Customer Service - County Of Mclennan

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					                                        QUESTIONNAIRE TABS

                                General Information
                                Financial Information
                                References
                                Customer Service
                                Technical Information - Fully Insured
                                Technical Information - TPA or ASO
                                Implementation Information
                                Preferred Provider Network
                                Pharmacy Benefit Management
                                Dental
                                Vision
                                HIPAA
                                Stop Loss
                                COBRA Administration
                                Section 125 (Flex)
                                Life
                                Disability
                                Voluntary Cancer
                                Voluntary Intensive Care
                                Voluntary Accident
                                Voluntary Heart Stroke

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this
time or will provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the
question. All responses must be made within the designated cell(s) of the worksheet provided.




COVER                                                            32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012      1 of 55
GENERAL INFORMATION

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at a later
date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within the
designated cell(s) of the worksheet provided.


1        Parent Company Name:
2        Address:
3        City/State/Zip:
4        Company Name: (If not same as above)
5        Address:
6        City/State/Zip:
7        Contact Person: (Employee of vendor)
8        Contact Phone #:
9        Contact Cellular #:
10       Contact Email:
11       Contact Fax #:
12       Local Address:
13       Local City/State/Zip:
14       Local Contact Person: (Employee of vendor)
15       Local Contact Phone #:
16       Local Contact Cellular #:
17       Local Contact Email:
18       Local Contact Fax #:
19       Federal Tax ID Number:
20       Date Parent Company formed:
21       Date Subsidiary Company formed:
22       Date Company enrolled first group in State of Texas:

23       Date Company was licensed to transact the
         appropriate line of insurance products in the State of
         Texas:
24       Number of employees employed in Texas and
         Nationwide:
25       Number of groups you insure with over 800
         employees in force. Please identify
                                               Private Sector
                                                         Texas
                                                    Nationwide
                                                Public Sector
                                                         Texas
                                                    Nationwide




General Information                                               32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                   2 of 55
GENERAL INFORMATION
26       Number of lives your insure:
                                               Private Sector
                                                         Texas
                                                    Nationwide
                                                Public Sector
                                                         Texas
                                                    Nationwide
27       Is your company using any sub-contractors? If so,
         please provide the following information in your
         response for each sub-contractor: Name of sub-
         contractor, the scope of services the sub-contractor
         will perform, the reasons why you are sub-
         contracting these services, the benefit of sub-
         contracting these services, the depth of experience
         of the sub-contractor performing these services, and
         how you evaluated the sub-contractor, and why you
         selected this vendor to perform these services.


28       Has your company recently been acquired or been
         involved with any merger/acquisition? If yes, briefly
         describe.
29       Is your company involved in any pending or
         contemplated acquisition in the next 36 months? If
         yes, briefly describe.
30       Under what other or former names has your
         company operated? If yes, briefly describe.
31       Identify any officer, director, employee or agent of
         your organization who is also an employee of
         McLennan County.
32       Disclose the name of any McLennan County
         employee who owns, directly or indirectly, an
         interest of 5% or more in your firm or any of its
         subsidiaries. Also disclose any familial or financial
         relationship anyone in your firm may have with any
         employee of the McLennan County or member of
         the family of an employee of the McLennan County.

33        Identify any affiliation your firm or an employee of
         yours currently has with McLennan County such as
         a current contract, sub-contractor on a current
         contract, a member of an advisory board, etc.

34       Describe your company’s disaster recovery and
         contingency plans. Have you ever tested or actually
         implemented these plans?


General Information                                              32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   3 of 55
GENERAL INFORMATION recovery and
34  Describe your company’s disaster
         contingency plans. Have you ever tested or actually
         implemented these plans?
35       State your type of business: corporation, non-profit
         corporation, partnership, joint venture, etc.
36       Has your company been involved in any litigation
         over the last five years; pending, settled, or
         dismissed? Explain each separately. If there is any
         pending litigation, please include an opinion of
         counsel as to whether the pending litigation will
         impair the proposer’s performance in a contract
         under this RFP.)
37       Has the proposer or any of the proposer’s
         employees, agents, independent contractors or sub-
         contractors ever been convicted of, pled guilty to, or
         pled nolo contendere to any felony; and if so,
         provide an explanation of the relevant details.

38       Has your company, within the last 10 years, filed (or
         had filed against it) any bankruptcy or insolvency
         proceeding, whether voluntary or involuntary, or
         undergone the appointment of a receiver, trustee, or
         assignee for the benefit of creditors; and if so,
         provide an explanation of the relevant details.

39       What separates your firm from other competitors?


40       Has the interested firm, its principals, officers, or
         predecessor organization(s) been debarred or
         suspended from bidding by any government during
         the last five (5) years? If yes, provide details.

41       Have you ever failed to complete any work awarded
         to you? If so, where and why?




General Information                                               32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   4 of 55
FINANCIAL INFORMATION
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must
be made within the designated cell(s) of the worksheet provided.


1    Ratings:
                                           AM Best
                                           Moody’s
                                Standard & Poors
                                               Fitch
2    Describe your firm’s financial condition for
     the last three years. Specify fiscal period,
     retained earnings, debt, and equity. Detail
     each year separately:


                                             Year1
                                             Year2
                                             Year3
3    Has your company received any corrective
     action requests from any State or Federal
     Government in the last 5 years? If yes,
     briefly explain.

4    How do you establish and maintain
     reserves for unreported claims?
5    How do you establish and maintain
     reserves for known claimants?




Financial Information                                        32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                          5 of 55
CUSTOMER SERVICE INFORMATION
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at a
later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within the
designated cell(s) of the worksheet provided.


1    What are your customer service hours of operation?


2    Describe how calls are received and by whom.
3    How are calls handled after hours and by whom?
4    Is there a toll free number?
5    Are you able to service the hearing impaired or those
     that speak a foreign language?
6    What office will handle claims processing and
     payment? Are all claims adjudicated in one location?
     By one claims team?
7    Do you monitor member satisfaction? How do you
     monitor satisfaction? How do you handle unsatisfied
     customers?
8    How are the results communicated to the client and
     with what frequency?

9    Describe your organization's capabilities with respect to
     providing communications in Spanish.

10   Will an employee be able to access data or submit
     inquiries and receive responses on-line? Describe your
     on-line access capabilities.
11   Please describe your standard member appeal
     process. Include in your response the differentiation
     betweens claims appeals and appeals regarding
     medical treatment.




Customer Service                                                 32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                              6 of 55
Customer Service   32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   7 of 55
REFERENCES
Provide the contact information for five current and three former clients of similar size, preferably in the public sector area. Include
Organization Name, Address, Contact Person Name and Phone #, number of employees, indicate private/public sector, and briefly explain
what services you provided and for how long was your contract.


1    #1 Current
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
2    #2 Current
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
3    #3 Current
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:



References                                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                         8 of 55
REFERENCES
Provide the contact information for five current and three former clients of similar size, preferably in the public sector area. Include
Organization Name, Address, Contact Person Name and Phone #, number of employees, indicate private/public sector, and briefly explain
what services you provided and for how long was your contract.


1    Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
4    #4 Current
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:




References                                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                         9 of 55
REFERENCES
Provide the contact information for five current and three former clients of similar size, preferably in the public sector area. Include
Organization Name, Address, Contact Person Name and Phone #, number of employees, indicate private/public sector, and briefly explain
what services you provided and for how long was your contract.


