option B has lower premiums and a higher deductible and drug coinsurance out-of pocket maximum.)
Plan 2
• For policyholders under age 65 who qualify for Medicare due to a disability. Policyholders who reach age 65 while enrolled in HIRSP may retain their HIRSP coverage. (Note that individuals age 65 and older are eligible for HIRSP only if they meet the eligibility requirements for an “eligible individual” as defined in HIRSP statutes).
• Provides identical coverage to Plan 1, but coordinates benefits with Medicare.
Summary of HIRSP Cost-Sharing Requirements by Plan
| |Plan 1, Option A |Plan 1, Option B |Plan 2 |
|Premiums |Based on rate tables developed by actuaries and approved by Board. |
|Premium reductions available? |Yes |No |Yes |
|Medical deductible |$1,000 per year |$2,500 per year |$500 per year |
|Medical deductible reductions available?|Yes |No |No |
|Medical coinsurance |20% of allowed amount up to $1,000|20% of allowed amount up to $1,000|No |
| |total per year |total per year | |
|Individual medical out-of-pocket maximum|$2,000 per year. |$3,500 per year. |$500 per year. |
|(Total medical deductible and medical | | | |
|coinsurance, after which HIRSP will pay | | | |
|100%.) | | | |
|Drug coinsurance |20% up to $25 per prescription. |20% up to $25 per prescription. |20% up to $25 per |
| | | |prescription. |
|Drug coinsurance out-of-pocket maximum |$750 per year. This is in |$1,000 per year. This is in |$125 per year. This is in |
|(Total drug coinsurance, after which |addition to medical coinsurance. |addition to medical coinsurance. |addition to medical |
|HIRSP will pay at 100%.) | | |coinsurance. |
|Drug coinsurance out-of-pocket maximum |Yes |No |No |
|reductions available? | | | |
|Maximum lifetime benefit |$1,000,000 |$1,000,000 |$1,000,000 |
1.4 Premium, Deductible and Drug Coinsurance Subsidy Program
Qualifying, low-income policyholders may apply for reduced premiums, medical deductible and drug coinsurance. The criteria for and amount of these reductions, which are set in state law, are specific to the plan, option and income level of the policyholder. Approximately 25 percent of HIRSP policyholders receive subsidies.
Premium reductions are available to Plan 1A and Plan 2 policyholders with annual household incomes less than $25,000. Reduced medical deductibles and drug coinsurance amounts are available to Plan 1A policyholders with annual household incomes less than $20,000. Plan 1B policyholders are not eligible for any reductions in premiums, medical deductibles or drug coinsurance amounts. Plan 2 policyholders are eligible for premium reductions but are not eligible for reductions in medical deductibles or drug coinsurance amounts.
Reduced premium and medical deductible amounts for Plan 1A are as follows:
|Annual Household Income |Premium as % of Standard | | |
| |Rates |Deductible |Drug Coinsurance |
|at Least |but Less Than | | | |
|$0 |$10,000 |100.0% |$500 |$375 |
|$10,000 |$14,000 |106.5% |$600 |$450 |
|$14,000 |$17,000 |115.5% |$700 |$525 |
|$17,000 |$20,000 |124.5% |$800 |$600 |
|$20,000 |$25,000 |130.0% |$1,000 |$750 |
1.5 Covered and Non-Covered Services
HIRSP law specifies the services HIRSP covers as well as services that HIRSP does not cover. HIRSP is permitted by law to reimburse only those medical services that policyholders obtain through Wisconsin Medicaid-certified providers. Reimbursement is reduced by applicable cost sharing requirements (deductible or coinsurance) that are the responsibility of the policyholder.
HIRSP requires a six-month waiting period for coverage of pre-existing conditions. This pre-existing condition-waiting period does not apply for HIRSP policyholders that meet the requirements of an “eligible individual.”
Covered services are medically necessary and appropriate covered services received from Wisconsin Medicaid-certified providers, including:
• Basic medical-surgical and hospital services, including AODA and mental health.
• Prescription drugs, insulin, and services and supplies for treatment of diabetes.
• Home care, durable medical equipment and disposable medical supplies.
• Diagnostic X-rays and laboratory tests.
• Physical therapy services.
• Skilled nursing facility services.
• Hospice care.
• Chiropractic services.
• Maternity and newborn services.
Non-covered services include:
• Routine exams and related services.
• Cosmetic treatments.
• Eyeglasses.
• Hearing aids.
• Routine dental care.
• Custodial care.
• Infertility, impotence, and sterility services or drugs.
• Experimental or investigative services or procedures, (except drugs for the treatment of HIV infection).
1.6 HIRSP Budget and Financing
HIRSP’s operating budget for the SFY 2004 is approximately $170 million. Policyholder premiums fund 60 percent of HIRSP costs. The remaining 40 percent of HIRSP costs are shared equally between health care providers and private health insurance companies. Health care providers pay their 20 percent through reductions in reimbursement for HIRSP claims. Insurers pay their 20 percent through assessments.
The Plan Administrator and actuary assist the Department and Board with establishing annual operating budgets and a mandatory annual reconciliation of plan costs to be completed by April 30th of each year to ensure that policyholders, providers and insurers each contribute their required level of plan funding.
1.7 Current Plan Administrator
Electronic Data Systems (EDS) is the incumbent Plan Administrator for HIRSP and has served in this capacity since July 1, 1998. Prior to EDS, Blue Cross Blue Shield United of Wisconsin was the Plan Administrator.
1.8 Scope of the Project
The Contractor will perform administrative services for HIRSP as described in this RFP including, but not limited to, the enrollment of policyholders in the HIRSP program, administering HIRSP subsidies, collecting policyholder premiums, collecting the HIRSP assessment from insurers, administering cost containment strategies, the customer service process, publications functions, claims processing, computing provider contribution to HIRSP expenses in the form of reduced provider reimbursement amounts, financial processes and the appeal and grievance process.
The Contractor must have the flexibility to meet and respond to the changing requirements of HIRSP, including; increasing enrollment, new initiatives or policy changes requiring additions or changes to benefit designs or discounting arrangements, or other related responsibilities for HIRSP.
If significant changes in the Contractor’s responsibilities are required, the Department will attempt to provide the Contractor with as much lead time as possible.
1.9 Definitions and Acronyms
The following definitions and acronyms are used throughout the RFP:
• Board means HIRSP Board of Governors.
• Contract means the agreement to be executed between the selected proposer and the Department to accomplish the purposes specified in this RFP.
• Contractor(s) means proposer(s) awarded the contract resulting from this RFP to provide HIRSP administrative services.
• DHFS or Department means the Wisconsin Department of Health and Family Services.
• GPR means State General Purpose Revenue (i.e., state tax collections).
• HIPAA means Health Insurance Portability and Accountability Act.
• HIRSP means the Health Insurance Risk Sharing Plan.
• OCI means Office of the Commissioner of Insurance.
• Proposer or Vendor means a firm submitting a Proposal in response to the RFP.
• Provider means Wisconsin Medicaid Certified Provider.
• Policyholder means an individual who has been enrolled as a member, has paid premiums and is eligible to receive benefits under HIRSP.
• RFP means Request for Proposal.
• State means State of Wisconsin.
• Wisconsin Health Insurance Risk Sharing Plan (HIRSP) means the program operated by the Department under Ch. 149, Wis. Stats. and related State and Federal rules and regulations.
• Wisconsin Medicaid Program (MA) means the program operated by the Department under Title XIX of the Federal Social Security Act, Ch. 49, Wis. Stats. and related State and Federal rules and regulations.
1.10 Access to Program Information for Proposers
Proposers are encouraged to view information regarding HIRSP on the Department’s website at dhfs.state.wi.us/hirsp. This information will assist proposers in the preparation of proposals. Available information includes the most recent HIRSP Annual Report, the HIRSP Outline of Coverage, the HIRSP Policy, Premium Tables, application materials, HIRSP newsletter, etc. While a reasonable attempt is made to maintain accurate and up-to-date information on the Department’s website, the Department makes no assurances or guarantees that all information and data displayed are accurate or complete. The State of Wisconsin and the Department disclaim responsibility for the accuracy or completeness of the information displayed on the Department website. If any materials, documentation, information, or data displayed on the website are discovered to be inaccurate and/or incomplete, such inaccuracy or incompleteness shall not constitute a basis for challenging the contract award or contract rejection, nor shall it provide a basis to renegotiate a payment amount or rate after contract award.
Requirements specified in the RFP shall take precedence over any documentation on the website if a conflict exists.
A listing of additional websites containing detailed information on HIRSP can be found in Attachment A of this RFP.
1.11 Overview of Demographics, Statistics and Operations
Enrollment
Geographic Distribution of HIRSP Policyholders
HIRSP policyholders reside in every county in the state. The map represents the number of residents in each county who were covered by HIRSP at any time during the year 2002; therefore, the total number of policyholders indicated on the map will not reconcile with the 15,882 enrolled in December of 2002.
Application Statistics
In 2002, rejection for health insurance coverage was the primary reason applicants sought and were approved for HIRSP coverage, accounting for 63.9 percent of the approvals. Qualifying under HIPAA as an eligible individual was the second most frequent reason for approval.
|Application Statistics, 1999 – 2002 |
|Year |Received |Approved |Reason for approval |
| | | | | | | |
| | | | | |HIPAA- | |
| | | |Medicare | |eligible |Notice of |
| | | |eligible |HIV+ |individual |Rejection |
|2001 Percent of Total Applications Approved |4.2% |0.7% |35.2% |57.8% |1.5% |0.5% |
|2000 Percent of Total Applications Approved |3.6% |0.8% |45.0% |48.7% |1.3% |0.6% |
|1999 Percent of Total Applications Approved |5.0% |1.5% |32.8% |57.8% |2.3% |0.6% |
The majority of HIRSP applicants who were approved for HIRSP coverage applied because they received a notice of rejection from an insurance carrier.
Diagnosis Categories
Overview of HIRSP Operations
CY 2003 Average Monthly Statistics
|Application Processing |Average Per Month |
|Application packets mailed out |200 |
|Applications for Coverage Received |550 |
| - Applications for Coverage Approved |480 |
|Applications for Reduced Premium, Deductible & Drug Coinsurance Received |90 plus 4,000 annual reapplications submitted between March and |
| |May 1st for a July 1st effective date |
|Requests to change HIRSP plans |550 |
|(Received by November 1st; effective January 1st) | |
|Claims Processing | |
|Total Claims (including adjustments) |81,500 |
| - (Professional and Hospital Claims) |26,000 |
| - (Prescriptions Drug Claims) |58,000 |
|Customer Service | |
|Telephone Calls to Customer Service |11,000 |
|Written Correspondence |700 |
|Medical Review | |
|Claims reviewed for pre-existing conditions |1,550 |
|Claims reviewed for Medical Necessity |900 Claims, (500 Drug, 400 Medical) |
|Prior Authorization Reviews |200 |
|Appeals and Grievances | |
|Appeals |100 |
|(Plan Administrator researches, decides, responds) | |
|Grievances |10 |
|(Plan Administrator researches) | |
Overview of Key Annual/Quarterly Events
Annual Choice of Coverage
September mailing to Plan 1A and 1B policyholders, offering them the opportunity to change and enroll in a different plan. Requests for changes are due in November to accommodate an effective date of January 1. Premium notices reflecting the members’ requested plan changes must be generated in addition to system changes reflecting the changes in deductibles and out-of-pocket drug coinsurance amounts.
Annual Requalification for Reductions in Premium, Deductible and Drug Coinsurance Out-of-Pocket Maximums
March mailing to Plan 1A and Plan 2 policyholders, advising on the requirement that members must annually requalify to receive, or for continuation of, reductions. In CY ’02, approximately 4,000 applications were returned for processing. Following HIRSP’s annual budget and premiums setting, subsidy levels and corresponding premium rates are set for a July 1 effective date. The corresponding deductible and drug coinsurance out-of-pocket maximums are later set for a January 1 effective date.
Annual Out-of-Pocket Costs Amendments
December mailing sent to Plan 1A policyholders that have previously qualified for reduced out-of-pocket costs either during the March requalification period or at a later date. This mailing serves to amend the out-of-pocket costs section of the HIRSP Policy to reflect the reduced out-of-pocket costs that the member has qualified for and which will go into effect on January 1.
Annual Premium Rate Change Notification
Annual May mailing which is plan specific and provides all policyholders with information on premium rate changes and charts, if applicable, following annual reconciliation process. Premium rates must be calculated and rate charts developed for premium rate changes to go into effect on July 1 (or more often, if applicable).
Quarterly Newsletter
Publication providing all policyholders with information on important or timely topics.
2.0 STATEMENT OF OBJECTIVES
The purpose of the contract with the HIRSP Plan Administrator is to assist the Department and Board in operating a cost-effective, efficient and customer-friendly program in conformance with all applicable state and federal regulations. Objectives include contracting with an organization that will:
• Ensure a smooth transition with minimal disruption to policyholder and providers from contract implementation and throughout the contract term, including transition to the succeeding Plan Administration.
• Demonstrate a proven ability to administer an insurance plan similar to HIRSP. Must demonstrate ability to perform the required administrative services in a cost-effective manner and assure compliance with all state and federal regulations throughout the contract period.
• Demonstrate proven excellence in Customer Service and the ability to service populations similar to HIRSP.
• Incorporate continuous quality improvement principles and practices in all aspects of operation.
• Demonstrate data management capabilities to include the production of timely and accurate cost, statistical and utilization reports for program analysis and use as management tools.
• Demonstrate experience and the ability to manage pharmacy benefits.
• Demonstrate an ability to provide disease management services in a cost-effective manner; proven focus on population health management initiatives geared towards meeting the unique needs of people with chronic illnesses including those with behavioral health issues.
• Perform covered functions for current and new HIPAA regulations published during the term of the contract with no disruption to operations. Anticipate and provide flexible solutions that are positioned to effectively meet upcoming HIPAA regulations.
3.0 PROCUREMENT AND CONTRACTING INFORMATION
3.1 Procuring and Contracting Agency
The Wisconsin DHFS issues this RFP and is the sole point of contact for the state of Wisconsin during the selection process. Within the Department, the Wisconsin Division of Health Care Financing (DHCF) will administer the contract resulting from this RFP. The contract administrator will be Margaret Kristan.
3.2 Clarification or Revisions to Specifications and Requirements
Any questions concerning this RFP must be submitted in writing on or before February 5, 2004, to:
Margaret Kristan, HIRSP Director
Division of Health Care Financing
1 West Wilson Street, Room 265
P.O. Box 309
Madison, WI 53701-0309
Phone: (608) 266-2833
Fax: (608) 261-7792
E-mail: kristma@dhfs.state.wi.us
Vendors are expected to raise any questions, exceptions, or additions they have concerning the RFP document at this point in the RFP process. If a vendor discovers any significant ambiguity, error, conflict, discrepancy, omission, or other deficiency in this RFP, the vendor should immediately notify the above named individual in writing by the date above, of such error and request modification or clarification of the RFP document.
In the event that it becomes necessary to provide additional clarifying data or information, or to revise any part of this RFP, revisions, amendments, and/or supplements will be provided to vendors who have submitted a letter of intent to submit a proposal in accordance with section 3.8 of this RFP.
Each proposal shall stipulate that it is predicated upon the terms and conditions of this RFP and any supplements or revisions thereof.
Any contact with State employees concerning the RFP are prohibited, except as authorized by the RFP manager during the period from date of release of the RFP until the notice of intent to contract is released.
Violations of these conditions may, at the sole discretion of the Department, be considered sufficient cause for the Department to reject a bid, irrespective of any other consideration.
All written questions submitted on or before February 5, 2004, or at the Vendor Conference will be answered in writing by the State. Questions received after the due dates specified will not be answered. To the extent practicable, proposer’s questions will remain as written. However, the Department may consolidate and paraphrase questions received.
Telephone questions are highly discouraged. Any oral responses, information, dates, and/or advice (including telephonic responses, information and/or advise, and any oral responses given during the Vendor Conference) received by a prospective proposer from the Department or Department staff shall not, in any manner whatsoever and whether before or after the release of this RFP, be binding on the State of Wisconsin, unless followed-up and explicitly confirmed and stated in writing by the Contract Administrator.
