Request for Proposal Medical Plan Claims Administration Services

Download Request for Proposal Medical Plan Claims Administration Services

General Information

Purpose of Request for Proposal (RFP)

Provo City School District (PCSD) currently has a fully insured medical plan through SelectHealth. It is the district’s likely intention to convert their medical plans to a self-funded model as of September 1, 2023.

PCSD will use the responses to this RFP, potentially including claims repricing information, to evaluate which vendor is best to administer their medical plans starting in 2023.

RFP Instructions

We request that you read the entire RFP document before submitting and/or requesting additional information.

USI Insurance Services is the named consultant of record for PCSD. The lead Benefit Consultant is Dave Burbidge. The team also Katie Wood, Practice Leader, Julia McKay, Benefit Analyst, and Kelly Purdie, Account Executive, for purposes of this RFP. Please share any questions with Dave and Kelly. USI will also be compiling the proposal results, so vendors may reach out if any questions arise.

Please respond to the requirements and questions contained in this RFP as thoroughly as necessary, but as succinctly as possible. Unless specifically mentioned in your response, it is assumed that you can match all the requirements of the plan as outlined in this RFP and attachments.

In your responses, please point out how you can improve both the districts and their members’ experience financially and administratively. Pay particular attention to the plan designs of the medical plan as defined in the District’s Plan Document and SBCs since those plans contain plan provisions that will need to be handled by your claims system.

When preparing your response, please follow these instructions for Section 5: RFP Questionnaire/Requirements:
Each question should be retyped in your proposal with the response immediately following.
If a question is unclear to you, contact USI for clarification. Incomplete responses may result in the disqualification of your proposal.
Responses should reflect your claim payment system as of September 1, 2023, with any anticipated changes in the claims payment system noted.
Please avoid making references to other preprinted material. Responses should answer each question directly and thoroughly.

Finalists will be selected and asked to present in person. Additional information may be requested of the respondents at that time. Please note that stop loss coverage and PBM services are being marketed on both a package and separate basis. Please clearly mark services and rates accordingly.

Information contained in this RFP, including attachments, and any subsequent materials released during the RFP process are considered confidential. Vendors are expected to protect this information accordingly. Any breach in confidentiality should be reported to USI immediately.

Deadline for proposals is March 3, 2023. Proposals should be sent electronically to the entire team, Dave at dave.burbidge@usi.com, Kelly at Kelly.purdie@usi.com, Julia at Julia.mckay@usi.com. Proposals should not be sent directly to the district. Proposals received after the deadline will not be considered.

Background and Objectives

Background

Provo City School District resides in Northern Utah, in the Provo, Utah area. The district has 22 total schools (4 specialized schools, 13 elementary schools, 2 middle schools and 3 high schools) and 13,611 students. Additional information on the district can be found on their website: https://www.provo.edu.

To attract and retain high-caliber employees, the district offers an extensive employee benefits package. At the heart of these benefits is the two medical plan offerings:

Medical HSA – Qualified High Deductible Health Plan
Medical PPO – Traditional Health Plan

Additionally, the District pays 80% of the premium for single coverage and 80% of the premium for family coverage for both plans. Employees who do not participate in the annual biometric screenings will pay a higher premium. The employer also contributes to a Health Savings Account.

Enrollment & Eligibility

Employees are eligible for the medical plan if they work 30 hours or more per week. Covered members under the district’s medical plan are:

Employees and their eligible dependents
COBRA participants

As of the January member census that is available upon request, there are 800 enrolled employees. In addition, the district uses a two-tier coverage structure.

The census reflects medical plan elections as of January 1, 2023

RFP Objectives

Minimal provider disruption
Ability to duplicate requested plan designs as closely as possible with minimal manual intervention required by your claims system
Long-term price stability and financial stability of provider contracts
Three-year rate guarantee for all administrative fees
Ability to work with the district’s chosen PBM; PBM is being marketed separately.
Financial performance and service performance guarantees
- PPO Network savings
- Claims Administration / accuracy / efficiency.
- Customer Service to the employer and member
- Utilization reporting and case management.
Commitment to feed claims to 3D, USI’s proprietary claims database tool – reporting required monthly.

Current TPA Information and Services

Currently, the plan is fully-insured. All administrative fees are included in their premium.

Current Plan Designs

The current Plan Document, Plan Summaries & SBCs are included with this RFP.

Medical PPO – Qualified High Deductible Health Plan
Medical PPO – Essential Health Plan

Please pay attention to the plan designs as explained in these documents to ascertain the ability of your claims system to handle processing. Unless specified to the contrary, it is anticipated that your claims system can handle processing of all claims without manual intervention.