1
5    #5 Current
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
6    #1 Former
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
     Reason for termination:
7    #2 Former
     Organization Name:

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:



References                                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                         10 of 55
REFERENCES
Provide the contact information for five current and three former clients of similar size, preferably in the public sector area. Include
Organization Name, Address, Contact Person Name and Phone #, number of employees, indicate private/public sector, and briefly explain
what services you provided and for how long was your contract.


1    Private/public sector:

     Length of Service:
     Services Provided:
     Reason for termination:
8    #3 Former
     Organization Name

     Address:
     Contact Person:
     Phone #:
     Fax #:
     Email:
     Number of Employees:

     Private/public sector:

     Length of Service:
     Services Provided:
     Reason for termination:




References                                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                         11 of 55
TECHNICAL INFORMATION - FULLY INSURED
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at
a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within
the designated cell(s) of the worksheet provided.


1       Describe your claims facilities and procedures.
        Steps and procedures used in claims
        administration starting with the original claim
        form(s) completed by the employee and ending
        with the issuance of payment.

2       Provide turn around times of claims
        administration.
3       Please describe measures taken to prevent
        fraud by your own employees related to claims
        processing and claim/draft control.

4       Please describe measures taken to prevent
        fraud by claimants.
5       Please describe your grievance procedure.

6       When were your current claims, eligibility,
        member services, and data reporting systems
        last upgraded or enhanced? When is the next
        upgrade/enhancement scheduled?

7       What are your expectations of the employer’s
        role in the following processes: administration,
        appeal processing, investigations, etc?

8       Is it possible for the McLennan County to have
        on-line access to run reports and to view
        current status? Be specific as to how this would
        work.



9       What, if any, data is required from the current
        vendor in order to assure a smooth transition?

10      Describe your enrollment process for
        employees who elect coverage after the initial
        enrollment period.




Technical Info Fully Insured                                 32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                12 of 55
TECHNICAL INFORMATION - FULLY INSURED
11      Specify your capabilities to monitor legal and
        regulatory matters at State and Federal Levels
        and how do you keep the client abreast of any
        changes?
12      Explain in detail how you monitor and
        communicate with insureds who are disabled
        either partially or totally. Include any return to
        work initiatives.
13      If applicable to your policy, how do you handle
        waiver of premium liability when a policy is
        terminated?
14      What standard reports are available?
        Frequency? Are there additional costs
        associated with these standard reports?

15      Are online data reporting capabilities available
        for the client? If yes, what are they? Are there
        additional costs for this capability.
16      Describe functions your claim system
        automatically performs.

17      Identify the office/location from which this
        account will be handled for claim processing
        and payment.
18      What are your firms claim processing
        standards?
                                          Turnaround time
                                       Procedural accuracy
                                        Financial accuracy
19      What are your firms claim processing results
        for the current last 2 calendar years.
        What are your actual results for Year 1:
                                                      Year
                                          Turnaround time
                                       Procedural accuracy
                                        Financial accuracy
        What are your actual results for Year 2:
                                                      Year
                                          Turnaround time
                                       Procedural accuracy
                                        Financial accuracy
20      Do you send an acknowledgement receipt of a
        claim form?




Technical Info Fully Insured                                 32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   13 of 55
TECHNICAL INFORMATION - FULLY INSURED
21      Will your company participate in the Employer's
        Annual Health Fair and other promotional
        events?
22      Describe in detail how renewal rates will be
        determined after the initial guarantee period;
        your response should include an estimate of
        the credibility that will be given to McLennan
        County’s experience.



23      Please describe your underwriting process,
        including the number of years your company
        considers credible for experience rating
        purpose for McLennan County.


24      What performance guarantees will you offer? If
        your performance guarantee includes a
        financial penalty, please specify.


25      Please provide your website address and an
        explanation of your website’s capabilities and
        characteristics.
26      What information is available to members via
        different methods? (i.e. voice response, web
        page, etc.) Be detailed as to all the types of
        information that would be accessible via each
        method.
27      Please describe your plan design options in
        appropriate detail to allow McLennan County to
        assess your proposal, including co-payments,
        deductibles, percentage of network coverage,
        percentage coverage out of network, limits on
        coverage, etc. for an HMO and PPO Plan
        Benefit, limitation, exclusions, benefit durations,
        accelerated benefits, et cetera.




Technical Info Fully Insured                                  32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   14 of 55
SERVICES - TPA or ASO ADMINISTRATION/SYSTEMS INTERFACE/REPORTING

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses
must be made within the designated cell(s) of the worksheet provided.


  1   From what location will claims be paid?
  2   What are your standards for claims turnaround
      time? (provide documentation)
  3   Are these standards currently being met by the
      proposed claim office?
  4   How is turn around measured?
  5   Are pended or duplicate or denied claims
      included in measured turnaround statistics?
  6   What are your standards for payment accuracy?
      (number of claims paid correctly divided by the
      total number of claims).
  7   What are your standards for procedural
      accuracy? (number of claims processed correctly
      divided by the total number of claims).

  8   What are your standards for financial accuracy?
      (total dollars of under and over payment divided
      by the total claims dollars paid)for the time period
      January 1, 2010 through December 31, 2010.

  9   Provide reports confirming the results identified in
      questions 6, 7 and 8 above for the time period
      January 1, 2010 through December 31, 2010.

 10   How often and for what periods are these
      standards measured?
 11   Describe the process when an employee calls to
      discuss a claim. To whom will the employee be
      directed? What is the average response time for
      claim inquiries? What percent of inquires are
      resolved during the initial telephone call? What
      percent of inquiries are resolved within five (5)
      working days after the initial call?

 12   Will an employee be able to access data or
      submit inquiries and receive responses online?
      Describe your online access capabilities.




Technical Info - TPA or ASO                                  32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                     15 of 55
SERVICES - TPA or ASO ADMINISTRATION/SYSTEMS INTERFACE/REPORTING
 13   What software system do you use to adjudicate
      claims? Do you own or lease the software? Will
      you change systems within the next five (5)
      years?
 14   How long are records kept? Explain your
      document retention policies.
 15   Please provide samples of the standard
      claims/utilization reports provided on a routine
      basis, indicating the frequency and any additional
      charge for each report. Are reports available
      online? If so, how are the reports accessed and
      protected?
 16   Can you provide special ad hoc reports if
      requested by McLennan County? Please provide
      examples and identify any added costs not
      included in the base administration fees and turn
      around time for report requests.
 17   What networks does your company currently
      work with? Please list the various networks and
      number of lives accessing those networks.

 18   Is your company able to access various networks
      for the same client? For example, can you patch
      regional networks together to accommodate
      members who live in separate areas?

 19   Does your company have a proven track record
      working with wrap or national networks as well as
      a primary network? Provide details, examples
      and explanation.
 20   Describe your ability to track, file and recover
      stop loss reimbursement claims on behalf of the
      McLennan County.
 21   To what extent will your legal counsel assist
      McLennan County in defending suits contesting
      denial of benefits, eligibility, review of plan
      documents, legal compliance, etc.?
 22   Please describe services provided for a current
      client that you would describe as above and
      beyond the scope of requirements of your
      contracts.




Technical Info - TPA or ASO                                32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   16 of 55
IMPLEMENTATION INFORMATION

    SERVICE PROVIDED (Life,Den,Vis,etc):
What data would you request from McLennan
County and/or the existing carrier in order to
complete the implementation process?