3.3 Vendor Conference
A vendor conference will be held on February 12, 2004, at 10:00 a.m. to respond to questions and to provide any needed additional instruction to vendors on the submission of proposals. The vendor conference will be held in room 950A at the State Office Building located at 1 W. Wilson Street in Madison, Wisconsin. If no questions are received, the State reserves the right to cancel the vendor conference. All vendors who intend to respond to the RFP are strongly encouraged to attend the vendor conference.
Prospective proposers will have an opportunity to request clarification of any uncertainties that may exist in the RFP. Each prospective proposer is limited to a maximum of three (3) representatives at the Vendor Conference.
The Department reserves the right to hold the conference in an alternative location, and if so will post the location of the alternative room/location unless there is sufficient time to notify proposers by mail.
3.4 Reasonable Accommodations
The Department will provide reasonable accommodations, including the provision of informational material in an alternative format, for qualified individuals with disabilities upon request. If you need accommodations at a bid opening or vendor conference, contact Margaret Kristan.
3.5 Calendar of Events
Listed below are specific and estimated dates and times of actions related to this RFP. The actions with specific dates must be completed as indicated, unless otherwise changed by the Department. In the event that the state finds it necessary to change any of the specific dates and times in the calendar of events listed below, it will do so by issuing a supplement to this RFP. There may or may not be a formal notification issued for changes in the estimated dates and times.
|Date |Event |
|January 7, 2004 |Date of issue of the RFP. |
|January 22, 2004 |Letter of Intent to Submit Proposal due. |
|February 5, 2004 |Last day for submitting written questions. |
|February 12, 2004 |Vendor conference. |
|March 12, 2004 |Mail responses to questions and notification to vendors of supplements or |
| |revisions to the RFP |
|April 12, 2004 |Proposals due from vendors by 4:00 p.m. CST |
|April 26-30, 2004 (est.) |Oral presentations |
|May 5-7, 2004 (est.) |Site visits |
|May 28, 2004 (est.) |Notification of intent to award sent to vendors. |
|July 1, 2004 (est.) |Contract start/Transition In date |
3.6 Contract Term
The contract shall be effective on the date signed and shall run for three years with three possible one-year renewal options from that date. The earliest effective date will be July 1, 2004.
3.7 VendorNet Registration
The State of Wisconsin’s purchasing information and vendor notification service is available to all businesses and organizations that want to sell to the state. Anyone may access VendorNet on the Internet at to obtain information on state purchasing practices and policies, goods and services that the state buys, and tips on selling to the State. Vendors may use the same Website address for inclusion on the bidders list for goods and services that the organization want to sell to the state. A subscription with notification guarantees the organization will receive an e-mail message each time a state agency, including any campus of the University of Wisconsin System, posts a request for bid or a RFP in their designated commodity/service area(s) with an estimated value over $25,000. Organizations without Internet access receive paper copies in the mail. Increasingly, state agencies also are using VendorNet to post simplified bids valued at $25,000 or less. Vendors also may receive e-mail notices of these simplified bid opportunities.
If questions exist about VendorNet, call the VendorNet Information Center at 1-800-482-7813 or, for Madison area organizations, call 264-7898.
3.8 Letter of Intent to Submit Proposal
Prospective proposers are requested to submit a Letter of Intent by January 22, 2004. The Letter of Intent shall clearly and completely identify the prospective proposer (e.g., agency or organization) and the full name, title, complete street address, office telephone number, and fax number of the prospective proposer’s contact person. It shall also be clearly marked as Letter of Intent to Propose to Provide Administrative Services to HIRSP.
The Letter of Intent should be sent to the following address by January 22, 2004:
Margaret Kristan, HIRSP Director
Division of Health Care Financing
1 West Wilson Street, Room 265
P.O. Box 309
Madison, WI 53701-0309
Phone: (608) 266-2833
Fax: (608) 261-7792
E-mail: kristma@dhfs.state.wi.us
Failure to submit a timely and complete Letter of Intent will not preclude the submission of a proposal, nor does submission of a timely and complete Letter of Intent require that the prospective proposer submit a proposal.
However, only those prospective bidders submitting a timely and complete Letter of Intent will remain on the mailing list for:
A. RFP addenda or clarifications (if any);
B. Answers to oral and written questions;
C. Notices of changes to the procurement schedule specified below (if any); and
D. Other important information from the Department regarding this RFP. Such mailings will be sent to the contact persons identified in the respective Letters of Intent.
4.0 PREPARING AND SUBMITTING A PROPOSAL
4.1 General Instructions
The evaluation of the proposal and selection of a contractor will be based on the information submitted in the vendor’s proposal and oral presentations plus references and site visits (if required by the Department). Failure to respond to each of the requirements in the RFP may be the basis for rejecting a proposal.
Elaborate proposals (e.g., expensive artwork) beyond that sufficient to present a complete and effective proposal are not necessary or desired.
The Department reserves the right to reject any or all proposals deemed by the State as not meeting the provisions contained herein. The Department will not accept late or incomplete proposals. All proposals are to be complete when they are submitted. Failure to submit a complete proposal may be the basis for rejecting a proposal.
4.2 Incurring Costs
The State of Wisconsin is not liable for any costs incurred by proposers in replying to this RFP.
4.3 Submitting the Proposal
Proposers must submit an original and six copies of their proposal and all materials required for acceptance of their proposal by 4:00 p.m. April 12, 2004, to:
Margaret Kristan, HIRSP Director
Division of Health Care Financing
1 West Wilson Street, Room 265
P.O. Box 309
Madison, WI 53701-0309
Phone: (608) 266-2833
Fax: (608) 261-7792
E-mail: kristma@dhfs.state.wi.us
All proposals must be time-stamped in the DHCF by the above state time. Proposals not so stamped will not be accepted. Proposers mailing their proposals or using a commercial delivery service must allow sufficient time for delivery of their proposals by the specified time. For purposes of this RFP, receipt of a proposal by the State mail system does not constitute receipt of a proposal by the DHCF.
Proposals submitted by fax or e-mail, in whole or in part, shall be rejected. Late proposals shall be rejected and will be returned unopened. There are no exceptions.
To ensure confidentiality of the document, all proposals must be packaged, sealed and show the following information on the outside of the package:
• Proposer’s name and address
• Proposal to Provide Administrative Services for HIRSP
• RFP # 0428-DHCF-SM
• Proposal due date – April 12, 2004, at 4:00 p.m. CDT
An original plus three (3) copies of the Cost Proposal must be sealed and submitted as a separate part of the proposal. (Refer to sections 4.5 and 9.0 for additional instructions regarding the Cost Proposal.) The outside of the envelope must be clearly labeled with the words “Cost Proposal, HIRSP Administrative Services” and the name of the vendor and due date. The Cost Proposal is due to the addressee on the due date and time noted above. Faxed, E-mailed and late Proposals will not be accepted.
4.4 Use of Subcontractors
In the event of a proposal submitted jointly by more than one (1) organization, one (1) organization must be designated as the prime contractor, and the prime contractor will be solely responsible for assuring the performance of all aspects of the contract. All other participants shall be designated as subcontractors. Any use of subcontractors for this contract shall meet the requirements of this RFP.
Once the Letter of Intent to Award a Contract is issued and a contract is awarded, the use of subcontractors by the prime contractor (for any portion of the scope of work) is subject to the prior written consent of the Department (whether or not such subcontractor(s) were identified in the prime contractor’s proposal). The Department may request such additional information and/or written assurances as deemed necessary to ensure that only qualified, competent vendors perform services under the RFP and contract, and to ensure that the scope of work is performed in a professional manner.
No services performed under this contract may be subcontracted without the prior written consent of the State and the State must approve any vendors that will serve as subcontractors for HIRSP, including the required subcontract for actuarial services as specified in Section 8.2 of this RFP.
At any time during the contract period, the contractor shall not subcontract out, in whole or in part, any portion of the scope of work to an individual(s), corporation(s), partnership(s), agent(s), subsidiary(ies), or public agency(ies) without the prior express written consent of the Department.
If subcontractors are to be used, the proposer must clearly explain their participation. Subcontractors are required to abide by all terms and conditions of the contract. The prime contractor will be responsible for contract performance, including the oversight of and responsibility for all delegated/sub-contracted functions, when subcontractors are used.
The State of Wisconsin policy provides that minority-owned business enterprises certified by the Wisconsin Department of Commerce, Bureau of Minority Business Development should have the maximum opportunity to participate in the performance of its contracts. The supplier/contractor is strongly urged to use due diligence to further this policy by awarding subcontracts to minority-owned business enterprises or by using such enterprises to provide goods and services incidental to this agreement, with a goal of awarding at least 5 percent of the contract price to such enterprises. The listing is published on the Internet at: .
4.5 Proposal Organization and Format
Proposals should be typed and submitted on 8.5 by 11-inch paper bound securely. Proposals should be organized and presented in the order and by the number assigned in the RFP. Proposals must be organized with the headings and subheadings listed below. Each heading and subheading should be separated by tabs or otherwise clearly marked.
Technical Proposal
Introduction
Response to General Proposal Requirements (see Section 6.0)
Organization Capabilities
Financial Statements
Staff Qualifications
Proposer Client List and References
Oral Presentation and Materials
Response to Mandatory Proposal Requirements (see Section 7.0)
Transmittal Letter
Designation of Primary Contact Person
Location and Staff
Disaster Recovery Plan
Legal Representation
HIPAA Compliance
Response to Technical Requirements (see Section 8.0)
Policyholder and Provider Services
Eligibility Determination and Applications Processing
Customer Service
Communications and Publications
Appeal and Grievance Processes
Financial Management
Premium Administration
Accounting and Financial Services
Actuarial Services
Auditing Procedures
Claims and Systems Administration
Claims Processing
Pharmacy Benefit Management
Provider Network Maintenance
Medical Management
Medical and Other Clinical Consulting Services
Cost Containment
Disease Management
Detailed Transition Plan
Data Collection and Reporting
Required forms (see Section 12.0)
Designation of confidential and proprietary information
Affidavit
Vendor Information
Vendor Reference
No mention of the cost proposal may be made in the Technical Proposal of this RFP.
Cost Proposal (see Attachment F)
Cost Proposal Form and Worksheet
The vendor must submit its Cost Proposal on the form provided in Appendix F according to the instructions provided. Failure to provide any requested information in the prescribed format may result in disqualification of the proposal.
4.6 Multiple Proposals
Multiple proposals from a vendor will be permissible; however, each proposal must conform fully to the requirements for proposal submission. Each such proposal must be submitted separately and labeled as Proposal #1, Proposal #2, etc., on each page included in the response.
4.7 Oral Presentations
Vendors will be required to make oral presentations, which will be scored by the evaluation committee, regarding their written proposals. Key personnel of the vendor, to include any subcontractor personnel designated with the direct responsibility for the areas they are presenting, shall conduct the oral presentation. No outside consultants shall be used in the presentation.
The purpose of the oral presentation is for the vendor to demonstrate understanding of the requirements of the prospective contract and demonstrate their capability, including staffing, to meet those requirements. The presentation shall not be a marketing or sales presentation. The presentation shall address the vendor’s technical solution to the requirement. The cost proposal, past performance, references and financial information shall not be addressed in the presentation.
Vendors will be scheduled for their oral presentation by a random lottery drawing conducted by the Contract Administrator. Requests for rescheduling may not be accepted. If a vendor is not present at the scheduled time for its oral presentation, the proposal will be deemed a late proposal and may be excluded from further consideration.
Oral presentations will be limited to two hours. An additional thirty minutes will be set aside immediately following the oral presentation for Evaluation Committee members to ask follow-up questions of clarification.
Refer to Section 6.5 for additional information regarding oral presentations.
4.8 Site Visits
The Department may conduct a site visit to verify the information submitted in the proposals of top scoring vendors. Vendors will be given one (1) week notice prior to the site visit. During the site visit, vendors should be prepared to discuss any aspect of the RFP, retrieve files and demonstrate applicable processes, products, services, equipment etc., as requested during the site visit. Failure of a vendor to furnish the product(s) and/or service(s) it has proposed for demonstration within the time constraints of the preceding paragraph may result in rejection of that proposal. Failure of any product(s) and/or service(s) to meet the agency’s specified requirements during the site visit may result in rejection of the vendor’s proposal.
The successful demonstration of the vendor’s product(s) and/or service(s) does not constitute acceptance by the agent. Any product(s) and/or service(s) furnished by the vendor for the purposes of this demonstration must be identical in every respect to those that will be furnished if a contract results.
4.9 Withdrawal of Proposals
Proposals shall be irrevocable until contract award unless the proposal is withdrawn. Proposers may withdraw a proposal in writing at any time up to the proposal closing date and time or upon expiration of three (3) business days after the due date. To accomplish this, the written request must be signed by an authorized representative of the proposer and submitted to:
Margaret Kristan, HIRSP Director
Division of Health Care Financing
1 West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
Phone: (608) 266-2833
Fax: (608) 261-7792
Email: kristma@dhfs.state.wi.us
If a previously submitted proposal is withdrawn before the proposal due date and time, the proposer may submit another proposal at any time up to the proposal closing date and time.
5.0 PROPOSAL SELECTION AND AWARD PROCESS
5.1 Preliminary Evaluation
Proposals will be reviewed initially to determine if mandatory proposal requirements, as listed in Section 7.0 of this RFP, are met. Failure to meet mandatory requirements may result in rejection of the proposal. In the event that all vendors do not meet one or more of the mandatory requirements, the Department reserves the right to continue the evaluation of the proposals and to select the proposal which most closely meet the requirements specified in this RFP. Any proposal failing to provide all response requirements as specified in this RFP, and in the prescribed format, may be removed from further consideration and the vendor notified accordingly.
5.2 Proposal Scoring
Accepted proposals will be reviewed by an evaluation committee and scored against the stated criteria. A proposer may not have contact with any member of an evaluation committee except at the State’s direction. The committee may review references, request interviews, and/or conduct on-site visits and use the results in scoring the proposals. Proposals from certified Minority Business Enterprises may have points weighted by a factor of 1.00 to 1.05 to provide up to a five percent (5%) preference to these businesses (Wis. Stats. 16.75(3m)). The evaluation committee’s scoring will be tabulated and proposals ranked based on the numerical scores received.
Various costing methodologies and models are available to analyze the cost information to determine the lowest cost to the agency. The agency will select one method for scoring costs and will use it consistently throughout its analysis of all the cost proposals. The selected methodology will be available after the Department issues a notification of intent to award the contract.
5.3 Right to Reject Proposals and Negotiate Contract Terms
The Department reserves the right to reject any and all proposals and to negotiate the terms of the contract, including the award amount, with the top scoring proposers, prior to entering into a Contract.
5.4 Evaluation Criteria
The proposals will be scored using the following criteria:
|Description |Points |
|General Proposal Requirements (see Section 6.0) |200 |
|Organization Capabilities | |
|Financial Statements | |
|Staff Qualifications | |
|Proposer Client List and References | |
|Oral Presentation and Materials | |
|Technical Proposal Requirements (see Section 8.0) |500 |
|Policyholder and Provider Services |(100) |
|Eligibility Determination/Applications Processing | |
|Customer Service | |
|Communications and Publications | |
|Appeal and Grievance Processes | |
|Financial Management |(100) |
|Premium Administration | |
|Accounting and Financial Services | |
|Actuarial Services | |
|Auditing Procedures | |
|Claims and Systems Administration |(100) |
|Claims Processing | |
|Pharmacy Benefit Management | |
|Provider Network Maintenance | |
|Medical Management |(100) |
|Medical and Other Clinical Consulting Services | |
|Cost Containment | |
|Disease Management | |
|Detailed Transition Plan |(50) |
|Data Collection and Reporting |(50) |
|Cost Proposal (see Section 9.0) |300 |
|Total |1000 total |
5.5 Award and Final Offers
The Department will compile the final scores (technical and cost) for each proposal. The award will be granted in one of two ways. The award may be granted to the highest scoring responsive and responsible proposer. Alternatively, the Department may negotiate with the highest scoring proposer or proposers or may request they submit final and best offers.