RFP Questionnaire/Requirements

GeoAccess Report – Provider access analysis for your proposed network. GeoAccess reports should be run using the following parameters:
- 2 Primary Care Providers (PCPs) within 10 miles
- 2 Specialists within 10 miles
- 1 Acute Care Hospital within 15 miles
- If provider access is not desirable given these parameters, please provide options available to enhance provider access. For example, can you administer additional networks to be “wrapped” into the main network?
Network Disruption – There are several major provider systems in Provo and surrounding areas. Ideally, provider systems must be included in your proposed PPO network. Select the network with all systems that provides the best financial discounts. Please specify what PPO network you are proposing. Please provide a provider disruption analysis using the file that we provided with the RFP and designate by provider whether they are in your proposed network. Additionally, if applicable, please specify what “wrap” network you are proposing for members outside of the primary network, such as, dependent children away at school, etc.
Claims Repricing – Please provide medical claims discount analysis for your proposed PPO network utilizing the 2021 & 2022 Medical Claims Excel File included in the RFP and reprice the claims. At a minimum, provide analysis for the following based on your repricing:
- Aggregate group discounts, broken down by IP / OP / Professional/Total
- Average book-of-business discounts in the Provo area for your proposed network
PBM Compatibility – Please confirm the district can carve out Rx and what (if any) fees may apply to do so. If you cannot carve out Rx, what freedoms/options does the district have for further control over Rx spending? Are there any PBMs you cannot work with? If yes, please list.
Implementation – Outline the timeline / procedures required to implement the plans knowing that the PCSD will hold open enrollment in the fourth quarter for a September 1, 2023 effective date. Will you provide a dedicated implementation specialist? If yes, please provide biographical information on this individual.
Special Accommodations – The group may consider direct contract arrangements with a local healthcare provider. The group will likely need to have two separate group numbers set up so that the provider can determine the difference between the PPO and the QHDHP. In addition, the provider will bill a claim to the TPA so that it can be processed and applied to the member’s deductible and maximum out-of-pocket. Can this process be accommodated by the TPA? If so, are there any implications that we need to be aware of such as reporting, administration, etc.
Enrollment and Communication Materials:
- To what extent can these materials be customized for PCSD?
- Are there any additional charges for use of these materials?
- Please list communication materials available.
- Finalists will be asked to provide samples of these materials.
Value Added Services Available (no additional cost) – Please outline specifics for the following:
- Online portal / app for members
- Wellness Services / Programs
- EAP
- Patient Advocacy Support Team
- Telemedicine Services
- Case Management
- Disease management
Reports – Please furnish samples of all reports available and the frequency in which they are provided. The client has a complex group structure and reporting will need to be built to match that structure.
Claims Processing – Excellent claims processing service is of primary concern to PCSD. Briefly describe major capabilities that distinguish your firm from others. Briefly outline the steps in the claim adjudication process from receipt of initial claim through last benefit payment. Which of your offices will be responsible for processing claims? What is your average claim turnaround period? Outline your firm’s current service standards in the areas of claim turnaround time, implementation, and discount guarantees with at-risk money to be provided if your company does not perform to level in any area of the performance guarantee.
Claims System – Describe your claims processing system, clearly defining which aspects are automated and which require manual intervention. How long has the system been operational? Describe any significant enhancements that are planned for the next 24 months. Under what conditions and by what individuals can your automated system be manually overridden? Are such overrides reviewed? Explain the various security features built into the system to prevent fraudulent payment of claims.
Quality Assurance Reviews – How often do you perform quality assurance reviews to determine whether claims were processed and paid by your personnel in a timely and accurate manner? Briefly describe the nature and extent of any such review procedures. What percent of claims is subject to quality review? What criteria are used to determine the requirement for supervisory intervention?
Customer Satisfaction – What is your firm’s strategy for ensuring customer satisfaction with your claim service and any employer/carrier interfaces that may occur (i.e., online enrollment vendor, etc.)?
Member Services – What is the address of the office that will be providing member services for the district? Provide average wait time for member phone calls and average turnaround time on member emails. Will you provide a dedicated 800 number for the district’s members? Do you provide an on-line chat function for members? If yes, please explain. Additionally, discuss your member portal and its functionality.
Client Account Service – Provide the address of your company’s home office. Provide the address of the office which will have primary responsibility for providing account service to the PCSD. TPA must provide a dedicated client service representative who will serve as the primary day-to-day contact for contract and servicing; please list that individual’s name and title. Additionally, please list additional members of the account service team. Provide background information on the entire service team. How many years have each of these individuals been with your organization? How many years with any related organization? Will the ongoing service team be assigned to the implementation team as well?
Subrogation Services – TPA must provide subrogation services. Please explain your process for identification of claims needing subrogation and your monitoring process to assure that funds recovery is accomplished.
Compliance/Flexibility – Does your firm agree to administer the benefit plans exactly as described? If not, describe in detail any variations and the reasons for them.
Fee Guarantee – Please provide a three-year fee guarantee for your TPA services.
References – List four comparable clients to be contacted as references. Please provide the company name, address, telephone number, contact name and title. Provide the same information for two clients that have terminated your firm in the last two years.
Additional Information – If these specifications do not permit a full explanation of your firm’s capabilities, please make additional comments.

Proposed Fees

The proposal must include final fee pricing separately for the following:

Administration of plan, including but not limited to:
- Claims Processing
- Claims Fiduciary Coverage
- Customer Service
- Standard ID Cards
- Standard Management Reporting
- State/Federal Reporting
- Open Enrollment Meeting Support
- Electronic Version of Benefit Booklets
Utilization Review
Large Case Management
Disease Management programs
Centers of Excellence
Wellness Program
Telemedicine for Medical and Behavioral Health
Network Access & Interface Fees (PBM and Stop Loss carrier, if applicable)
Document charges (i.e., employee communications), if applicable
Optional – COBRA

Additional Considerations: Three-year fee guaranteed required. If TPA is providing any implementation credits, please note this in the proposal. Run-in claims administration will not be required.

Timeline

Below is a timeline of events pertaining to this RFP and implementation of a new TPA for the SDWDP.

Event	Date(s)
Release of RFP	February 28, 2023
Deadline for RFP questions	March 07, 2023
Deadline for receipt of proposals (no extensions will be granted)	March 08, 2023
Selection of finalists	March 2023
TPA & PBM partners selected	March 2023
Implementation meetings	May 2023
Open enrollment	May-July 2023
Effective date	September 1, 2023

Proposals, including questionnaire, must be received no later than 4 p.m. on March 08, 2023. Any deviations or omissions from these specifications should be specifically addressed in your cover letter. It is assumed that if not notified, all specifications have been addressed as requested. Any deviations or omissions from these specifications that are not noted in your cover letter may result in rejection of your proposal.