Provide a detailed workplan you would use to implement administration of McLennan County’s benefit program effective October 1, 2011. Include key activities, the dates
during which they will be performed, the person(s) on your team who would be responsible for carrying them through, and the anticipated time frame in which you would
anticipate McLennan County’s involvement. Please respond in a tabular or outline format rather than narrative format. Key activities should include the following:

                                                  Name of Person, Title, Role   Contact Email                Contact Phone   TimeFrame       Initial Date   Ending Date
                                                                                                                             (Business
                                                                                                                             days)
Initial planning meeting
Periodic update meetings
Preparation and distribution of enrollment kits

Employee enrollment, including participation
in employee meetings
Processing of elections
Preparation of your claim administration
system inclusive of website accessibility.
Customer services orientation
Establishing the account structure, including
initiation of periodic report generation (type
and frequency)
Identification card production
Identification card distribution
Certificate/SPD drafting, production and
distribution
Insurance contract draft, including applicable
amendments or riders
Provision of actual contract once drafts are
approved
Provision of standard customized claim forms

Provision of administration manual
PLEASE PROVIDE ANY ADDITIONAL KEY ACTIVITIES THAT ARE NOT LISTED ABOVE




Implementation Information                                     32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                                   17 of 55
IMPLEMENTATION INFORMATION

    SERVICE PROVIDED (Life,Den,Vis,etc):
What data would you request from McLennan
County and/or the existing carrier in order to
complete the implementation process?


Provide a detailed workplan you would use to implement administration of McLennan County’s benefit program effective October 1, 2011. Include key activities, the dates
during which they will be performed, the person(s) on your team who would be responsible for carrying them through, and the anticipated time frame in which you would
anticipate McLennan County’s involvement. Please respond in a tabular or outline format rather than narrative format. Key activities should include the following:

                                                  Name of Person, Title, Role   Contact Email                Contact Phone   TimeFrame       Initial Date   Ending Date
                                                                                                                             (Business
                                                                                                                             days)
Initial planning meeting
Periodic update meetings
Preparation and distribution of enrollment kits

Employee enrollment, including participation
in employee meetings
Processing of elections
Preparation of your claim administration
system inclusive of website accessibility.
Customer services orientation
Establishing the account structure, including
initiation of periodic report generation (type
and frequency)
Identification card production
Identification card distribution
Certificate/SPD drafting, production and
distribution
Insurance contract draft, including applicable
amendments or riders
Provision of actual contract once drafts are
approved
Provision of standard customized claim forms

Provision of administration manual
PLEASE PROVIDE ANY ADDITIONAL KEY ACTIVITIES THAT ARE NOT LISTED ABOVE




Implementation Information                                     32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                                   18 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses
must be made within the designated cell(s) of the worksheet provided.

SECTION 1
  1   Complete the General information regarding your
      company in the prior section.
  2   How many clients do you have as of January 1, 2011?
      How many of these clients are public entities?

  3   Perform a GeoAccess report for your network based
      on the census information provided in the attached
      census file. The access standard to be used is:
      Primary Care: two (2) providers within ten (10) miles
      of the employee census zip code
      Specialty Care: one (1) provider within ten (10) miles
      of the employee census zip code
      Hospitals: one (1) provider within 15 miles of the
      employee census zip code

      In addition, submit the listing of zip codes where the
      desired access is not met for each of the outlined
      provider types.


  4   How do you accommodate employees or dependents
      that live outside of the service area?
  5   What date was your area network established for
      McLennan County?
  6   If a plan participant is using a network physician prior
      to the start of the plan, and that physician is not
      accepting new patients under the plan, will the plan
      participant be able to continue seeing that physician?
      What transition and continuity of care rules would
      apply?
  7   Provide the reimbursement process for network
      physicians who refer a plan participant to a non-
      network specialist or hospital. Are network physicians
      required to refer within the network? What protocol is
      followed when referrals need to be made outside of
      the network for specialty care? How are referrals
      made out of network resolved? What repercussions
      are there, if any, for providers referring patients
      outside of the network?



Preferred Provider Network                                       32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                 19 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK
  8   What hospitals are under contract as of January 1,
      2011 in the McLennan County area?
  9   Do you consider Hillcrest, Providence and Scott &
      White Hospitals, Clinics and Doctors in-network?
 10   Are any of your hospital contracts renewing in the next
      three years? Please provide status of negotiations as
      of this RFP.
 11   Please list your network options for McLennan County
      (i.e. PPO, EPO, etc). Can your network be
      customized for McLennan County if applicable.
 12   Approximately how many members were enrolled in
      your McLennan County area network as of January 1,
      2011?
 13   Is your network self-built, leased or purchased?
      Please describe third party arrangements (i.e.
      subcontracting, delegation, PHO arrangements, etc.).

 14   Please provide a copy of your most recent provider
      network directory in both printed and electronic file
      format for the McLennan County area. This data may
      be used by McLennan County for a disruption
      analysis.
 15   What are your average fee discounts for:
      Primary Care Physicians
      Specialists
      Hospitals when all area hospitals are included in the
      network
      Hospitals when using a tiered or high performance
      network
      Dental Providers
      (itemize the discount by line item above)


 16   Please describe your physician contracts and attach a
      copy of your standard contract that is used in the
      McLennan County area. If you subcontract or
      delegate, please attach a copy of your contract with
      the local subcontractor, IPA or PHO.

 17   For the physicians in your McLennan County network,
      what is the negotiated reimbursement level as a
      percent of RBRVS? Which year is used in the
      formula? Describe any anticipated changes for 2011.




Preferred Provider Network                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   20 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK
 18   Does your organization contract with Urgent Care
      Centers? Does your organization contract with
      Emergency Care Centers? If so, please provide a list
      of both local and national centers with whom you
      contract.
 19   Please provide a list of “Centers of Excellence” for
      highly specialized care and what services are
      provided.
 20   Please describe in detail your credentialing process
      for hospitals and ambulatory surgery facilities. What
      “quality of care measures” are used?

 21   Do you credential your provider network based on
      standards other than NCQA? (Leapfrog; NSQP;
      AAGL; FLS)
 22   Do you individually credential all physicians or do you
      rely on a hospital or other entity to perform the
      credentialing process?
 23   Do you require an onsite inspection of the provider’s
      facilities as part of the initial credentialing process?

 24   Do you require physicians to have hospital privileges
      at an in-network facility?
 25   How often do you re-credential your providers? Do
      you have an organized system to identify the
      providers who are due to be re-credentialed?
 26   Provide a copy of your provider application form(s),
      and credentialing documents used for physicians,
      ancillary providers and hospitals. Are your
      credentialing requirements consistent with NCQA
      standards?
 27   Does your provider relations department have a
      structured program that provides support services to
      your physician network?
 28   Describe your capabilities to support the Federal
      Health Information Technology Initiatives.
 29   Describe your organization’s provider performance
      evaluation program. Please describe the extent to
      which evaluations are data driven and include
      utilization and outcome cost-effectiveness, and patient
      satisfaction.
 30   Does your organization determine and track
      complaints about providers and utilize this information
      as a factor in provider evaluations? If so, please
      describe this process.



Preferred Provider Network                                       32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   21 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK
 31   Describe your organization’s corrective action process
      for providers and how this information is captured and
      reported.
 32   What formal programs exist for working with providers
      to improve effectiveness and efficiency? Please
      describe them.
 33   How often would you meet with providers to
      specifically review and update them regarding
      McLennan County’s benefit plan?
 34   How many times a year are provider lists updated?
      How many times a year are updates sent to members
      and employers? Do you ever include a physician who
      has not actually signed a contract with you?