5.6 Notification of Intent to Award
All vendors who respond to this RFP will be notified in writing of the state’s intent to award the contract(s) as a result of this RFP.
After notification of the intent to award is made, and under the supervision of agency staff, copies of proposals will be available for public inspection from 9:00 a.m. to 3:30 p.m. at 1 West Wilson Street, Madison, Wisconsin. Vendors should schedule reviews with Margaret Kristan at (608) 266-2833.
5.7 Appeals Process
Notices of intent to protest and protests must be made in writing. Protesters should make their protests as specific as possible and should identify statutes and Wisconsin Administrative Code provisions that are alleged to have been violated.
Any written notice of intent to protest the intent to award a contract must be filed with:
Helene Nelson, Secretary
Department of Health and Family Services
1 W. Wilson Street
Madison, WI 53703
(608) 266-9622
The notice must be received in the Secretary’s office no later than five (5) working days after the notice of intent to award is issued.
Any written protest must be received within ten (10) working days after the notice of intent to award is issued.
The decision of the head of the procuring agency may be appealed to the Secretary of the Department of Administration within five (5) working days of issuance, with a copy of such appeal filed with the procuring agency. The appeal must allege a violation of a statute or a provision of a Wisconsin Administrative Code.
6.0 GENERAL PROPOSAL REQUIREMENTS
6.1 Organization Capabilities
Describe your organization’s capability to provide the administrative services required in this RFP.
Include a statement identifying the formal name, title, type of business, business address, location of proposer’s principal offices, and an identification of any other location or site which is proposed to provide any services or resources in the execution of duties of this RFP.
Include a brief history of your business entity and the firm’s experience over the past five (5) years, especially in providing comprehensive administrative services similar to those required in this RFP for a governmental health insurance program similar to HIRSP. Your response should include, but not be limited to, the following:
• Names and types of programs
• Specific dates and length of contracts or renewals
• Scope of your involvement
• Number of clients/customers served
• Specific outcomes
6.2 Financial Statements
The proposer and each subcontractor (if any) shall submit independently audited financial statements for the financially responsible entity for the last three (3) completed fiscal years. If the proposer is a subsidiary, the parent company must be identified, and audited financial statements from the parent company must be submitted. Statements must include:
• Balance sheet
• Statement of revenue, expenses & changes in net assets (profit & loss statement)
• Statement of cash flows
• Notes to financial statements
• Management discussion and analysis
• Auditors’ reports and statements
6.3 Staff Qualifications
Describe the proposed staffing for this proposal. Provide resumes describing the educational and work experiences for each of the key staff who would be assigned to the project. Indicate how adequate staffing will be assured if enrollment grows.
6.4 Proposer Client List and References
Proposers must include in their RFPs a list of all client organizations, including points of contact (name, address and telephone number). The State reserves the right to contact any clients listed, however the proposer may be required to recommend a maximum of five organizations that can be used as references. Selected organizations may be contacted to determine the quality of work performed and personnel assigned to the project. The results of the reference checks will be provided to the evaluation team and used in scoring the written proposals.
6.5 Oral Presentation and Materials
Vendors are required to make oral presentations regarding their written proposals. The oral presentation will be scored by the evaluation committee.
An outline of the oral presentation and all accompanying handouts or slides that will be used during the oral presentation must be submitted with the proposal. Modifications or substitutions to this material may not be accepted after the proposal submission. Only computer generated slides or overhead slides may be used. All information referenced in the handouts or slides must be presented within the two-hour allotted time. Proposers are allowed and encouraged to elaborate on information in the slides and handouts during the oral presentation, but will not be allowed to present new material. The Evaluation Committee may ask only follow-up questions for purposes of clarification in the question and answer session that follows the oral presentation.
Refer to Section 4.7 for additional information regarding oral presentations.
7.0 MANDATORY PROPOSAL REQUIREMENTS
7.1 Transmittal Letter
The Transmittal Letter must be on the official business letterhead of the prime Contractor submitting the proposal, and must be signed by an individual authorized to legally bind the proposer. It must be part of the Technical Proposal. The Transmittal Letter must include the following statements:
• An individual authorized to legally bind the proposer is signing the Transmittal Letter;
• The proposer is the prime contractor and is a corporation or other legal entity;
• A statement identifying any and all subcontractors that will be responsible for fulfilling the requirements of this RFP;
• No attempt has been made or will be made by the proposer to induce any other person or firm to submit or not to submit a proposal;
• No cost or pricing information has been included in the Transmittal Letter or the Technical Proposal;
• The Technical and Cost Proposal are valid for a minimum of six (6) months from the proposal due date;
• The person signing this proposal is authorized to make decisions on behalf of the proposer’s organization as to the prices quoted and that the person has not participated, and will not participate, in any action contrary to the above statement; and
• Assure that the proposer will agree to execute and fulfill a contract according to the conditions and terms specified in this RFP.
7.2 Designation of Primary Contact Person
In conducting any services under an agreement resulting from this proposal, the Plan Administrator shall designate in writing a primary contact person to open and maintain lines of communication with the state. The primary contact person may not be changed without written notification to the Department. All initial contacts and meetings with the Plan Administrator shall be arranged through the HIRSP Program Director.
7.3 Location and Staff
The Plan Administrator must have a Project Manager based in Madison, Wisconsin. Key staff and locations must be readily accessible to the Department and must be available for face-to-face meetings on short notice. At a minimum, key project personnel must be located within a 30-minute drive of the Department’s offices. Proposals that include other staff or operations located beyond a 30-minute drive of the Department’s offices must include an explanation regarding how these “off-site” operations will promote cost-effective, quality operations. Describe your plans for meeting this requirement. Please provide a work plan detailing:
• The location (by city) of each proposed physical site(s);
• The anticipated date(s) for locating staff at each site(s);
• The timing of hiring and training of all project staff; and
• The anticipated number of staff for each location if more than one location is proposed.
Describe program coverage in the event of employee absences, including long-term illness or interim hiring periods, and how continuity and project leadership will be maintained in the absence of the Project Manager or other key managerial positions.
7.4 Disaster Recovery Plan
Proposers will be required to have a disaster recovery plan, satisfactory to the Department, in place for HIRSP that will assure that key program operations will remain operational in the event of major systems failure or other disaster. Please describe your organization’s process for establishing a comprehensive disaster recovery plan. Include any successes experienced.
Please provide an example of a disaster recovery plan maintained by your organization.
7.5 Legal Representation
Unless directed otherwise by the Department in specific instances, the Plan Administrator shall represent or arrange for legal representation to defend against legal claims brought against HIRSP, including coverage and claims disputes, or to prosecute a claim on behalf of HIRSP. The Plan Administrator will also represent or arrange for legal representation in pursuing HIRSP’s subrogation interests. Please describe how your organization will meet this requirement.
7.6 HIPAA Compliance
The Plan Administrator must be able to perform, without disruption to operations, all HIRSP business services, activities or functions, such that the Department is in compliance with all final regulations implementing the Health Insurance Portability and Accountability Act (HIPAA) including, but not limited to, the following; Transactions and Code Sets, Employer Identifier, Privacy, Security and National Provider Identifiers (NPI).
Please describe how you will assure the Department’s compliance with HIPAA for the business services, activities or functions you will perform that if performed by the Department would be covered by HIPAA.
Along with the contract, the Plan Administrator will be required to sign and comply with the terms of a Business Associate Agreement (BAA) similar to that in Attachment G of this RFP. One requirement of the BAA is that the Plan Administrator must execute similar agreements with all subcontractors in certain situations defined in the BAA.
8.0 TECHNICAL REQUIREMENTS
The proposer’s response to the following requirements will serve to evaluate the contractor’s capabilities for performing HIRSP administrative services. The Department is seeking a Contractor with experience in and capacity for providing comprehensive administrative services for a health insurance program, subject to the program’s specific requirements.
TECHNICAL REQUIREMENTS ARE IDENTIFIED UNDER GENERAL HEADINGS IDENTIFIED AS ITEMS 8.1 THROUGH 8.6. FOR EACH TECHNICAL REQUIREMENT (EACH SUBHEADING IDENTIFIED UNDER ITEMS 8.1 THROUGH 8.6), YOUR PROPOSAL MUST BE ORGANIZED TO ADDRESS, IN ORDER, EACH OF THE FOLLOWING:
1. Your proposed technical solution.
2. Your strategies to monitor and assure quality.
3. Your recommended performance standards.
1) Your proposed technical solution: Describe how your organization will support that technical requirement. Include in your description, your organization’s proposed staffing and technological solution to meet the technical requirement in the most cost-effective manner possible. Please note that some of the technical requirements in this section list specific required tasks. These are intended to provide proposers with additional information about program requirements. Your response need not address each specific task but rather describe how your staffing and technological solution will address the technical requirement.
2) Your strategies to monitor and assure quality: Describe how your organization will assure and monitor the quality and confidentiality of the associated services, data and information provided to policyholders, providers and the Department.
3) Your recommended performance standards: The Plan Administrator will be required to meet specific performance standards throughout the contract period. Describe the specific performance standards your organization recommends in order to assure quality for each particular technical requirement. The actual performance standards that the plan administrator will be required to meet will be specified in the contract and will be based, in part, on the staffing and technical solutions of the selected proposer. Therefore, your proposal must detail performance standards appropriate to services you propose and should also include proposed appropriate financial penalties for performance standards that are not met.
8.1 Policyholder and Provider Services
Eligibility Determination and Applications Processing
The plan administrator shall perform all eligibility and applications processing functions for HIRSP, including eligibility for the premium and deductible reduction program. The plan administrator will be responsible for the development and distribution of necessary forms including but not limited to application forms, premium tables, policy forms, informational materials, and standard response letters.
On average, HIRSP receives approximately 550 applications per month. Approximately 25 percent of these also include an application for reduced premium and deductible amounts. Annual reapplications are required for premium, deductible and drug coinsurance reductions, which currently accounts for approximately 25 percent of HIRSP enrollment.
Please describe your ability to perform eligibility determinations and applications processing. Specific requirements include but are not limited to the following:
• Receive applications and checks from new applicants.
• Maintain file and on-line tracking system with information captured from the application and other sources for application status/pended/approved/ declined.
• Maintain copies of all applications received.
• Review applications for completeness and correspond, by telephone or in writing, with policyholders, insurers and employers to obtain information/ documentation to determine program eligibility or denial or application.
• Request any additional information needed to process applications within 10 business days.
• Screen applications to ensure that applicants are residents of Wisconsin and are not eligible for Medicaid.
• Determine if applicants are eligible based on medical condition or from having lost their employer sponsored group health insurance.
• Determine if applicants must complete waiting period for pre-existing conditions.
• Determine and apply correct premium amounts or potential qualification for reduced premium or deductible by according to age, zone, gender and income.
• Administer the premium, deductible and drug coinsurance subsidies in accordance with Wisconsin Statutes.
• Process Applications for Reduced Premium, Deductible and Drug Coinsurance.
• Maintain continued eligibility verification on all policyholders, including securing updated proof of Wisconsin residency documentation, including changes of residential address, investigation of other insurance (including eligibility for Wisconsin Medicaid, Medicare and other third party liability sources), obtaining employment information, as well as verifying all information necessary to establish continued eligibility under the Plan
• Process Emergency Application for Reduced Premium, Deductible and Drug Coinsurance.
• Determine subsidy level based on information provided on above applications and assist the State with an annual retrospective audit of eligibility for premium subsidies.
• Determine if more than one family member is enrolling or enrolled in program to determine if family out of pocket maximum amounts apply.
• Process changes (address, name, etc.) and policy cancellations. Effective dates and termination dates of coverage can, and do, occur on any date of the month, and are not limited to the first of the month.
• Issue welcome packet and identification card for approved applications.
• Process checks refunded for NSF, closed/cancelled accounts, stop payment, etc.
• Provide the Department with on-line access to status of applications and provide Department staff with training on how to use the on-line information.
Customer Service
The Plan Administrator shall maintain a dedicated customer support area including a toll-free telephone (including TTY) line for both policyholders and providers to obtain information about eligibility benefit levels, premiums, claims payment, and other information regarding HIRSP. Please describe your organization’s capability to provide customer service to the HIRSP population.
Please describe the Customer Service support your organization would provide for HIRSP. Be specific as to hours of operation, call escalation procedures, quality assurance and performance standards your organization will meet. At a minimum, the Customer Service operation must be able to:
• Receive and respond to telephone, walk-in, mail and email inquiries from providers, policyholders, insurance companies and agents, and the public.
• Respond to Department-initiated inquiries regarding high-priority or sensitive issues.
• Provide training and in-service programs for customer service staff.
• Maintain sufficient toll-free (including TTY) and toll bearing lines for policyholder, the public, and providers.
• Monitor, track and document Customer Service performance and reports to Department. Minimum daily reporting requirements include:
– Average length of time caller must wait before being connected to customer service.
– Average number of calls handled, average number of lost calls.
– Call resolution rate.
– Written correspondence resolution rate.
– Volume of complaints about customer service.
• Maintain a detailed database system to track all inquiries from policyholder, providers, insurers, agents and the public:
– Enter all telephone, walk-in, mail and email inquires/concerns into database.
– Ability to access all historical database entries to research and document all inquiries.
Communications and Publications
The Plan Administrator will be required to develop, draft and revise all program informational materials for publication and distribution through both written and electronic media. This shall include, but not be limited to, all forms, publications, ID cards, applications, brochures, booklets, envelopes, remittance and status (R&S) reports, Explanation of Benefits (EOBs), and maintenance of the content of the HIRSP website, as necessary for the operation of the plan.
The Plan Administrator will be expected to obtain Department approval on the form and content of all documents and publications. Documents must be submitted to the Department in a manner, sufficiently timely, to allow for the Department’s internal and external approval processes, such as OCI filings, in conjunction with the development and distribution deadlines that must be met. The Plan Administrator will also expected to maintain a current and adequate inventory of said materials.
Please describe your capabilities for providing the type of equipment, personnel, and warehousing space necessary to develop, distribute and maintain an adequate inventory and of all materials as necessary. Required functions include but are not limited to the following:
• Develop, distribute and maintain an adequate supply of the following forms for use by applicants, policyholders and providers:
– Outline of Coverage booklet.
– ID cards.
– “For Your Benefit” newsletter.
– HIRSP application and related materials.
– Application and Annual Requalification Materials for Subsidies (Reduced Premium, Deductible and Drug Coinsurance).
– Emergency Application for Reduced Premium, Deductible and Drug Coinsurance.
– HIRSP family cross reference form.
– Referral fee information letter.
– HIRSP change notice form.
– Annual choice of coverage form and materials.
– HIRSP policy and amendments.
– Welcome Packets.
– Premium notice/policy lapse and cancel form-notification.
– Policyholder claim form and filing instructions.
– Premium rate schedules.
– Materials describing premium rate changes.
– HIPAA creditable coverage certificates.
– Letters regarding status of applications and enrollment.
– Customer Service letters.
– Medical review letters.
– Provider handbooks.
– Additional materials as necessary.
• Website
The Department’s HIRSP website, which can be found at dhfs.state.wi.us/hirsp includes all major HIRSP forms and publications including the HIRSP policy, outline of coverage, application materials, premium rate tables and key communications to policyholders and providers.
Describe how you will develop and implement procedures to maintain the Department’s HIRSP website, accommodating updates to forms, publications and other material for HIRSP policyholders, providers, insurance agents or other customers.
Describe any additional internet or website-based functions your organization could apply to HIRSP to facilitate applications processing, premium payments and dissemination of information to policyholders, providers, insurance agents or other customers.
Appeal and Grievance Processes
The Plan Administrator will be required to research, process and respond to appeals according to the terms of the HIRSP policy. The Plan Administrator will also be required to research grievances and submit complete and thorough documentation to the Department according to timeframes established by the Department. Please describe how you will meet these requirements which include, but are not limited, to the following:
• Research and respond to appeals (an appeal is a written request for the Plan Administrator to reconsider an action, including payment of a claim and/or an eligibility decision (i.e., denial of an application or imposition of a pre-existing condition exclusion period):
– Receive policyholder’s written request for appeal.