 35   Do marketing materials indicate physicians who are
      not accepting additional patients?
 36   How will you handle situations where a member and
      their dependents live in separate cities? Please
      distinguish between temporary situations (e.g.,
      students attending college) and permanent situations
      (e.g., children residing with a former spouse).
      Address the case where you have networks in both
      cities as well as where you have a network in only one
      of the cities.
 37   Can family members select their PCP on an individual
      basis? Please describe.
 38   What controls have you used to prevent cost shifting
      from inpatient to outpatient settings and to ensure a
      logical relationship between, for example, the cost of
      day surgery and the cost of one night’s surgical
      admission? How do you identify and control “code
      creeping” or other techniques providers use to
      circumvent your attempts to address accurate coding
      and repricing.

 39   What provisions do you have to expedite or guarantee
      that all medical providers rendering services at
      network facilities (i.e. hospitals) are also preferred
      providers?
 40   Please describe how your hospital network
      reimbursements are currently arranged (i.e., % off
      retail, DRG, per diem, capitation, other)? If a
      combination of methodologies exist, please provide
      the approximate percentage distribution of each.




Preferred Provider Network                                     32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   22 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK
SECTION 2 - QUALITY MEASUREMENTS
 41   Does your organization measure surgical outcomes
      from claims data, chart review, patient survey and/or
      MD Survey?
 42   What is your readmission rate related to surgical
      interventions?
 43   Does your organization use incentives to encourage
      members to seek out minimally invasive surgical
      providers within their network? If so, please explain.

 44   Will your organization work with health plan
      participants to develop high performance networks
      that will steer care to specialty providers that meet
      specific efficiency and quality criteria?
 45   Will your re-credentialing process review data from
      member complaints, individual utilization
      performance, individual quality performance, and
      member satisfaction surveys?
 46   Will your plan provide online tools to members
      seeking referrals to surgeons trained in minimally
      invasive surgery or using the laparoscopic technique?


SECTION 3 - COST EVALUATION/QUANTITATIVE ASSESSMENT
 47   Will your organization provide information directly to
      the member to make specialist physician selections
      that are cost effective for the plan? If so, please
      explain.
 48   Does your organization work with members to
      encourage the adoption of cost-effective surgical
      care? If so, please explain.
 49   Do you provide and maintain a network of qualified
      providers to include those credentialed as having
      advanced skills and training? If so, does this provider
      network deliver cost-effective, quality healthcare
      services that is established and maintained by service
      contracts that reward quality/outcomes performance?

 50   Do your contracted hospitals have financial incentives
      to achieve utilization or cost objectives?
 51   Describe incentives in place to reduce hospital
      lengths of stay and re-admissions.
SECTION 4 - Utilization Review/Case Management



Preferred Provider Network                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   23 of 55
MEDICAL/ DENTAL PREFERRED PROVIDER NETWORK
 52   Will your organization provide information that will
      refer members to more efficient specialists without
      reducing quality?
 53   Describe the services offered that result in members
      returning back to work and/or returning to routine
      activities sooner.




Preferred Provider Network                                   32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   24 of 55
PHARMACY BENEFIT MANAGER

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses
must be made within the designated cell(s) of the worksheet provided.

  1    Complete the General information regarding your
       company in the prior section.
  2    Provide a list of network pharmacies in the McLennan
       County area. Can this list be customized for
       McLennan County?
  3    What credentialing criteria are used to select
       participating pharmacies? Are pharmacies required
       to be re-credentialed? How often?

  4    Confirm that the pharmacies in your network are
       contractually bound to accept the reimbursement
       formula you are proposing. Can a network pharmacy
       choose not to participate if it does not like the
       reimbursement formula? Describe the process by
       which a network pharmacy is removed from the
       network.
  5    Confirm your ability to coordinate ID card production
       with the TPA vendor to produce a single ID card.

Maximum Allowable Cost (MAC) Features:
  6   How many individual entities (i.e., generic drug,
      strength, and dosage form) are on your current MAC
      list? Provide a copy of your complete MAC list,
      including all MAC prices as of January 1, 2011 or
      your most current list.
  7   What formula do you use to set the MAC? How often
      do you update the MAC list? Can you customize the
      list to meet preferences from McLennan County?
      How does the MAC price compare to your discount
      formula in terms of a comparable percentage
      discount?
  8   Complete the following table for both retail and mail
      order claims (use the time period January 1, 2010
      through December 31, 2010): *Cost before benefit
      co-pays applied.
                                       Retail - Avg. Cost Rx*
                                   Retail - Avg. Days Supply
                                       Retail - Avg. Cost/Day
                                  Mail Order - Avg. Cost Rx*



Pharmacy Benefit Mgmt                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                  25 of 55
PHARMACY BENEFIT MANAGER
                              Mail Order - Avg. Days Supply
                                  Mail Order - Avg. Cost/Day
  9  Confirm that all of your pharmacies comply with your
     MAC pricing limits.
 10 What was your generic substitution rate for the time
     period January 1, 2010 through December 31, 2010
     with and without the employee “pay the difference”
     penalty feature?
 11 Provide your percent of prescriptions dispensed as
     “Dispense As Written” by physician DAW and patient
     DAW separately for the time period January 1, 2010
     through December 31, 2010.
Communications/Customer Service
 12 Describe communication efforts for notifying all
     McLennan County plan participants of the new
     pharmacy plan. Enclose copies of all communication
     pieces. Indicate which pieces are available in
     Spanish and other languages.
 13 Provide examples of your standard communications
     materials (both English and Spanish and other
     languages), including without limitation:
     • Principals of managed pharmacy/introduction to
     “managed pharmacy benefits”
     • Formulary features
     • How to Transfer Prescriptions
     • Merits of generic substitution
     • Physician education regarding generic alternatives
     • Letter targeting specific brands or medical
     conditions which are candidates for generic
     alternatives
     • Specialty Pharmacy and Home Delivery programs




  14   Do you have Internet access for member to access
       your pharmacy directory? If yes, what is your Internet
       address and how often is it updated?
  15   Provide the following statistics for the customer
       service unit you are proposing for McLennan County
       accountfor the time period January 1, 2010 through
       December 31, 2010.
       Total calls Received (Count)
       Total calls answered <30 seconds (Count)




Pharmacy Benefit Mgmt                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   26 of 55
PHARMACY BENEFIT MANAGER
       Total calls answered <30 seconds (Percentage of
       Total)
       Total calls abandoned (Count)
       Total calls abandoned (Percentage of Total)
Drug Utilization Review (DUR)
  16 Describe your real time and retrospective system for
      detecting fraud or abuse (patient or pharmacy). Once
      detected, how do you intervene? Provide examples
      of reports used to support these efforts. Provide total
      dollar amounts and percentage amounts of recovered
      fraudulent claims for the time period January 1, 2010
      through December 31, 2010.

  17   Describe what areas are targeted for savings, and
       why?
  18   Indicate the staffing levels of your clinical resources
       (do not include staff model, mail order, or any other
       staffing to support dispensing activities):

       Pharmacist (Pharm D's)
                                               No. of Full-Time
                                               No. of Part-Time
                                Length of Time with Company
       Pharmacist (Masters)
                                               No. of Full-Time
                                               No. of Part-Time
                                Length of Time with Company
       Pharmacist (R. Ph.)
                                               No. of Full-Time
                                               No. of Part-Time
                                Length of Time with Company
       Analyst/Clerical
                                               No. of Full-Time
                                               No. of Part-Time
                                Length of Time with Company
  19   How many accounts are assigned to each clinical
       pharmacist? Are pharmacists responsible for client
       contact and regular meetings?
  20   Describe your physician profiling capability. What do
       you do with this information? Will summary reports
       be available to McLennan County?



Pharmacy Benefit Mgmt                                             32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   27 of 55
PHARMACY BENEFIT MANAGER
  21   Do you have the ability to create edits that would be
       able to block or flag suspected individual aberrant
       prescribing patterns?
  22   Describe your efforts and results in disease
       management. What clinical protocols do you
       currently have in place (if any)? What kind of
       reporting will you provide to show McLennan County
       your results? Does any pharmaceutical manufacturer
       underwrite these programs? If so, how often are
       protocols developed not involving their products?
       Provide examples and proof sources.

  23  Describe your capabilities of integrating medical and
      pharmacy claims data.
  24 Describe your prior authorization programs and their
      measurable results. Include the list of drugs
      McLennan County should consider for prior
      authorization and explain why.
  25 Describe you Specialty Pharmacy Program and
      results.
Formulary Systems
  26 How long has your current formulary been in place?
      How many accounts and employee contracts are
      covered by this system as of January 1, 2011?

  27   Do you have an exception or appeal policy? Who
       handles these requests? Please detail your
       experience and/or proposal for managing exceptions
       and appeals. Will you allow the medical director
       from the Third Party Administrator’s medical review
       unit an opportunity to review formulary changes?

  28   How is drug coverage determined in the formulary?
       What medical resources and references are used?

  29   How often is the formulary updated? How are new
       drug products that arrive on the market prior to a
       formulary update handled? How are physicians and
       plan sponsors notified of new products or product
       changes in the formulary? Provide actual examples.

  30   Is your formulary broken down by therapeutic or
       disease state category? Provide a copy of your
       current mail service and/or retail formulary. Indicate
       changes to be made that may impact McLennan
       County for January 1, 2011.


Pharmacy Benefit Mgmt                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   28 of 55
PHARMACY BENEFIT MANAGER
  31   Will McLennan County, as a self-funded client, be
       eligible for a pharmaceutical manufacturer’s volume
       discount program (“rebates”) if they use an
       open/passive formulary? Will McLennan County
       receive the full amount of the rebates or is a portion
       retained as a management fee? Provide your
       formulas for the calculations of rebates and describe
       the audit procedures to verify the accuracy of the
       rebates.
  32   Can you offer a guaranteed rebate program? Please
       describe.
  33   What programs do you have to increase formulary
       compliance by physicians? How do you monitor and
       promote this compliance?
  34   What programs do you have in place to promote
       generic substitution? Please explain and provide
       specific examples.
  35   What types of programs are in place involving
       therapeutic substitution? Provide examples. If a plan
       sponsor does not want to participate, is that optional?

  36   Are you able to indicate the full retail cost of a
       prescription on receipts presented at the pharmacy?

Mail Service and Specialty Drug Operations
 37 Provide a copy of your typical patient profile,
       prescription order forms, and prescription labels.
 38 Describe your system of providing patient advisory
       information with prescriptions filled:
       • What percentage of prescriptions receives a patient
       information supplement?
       • What is your source for this information? (Provide
       examples.)
       • What is your policy regarding auxiliary
       labels/stickers on the actual prescription vials?

  39   What are the operating hours and location of the mail
       service facility proposed for McLennan County?

  40   Describe your process for ordering refills by mail and
       include a sample refill order form.
  41   Describe your process for ordering refills by phone,
       including zero refill situations. What percentage of
       your refills are ordered by phone? Does the phone
       refill system operate on a 24-hour basis?



Pharmacy Benefit Mgmt                                            32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   29 of 55
PHARMACY BENEFIT MANAGER
  42   How are participants notified of their next refill date?

  43   Detail the methodology used to measure turnaround
       time and track prescriptions through the dispensing
       process. When is a prescription "logged" into the
       system, and visible to customer service
       representatives?
  44   Describe your policy regarding overall generic
       substitution. Are there any products you will not
       substitute? Does this vary from facility location to
       facility location?
  45   Do you engage in repackaging? If so, provide details.

  46   Describe the logistics and management of your
       Specialty Drug Program.
Quality Control
 47 When hiring Registered Pharmacists, what are your
       preferred standards for experience? Do you have
       any absolute minimum standards for experience?
       What steps do you take at hire to verify credentials?

  48   Do you conduct any type of drug screening for new
       hires (professional and non-professional)? Please
       explain.
 49 How are the automated dispensing functions
       supervised and monitored?
 50 What is the in-house turnaround time for
       prescriptions? What process exists to track problem
       prescriptions that are not filled within normal
       turnaround time? How is your turnaround time goal
       monitored?
 51 What type of controls are in place to handle the
       mailing of prescriptions during extreme weather
       conditions?
 52 Explain your process for rectifying damaged
       packages when received by the member.
Reporting
 53 Please describe your standard report package (i.e.,
       no additional cost to McLennan County).
 54 Provide examples of recent client-specific ad hoc
       reporting.




Pharmacy Benefit Mgmt                                             32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   30 of 55
PHARMACY BENEFIT MANAGER
  55  Will McLennan County or the Third Party
      Administrator have an online inquiry and ad hoc
      reporting access to the claims system? Describe how
      this interface would operate. Are there any additional
      costs?
Pharmaceutical Manufacturer (PM)/PBM Relationships
  56 Is your organization owned by a pharmaceutical
      manufacturer? If yes, describe the organizational
      linkages and the degree of integration/collaboration
      between your organizations.

  57   Is your organization not owned by, but strategically
       aligned with a PM? If yes, describe the strategic
       alliance and the degree of integration/collaboration
       between your two organizations.

If you answered Yes to the above 2 questions, please continue this section
   58 What are your owner/partner PM’s top five drug
        products by dollar volume through your organization
        (provide separately for mail and retail). For 2009 and
        2010, provide the following for the drugs identified by
        the previous question:
        • Percentage market share (within the most widely
        prescribed therapeutic category)
        • By units dispensed
        • By dollar volume
        • Provide the above information for each of the top
        three competing products within the same therapeutic
        categories.

  59   For each of the top five PM owner/partner products
       above and their top three competing drugs, show how
       each are currently displayed in your formulary
       document (including relative dollar or other price
       indicator). Further, for all of these products, list
       current your current discount and allowable amount
       (bottle of 100), and what percent of the list price each
       are reduced by rebates or other special pricing
       arrangements that will flow back to plan costs.




Pharmacy Benefit Mgmt                                             32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   31 of 55
PHARMACY BENEFIT MANAGER
  60   If you have a mail-order operation, list all preferred
       drugs that are involved with phoning physicians to
       request changing the prescription. Indicate which of
       these drugs are manufactured by your owner/partner
       PM. Further, for each therapeutic exchange, indicate
       the percentage of the physician calls that result in a
       changed prescription.