– Collect pertinent documents for research (claim copies, claim history screens, claim history report, correspondence from the policyholder’s/applicant’s file, etc.).
– Enter appeal into logging/tracking system.
– Research the appeal and determine whether the action should be reversed.
– Notify the policyholder in writing of the appeal decision.
• According to timeframes established by the Department, research grievances and provide the Department with complete and accurate documentation (a grievance is a formal written request to the HIRSP Grievance Committee to reconsider an action, including payment of a claim and/or an eligibility decision):
– Research grievance and document findings in synopsis/summary.
– Prepare a file for each grievance, including what the grievance is about and all pertinent research information and the synopsis/ summary in ten working days.
– At Department request present grievance cases to the Committee.
– Act on Committee’s ruling:
➢ Submit a claim or adjustment to a previously paid claim to generate payment, including interest; or add coverage for applicant, or change pre-ex decision.
➢ As requested by the Department, provide information to the Department to be included in the Department final written notification to the policyholder of the grievance committee decision.
➢ File the grievance, along with a copy of the synopsis and summary presented to the grievance committee with a copy of decision letter (retain records for at least three years).
• Cases Referred to an Independent Review Organization (IRO)
Assist the Department as necessary to compile complete documentation for any cases in which a policyholder requests a review of the grievance committee’s determination by an IRO.
Process the claim or adjustment according to the IRO’s decision.
8.2 Financial Management
Premium Administration
The contractor will be responsible for the maintenance of an automated premium billing and reconciliation system. This includes issuing premium notices, monitoring the timeliness of payment and issuing the corresponding lapse, cancel, non-sufficient fund, partial payment or termination notices. HIRSP premiums are billed on a calendar quarterly basis, however, exceptions are given to policyholders that demonstrate a financial need for a monthly billing cycle.
The contractor is responsible for the collection and reconciliation of premium payments. Premium payments will be submitted to the HIRSP lockbox. Premium payments must be processed in a timely manner, recorded on a remittance statement and provided in a formatted data file that updates the HIRSP premium accounts receivable system.
The contractor’s premium billing system must have the capability to issue premium or cancellation notices on a variety of premium rates on a daily, quarterly, or monthly cycle basis.
Please describe your premium administration capabilities. Specific requirements include but are not limited to:
• Issue premium notices to policyholders.
• Collect premium payments from the HIRSP lockbox, processing the payments and maintaining an updated HIRSP premium accounts receivable system.
• Process premium payment checks on a daily basis.
• Post payments to policyholder account within 2 business days.
• Issue premium notices to process lockbox transactions.
• Issue premium lapse and cancel notices as appropriate.
• Issue premium refunds as appropriate.
• Follow-up on non-sufficient fund payments and partial payments.
• Maintain security and audit procedures to account for 100 percent of premium payments received (including checks, cash and money orders).
• Provide monthly report documenting premium receipts and premiums earned by month.
• Have the ability to adjust premium notices and payment posting on an ad hoc basis.
• Contractor should be able to demonstrate their capability for electronic funds transfer (EFT).
• Provide the Department with on-line access to all policyholder premium and related information and provide Department staff with training on how to access the on-line information.
Accounting and Financial Services
The Plan Administrator shall provide accounting and financial services typically associated with an insurance program as well as those required of state-administered programs and may be required to analyze the impact on HIRSP of potential program or legislative changes. Please describe your organization’s ability to provide accounting and financial services, including those described below:
• Prepare accrual based financial statements and other financial reports required by the Department on a monthly basis, including interim reconciliations detailing funding by policyholders, providers and insurers.
• Prepare all required financial statements in accordance with generally accepted accounting principles and State Accounting Principles.
• Maintain complete and auditable records.
• Monitor and advise the Department regarding the financial status of the program.
• Assist with development of annual fiscal year operating budget and calendar year reconciliation.
• Prepare monthly forecasts of projected fund balances at 45 and 60 days in the future. Immediately notify the Department of any problems in HIRSP fund balances.
• Annually, calculate the amounts each Wisconsin health insurer must be assessed in conformance with state law. (Assessments are based on the budget approved by the Board and information obtained from the Office of the Commissioner of Insurance regarding the ratio of each insurer’s total health care coverage revenue for state residents during the preceding calendar year to the aggregate health care coverage revenue of all participating insurers.)
• Prepare and mail semi-annual assessment notices to each insurer, due in two monthly installments. Receive and deposit assessment payments.
• Report to Department on any delinquent assessments. Work with the Department and OCI as necessary to take appropriate steps to follow-up on delinquent assessments.
• Handle phone calls and correspondence regarding assessments.
• Maintain records of assessment payment history for each insurer for current and prior years.
• Oversee all financial processes of the program, including but not limited to:
– Maintain the HIRSP bank account:
➢ Deposit Plan receipts to the State of Wisconsin Treasury checking account, including checks from policyholders, insurance carriers, and providers, into the State of Wisconsin Treasury account.
➢ Process the daily HIRSP lockbox tape/file to record premium payments.
➢ Accrue all daily balances in the Plan’s accounts to the benefit of the Plan.
• Issue payments by the Plan from the Plan’s checking account to:
– Providers and policyholders for approved claims.
– Insurance agents for referral fees.
– Policyholders to refund premium payments/overpayments.
– State Treasury for unclaimed property (Escheat Procedures).
– Insurance companies (overpaid assessments).
• Monitor the Plan’s checking account to determine that it contains adequate funds:
– Request more funds if needed to pay Plan expenses.
– Provide DHFS weekly financial information regarding claims paid and the balance in the HIRSP account.
– Reconcile the Plan’s bank account monthly and file year-end reconciliation forms.
– Comply with all applicable state statutes and administrative rules.
• Produce policyholder Explanation of Benefits (EOBs) and policyholder/ provider Remittance and Status (R&S) reports:
– Produce and mail monthly EOBs to policyholders documenting claims that are allowed, paid, applied to deductible or coinsurance, pending or denied:
➢ EOBs will indicate the specific reason for payment action taken and will describe procedure to appeal the payment action to the Plan Administrator.
– Produce and mail weekly remittance advice statements to providers documenting claims and the payment action (approved, paid, applied to deductible or coinsurance, pending or denied):
➢ Exclude claims paid to policyholders.
➢ Issue R&S reports to policyholders that submit their own claims for payment.
• Consistent with all relevant federal Internal Revenue Service (IRS) filing requirements, produce annual 1099s for providers and insurance agents:
– Produce and mail annual 1099s to providers and insurance agents documenting calendar year claim earnings by January 31.
– According to specifications and timeframe established by the IRS, submit documentation of annual 1099s to the IRS.
– Within seven (7) days of the completion of the filing of these documents, the plan administrator shall provide to the Department a statement attest to the timely and correct filing of these documents.
– Produce and mail annual 1099s to insurance agents who receive referral checks if income meets or exceeds the 1099 threshold.
– Exclude claims paid to policyholders.
• Track and report outstanding checks (Escheat Procedures):
– Send letter to check payee on all four-month old outstanding checks requesting the status of the check. Send a second letter when, check is six months old.
– Initiate stop-pay and issue new check if policyholder reports check was not received/lost:
➢ If letter returned because post office cannot deliver, retain the check on the outstanding file.
– Send letters to check payees (not more than 120 days before May 1) requesting the status of the outstanding checks. Inform payee that the check is subject to the Wisconsin Unclaimed Property Act and that if no response is received, the funds will be forwarded to the State Unclaimed Property Division.
– Provide a report to DHFS (prior to April 1 of even years) showing outstanding checks issued during the two calendar years preceding the last full calendar year.
– Place stop payment on unclaimed property checks and issue a HIRSP check payable to the State Treasury (Prior to December 1 of even years).
• Submit invoices, and supporting documentation, for payment of services provided under this plan:
– Prepare ad-hoc analyses and reports as directed by the Department.
Actuarial Services
The Plan Administrator must arrange for actuarial services necessary for the Department and HIRSP Board to make appropriate decisions, consistent with statutory requirements and sound financial practices on matters such as: the annual operating budget and annual financial reconciliation, premiums, assessments and adjustments to provider rates needed to generate the required provider contribution. In order to maintain independent actuarial services, actuarial professionals shall not be employed by the Plan Administrator and must be subcontracted under the guidelines in section 3.4.
The name of the selected actuarial firm and sufficient information regarding the qualification of the firm must be included in the proposal. Resumes of key actuarial staff should be submitted with the proposal. The Department and Board will review the qualifications of the subcontractor.
Actuarial Services must be performed by actuaries with the professional designation of Associate of the Society of Actuaries (ASA) or Fellow of the Society of Actuaries (FSA). In addition, actuarial services must be performed by individuals with the professional designation of Member of the American Academy of Actuaries (MAAA).
Duties of the Actuary include but are not limited to:
• Establish annual operating budget and financial reconciliation of the prior calendar year in sufficient time for the Department and Board to approve prior to April 30th of each year. This will require attendance at Board and Committee meetings and detailed presentations regarding budget development and recommendations.
• Monitor operating budget as approved by the Board:
– On a monthly basis, project the cash reserves adequate to pay all claims.
– On a semi-annual basis, prepare an actuarial opinion of loss liability estimates.
– Use prior year plan enrollment and claim data, and health care costs and utilization trends to project HIRSP claim and administrative expenses.
• Annually, conduct an industry survey to determine industry standard premium rates for a benefit package equivalent to the plan offered by HIRSP:
– Select the top carriers that make up approximately 90 percent of the total volume as determined by policy and premium volume.
– Choose the plan offered by these companies that provides the most comparable premium, coverage, deductible and coinsurance to the HIRSP plan and adjust, as necessary, for differences in coverage, benefits, effective date, duration.
– Set HIRSP premium rates in conformance with state law. Premiums for Plan 1A and 1B can be no lower than 140 percent of the standard rate and no higher than 200 percent of the standard rate. Plan 2 premiums are set based on the criteria set in the law. Total premiums must be set at a level necessary to fund 60 percent of the costs of the program.
– Calculate subsidized premium rates according to state law.
– Determine total insurance industry assessment amount required to fund 20 percent of total program costs excluding premium and deductible subsidies plus 50 percent of the subsidy costs.
– Develop adjustments to provider payment rates so that HIRSP health care providers fund 20 percent of total program costs excluding premium and deductible subsidies plus 50 percent of the subsidy costs.
• Perform accrual reconciliation based on the prior calendar year according to timelines established by the Department to meet a statutorily mandated April 30th date. The key purpose for this reconciliation is to determine any under or over payments made by policyholders, the insurance industry and providers in the prior calendar year and make any necessary adjustments resulting from the reconciliation in the next operating budget. Also, provide accrual reconciliation on a quarterly basis:
– Account for any expense or revenue in the year it was incurred.
– Reduce the HIRSP operating and administrative costs by the amount of prescription drug rebates.
– Allocate the net HIRSP costs (after interest and miscellaneous revenues) to the three funding sources: Sixty percent to policyholder premiums, 20 percent to the insurance industry, and 20 percent to health care providers. The subsidy costs are evenly split between the insurers and health care providers.
– Propose resolution to any overpayment or underpayment by the insurance industry, health care providers, or policyholders. Underpayments or overpayments may be offset when apportioning each group’s share of the HIRSP plan cost in the following plan year.
• Establish adequate cash reserves to pay all claims, including a semi-annual actuarial opinion of loss liability estimates.
• Prepare ad-hoc analyses and reports as directed by the Department.
Auditing Procedures
• Internal Audits and Quality Controls
The Department shall have the right to review, during regular business hours, all records and data maintained by the Plan Administrator related to operation of the plan. The Plan Administrator shall implement and maintain a separate accounting function for services performed pursuant to the contract. The Plan Administrator shall maintain comprehensive auditing and internal control procedures. At a minimum, the Plan Administrator shall perform monthly random audits of sufficient medical and prescription drug claims volume to maintain a 95 percent confidence level with no more than a 5 percent error level. Internal audits shall also be conducted of eligibility determinations, premium billing, and customer service areas. The results of all internal audits will be reported to the Department.
The Plan Administrator and all of its key subcontractors shall obtain, at least once a year, an external review of their internal controls. One independent review mechanism, commonly referred to as a Statement of Auditing Standards (SAS) 70, is an in-depth audit of a service organization’s control activities and their operating effectiveness presented in a uniform reporting format. Please indicate whether or not your organization currently undergoes SAS 70 audits that would include HIRSP and, if not, please explain what in-depth audit procedures will be utilized and how the results will be reported.
• External Audits
The Department will conduct periodic audits of the Plan Administrator, including but not limited to:
– Annual financial/compliance audit by an external auditing firm designated by the Department.
– Audit, on a random sample or a focused basis, medical review and eligibility determinations and claims.
– Performance standard audit to confirm the validity of the performance results reported by the Plan Administrator.
The Plan Administrator will provide the necessary facilities and access to all systems and records involving HIRSP to facilitate these audits in a timely manner and will otherwise fully cooperate with the Department’s auditors. The results will be reported and discussed with the HIRSP Board and the Plan Administrator and appropriate steps will be taken to implement or remedy any audit findings.
• Fraud and Abuse Detection and Control
The Plan Administrator will be required to have a fraud and abuse detection and control system in place to detect and control fraud and abuse. The system must address policyholder eligibility, subsidies and claims and provider eligibility and claims and other entities or individuals as required by HIRSP or requested by the Department.
The Plan Administrator will also be required to have in place a fraud and abuse detection and control system to detect and control internal fraud and abuse.
Any case of fraud or abuse detected by the Plan Administrator shall be immediately reported to the Department for necessary action. The Plan Administrator will be required to assist the Department or law enforcement authorities in any manner determined to be appropriate. Proper documentation must be maintained for all findings and judgements relative to such cases.
8.3 Claims and Systems Administration
Claims Processing
The contractor shall perform all necessary functions to assure timely payment of claims for covered benefits to policyholders. The claims processing system must comply with HIPAA. HIRSP’s network of providers is the list of providers, currently consisting of approximately 47,190 providers, certified by the Wisconsin Medicaid program. HIRSP receives approximately 26,000 hospital and professional claims per month and approximately 58,000 claims for prescription drugs per month.
By law, HIRSP can reimburse for covered services only when performed by Wisconsin Medicaid-certified providers. In addition, the law specifies that HIRSP allowed amounts are based on reimbursement rates established by Wisconsin Medicaid. Please describe how you will assure compliance with these requirements, including how you will exchange or obtain information with the Medicaid fiscal agent on a regular basis to maintain up-to-date Wisconsin Medicaid provider certification and reimbursement rate information and how your claims processing system will be updated.
Specific requirements include but are not limited to the following:
• Make available information relating to the proper manner of submitting a claim for benefits under HIRSP and distributing forms upon which submissions shall be made.
• Evaluate the eligibility of each claim for payment under HIRSP.
• Issue to each claimant an EOB within 30 days after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected or paid in part.
• Must have capability to track against individual policyholder out-of-pocket cost sharing requirements, including the carry-over of fourth calendar quarter deductible.
• Maintain staff trained to respond to inquiries from providers and to provide information on an ongoing basis regarding changes or updates in billing procedures or requirements.
• Receive and enter claims:
– Maximize electronic claims submission.
– Receive claims (paper and electronic claims from Medicaid certified providers and paper claims from policyholder).
– Maintain digital copies of all claims received.
– Assign an internal control number (ICN) to all claims for processing.
– Enter claims:
➢ Accept electronic claims from providers.
➢ Data enter paper claims from providers and policyholders.
➢ Perform data validity editing to verify required fields are present and contain valid data.
• Comply with HIPAA transaction standards.
• Price claims.
Claims are priced at HIRSP allowed amounts as specified in law, adjusted for the required provider contribution.
The Plan Administrator will be required to:
– On an ongoing basis, continue to maintain the payment rates established by the Wisconsin Medicaid program. These rates are the basis for determining HIRSP allowed amounts for prescription drugs, professional, inpatient hospital and outpatient hospital services, as specified in law and or determined by the Department.
– Calculate a usual and customary charge, provider contribution and an allowable amount for reimbursement of each medical claim.
– Calculate reimbursement using HIRSP reimbursement methodologies, including appropriate reimbursement for HIRSP Plan 2. Plan 2 is a Medicare wrap-around-like policy, under which HIRSP pays Medicare deductible and coinsurance for HIRSP-covered services after the appropriate HIRSP deductible has been met.
– Reduce payment amount by any remaining HIRSP deductible for the year (including 90-day previous year carryover).
– Deduct HIRSP coinsurance.
– Discontinue deductible, co-payment and coinsurance deductions when annual out-of-pocket max for individual or family has been reached.
• Perform edits and audits to verify policyholder eligibility, provider certification, covered services and limitations, etc.
– Data correct edit/audit failure worksheet:
➢ Deny claims that fail edits for missing or invalid information:
← Send letter to providers asking for required information; physical claim form may also be returned at this time. Ensure that all required information is requested with the initial return and that no claim is returned for information that could have been obtained internally. Claim form would be resubmitted with newly provided information.
← Follow documented procedure and adjudicate edit and audit failures for policy restrictions and override or deny claims as appropriate.
➢ Notify policyholders if claim cannot be finalized within 30 calendar days of receipt.
– Maintain claim history file:
➢ Capture the following data on-line and make such data available in a timely manner: policy number, claim number, date of loss, date loss reported, date loss paid, payee’s name, diagnosis, service, amount of benefits claimed, amount of benefits paid, and amount of payment reduction, and type of benefit paid.
• Adjust claims to change payment:
– Receive written and telephone requests from providers and policyholders to reconsider claim payment or denial.
– Determine if additional payment is appropriate:
➢ Provide professional medical consultation in the event of a dispute over benefits denied or reduced.
– Submit adjustment request and reprocess claim.
• Finalize and maintain history:
– Finalize claim.
– Receive adjustment requests from providers.
Coordination of Benefits:
• Determine at the time of enrollment, and regularly thereafter, whether policyholder has other insurance or Medicare coverage available. Under certain circumstances, policyholders can have other insurance and HIRSP coverage.
• Verify HIRSP is the payer of last resort and ensure that, when appropriate, HIRSP claims do not pay until other insurance coverage has paid.
Subrogation:
• Retain subrogation specialist staff to review claims on a regular basis to determine subrogation possibilities resulting in third party liability or workers compensation insurance liability.
• Contact policyholders to determine the applicability of the subrogation provision.
• Evaluate subrogation possibilities to determine the economic feasibility of recovery.
• Attempt recovery on behalf of the Plan where subrogation is appropriate, including negotiating settlements with other insurance companies and/or legal counsel for plaintiff or defendant.
• Produce monthly reports on the number of claims in which subrogation action has occurred and the amount of recoveries thereon.
• Pursue the plan’s subrogation interest prior to litigation unless the Department engages outside legal counsel. If the Department decides that outside legal representation is needed prior to litigation, the Department will instruct the Plan Administrator to engage legal counsel for such services at the expense of the Plan. When a case proceeds to litigation, the Plan Administrator may engage counsel to represent the Plan on the most favorable terms available. Attorney fees for outside counsel will be charged as an expense to the plan.
Pharmacy Benefit Management
The Plan Administrator must propose a pharmacy benefit management system designed to assure cost effective strategies and management of pharmaceutical benefits through rebates and managed pharmacy initiatives. Requirements include but are not limited to:
• The Plan Administrator must have an on-line, real-time HIPAA-compliant system to adjudicate prescription drug claims based on payment rates of the Wisconsin Medicaid program. The current pricing system includes a discount from the Average Wholesale Price (AWP) for brand-name drugs, a Maximum Allowable Cost (MAC) list for generic drugs and multiple dispensing fees.
• Provide the Department with on-line access to all HIRSP drug claims processing and rebate information and provide Department staff with training on how to use the on-line system.
• The Plan Administrator’s PBM must have rebate agreements with drug manufacturers. One hundred percent of the rebate dollars generated by HIRSP claims are to be returned to HIRSP. The Plan Administrator must maintain a detailed accounting of rebate billings and collections and must submit monthly reports to the Department on the billing and collections of rebates.
• The pharmacy network for HIRSP must include all pharmacies certified by the Wisconsin Medicaid program and may, at the Department’s discretion, include additional out-of-state pharmacies in the contractor’s pharmacy provider network.
• On-line, real-time eligibility verification and the capability to inform pharmacies at the point of sale, of the correct amount to collect from a HIRSP policyholder. This is based on HIRSP prescription drug coinsurance, which is currently equal to 20 percent of the HIRSP allowed amount per prescription, up to $25 per prescription, and which is subject to an annual maximum prescription drug coinsurance amounts.
• Management of claims, including on-line transaction processes, manual/ paper claims, eligibility verification, pricing, edits, drug-to-drug interactions, duplicate claims identification and coordination of benefits.
• Prescription drug cost containment mechanisms, including but not limited to: drug utilization review, day supply limitations, early refill policies, prior authorization for high-cost drugs, coordination of benefits, etc.
• Capability for electronic transmission of all HIRSP drug claims processing information to the Plan Administrator’s main data system as well as capability to electronically receive eligibility and other information from the Plan Administrator necessary to correctly adjudicate pharmacy claims.
• Customer service/help desk operations for policyholders and providers.
• Ad-hoc and routine production reporting to include information such as claims, utilization, payment, provider and policyholder activity as requested by the Department.
Please describe your organization’s pharmacy benefit management capabilities to perform the requirements referenced above. In addition, please address the following:
• Describe your out-of-state network.
• Describe your audit procedures for pharmacy providers.
• What are your internal audit procedures to verify pricing and eligibility.
• How are fraud and abuse situations detected and how are they addressed?
• Describe the formulary or Preferred Drug List (PDL) you currently use that would be applicable for HIRSP.
• Describe your rebate agreements and how they will benefit HIRSP. What baseline guarantees can you offer?
• Describe your reporting capabilities, including paper, on-line, invoicing and like comparisons. What analysis and advice is included in your standard reporting package? Do you have customized reporting capability? Can utilization information be provided to the Department on-line, allowing Department staff to extract and manipulate data themselves?
• Describe any value-added services that your PBM provides at no additional cost to our base PMPM, such as mail-order or 24-hour prescription service.
• Describe your experience in handling PBM services for individual health insurance and governmental programs.
• Please describe any organizational affiliations you or your PBM have with vendors or business partners and what impact those affiliations would have on product selection or management of HIRSP?
Provider Network Maintenance
The provider network for HIRSP is the network of all providers certified by the Wisconsin Medicaid program. There are approximately 47,190 providers that are currently certified by the Wisconsin Medicaid program. The Plan Administrator will be required to establish and implement processes to maintain an updated file of Medicaid-certified providers and process claims against that list. The Plan Administrator will also be required to work with the Medicaid fiscal agent to assist providers in obtaining Medicaid certification. Please describe your plans for maintaining a current file.
8.4 Medical Management
Medical and Other Clinical Consulting Services
The Plan Administrator will be required to maintain sufficient medical and clinical consultants, including a physician Medical Director, to establish and implement all necessary policies and procedures to make all necessary medical or clinical determinations on behalf of HIRSP and consistent with the HIRSP policy and state law governing HIRSP. Requirements include but are not limited to the following:
• Reviewing policyholder medical records to determine if services billed to HIRSP are payable. This involves determinations related to pre-existing conditions and medically necessary and appropriate services.
• Responding to policyholder or provider inquiries related to medical or clinical issues, using non-clinical terminology and in a clear and concise manner.
• Pre-approval of high-cost services and drugs.
• Reviewing and making determinations regarding policyholder complaints, inquiries, appeals and grievances related to medical or clinical issues and providing thorough, accurate and clear written responses.
• Regular attendance in monthly HIRSP Grievance Committee meetings.
• Reviewing new procedures or drugs to determine if they should be added as a HIRSP benefit.
Cost Containment
The Plan Administrator will be required to implement cost containment strategies approved by the Department. Please describe the cost containment strategies your organization has in place and how such strategies would be implemented for HIRSP.
Disease Management
The Plan Administrator will be required to provide disease management services for HIRSP that focus on persons with chronic illnesses, such as; diabetes, AIDS, heart disease, asthma, etc.
Services should include assisting enrollees manage their diseases in a manner that reduces or delays the detrimental clinical and functional effects of the disease and reduces the need for and cost of medical care. This would be achieved either by delaying or avoiding complications of diseases or preventing acute exacerbations that may require hospitalization or Emergency Department care.
Explain the strategy you intend to employ to develop disease management services for HIRSP. Do you have your own internal disease management program or do you intend to consult or contract with a disease management company to assist you in designing or providing disease management services to HIRSP policyholders?
Explain how you will address the following disease management program objectives:
• Improving the health of enrollees with multiple chronic conditions and co-morbidities:
– Improving enrollee satisfaction with their health care.
– Satisfaction surveys.
• Reducing health care costs:
– Reducing the need for urgent and emergent and hospital care.
– Reducing the need for physician office visits.
• Simplifying the delivery of patient services through coordination and physician collaboration and thus reducing duplicative services.
• Addressing multiple disease states and co-morbidities.
• HIPAA Privacy compliance.
• Identifying policyholders who could benefit from disease management utilizing any or all of the following:
– Health risk assessment forms.
– Predictive models.
– Referrals from health care professionals, family members or patients.
– Information technology that will support aggregation and analysis of claim and other data to identify members for enrollment.
• Your procedures for Enrollment/Reenrollment/Disenrollment/Risk Stratification:
– How policyholders are invited to enroll.
– Your schedule for reevaluating enrollees.
– Disenrollment methods and how you determine when self-management status has been attained.
• Clinical information sources:
– Describe guidelines, reference materials and best practices you use to establish preventive and maintenance care protocols.
– Describe your access to medical and other clinical experts.
– Describe the type of interactive medical management systems you may utilize which provide automatic reminders and cues to nurses to offer services.
– Detail availability and staffing of telephone system to address routine and urgent calls from policyholders.
– Website services for physicians or enrollees.
• Describe the enrollee interventions you currently utilize:
– Care delivery model.
– Explain you assessment process and the skills of the assessor.
– Describe how Care plans are established and adherence is encouraged.
– Describe your program for enrollee education and communication.
– Telephone contact – explain what type of telephone system you utilize and its staffing and accessibility
– Mailings.
– Web sites.
• Describe how you will evaluate the effectiveness of the disease management program, including cost-effectiveness and improved clinical outcomes.
• Detail any affiliations, organizations, licenses or accreditations that you have.
8.5 Detailed Transition Plan
Proposers must describe in detail their proposed transition method(s) and timetable for transferring each of the required tasks from the current Administrator. Proposers must demonstrate they will be able to adequately perform all of the tasks related to the administration of the Plan no later than January 1, 2005. The proposal should include a complete description of the transition work plan. Proposers must agree to cooperate in any transfer of function from the existing Administrator to the replacement Administrator. Proposers must also agree to finalize contract language by no later than July 1, 2004, and agree to begin operations on January 1, 2005.
Proposers should present a comprehensive description of and timeline for start-up activities. The description shall specifically address how the proposer will minimize disruption to policyholders. Continuity of services for policyholders during a contract transition should be made as seamless as possible.
Proposers should include a description of and timeline for establishing key conversion dates for current Plan Administrator files.
The plan must describe the process for start-up training, documentation and user support products proposed for accessing the data as well as the process for start-up and transition of data systems into and out of the prospective contract.
The proposer shall demonstrate a commitment to engage in a collaborative and partnering manner with other HIRSP contractors and subcontractors to successfully carry out the objectives and requirements of the HIRSP program.
8.6 Data Collection and Reporting
The Plan Administrator shall establish, maintain, update, and make accessible a data repository that assures timely and reliable electronic access to designated individuals. Access requires ongoing user training and support, software with user friendly ad hoc query capability, report generation ability, and export capability on industry-standard platforms and in universally accepted formats.
The Plan Administrator must agree to provide the Department with on-line network access, in a secure and user-friendly environment, to application/ eligibility, enrollment, premium administration, claims adjudication and other applicable systems. The Plan Administrator will provide training to the Department on the use of these systems. The Department, at its discretion, may use this network access on an inquiry basis or to download data for further analysis and auditing.
The Plan Administrator shall produce reports regarding the operation of HIRSP. The form of the reports shall be subject to approval of the Department. The content shall include information such as operational and financial information, data on claims and losses, and policyholder demographic information. The contract with the Plan Administrator will detail reports required, which will include but not be limited to monthly operational reports which will be due no later than the 20th of the month for the prior month and a comprehensive annual report on the operation of the Plan which will be due by April 30th for the prior calendar year. Examples of reports produced by the current carrier are attached in Attachment A.
Please describe the types of reports your organization would provide as well as how your organization would review the information provided in the reports and advise the Department on emerging trends and make recommendations.
Specific reporting requirements include but are not limited to the following:
• Daily Customer Service Statistics regarding call volume, wait times, lost call rates, average call length and list of top five reasons for calls.
• Weekly Reports to contain the following information: Customer service, enrollment, underwriting, claims processing, and financial areas.
• Monthly reports will contain, at a minimum, the following information:
– Premium amounts billed and collected, reported separately for each type of policy under the Plan.
– Total claim expenses by month incurred and month paid.
– Administrative fees by category, including fees for plan administrator, actuarial fees, agent referral fees, etc.
– Financial statements.
– Enrollment and disenrollment information broken down demographically by age, gender, location, employment status, reason for application, and reasons for rejection by other insurance companies for each type of policy issued by the Plan. Number of covered persons, identifying the number of applicants becoming enrolled and the number of covered persons withdrawing by age group and sex for each type policy issued by the Plan.
– Number of applicants requesting coverage who were rejected with reason for rejection.
– Number of claims processed and processing times.
– Number of claims denied and paid.
– Estimate of the dollar amount of incurred claims not paid.
– Number and type of appeals and grievances.
– Number of policyholders receiving premium reductions, and percent of reductions.
– Policyholder demographic information.
– Number of pending claims.
– Number of customer service contacts.
– Total claims billed and paid.
– Subrogation liens and recoveries
• Quarterly Reports – Please describe the kind of quarterly report your organization would submit to the Department and how it would assist the Department in its administration of HIRSP.
• Annual Report – State law outlines annual reporting requirements of the Board. (Refer to chapter 149, Wisconsin Statutes.) The Plan Administrator will be required to draft required reports and submit them to the Department for review and approval.
• In addition to the required annual reports, please describe the kind of annual report your organization would submit to the Department and how it would assist the Department in its administration of HIRSP.
• Ad Hoc Reports. The Plan Administrator must be prepared to produce ad-hoc reports at the request of the Department, or at the request of the Board via the Department.
• All reports and documentation shall be easily accessible and remain the property of the Plan. Distribution of all reports and documentation shall be subject to Board direction and consistent with any applicable state or federal laws regulating confidentiality.
9.0 COST PROPOSAL
9.1 General Instructions and Information on Preparing Cost Proposals
The cost proposal should be submitted in a separate envelope with the written proposal. The proposal will be scored using a standard quantitative calculation where the most points will be awarded to the proposal with the lowest cost.
9.2 Method of Invoicing and Payment
Invoices for Plan Administrator fees must be submitted within 60 days following the end of the month for which they apply. Invoices must based on the enrollment as of the last day of the month for which they apply and must be based on the per-member per-month (PMPM) approach described below. Invoices will be paid monthly within thirty (30) days of the receipt of a detailed invoice.
9.3 Formula for Payment
Fees are to be quoted on a per-member per-month (PMPM) basis, based on 17,447 policyholders (enrollment as of January 1, 2004) and must include all services and incidentals encompassed by this RFP. Direct and indirect expenses associated with this RFP must be included in the PMPM. The quoted fees shall remain in effect for the three (3) years of the contract.
The selected proposer may not begin to submit monthly invoices on a PMPM basis until January 1, 2005. Therefore, proposers must structure their cost proposal to factor in any required start-up or transition costs associated with the implementation of the contract.