  61   For 2009 and for January 1, 2010 through December
       31, 2010, in mail order, what percent of generics
       dispensed were manufactured by your owner/partner
       PM?
  62 List all of the currently operational or planned disease
       management programs. Indicate which of these
       involve products of your owner/partner.
Pricing/Performance Guarantees
  63 Please provide your:
       • Discount formula pricing as of January 1, 2011.
       Identify your process for determining discounts and
       base pricing and the frequency with which the
       discount is recalculated.
       • MAC pricing must be used for generics. Confirm
       your agreement to this provision. How are generics
       outside the MAC list priced?
       • Dispensing fee for brand; dispensing fee for generic.

       • Provide your administrative fee on a per claim basis.
       Indicate if administrative fees are applied to denied
       claims.
       • Formulary:
       a) % rebates shared with McLennan County
       b) % retained or fixed administrative fee (if any)
       c) Guaranteed level of rebates (on "per prescription"
       basis; guarantee must be NET of retention or
       administrative fees)

       • “Lower of" pricing: confirm that the "lower of"
       formula price or usual and customary price prevails.
       Describe how your system for this works, including
       how your pharmacy contract defines usual and
       customary price. What are your 2010 results for the
       "lower of" feature?
       • Do you have any special pricing formulas other than
       those described for “specialty” or injectable products?
       Please provide details.



Pharmacy Benefit Mgmt                                            32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   32 of 55
PHARMACY BENEFIT MANAGER
      • Indicate all reports and communication materials
      covered by the proposed administrative fee. Provide
      examples.
      • Do you pass administrative rebates back to the
      client? Please elaborate.




Pharmacy Benefit Mgmt                                       32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   33 of 55
SERVICE - DENTAL
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at a later
date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within the
designated cell(s) of the worksheet provided.


1    Give a brief description of the dental care services of
     your company, including prior experience.

2    Please provide a comprehensive description of covered
     benefits and co-payments.

3    Describe how the copay schedule is developed,
     including the targeted percentage discount from usual
     and customary that the copays will provide for
     participants. What percentiles are offered?

4    How often are copays changed? When was the last
     revision? When is the next revision scheduled?

5    What is your procedure for Coordination of Benefits?



6    Describe your provider selection and credentialing
     process?



7    Is you provider network proprietary?



8    Please provide a copy of your provider directory. How
     often are provider directories updated? Is the provider
     directory available on-line via your website?

9    How many providers voluntarily left the Network each
     year for the past three years? Provide the actual
     number and the turnover percentage.

10   Please indicate the number of providers currently
     accepting new patients. How often are provider
     directories updated? Provide a provider directory,
     service area map, and zip code listing for your plan.




Dental                                                         32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                      34 of 55
SERVICE - DENTAL
11   What communication services are available to the
     McLennan County and in what languages. Please
     provide samples of introductory brochures, Summary
     Plan Descriptions, posters, payroll stuffers, identification
     cards, monthly newsletters, etc.
12   Are you duplicating exactly all existing Dental plan
     provisions and features? If not, please explain any
     deviations in your proposed contract compared to the
     current contract.


13   Please describe the type of reporting that will be
     generated on a regular basis and/or tracking utilization
     patterns and costs. Please verify that you will provide
     the following reports with the frequency indicated. Any
     deviations should be clearly indicated. In the event a
     report is required which is not detailed, please indicate
     any additional charges which would be incurred.


     Monthly
     Experience
     Premium vs Claims
     Number of Employees
     Number of Claimants

     Annually
     Claims Analysis Reports - Utilization
     Provider
     Location

     Dollar Amount and Percent Relationships
     Submitted Claims
     Covered Charges

     Year End Accounting




Dental                                                              32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   35 of 55
SERVICES - VISION

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must
be made within the designated cell(s) of the worksheet provided.


1        Give a brief description of the vision care services
         of your corporation including
         Any sub-contractors who will provide services under
         this contract;
         A description of your prior experience in
         administering vision care plans.
         The procedures involved in obtaining services. Do
         employees use a card or claim forms?

2        Provide a description of your claim processing
         system and any manual operations required.

3        Describe any maximum or minimum size restrictions
         on the groups you process.

4        Please review the following scenarios and indicate
         how your plan would address the situation:

         1) An employee's child has lost or broke his/her
         glasses and needs a replacement right away.
         2) An employee's child has lost his glasses several
         times.
5        Please indicate the number of providers currently
         accepting new patients. How often are provider
         directories updated? Provide a provider directory,
         service area map, and zip code listing for your plan.

6        Provide information regarding the various
         reimbursement schedules available through your
         organization's plans, i.e., frames are reimbursed at
         $25, $40, $50, etc. This information should be
         provided for all items covered by your plan

7        How many providers voluntarily left the Network
         each year for the past three years? Provide the
         actual number and the turnover percentage.




Vision                                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                      36 of 55
SERVICES - VISION
8        What communication services are available to the
         McLennan County and in what languages. Please
         provide samples of introductory brochures,
         Summary Plan Descriptions, posters, payroll
         stuffers, identification cards, monthly newsletters,
         etc.

9        Please describe the type of reporting that will be
         generated on a regular basis and/or tracking
         utilization patterns and costs.

10       Are you duplicating exactly all existing Vision plan
         provisions and features? If not, please explain any
         deviations in your proposed contract compared to
         the current contract.


11       Please verify that you will provide the following
         reports with the frequency indicated. Any deviations
         should be clearly indicated. In the event a report is
         required which is not detailed, please indicate any
         additional charges which would be incurred.

         Monthly
         Experience
         Premium vs Claims
         Number of Employees
         Number of Claimants

         Annually
         Claims Analysis Reports - Utilization
         Provider
         Location

         Dollar Amount and Percent Relationships
         Submitted Claims
         Covered Charges

         Year End Accounting




Vision                                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   37 of 55
HIPAA INFORMATION
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at a later
date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within the
designated cell(s) of the worksheet provided.

1      Is your organization compliant with HIPAA and
       HITECH Privacy regulations? If not, what is your plan
       for achieving compliance by the deadlines?

2      Do you have a copy of your Privacy Procedures Plan?
       If so please provide a copy.
3      Do you have a HIPAA compliance team that is
       charged with overseeing compliance? Please
       elaborate.
4      Do you currently share any PHI with any of your other
       sub-contractors or business associates? Do you
       require proof of compliance from your business
       associates? Describe the steps that you implement
       to ensure HIPAA compliance.

5      Will you indemnify McLennan County from penalities
       associated from non-compliance?




HIPAA Information                                              32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                      38 of 55
STOP LOSS

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide
at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made
within the designated cell(s) of the worksheet provided.


1     How long have you (the stop loss reinsurance carrier)
      been in business?

2     Please provide the following financial ratings for the
      stop loss reinsurance carrier.
      AM Best                                        AM Best
                                                    Moody's
                                           Standard & Poors
                                                        Fitch
3     Provide the most recent financial statement for the
      stop loss reinsurance carrier.
4     What percentage of your overall business is medical
      stop loss reinsurance related?
5     Please indicate your company’s annual stop-loss
      premium.
6     Please indicate your company’s total number of stop-
      loss cases (clients) (United States only).
7      Do you reinsure the stop-loss coverage? If so,
      provide details.
8      Please explain your company’s procedure for
      determining reimbursement of claims that exceed the
      specific stop-loss level. When would those amounts
      be reimbursed?
9      Are cost-containment investigation expenses and
      PPO percentage of discount costs included in your
      Specific reimbursements?
10     What is the maximum Specific payout limit?
11     Is there a Run-In limit (amount or time) on “paid” stop
      loss coverage for both the initial year of coverage or
      renewal years?
12     How are specific stop-loss charges derived? Provide
      a description of your rating methodology.
13     Does your Stop Loss contract have any limits for any
      of the following? If so, please describe.
                                                   Transplants
                                            Substance Abuse
                                   Mental Nervous Conditions
                                                         AIDS


Stop Loss                                                        32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                         39 of 55
STOP LOSS
14     If your company offers discounts for utilizing centers
      of excellence or cost management programs, please
      provide details on the programs, affiliated costs at the
      time of claim, and details regarding discounts for
      utilizing those programs.