Plan Administrator fees shall in no way be contingent on premiums, percent of claims paid, or charge per claim transaction. The total fees paid to the Contractor may be subject to applicable performance penalties to be established in the final contract.
9.4 Allocation of Administrative Fees
Proposals for the cost(s) of administration should be clearly defined and must adequately explain the basis for calculation of cost(s). At a minimum, a brief outline of services included in these costs should be given. In addition, the cost proposal must clearly identify how change orders to accommodate major systems changes will be handled.
Proposers are expected to quote firm PMPM prices for the administration of the plan for the contract period as it is described herein. Proposed PMPM prices are to be based on 17,447 policyholders (enrollment as of January 1, 2004).
9.5 Format for Submitting Cost Proposals
A cost proposal form and worksheet are included in Attachment F of this RFP. Complete it with your PMPM proposal for the three-year contract period.
• Implementation costs.
• Salaries: List each position by title with the accompanying salary amount.
• Fringe Benefits: Indicate the percentage of salaries that is used in the calculation of fringe benefits as well as the actual amount. Provide a total amount for personnel services.
• Program Supplies: Identify the supplies you will use and the proposed amount required for them.
• Agency Operations: Identify operational costs including computers and other equipment, telephone and postage charges, printing and copying, and travel for field staff and project management.
• Space: Identify space costs for regional fixed-sites and program operations.
• Indirect Costs: Identify other indirect costs that will be necessary to implement your proposal.
• Total Cost: Identify the total of the component costs.
Following the cost proposal worksheet, include a narrative that explains and justifies each line item shown in the cost proposal worksheet.
9.6 Fixed Price Period
All prices, costs, and conditions outlined in the proposal shall remain fixed and valid for acceptance for 180 calendar days starting on the due date for proposals.
9.7 Inflationary Adjustment
The Contractor may receive an inflationary adjustment to the PMPM at the start of each annual contract extension/renewal period. This increase will be based on either seventy-five percent (75%) of the increase in the prevailing Consumer Price Index for Urban Wage Earners (CPI-U) for Milwaukee, Wisconsin, in effect for the quarter ending January of the then current year or five percent (5%) of the then current Contractor’s base fee, whichever is lower.
10.0 SPECIAL CONTRACT TERMS AND CONDITIONS
10.1 Payment Requirements
Payment will be according to monthly invoice submitted by the contracted agency, with detail and supporting information as determined by the Department. Invoices will be submitted to:
Division of Health Care Financing
Attn: HIRSP Financial Analyst
1 West Wilson Street, Room 265
P.O. Box 309
Madison, WI 53701-0309
10.2 Independence of Proposer
The proposer must meet the following conditions with respect to this proposal:
A. No person who is an owner, employee, or consultant of the proposer, or has a contract with the proposer:
1. Has any direct or indirect financial interest in any managed care entity or health care provider that furnishes services in the State of Wisconsin;
2. Has been excluded from participation under Title XVIII or Title XIX of the Social Security Act;
3. Has been debarred by any Federal agency; or
4. Has been, or is now, subject to a civil money penalty under the Social Security Act.
10.3 Performance Review, Liquidated Damages and Other Remedies
All requirements described in this RFP and the final contract will be subject to monitoring by the Department. The Department reserves the right to monitor performance of the Contractor (including any or all personnel and sub-contractors thereof) and may exercise such option at its discretion without notice. The results of the monitoring will be used to provide the basis for improved project implementation and operations and to determine whether liquidated damages should be levied against the Contractor under the terms and conditions of this RFP and as further specified in the final contract.
The Contractor agrees that the Department, in its sole discretion, in the event of contract non-compliance by Contractor, may terminate part of Contractor’s obligations under this agreement and replace those services by either contracting with another entity to perform those obligations or performing those obligations itself. In the event the Department elects the remedy under this paragraph, the Contractor may bill the Department only for those costs associated with performance of contract obligations that have not been terminated. The Contractor will reimburse the Department for any replacement cost in excess of what the Contractor would have been paid to continue performing those services.
10.4 Executed Contract to Constitute Entire Agreement
In the event of contract award, the contents of this RFP (including all attachments), RFP addenda and revisions, and the proposal of the successful proposer, and additional terms agreed to, in writing, by the agency and the Contractor shall become part of the contract. Failure of the successful proposer to accept these as a contractual agreement may result in a cancellation of award. The following priority for contract documents will be used if there are any conflicts or disputes:
• Official Purchase Orders
• State RFP Dated January 7, 2004
• Vendor’s Proposal to the RFP, Dated on or before April 12, 2004
• Standard Terms and Conditions
10.5 News Releases
News releases pertaining to this procurement or any part of the proposal shall not be made without the prior approval of the Department.
10.6 Right to Publish
If an awarded contract results in a book or other material, the Department reserves a royalty-free, nonexclusive irrevocable license to reproduce, publish or otherwise use, and to authorize others to use, all material from the approved program. Any discovery or invention arising out of, or developed in the course of work aided by any awarded contract agreement, shall be promptly and fully reported to the Department.
10.7 Agreement Revisions and/or Termination
1. Discretionary Termination
The Department may terminate the Contract at any time in its sole discretion by delivering ninety days written notice to the Contractor. Upon termination, the Department’s liability will be limited to payment as provided under the Contract for services performed as of the effective date of the termination, plus any termination expenses incurred with the prior written approval of the Department.
2. Termination for Cause
Either party may terminate the Contract at any time for a material breach by the other, after providing 30 days prior written notice, if the breaching party does not cure its breach by the end of the notice period.
3. This Contract or any part thereof may be renegotiated in such circumstances as:
• Significant change in scope or volume of services;
• Changes required by state and federal law or regulations; or
• Monies available.
4. The Contractor shall notify the Department whenever it is unable to provide the required quality or quantity of services specified. Upon such notification, the Department may terminate the Contract or take other action consistent with the terms of the RFP and Contract.
11.0 STANDARD/SUPPLEMENTAL STANDARDS TERMS AND CONDITIONS
The State of Wisconsin reserves the right to incorporate standard State contract provisions into any contract negotiated with any proposal submitted responding to this RFP (Standard Terms and Conditions (DOA-3054) and Supplemental Standard Terms and Conditions for Procurements for Services (DOA-3681). Failure of the successful proposer to accept these obligations in a contractual agreement may result in cancellation of the award.
The Standard and Supplemental Terms and Conditions follow:
1.0 SPECIFICATIONS: The specifications in this request are the minimum acceptable. When specific manufacturer and model numbers are used, they are to establish a design, type of construction, quality, functional capability and/or performance level desired. When alternates are bid/proposed, they must be identified by manufacturer, stock number, and such other information necessary to establish equivalency. The State of Wisconsin shall be the sole judge of equivalency. Bidders/proposers are cautioned to avoid bidding alternates to the specifications which may result in rejection of their bid/proposal.
2.0 DEVIATIONS AND EXCEPTIONS: Deviations and exceptions from original text, terms, conditions, or specifications shall be described fully, on the bidder’s/proposer’s letterhead, signed, and attached to the request. In the absence of such statement, the bid/proposal shall be accepted as in strict compliance with all terms, conditions, and specifications and the bidders/proposers shall be held liable.
3.0 QUALITY: Unless otherwise indicated in the request, all material shall be first quality. Items which are used, demonstrators, obsolete, seconds, or which have been discontinued are unacceptable without prior written approval by the State of Wisconsin.
4.0 QUANTITIES: The quantities shown on this request are based on estimated needs. The state reserves the right to increase or decrease quantities to meet actual needs.
5.0 DELIVERY: Deliveries shall be F.O.B. destination freight prepaid and included unless otherwise specified.
6.0 PRICING AND DISCOUNT: The State of Wisconsin qualifies for governmental discounts and its educational institutions also qualify for educational discounts. Unit prices shall reflect these discounts.
6.1 Unit prices shown on the bid/proposal or contract shall be the price per unit of sale (e.g., gal., cs., doz., ea.) as stated on the request or contract. For any given item, the quantity multiplied by the unit price shall establish the extended price, the unit price shall govern in the bid/proposal evaluation and contract administration.
6.2 Prices established in continuing agreements and term contracts may be lowered due to general market conditions, but prices shall not be subject to increase for ninety (90) calendar days from the date of award. Any increase proposed shall be submitted to the contracting agency thirty (30) calendar days before the proposed effective date of the price increase, and shall be limited to fully documented cost increases to the contractor which are demonstrated to be industrywide. The conditions under which price increases may be granted shall be expressed in bid/proposal documents and contracts or agreements.
6.3 In determination of award, discounts for early payment will only be considered when all other conditions are equal and when payment terms allow at least fifteen (15) days, providing the discount terms are deemed favorable. All payment terms must allow the option of net thirty (30).
7.0 UNFAIR SALES ACT: Prices quoted to the State of Wisconsin are not governed by the Unfair Sales Act.
8.0 ACCEPTANCE-REJECTION: The State of Wisconsin reserves the right to accept or reject any or all bids/proposals, to waive any technicality in any bid/proposal submitted, and to accept any part of a bid/proposal as deemed to be in the best interests of the State of Wisconsin.
Bids/proposals MUST be date and time stamped by the soliciting purchasing office on or before the date and time that the bid/proposal is due. Bids/proposals date and time stamped in another office will be rejected. Receipt of a bid/proposal by the mail system does not constitute receipt of a bid/proposal by the purchasing office.
9.0 METHOD OF AWARD: Award shall be made to the lowest responsible, responsive bidder unless otherwise specified.
10.0 ORDERING: Purchase orders or releases via purchasing cards shall be placed directly to the contractor by an authorized agency. No other purchase orders are authorized.
11.0 PAYMENT TERMS AND INVOICING: The State of Wisconsin normally will pay properly submitted vendor invoices within thirty (30) days of receipt providing goods and/or services have been delivered, installed (if required), and accepted as specified.
Invoices presented for payment must be submitted in accordance with instructions contained on the purchase order including reference to purchase order number and submittal to the correct address for processing.
A good faith dispute creates an exception to prompt payment.
12.0 TAXES: The State of Wisconsin and its agencies are exempt from payment of all federal tax and Wisconsin state and local taxes on its purchases except Wisconsin excise taxes as described below.
The State of Wisconsin, including all its agencies, is required to pay the Wisconsin excise or occupation tax on its purchase of beer, liquor, wine, cigarettes, tobacco products, motor vehicle fuel and general aviation fuel. However, it is exempt from payment of Wisconsin sales or use tax on its purchases. The State of Wisconsin may be subject to other states’ taxes on its purchases in that state depending on the laws of that state. Contractors performing construction activities are required to pay state use tax on the cost of materials.
13.0 GUARANTEED DELIVERY: Failure of the contractor to adhere to delivery schedules as specified or to promptly replace rejected materials shall render the contractor liable for all costs in excess of the contract price when alternate procurement is necessary. Excess costs shall include the administrative costs.
14.0 ENTIRE AGREEMENT: These Standard Terms and Conditions shall apply to any contract or order awarded as a result of this request except where special requirements are stated elsewhere in the request; in such cases, the special requirements shall apply. Further, the written contract and/or order with referenced parts and attachments shall constitute the entire agreement and no other terms and conditions in any document, acceptance, or acknowledgment shall be effective or binding unless expressly agreed to in writing by the contracting authority.
15.0 APPLICABLE LAW: This contract shall be governed under the laws of the State of Wisconsin. The contractor shall at all times comply with and observe all federal and state laws, local laws, ordinances, and regulations which are in effect during the period of this contract and which in any manner affect the work or its conduct. The State of Wisconsin reserves the right to cancel any contract with a federally debarred contractor or a contractor which is presently identified on the list of parties excluded from federal procurement and non-procurement contracts.
16.0 ANTITRUST ASSIGNMENT: The contractor and the State of Wisconsin recognize that in actual economic practice, overcharges resulting from antitrust violations are in fact usually borne by the State of Wisconsin (purchaser). Therefore, the contractor hereby assigns to the State of Wisconsin any and all claims for such overcharges as to goods, materials or services purchased in connection with this contract.
17.0 ASSIGNMENT: No right or duty in whole or in part of the contractor under this contract may be assigned or delegated without the prior written consent of the State of Wisconsin.
18.0 WORK CENTER CRITERIA: A work center must be certified under s. 16.752, Wis. Stats., and must ensure that when engaged in the production of materials, supplies or equipment or the performance of contractual services, not less than seventy-five percent (75%) of the total hours of direct labor are performed by severely handicapped individuals.
19.0 NONDISCRIMINATION / AFFIRMATIVE ACTION: In connection with the performance of work under this contract, the contractor agrees not to discriminate against any employe or applicant for employment because of age, race, religion, color, handicap, sex, physical condition, developmental disability as defined in s. 51.01(5), Wis. Stats., sexual orientation as defined in s. 111.32(13m), Wis. Stats., or national origin. This provision shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. Except with respect to sexual orientation, the contractor further agrees to take affirmative action to ensure equal employment opportunities.
1. Contracts estimated to be over twenty-five thousand dollars ($25,000) require the submission of a written affirmative action plan by the contractor. An exemption occurs from this requirement if the contractor has a workforce of less than twenty-five (25) employes. Within fifteen (15) working days after the contract is awarded, the contractor must submit the plan to the contracting state agency for approval. Instructions on preparing the plan and technical assistance regarding this clause are available from the contracting state agency.
19.2 The contractor agrees to post in conspicuous places, available for employes and applicants for employment, a notice to be provided by the contracting state agency that sets forth the provisions of the State of Wisconsin’s nondiscrimination law.
19.3 Failure to comply with the conditions of this clause may result in the contractor’s becoming declared an "ineligible" contractor, termination of the contract, or withholding of payment.
19.4 To the extent required by law, 41 CFR 60-1.4(a) and (b) are incorporated by reference in these Standard Terms and Conditions. Additionally, the contractor certifies compliance with 41 CFR 60-1.8 and does not and will not maintain any facilities provided for employes in a segregated manner. The contractor further agrees to obtain identical certifications from any subcontractors prior to the award of a subcontract exceeding $25,000 which is not exempt and will retain such certification for audit purposes.
20.0 PATENT INFRINGEMENT: The contractor selling to the State of Wisconsin the articles described herein guarantees the articles were manufactured or produced in accordance with applicable federal labor laws. Further, that the sale or use of the articles described herein will not infringe any United States patent. The contractor covenants that it will at its own expense defend every suit which shall be brought against the State of Wisconsin (provided that such contractor is promptly notified of such suit, and all papers therein are delivered to it) for any alleged infringement of any patent by reason of the sale or use of such articles, and agrees that it will pay all costs, damages, and profits recoverable in any such suit.
21.0 SAFETY REQUIREMENTS: All materials, equipment, and supplies provided to the State of Wisconsin must comply fully with all safety requirements as set forth by the Wisconsin Administrative Code, the Rules of the Industrial Commission on Safety, and all applicable OSHA Standards.
22.0 WARRANTY: Unless otherwise specifically stated by the bidder/proposer, equipment purchased as a result of this request shall be warranted against defects by the bidder/proposer for ninety (90) days from date of receipt. The equipment manufacturer’s standard warranty shall apply as a minimum and must be honored by the contractor.
23.0 INSURANCE RESPONSIBILITY: The contractor performing services for the State of Wisconsin shall:
23.1 Maintain worker’s compensation insurance as required by Wisconsin Statutes, for all employes engaged in the work.
23.2 Maintain commercial liability, bodily injury and property damage insurance against any claim(s) which might occur in carrying out this agreement/contract. Minimum coverage shall be one million dollars ($1,000,000) liability for bodily injury and property damage including products liability and completed operations. Provide motor vehicle insurance for all owned, non-owned and hired vehicles that are used in carrying out this contract. Minimum coverage shall be one million dollars ($1,000,000) per occurrence combined single limit for automobile liability and property damage.
23.3 The state reserves the right to require higher or lower limits where warranted.
24.0 CANCELLATION: The State of Wisconsin reserves the right to cancel any contract in whole or in part without penalty due to nonappropriation of funds or for failure of the contractor to comply with terms, conditions, and specifications of this contract.
25.0 VENDOR TAX DELINQUENCY: Vendors who have a delinquent Wisconsin tax liability may have their payments offset by the State of Wisconsin.
26.0 PUBLIC RECORDS ACCESS: It is the intention of the state to maintain an open and public process in the solicitation, submission, review, and approval of procurement activities.
Bid/proposal openings are public unless otherwise specified. Records may not be available for public inspection prior to issuance of the notice of intent to award or the award of the contract.
27.0 PROPRIETARY INFORMATION: Any restrictions on the use of data contained within a request, must be clearly stated in the bid/proposal itself. Proprietary information submitted in response to a request will be handled in accordance with applicable State of Wisconsin procurement regulations and the Wisconsin public records law. Proprietary restrictions normally are not accepted. However, when accepted, it is the vendor’s responsibility to defend the determination in the event of an appeal or litigation.
27.1 Data contained in a bid/proposal, all documentation provided therein, and innovations developed as a result of the contracted commodities or services cannot by copyrighted or patented. All data, documentation, and innovations become the property of the State of Wisconsin.
27.2 Any material submitted by the vendor in response to this request that the vendor considers confidential and proprietary information and which qualifies as a trade secret, as provided in s. 19.36(5), Wis. Stats., or material which can be kept confidential under the Wisconsin public records law, must be identified on a Designation of Confidential and Proprietary Information form (DOA-3027). Bidders/proposers may request the form if it is not part of the Request for Bid/Request for Proposal package. Bid/proposal prices cannot be held confidential.
28.0 DISCLOSURE: If a state public official (s. 19.42, Wis. Stats.), a member of a state public official’s immediate family, or any organization in which a state public official or a member of the official’s immediate family owns or controls a ten percent (10%) interest, is a party to this agreement, and if this agreement involves payment of more than three thousand dollars ($3,000) within a twelve (12) month period, this contract is voidable by the state unless appropriate disclosure is made according to s. 19.45(6), Wis. Stats., before signing the contract. Disclosure must be made to the State of Wisconsin Ethics Board, 44 East Mifflin Street, Madison, Wisconsin 53707 (Telephone 608-266-8123).
State classified and former employes and certain University of Wisconsin faculty/staff are subject to separate disclosure requirements, s. 16.417, Wis. Stats.
29.0 RECYCLED MATERIALS: The State of Wisconsin is required to purchase products incorporating recycled materials whenever technically and economically feasible. Bidders are encouraged to bid products with recycled content which meet specifications.
30.0 MATERIAL SAFETY DATA SHEET: If any item(s) on an order(s) resulting from this award(s) is a hazardous chemical, as defined under 29CFR 1910.1200, provide one (1) copy of a Material Safety Data Sheet for each item with the shipped container(s) and one (1) copy with the invoice(s).
31.0 PROMOTIONAL ADVERTISING / NEWS RELEASES: Reference to or use of the State of Wisconsin, any of its departments, agencies or other subunits, or any state official or employe for commercial promotion is prohibited. News releases pertaining to this procurement shall not be made without prior approval of the State of Wisconsin. Release of broadcast e-mails pertaining to this procurement shall not be made without prior written authorization of the contracting agency.
32.0 HOLD HARMLESS: The contractor will indemnify and save harmless the State of Wisconsin and all of its officers, agents and employes from all suits, actions, or claims of any character brought for or on account of any injuries or damages received by any persons or property resulting from the operations of the contractor, or of any of its contractors, in prosecuting work under this agreement.
33.0 OMNIBUS RECONCILIATION ACT: (Public Law 96-499) To the extent required by law, if this contract is for acquisition of services with a cost or value of $25,000 or more within any 12-month period, including contracts for both goods and services in which the services component is worth $25,000 or more within any 12-month period, the contractor shall in accordance with 42 C.F.R., Part 420, Section 1861 of the Omnibus Reconciliation Act of 1980 (P.L. 96499) permit the comptroller general of the United States, the United States Department of Health and Human Services, and their duly authorized representatives, access to the contractor’s books, documents and records until the expiration date of four (4) years after the approval of procurement activities.
34.0 ANTI-KICKBACK ACT OF 1986: (41 USC 51 et. seq) To the extent required by law, the officer or employe responsible for submitting this bid shall certify, in accordance with 48 CFR 52.203-7, to the best of their knowledge that they have no information concerning the violation of the Anti-Kickback Act in connection with the submitted bid/proposal. Signing the bid/proposal with a false statement shall void the submitted bid/proposal and any resulting contract(s).
1.0 ACCEPTANCE OF BID/PROPOSAL CONTENT: The contents of the bid/proposal of the successful contractor will become contractual obligations if procurement action ensues.
2.0 CERTIFICATION OF INDEPENDENT PRICE DETERMINATION: By signing this bid/proposal, the bidder/proposer certifies, and in the case of a joint bid/proposal, each party thereto certifies as to its own organization, that in connection with this procurement:
2.1 The prices in this bid/proposal have been arrived at independently, without consultation, communication, or agreement, for the purpose of restricting competition, as to any matter relating to such prices with any other bidder/proposer or with any competitor;
2.2 Unless otherwise required by law, the prices which have been quoted in this bid/proposal have not been knowingly disclosed by the bidder/proposer and will not knowingly be disclosed by the bidder/proposer prior to opening in the case of an advertised procurement or prior to award in the case of a negotiated procurement, directly or indirectly to any other bidder/proposer or to any competitor; and
2.3 No attempt has been made or will be made by the bidder/proposer to induce any other person or firm to submit or not to submit a bid/proposal for the purpose of restricting competition.
2.4 Each person signing this bid/proposal certifies that: He/she is the person in the bidder’s/proposer’s organization responsible within that organization for the decision as to the prices being offered herein and that he/she has not participated, and will not participate, in any action contrary to 2.1 through 2.3 above; (or)
He/she is not the person in the bidder’s/proposer’s organization responsible within that organization for the decision as to the prices being offered herein, but that he/she has been authorized in writing to act as agent for the persons responsible for such decisions in certifying that such persons have not participated, and will not participate in any action contrary to 2.1 through 2.3 above, and as their agent does hereby so certify; and he/she has not participated, and will not participate, in any action contrary to 2.1 through 2.3 above.
3.0 DISCLOSURE OF INDEPENDENCE AND RELATIONSHIP:
3.1 Prior to award of any contract, a potential contractor shall certify in writing to the procuring agency that no relationship exists between the potential contractor and the procuring or contracting agency that interferes with fair competition or is a conflict of interest, and no relationship exists between the contractor and another person or organization that constitutes a conflict of interest with respect to a state contract. The Department of Administration may waive this provision, in writing, if those activities of the potential contractor will not be adverse to the interests of the state.
3.2 Contractors shall agree as part of the contract for services that during performance of the contract, the contractor will neither provide contractual services nor enter into any agreement to provide services to a person or organization that is regulated or funded by the contracting agency or has interests that are adverse to the contracting agency. The Department of Administration may waive this provision, in writing, if those activities of the contractor will not be adverse to the interests of the state.
4.0 DUAL EMPLOYMENT: Section 16.417, Wis. Stats., prohibits an individual who is a State of Wisconsin employe or who is retained as a consultant full-time by a State of Wisconsin agency from being retained as a consultant by the same or another State of Wisconsin agency where the individual receives more than $12,000 as compensation for the individual’s services during the same year. This prohibition does not apply to individuals who have full-time appointments for less than twelve (12) months during any period of time that is not included in the appointment. It does not include corporations or partnerships.
5.0 EMPLOYMENT: The contractor will not engage the services of any person or persons now employed by the State of Wisconsin, including any department, commission or board thereof, to provide services relating to this agreement without the written consent of the employing agency of such person or persons and of the contracting agency.
6.0 CONFLICT OF INTEREST: Private and non-profit corporations are bound by ss. 180.0831, 180.1911(1), and 181.225, Wis. Stats., regarding conflicts of interests by directors in the conduct of state contracts.
7.0 RECORDKEEPING AND RECORD RETENTION: The contractor shall establish and maintain adequate records of all expenditures incurred under the contract. All records must be kept in accordance with generally accepted accounting procedures. All procedures must be in accordance with federal, state and local ordinances.
The contracting agency shall have the right to audit, review, examine, copy, and transcribe any pertinent records or documents relating to any contract resulting from this bid/proposal held by the contractor. The contractor will retain all documents applicable to the contract for a period of not less than three (3) years after final payment is made.
12.0 REQUIRED FORMS
The following forms must be completed and submitted with the proposal in accordance with the instructions given in Section 4.5. Blank forms are attached.
Designation of Confidential and Proprietary Information (DOA-3027)
Affidavit (DOA-3476)
Vendor Information (DOA-3477)
Vendor Reference (DOA-3478)
Cost Proposal Form Worksheet
ATTACHMENTS
Attachment
HIRSP Vendor Information A
Designation of Confidential and Proprietary Information Form B
Affidavit Form C
Vendor Information Form D
Vendor Reference Form E
Cost Proposal Form F
Business Associate Agreement………………………………………………………………G
Attachment A
HIRSP Vendor Information
• Provider Handbook
• HIPAA Companion Documents
• Outline of Coverage
• Policyholder Contract
• Policyholder Applications
,
• Policyholder Change Notice
• Policyholder Newsletter samples
• HIRSP Statute
• HIRSP Administrative Code
• Office of Commissioner of Insurance Statute
• Monthly Report samples
• Legislative Audit Bureau reports
• HIRSP Annual reports
STATE OF WISCONSIN
DOA-3027 N(R01/98)
Attachment B
DESIGNATION OF CONFIDENTIAL AND PROPRIETARY INFORMATION
The attached material submitted in response to Bid/Proposal # includes proprietary and confidential information which qualifies as a trade secret, as provided in s. 19.36(5), Wis. Stats., or is otherwise material that can be kept confidential under the Wisconsin Open Records Law. As such, we ask that certain pages, as indicated below, of this bid/proposal response be treated as confidential material and not be released without our written approval.
Prices always become public information when bids/proposals are opened, and therefore cannot be kept confidential.
Other information cannot be kept confidential unless it is a trade secret. Trade secret is defined in s. 134.90(1)(c), Wis. Stats. as follows: “Trade secret” means information, including a formula, pattern, compilation, program, device, method, technique or process to which all of the following apply:
1. The information derives independent economic value, actual or potential, from not being generally known to, and not being readily ascertainable by proper means by, other persons who can obtain economic value from its disclosure or use.
2. The information is the subject of efforts to maintain its secrecy that are reasonable under the circumstances.
We request that the following pages not be released
Section Page # Topic
IN THE EVENT THE DESIGNATION OF CONFIDENTIALITY OF THIS INFORMATION IS CHALLENGED, THE UNDERSIGNED HEREBY AGREES TO PROVIDE LEGAL COUNSEL OR OTHER NECESSARY ASSISTANCE TO DEFEND THE DESIGNATION OF CONFIDENTIALITY AND AGREES TO HOLD THE STATE HARMLESS FOR ANY COSTS OR DAMAGES ARISING OUT OF THE STATE’S AGREEING TO WITHHOLD THE MATERIALS.
Failure to include this form in the bid/proposal response may mean that all information provided as part of the bid/proposal response will be open to examination and copying. The State considers other markings of confidential in the bid/proposal document to be insufficient. The undersigned agrees to hold the State harmless for any damages arising out of the release of any materials unless they are specifically identified above.
Company Name
Authorized Representative
Signature
Authorized Representative
Type or Print
Date
This document can be made available in accessible formats to qualified individuals with disabilities.
|State of Wisconsin | | |
|Department of Administration |Bid/Proposal # | |
|DOA-3476 (R01/2000) | | |
Attachment C
Affidavit
This completed affidavit must be submitted with the bid/proposal.
Proposer Preference: Please indicate below if claiming a proposer preference.
Minority Business Preference (s. 16.75(3m), Wis. Stats.) - Must be certified by the Wisconsin Department of Commerce. If you have questions concerning the certification process, contact the Wisconsin Department of Commerce, 8th Floor, 123 W. Washington Ave., P.O. Box 7970, Madison, Wisconsin 53707-7970,
(608) 267-9550.
Work Center Preference (s 16.752, Wis Stats.) - Must be certified by the State of Wisconsin Use Board. If you have questions concerning the certification process, contact the Wisconsin State Use Board, 101 East Wilson Street, 6th Floor, PO Box 7867, Madison, Wisconsin 53707-7867 or 608/266-2553.
American-Made Materials: The materials covered in our proposal were manufactured in whole or in substantial part within the United States, or the majority of the component parts thereof were manufactured in whole or in substantial part in the United States.
Yes No Unknown
Non-Collusion: In signing this proposal we also certify that we have not, either directly or indirectly, entered into any agreement or participated in any collusion or otherwise taken any action in restraint of free trade; that no attempt has been made to induce any other person or firm to submit or not to submit a proposal; that this proposal has been independently arrived at without collusion with any other proposer competitor or potential competitor; that this proposal has not been knowingly disclosed prior to opening of proposals to any other proposer or competitor; that the above statement is accurate under penalty of perjury.
We will comply with all terms, conditions, and specifications required by the State of Wisconsin in this Announcement of Bid/Proposal and the terms of our bid/proposal.
|Authorized Representative | |Title | |
| |Type or Print | | |
| | | | |
|Authorized Representative | |Date (mm/dd/ccyy) | |
| |Signature | | |
| | | | |
|Company Name | |Telephone |( ) |
This document can be made available in accessible formats to qualified individuals with disabilities.
|State of Wisconsin |Bid / Proposal # | |
|DOA-3477 (R05/98) | | |
| |Commodity / Service | |
Attachment D
Vendor INFORMATION
|1. |BIDDING / PROPOSING COMPANY NAME | |
| |FEIN | | | |
| |Phone |( ) |Toll Free Phone |( ) |
| |FAX |( ) |E-Mail Address | |
| |Address | |
| |City | |State | |Zip + 4 | |
| | |
|2. |Name the person to contact for questions concerning this bid / proposal. |
| |Name | |Title | |
| |Phone |( ) |Toll Free Phone |( ) |
| |FAX |( ) |E-Mail Address | |
| |Address | |
| |City | |State | |Zip + 4 | |
| | |
|3. |Any vendor awarded over $25,000 on this contract must submit affirmative action information to the department. Please name the Personnel / Human |
| |Resource and Development or other person responsible for affirmative action in the company to contact about this plan. |
| |Name | |Title | |
| |Phone |( ) |Toll Free Phone |( ) |
| |FAX |( ) |E-Mail Address | |
| |Address | |
| |City | |State | |Zip + 4 | |
| | |
|4. |Mailing address to which state purchase orders are mailed and person the department may contact concerning orders and billings. |
| |Name | |Title | |
| |Phone |( ) |Toll Free Phone |( ) |
| |FAX |( ) |E-Mail Address | |
| |Address | |
| |City | |State | |Zip + 4 | |
| | |
|5. |CEO / President Name | |
This document can be made available in accessible formats to qualified individuals with disabilities.
|State of Wisconsin | | |
|DOA-3478 (R12/96) |Bid/Proposal # | |
Attachment e
vendor Reference
|FOR VENDOR: | |
Provide company name, address, contact person, telephone number, and appropriate information on the product(s) and/or service(s) used for four (4) or more installations with requirements similar to those included in this solicitation document. If vendor is proposing any arrangement involving a third party, the named references should also be involved in a similar arrangement.
|Company Name | |
|Address (include Zip + 4) | |
|Contact Person | |Phone No. | |
|Product(s) and/or Service(s) Used | |
| |
| |
|Company Name | |
|Address (include Zip + 4) | |
|Contact Person | |Phone No. | |
|Product(s) and/or Service(s) Used | |
| |
| |
|Company Name | | | |
|Address (include Zip + 4) | |
|Contact Person | |Phone No | |
|Product(s) and/or Service(s) Used | |
| |
| |
|Company Name | |
|Address (include Zip + 4) | |
|Contact Person | |Phone No. | |
|Product(s) and/or Service(s) Used | |
| |
| |
This document can be made available in accessible formats to qualified individuals with disabilities.