15     Is the Stop Loss through an MGU? If so, please
      provide Name, Address, and Phone Number of the
      MGU being used.
16     If an MGU, do you handle claims “in-house”? If not,
      who handles them?
17     If an MGU, are there additional Insurance Carriers
      accepting layers of risk? Please disclose the Names,
      Address, and Phone Numbers of those carriers and
      the percentage of risk taken. Answer all of the
      questions in this RFP relating to any carrier assuming
      risk.
18     What type of claims data reporting do you require if
      you provide stop-loss coverage and are not the
      claims payor? Explain in detail the claim data
      information you need from the claims administrator at
      the time of claim.
19     Describe your experience in coordinating claims data
      exchange with Aetna. Are there any additional fees
      or resources needed to coordinate with Aetna?

20     At time of renewal will you agree to quote removing
      any existing large claim from your rating for the group
      overall? Please specify what determines a large
      claim?
21     Will you agree to recognize all eligible claims on the
      effective date of the contract including
      hospitalizations, if any, and those related to pre-
      existing conditions or members no actively at work?

22     Do you require the client to make the initial payment
      for eligible Specific claims, or do you reimburse
      simultaneously once the claim exceeds the retention
      level?
23     Provide details on any claims turnaround
      guarantees.
24     What is the maximum time beyond the date of
      service that you allow for submission of Stop Loss
      payments by a Claims Administrator?




Stop Loss                                                        32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   40 of 55
STOP LOSS
25     How recent must claims experience be in order to
      provide “final terms” and what is the earliest point in
      time that you will finalize and guarantee your terms
      and conditions of coverage?
26     Will you agree to waive any “actively-at-work”
      requirement?
27     Please list three client references for which stop-loss
      claims have been paid.
28     Do you require the TPA to provide Errors &
      Omissions coverage? At what limits?
29     Does your firm have Errors & Omissions coverage?
      If so, who is the carrier and what are your policy
      limits?
30     Do you reserve the right to unilaterally terminate a
      group for poor Experience?
31     Are you licensed to conduct business in the State of
      Texas?
32     Are there any additional surcharges or taxes not
      disclosed in this proposal? Please explain
33     Explain how your company will handle lasering of
      any members, both initially and at renewal. Will you
      guarantee that future enrollees will not be lasered?

34     Will you guarantee renewal terms and conditions in
      advance? Will you guarantee a maximum rate
      adjustment with no additional lasering upon renewal?
      If so, please provide a detailed response.

35     Offer your rate quotations in your standard format.




Stop Loss                                                        32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   41 of 55
COBRA ADMINISTRATION

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide at
a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made within
the designated cell(s) of the worksheet provided.


1       What happens to fees with
        increases/decreases in the population?
2       What other criteria affect fees?
3       Please provide any fee adjustments if the
        client chooses to contract with you for both
        FSA and COBRA Services.
4       Describe the manner in which the change in
        COBRA Administrator would be communicated
        to current participants? Provide samples of
        materials that will be used.

5       Can materials be customized to meet the
        client's needs in English and Spanish?
6       What will you do to assist during
        implementation?
7       Please describe banking arrangements and
        how contributions are collected and transferred
        from beneficiaries to carriers or the employer.

8       Will you assume all mailing responsibility to
        employees?
9       Will the COBRA administrator notify the
        insurance carriers when an employee elects
        COBRA coverage or will the client be required
        to do this?
10      What administrative responsibility will the
        carrier have and what responsibility will the
        client have?
11      How long have you been providing COBRA
        administration?
12      Will invoices be received by mail or
        electronically each month?
13      How will the client communicate eligibility
        information to the carrier? Can everything be
        done electronically via weekly/monthly file
        feeds?




COBRA                                                        32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                                42 of 55
COBRA ADMINISTRATION
14      Provide a description of how this service will
        be administered relating to implementation,
        Initial COBRA notice, Open Enrollment,
        Processes and functions that occur for COBRA
        during open enrollment such as preparation-
        mailing of all materials, receipt and tracking of
        all enrollment forms, handling all customer
        service calls from participants, input of all data
        into the system, reporting of all eligibility to the
        carriers, generation of all new payment
        coupons, reporting of all activity to client,
        COBRA event letters, Premium reconcilation,
        New Hire/Newly eligible notices, Premium
        grace letters, on-line access, shipping and
        handling, reporting.




COBRA                                                          32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   43 of 55
SERVICE - SECTION 125

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses
must be made within the designated cell(s) of the worksheet provided.


1     Will you provide approved employee
      communications? If so, please
      provide samples.
2     Do you have the ability to provide
      daily claims processing?
3     Do you have the ability to provide
      participant status, fund balance and
      claim submissions inquiry via your
      website?
4     Do you offer direct deposit of claims
      reimbursement to your members?

5     Do you provide a 24-hour toll-free
      automated information line for
      participants?
6     Do you provide a 24-hour toll-free
      number for hearing impaired
      individuals?
7     Do you have the ability to provide
      Internet Based Open Enrollment, or
      receive data from the employers on-
      line enrollment system?
8     What ability do you have to provide
      legislative updates?
9     Under the Dependent Care
      Assistance Program, do you offer
      direct reimbursement to day care
      providers?
10    Will you provide annual non-
      discrimination testing?
11    Will you provide a customized Plan
      Document and Plan Description for
      the plan?
12    Do you provide a debit card for
      reimbursement? Please describe any
      additional costs.




Section 125                                                 32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                      44 of 55
SERVICE - SECTION 125
13    Can you provide administrative
      support and claims processing
      support for the Premium Only Plan,
      The Flexible Spending Account and
      Dependent Care Assistance Plan?

14    Would you be willing to provide
      enrollment support throughout the
      year?
15    Can you provide administration of
      elections for contributions to an HSA
      account including deposits into the
      actual HSA account at a designated
      financial institution.




Section 125                                   32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   45 of 55
SERVICE - BASIC & SUPPLEMENTAL LIFE

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must
be made within the designated cell(s) of the worksheet provided.


1      Confirm that you will waive any actively at
       work provisions during the takeover for all
       Life programs.

2      Please detail your definition of “Actively at
       Work”. Under what conditions will coverage
       cease?

3      Confirm that you will take over all existing
       supplemental life insurance volumes for
       employees and their dependents without
       evidence of insurability.

4      Will you offer a one time special open
       enrollment opportunity offering guarantee
       issue without evidence of
       insurability to all eligible applicants?

5      Please detail any minimum participation
       requirements for voluntary life benefit plans.


6      What is the guaranteed issue amount for
       voluntary life insurance for both employee
       and dependents?


7      What evidence of insurability is required for
       amounts over the guaranteed issue?



8       What is the EOI process inclusive of
       turnaround times?



9      Do the life rates include waiver of premium
       for disabled employees?



Life                                                         32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                          46 of 55
9      Do the life rates include waiver of premium
SERVICE - BASIC & SUPPLEMENTAL LIFE
       for disabled employees?


10     Confirm that active covered employees can
       continue coverage on a contributory basis
       once retired.

11     Will you provide quarterly premium and
       claims reports? Please provide a sample of
       these reports.

12     Are you duplicating exactly all existing Life
       and AD&D plan provisions and features? If
       not, please explain any deviations in your
       proposed contract compared to the current
       contract.




Life                                                   32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   47 of 55
SERVICES - DISABILITY

Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will
provide at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be
made within the designated cell(s) of the worksheet provided.


1    Provide the name address and contact
     information for your company.


2    What is normal claim processing time?



3    Please describe your claim filing process?



4    Complete the following chart for each
     proposed plan of benefits:
                     Company’s A.M. Best Rating
                       Maximum Benefit Duration
                             Elimination Period(s)
                  Minimum and Maximum Benefit
                        Hospital Indemnity Benefit
                                 Doctor Bill Benefit
                                              AD&D
                               Waiver of Premium
                                   Survivor Benefit
                      Accelerated Survivor Benefit
                                          Portability
                                       Conversion
                         Partial Disability Benefits
                           Alcohol/Drug Provision
                          Mental Illness Provision
                             Pregnancy Provision
                                Benefit Integration
      Guaranteed Minimum Benefit after Integration

                       Definition of Total Disability
                  Pre-Existing Condition Limitation
                Guarantee Issue - Initial Enrollment
                 Guarantee Issue - Re-Enrollments
                                   W-2 Preparation
                                    Other Benefits:




Disability                                                   32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012                             48 of 55
SERVICES - DISABILITY
5    What are your "guarantee issue" underwriting
     guidelines for the initial enrollment? Please
     describe your pre-existing provisions?

6    Describe underwriting guidelines for currently
     insured employees.



7    Describe the underwriting guidelines for
     annual re-enrollments.


8    Describe initial enrollment procedures.
     (Include sample of enrollment materials)


9    Are you duplicating exactly all existing Dental
     plan provisions and features? If not, please
     explain any deviations in your proposed
     contract compared to the current contract.


10 Does Vendor/Proposer’s proposal assume
   fully pooled rating?

11 If you propose an experience rating approach,
   please describe in detail the morbidity and
   interest assumptions used in arriving at a
   present value of known claims, formula for
   developing delayed claims and IBNR
   reserves, etc.
12 Please provide a detailed description of your
   standard STD/LTD claims procedures,
   including standard procedures for field
   investigators and use of clinics or other
   medical facilities for claim verification.




Disability                                             32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   49 of 55
SERVICES - DISABILITY
13 What is your standard procedure for payment
   of benefits in the event of delay in receipt of
   Social Security or other offset benefits?

14 Please explain Vendor/Proposer’s method for
   establishing claim reserves as new claims
   "open."

15 What is Vendor/Proposer’s formula for
   establishing reserves for incurred but
   unreported claims?


16 Do you offer both Integrated and Non-
   Integrated Plans?
17 Do you have an in-house rehabilitation staff
   dedicated solely to disability claimants? What
   is the background of your rehabilitation staff?


18 What rehabilitation services are provided to
   claimants as incentive for them to return to
   work?
19 Please describe in detail how you administer
   the rehabilitation provision, including
   documentation on its effectiveness.

20 How many claimants per 1,000 of open, active
   claims are involved in an active rehabilitation
   program (your block of business)?

21 What services are provided to provide comfort
   for claimants with ongoing disabilities?

22 What services are provided to assist claimants
   in obtaining Social Security disability?

23 How frequently is proof of disability required?
   What criteria are used for follow-up requests?
   Are benefits suspended if no reply is sent?

24 How are preliminary approving/conditional
   payments handled?
25 Who performs claim investigations? Internal
   or out-sourced?


Disability                                           32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   50 of 55
SERVICES - DISABILITY




Disability              32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx4/23/2012   51 of 55
Voluntary-Cancer Plan
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide
at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made
within the designated cell(s) of the worksheet provided.

1   When did you begin offering cancer
    insurance?
2   Has your company had rate increases on
    existing cancer policies in the last five
    years?
3   Who is eligible for coverage?
4   What are the policy limitations and
    exclusions?
5   Does the policy offer a Waiver of Premium
    Benefit? If yes, please explain.

6    Does the policy offer a first occurrence
    benefit for diagnosis of cancer? Please
    explain.
7   Is the plan portable? If so, do rates change
    upon portability?
8   Provide various rates and levels of
    coverage to allow for differing needs of
    (ACCOUNT NAME) employees.
9   Does this plan offer a wellness benefit?

10 Describe the plan and special features.




Voluntary-Cancer Plan                                         32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx 4/23/2012                           52 of 55
Voluntary-Intensive Care Plan
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide
at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made
within the designated cell(s) of the worksheet provided.


1   What is the minimum and maximum policy
    issue age?
2   What are the eligibility requirements for this
    plan?
3   Who is eligible for coverage?
4   Are benefits guaranteed-renewable for life?

5  Are eligible dependents covered?
6  Are benefit payments made regardless of
   other coverages?
7  What are the policy limitations and
   exclusions?
8  Provide various rates and levels of
   coverage to allow for differing needs of
   (ACCOUNT NAME) employees.
9  Define actively at work and pre-existing
   conditions.
10 Describe the plan and special features.
11 Is the plan portable? If so, do rates change
   upon portability?
12 Does the plan offer a waiver of premium
   benefit?




Voluntary-Intensive Care                                      32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx 4/23/2012                           53 of 55
Voluntary-Accident
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide
at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made
within the designated cell(s) of the worksheet provided.

1   When did you begin offering accident
   expense insurance?
2  What are the eligibility requirements of your
   product?
3  Who is eligible for coverage?
4  Is the plan guaranteed-renewable?
5  Is the plan portable. If so, do the premiums
   change upon portability?
6   Is there a wellness benefit?
7   Is family coverage available?
8  What are the policy limitations and
   exclusions?
9  Define pre-existing conditions.
10 Describe the plan and special features.
11 Does the plan offer a Waiver of Premium
   Benefit?




Voluntary-Accident                                            32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx 4/23/2012                           54 of 55
Voluntary-Heart Stroke
Notice: All questions must be answered. Please refrain from responding with a phrase such as “cannot provide at this time or will provide
at a later date if selected, etc.” The reviewer will consider these answers non-responsive to the question. All responses must be made
within the designated cell(s) of the worksheet provided.


1   When did you begin offering heart/stroke
    insurance?
2   Has your company had rate increases on
    existing heart/stroke policies in the last five
    years?
3   Who is eligible for coverage?
4   What are the policy limitations and
    exclusions?
5   Does the policy offer a Waiver of Premium
    Benefit? If yes, please explain.

6   Does the policy offer a first occurrence
   benefit? Please explain.
7  Is the plan portable? If so, do rates change
   upon portability?
8  Provide various rates and levels of
   coverage to allow for differing needs of
   (ACCOUNT NAME) employees.
9  Does this plan offer a wellness benefit?
10 Describe the plan and special features.




Voluntary-HeartStroke                                         32ae42c0-9ec7-4ef6-93b9-f19d586fa535.xlsx 4/23/2012                           55 of 55

				
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