Attachment F
Cost Proposal Form
$__________________________= our proposed PMPM to be billed in performing the services described in this RFP and in the subsequent contract. This amount is all-inclusive of costs in performing the contract and is detailed in the Cost Proposal Worksheet and there are no other direct, indirect or incidental expenses to be charged in performance of contract.
|Signature of Authorized Representative | |Date |
| | | |
| | | |
|Title | | |
| | | |
| | | |
|Company Name | | |
Cost Proposal Worksheet
Include a narrative that explains and justifies each line item below. Complete it with a proposal for the three-year contract.
• Implementation costs.
• Salaries: List each position by title with the accompanying salary amount.
• Fringe Benefits: Indicate the percentage of salaries that is used in the calculation of fringe benefits as well as the actual amount. Provide a total amount for personnel services.
• Program Supplies: Identify the supplies you will use and the proposed amount required for them.
• Agency Operations: Identify operational costs including computers and other equipment, telephone and postage charges, printing and copying, and travel for field staff and project management.
• Space: Identify space costs for regional fixed-sites and program operations.
• Indirect Costs: Identify other indirect costs that will be necessary to implement your proposal.
• Total Cost $______________.
Attachment G
BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement (Agreement) supplements and is incorporated into the existing Underlying Contract (Contract) known as the [Insert Contract Title] covering the provision of [Insert Description of Contracted Services] entered into by and between [Insert Legal Name of Business Associate] (Business Associate) and [Insert Legal Name of Covered Entity] (Covered Entity) on [Insert Contract Effective Date]. This Agreement is effective beginning on [Insert Agreement Effective Date] and terminates any prior existing Agreements.
This Agreement is specific to those services, activities, or functions covered in the Contract where it has been determined that the Business Associate is performing services, activities, or functions on behalf of the Covered Entity that are covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). These services, activities, or functions include:
[Insert Description of Services, Activities or Functions Contracted for]
The Covered Entity and Business Associate agree to modify the Contract to incorporate the terms of this Agreement and to comply with the requirements of HIPAA addressing confidentiality, security and the transmission of individually identifiable health information created, used or maintained by the Business Associate during the performance of the Contract and after the Contract is terminated. The Business Associate agrees that any conflict between provisions of the Contract and the Agreement will by governed by the terms of the Agreement.
1. Definitions
Protected Health Information (PHI) means:
Health information, including demographic information, created, received, maintained, or transmitted by the Business Associate, on behalf of the Covered Entity, where such information relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the payment for the provision of health care to an individual, that identifies the individual or provides a reasonable basis to believe that it can be used to identify an individual.
PHI excludes individually identifiable health information in education records covered by the Family Educational Rights and Privacy Act (FERPA) (see 20 U.S.C. 1232g, et. seq.) and employment records held by the Covered Entity in its role as employer.
Individual means:
The person who is the subject of protected health information or the personal representative of an Individual as defined and provided for under applicable provisions of HIPAA.
Disclosure means:
The release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.
Designated Record Set means:
1) A group of records maintained by or for a covered entity that is:
i) The medical records and billing records about individuals maintained by or for a covered health care provider;
ii) The enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; or
iii) Used, in whole or in part, by or for the covered entity to make decisions about individuals.
(2) For purposes of this Agreement, the term record means any item, collection, or grouping of information that includes protected health information and is maintained, collected, used, or disseminated by or for a covered entity.
2. Prohibition on Unauthorized Use or Disclosure of Protected Health Information
The Business Associate shall not use or disclose any PHI except as permitted or required by the Contract or this Agreement, as permitted or required by law, or as otherwise authorized in writing by the Covered Entity.
3. Permitted Use and Disclosure of Protected Health Information
The Business Associate may use or disclose PHI only for the following purpose(s):
a. for the delivery of the services, program management, activities, or functions contracted for in the Contract; or
b. for meeting contractual or legal obligations as established in any agreements between the parties evidencing their business relationship; or
c. as permitted by HIPAA if such use or disclosure were made by the Covered Entity or otherwise required by applicable law, rule or regulation; or
d. for use in the operations of the Business Associate as provided in paragraph 4 of this Agreement; or
e. as otherwise authorized by the Covered Entity in writing; or
f. data aggregation for the health care operations of the Covered Entity.
4. Use of Protected Health Information in Business Associate Operations
The Business Associate may use or disclose PHI as necessary for the delivery of the services or programs provided for in the Agreement, including appropriate management and administration of programs or services, or to fulfill the contractual or legal obligations of the Business Associate provided:
a. the disclosure is permitted or required by law; or
b. the Business Associate obtains reasonable assurances, evidenced by a written contract, from any person or organization to which the Business Associate will disclose PHI that such person or organization shall:
i) hold all PHI in confidence and use or further disclose it only for the purpose for which the Business Associate disclosed it to the person or organization, or as required by law; and
ii) notify the Business Associate, who will in turn promptly notify the Covered Entity, of any instance that the person or organization becomes aware of in which PHI was improperly disclosed.
5. Safeguarding and Maintenance of Protected Health Information
a. The Business Associate will develop, implement, maintain, and use:
i) reasonable and appropriate administrative, technical, and physical safeguards to prevent improper use or disclosure of PHI, in any form or media; and
ii) reasonable and appropriate administrative, technical, and physical security measures to protect the confidentiality, integrity and availability of electronically maintained or transmitted PHI.
b. The Business Associate will document and keep these safeguards and security measures current and available for inspection by the Covered Entity or its agents, upon request. Security measures employed by the Business Associate must comply with HIPAA security requirements on or before the date such requirements become effective.
6. Use or Disclosure of Protected Health Information by Subcontractors and Agents of the Business Associate
The Business Associate agrees to require any agent, including subcontractors, to whom the Business Associate provides PHI to comply with the same restrictions and conditions applicable to the Business Associate with respect to PHI. The Business Associate agrees to execute a written agreement with any agent or subcontractor to comply with this requirement as requested by the Covered Entity. This provision does not apply to the use or disclosure of PHI by subcontractors that provide health care treatment to individuals or to other persons or organizations that have entered into an Organized Health Care Arrangement (OHCA) as provided for under the provisions of HIPAA.
7. Compliance with Electronic Transactions and Code Set Regulations
If the Business Associate conducts any HIPAA-covered standard electronic transaction(s) on behalf of the Covered Entity, the Business Associate will comply with the applicable provisions of HIPAA for such standard transaction(s). The Business Associate will likewise require any subcontractor or agent conducting any standard electronic transaction(s) on behalf of the Business Associate, for services or programs covered by the Contract, to comply with the applicable provisions of HIPAA relating to standard transactions.
a. General requirements.
i) If any entity requests the Business Associate to conduct any of the standard electronic transactions, the Business Associate must comply with the request.
ii) The Business Associate may not delay or reject a transaction, or otherwise adversely affect or impact the other entity or the transaction submitted, because the transaction is a standard electronic transaction.
iii) The Business Associate may not reject a standard electronic transaction on the basis that it contains data elements not needed or used by the Business Associate (e.g., coordination of benefits information).
iv) The Business Associate may not offer an incentive to a health care provider to conduct a covered transaction through direct data entry (as described in CFR 45 §162.923(b)) rather than as a standard electronic transaction.
v) Business Associates operating as a health care clearinghouse, or requiring an entity to use a health care clearinghouse to receive, process, or transmit standard electronic transactions may not charge fees or impose costs in excess of the fees or costs for normal telecommunications that the entity incurs when it directly transmits, or receives, a standard electronic transaction to, or from, the Business Associate.
b. The Business Associate will not enter into, or permit its subcontractors or agents to enter into, any agreement related to the conducting of standard electronic transactions for or on behalf of the Covered Entity that:
i) changes or modifies the definition, data condition, or use of a data element or segment in an implementation specification; or
ii) adds any data elements or segments to the maximum defined data set; or
iii) uses any code or data elements that are marked “not used” in the implementation specification or are not contained within the implementation specification; or
iv) changes the meaning or intent of any implementation specification.
c. If the Business Associate receives a standard electronic transaction and coordinates benefits with another health plan, it must store the coordination of benefits data it needs to forward the standard electronic transaction to the other health plan.
8. Access to Protected Health Information
At the request of the Covered Entity, the Business Associate agrees to provide access to PHI held by the Business Associate that the Covered Entity has determined to be part of the Designated Record Sets of the programs covered by the Agreement. Access to PHI will be provided to the Covered Entity or to an Individual as directed by the Covered Entity to comply with applicable HIPAA requirements. The Covered Entity may delegate responsibility for the performance of all legal obligations, including HIPAA rights, relating to the Designated Record Set to the Business Associate.
9. Amendment or Correction to Protected Health Information
At the direction of the Covered Entity, the Business Associate agrees to amend or correct PHI that the Covered Entity determines is included in the Designated Record Set held by the Business Associate. The Business Associate agrees that any amendment or correction will be completed by the Business Associate in accordance with applicable HIPAA provisions.
10. Reporting of Unauthorized Use or Disclosure of Protected Health Information
The Business Associate will inform the Covered Entity of any use or disclosure of PHI not authorized by this Agreement or in writing by the Covered Entity within [Insert Number of Days] business days of becoming aware of such use or disclosure. The Covered Entity, at its discretion, may require a written report. If a written report is requested by the Covered Entity, the Business Associate agrees to forward a written report to the Covered Entity not more than [Insert Number of Days] business days after such request is made. Written and verbal reports of unauthorized use or disclosure will include:
a. A description of the circumstances of the unauthorized use or disclosure;
b. the PHI used or disclosed;
c. the name of persons assigned to review and investigate the unauthorized disclosure;
d. the name of persons or organization that received the unauthorized disclosure;
e. what actions the Business Associate has undertaken or will undertake to mitigate any harmful effect of the unauthorized use or disclosure; and
f. the actions the Business Associate has taken or will take to prevent future similar unauthorized uses or disclosures.
11. Mitigating Effect of Unauthorized Disclosures or Misuse of Protected Health Information
The Business Associate agrees to mitigate, to the extent practicable, any harmful effect known to the Business Associate created by an improper use or disclosure of PHI by the Business Associate in violation of the requirements of this Agreement.
12. Tracking and Accounting of Disclosures of Protected Health Information by the Business Associate
a. The Business Associate agrees to track disclosures of PHI as required by the applicable provisions of HIPAA. Specifically, the Business Associate agrees that it will maintain a record of all PHI disclosures made to third parties. The Business Associate agrees that the following information will be recorded:
i) the date the PHI was disclosed;
ii) the name and address, if known, of the person or entity that the PHI was disclosed to;
iii) a brief description of the PHI disclosed; and
iv) a brief statement describing the purpose for the disclosure.
b. For repetitive disclosures that the Business Associate makes to the same person or entity for a single purpose, the Business Associate will provide:
i) the disclosure information as specified in Paragraph 12(a)(i-iv) of this Agreement for the first of such repetitive disclosures;
ii) the frequency, periodicity or number of such repetitive disclosures; and
iii) the date of the most recent of such repetitive disclosures.
c. The Business Associate will make the record of disclosures available to the Covered Entity within [Insert Number of Days] business days after receiving a request by the Covered Entity.
d. Exceptions from Disclosure Tracking.
The Business Associate is not required to track or record disclosures of PHI, or to provide an accounting of disclosures for PHI meeting the following conditions:
i) disclosures of PHI that are permitted under this Agreement, or otherwise expressly authorized by the Covered Entity in writing; and
ii) disclosures of PHI for the following:
1) for purposes of treatment, payment or health care operations activity of the Covered Entity;
2) in response to a request from an Individual who is the subject of the disclosed PHI, or to that Individual’s Personal Representative;
3) made to persons involved in health care or payment for health care of the Individual;
4) for disaster relief notification purposes;
5) for national security or intelligence purposes; or,
6) to law enforcement officials or correctional institutions regarding Individuals in custodial situations.
e. Disclosure Tracking Time Periods.
Business Associate agrees to maintain and make available to the Covered Entity upon its request information on disclosures of PHI made by the Business Associate for the six-year period preceding the request, but not including disclosures made prior to April 14, 2003, or the date that the Business Associate began performing covered services, activities, or functions on behalf of the Covered Entity, whichever is later.
13. Access to Records and Notification to Covered Entity
a. Access to Records.
The Business Associate agrees to make its internal books and records relating to the use and disclosure of PHI available to the Covered Entity, or to federal agencies including, but not limited to, the Department of Health and Human Services or the Department of Justice in a time and manner determined by the Covered Entity or federal agency for purposes of determining compliance by the Covered Entity with the requirements of HIPAA.
b. Notification to Covered Entity.
The Business Associate agrees to notify the Covered Entity of any contact with a federal agency regarding HIPAA compliance that occurs as a result of any HIPAA-covered activity related to the performance of the Contract by the Business Associate or subcontractor of the Business Associate. Federal agencies include, but are not limited to, the Department of Health and Human Services and the Department of Justice. Notification required under this paragraph will occur within 2 (two) business days after the Business Associate becomes aware of any such contact. Additionally, the Business Associate agrees to provide the Covered Entity with copies of any PHI or other information the Business Associate has made available to HHS or other federal agency under this paragraph.
14. Term and Termination of Agreement
a. The Business Associate agrees that if in good faith the Covered Entity determines that the Business Associate has materially breached any of its obligations under this Agreement, the Covered Entity at its discretion, has the right to:
i) exercise any of its rights to reports, access and inspection under this Agreement, and, or
ii) require the Business Associate to submit to a plan of monitoring and reporting, as the Covered Entity determines necessary to maintain compliance with this Agreement; and, or
iii) provide the Business Associate with a defined time period to cure the breach; or
iv) terminate the Agreement in accordance with applicable state statutes.
b. Before exercising any of these options, the Covered Entity will provide written notice of preliminary determination to the Business Associate describing the violation and the action the Covered Entity intends to take.
15. Return or Destruction of PHI
Upon termination, cancellation, expiration or other conclusion of this Agreement or the Contract, the Business Associate will:
a. Return to the Covered Entity or, if return is not feasible, destroy all PHI and any compilation of PHI in any media or form. The Business Associate agrees to ensure that this provision also applies to PHI in possession of subcontractors or agents of the Business Associate provided to the agent or subcontractor by the Business Associate. The Business Associate agrees that any original record or copy of PHI in any media is included in this provision as are any original or copy of PHI provided to subcontractors or agents of the Business Associate by the Business Associate. The Business Associate agrees to complete the return or destruction as promptly as possible, but not more than [Insert Number of Days] business days after the effective date of termination of this Agreement. The Business Associate will provide written documentation evidencing that return or destruction of all PHI has been completed.
b. If the Business Associate believes that the return or destruction of PHI is not feasible, the Business Associate shall provide written notification of the conditions that make return or destruction infeasible. Upon mutual agreement of the Business Associate and Covered Entity that return or destruction is not feasible, The Business Associate shall extend the protections of this Agreement to PHI and prohibit further uses or disclosures of the PHI of the Covered Entity without express written authorization of the Covered Entity. Subsequent use or disclosure of any PHI subject to this provision will be limited to the use or disclosure that makes return or destruction unfeasible.
16. Miscellaneous
a. Automatic Amendment: This Agreement shall automatically incorporate any change or modification to HIPAA as of the effective date of the change or modification. The Business Associate agrees to maintain compliance with all changes or modifications to HIPAA as required.
b. Interpretation of Terms or Conditions of Agreement: Any ambiguity in this Agreement shall be construed and resolved in favor of a meaning that permits the Covered Entity and Business Associate to comply with HIPAA.
c. Submission of Compliance Plan: The Business Associate agrees that a HIPAA compliance plan may be requested by the Covered Entity. If requested by the Covered Entity, the Business Associate agrees to provide periodic reports of the progress of the compliance plan. Further, the Business Associate agrees that the plan and progress reports will comply with the requirements of the Covered Entity.
IN WITNESS WHEREOF, the undersigned have caused this Agreement to be duly executed by their respective representatives.
COVERED ENTITY BUSINESS ASSOCIATE
By: _______________________________ By: ________________________________
Title: ______________________________ Title: ______________________________
Date: ______________________________ Date: ______________________________
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