Medical RFP by HC120829193156

VIEWS: 4 PAGES: 29

									Exhibit 1                                                                                                 RFP 11-0111




                                                                                Exhibit 1
                                                                                Single Location: SI PPO
BACKGROUND AND ADMINISTRATIVE INFORMATION RFP 11-0111
Geo Access Reporting
The City would like to determine the availability of key health care providers to each local employee
population. Please prepare Geo-Access report(s) for each network and/or plan type that you are
quoting on, using the parameters in the table below. Note that it is important that you follow the exact
parameters. The report should show hospital and provider availability by physician specialty for each zip
code (or community). Report output is required for those with access and those without access, based
upon the stipulated parameters. The report output should show the average distance to each provider
group. Do not send the data in a read-only file. Use only physicians accepting new patients in your
Geo-Access provider file. The census you need to perform this mapping is described in the worksheet
"Census". Label completed Geo-Access report as Attachment Geo-Access Report.




                Practice Specialty                      Number of Providers      Miles from Employees
                                                            Available                  Residence
Adult Physicians (Family Practice, General Practice,                 2                       8
General Internal Medicine)

General Pediatricians                                                2                       8
Obstetricians/Gynecologists                                          2                       8
Acute Care Hospitals                                                 1                      10



Current and Proposed Medical Plans
Currently the City of Fort Worth offers two PPO benefit plans to their active employees, under age 65
retirees and COBRA participants. The option of a traditional indemnity plan and a Medicare Advantage
plan is offered to their Medicare Eligible retirees over age 65. Beginning in 2013 HSA benefit plan may
be offered to their active employees, under 65 retirees and COBRA participants. The benefit plan
options offered to their retirees over age 65 will not change.

The selected plan will replace the current medical plan offerings.


A summary of the proposed plan(s) is provided in the "Plan Design" worksheet(s). A summary of the
current benefits offered by The City is included in the same worksheet(s). Deviations should be clearly
noted and explained.


The details of the current plan(s) are included in the following supplemental exhibit(s)/appendix(ces):
Summary Plan Description (SPD) and Summary of Material Modifcations




Contribution Levels
Employees elect to make contributions on a before-tax basis.

cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012       1
Exhibit 1                                                                                             RFP 11-0111


                                                                             Exhibit 1
                                                                            Single Location: SI PPO
The percent and/or dollar amounts of employee and/or employer contributions are as follows:



The following chart indicates the employee and employer contribution for 2010 - see attachments for
rate history:

         Coverage              Plan Option #1 Basic      Plan Option#2 Basic
                                                                Plus
Single                          EE = $55.36 - ER =       EE = $138.38 - ER =
                                     $498.19                   $498.19
Employee + Spouse               EE= $346.64- ER =        EE = $516.05 - ER =
                                     $782.62                   $782.62

Employee + Child(ren)          EE = $299.59 - ER =       EE = $454.86- ER =
                                     $735.56                  $735.56

Family                         EE = $468.14 - ER =        EE = $722.84 - ER
                                    $1081.84                  $1059.62

Refer to contribution attachments for details regarding the retiree's contributions


  Coverage Effective           Plan Option #1 Basic      Plan Option#2 Basic
    January 1, 2011                                             Plus
Current Vendor                        Aetna                     Aetna
Plan Type                             PPO                         PPO
Funding Arrangement                Self-Funded                Self-Funded
Stop Loss: Aggregate                   N/A                        N/A
Attachment Point
Stop Loss: Aggregate                   N/A                        N/A
Corridor
Stop Loss: Specific                 $400,000                   $400,000
Deductible


Rate History
The rate history is attached


Enrollment, Premiums (if appropriate) and Claims History
Enrollment and claims information are included


Large claims are provided.




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012        2
Exhibit 1                                                                                                 RFP 11-0111


                                                                              Exhibit 1
                                                                             Single Location: SI PPO
Enrollment elections may not be changed until the next open enrollment period, unless there is an IRS-
qualified change in status.
Selection Criteria
The City is committed to offering health care programs which promote cost-effective and patient-
oriented care.
The City has provided selection criteria in their Attachment 1 (City RFP 11-0111). The City's selection
committee and Aon Hewitt will review the proposals and determine which meets the objectives and
goals of the City.
Additional information for your consideration in rfp preparation:
* Competitive program costs or premiums, as applicable

* Ability to maximize managed care network and utilization management savings
* Willingness to accept performance standards for achievement of projected cost savings and other
operational activities

Network Superiority
* Availability of competitively-priced provider networks
* Accessible panel consisting of "providers of choice"

* Acknowledgement by vendor's current Citys that provider networks and utilization management
services meet or exceed expectations
Benefit Provisions
* Ability to provide the requested benefit plan designs

Administrative Services

* Proven claims administration system with advanced cost management features
* Willingness to dedicate superior staff to The City's account management function
* Satisfied Citys of similar size and complexity to The City
* Ability to accept a self-bill and monthly carrier reconciliation, faxing and/or emailing discrepancies to

* Ability to accept electronic transfer of employee eligibility information
* Evidence of an organized approach to program implementation (project management)

Proposal Process
This is a confidential marketing effort. The RFP questions and workbook should be treated as
confidential business documents.




We want this to be an interactive process. We will make every reasonable effort to provide you with
sufficient data for your responses. You are invited to ask questions during the proposal process and to
seek additional information, if needed. All questions relating to the City required documentation or
information should be directed to the Purchasing Manager listed in Attachment 1.




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012              3
Exhibit 1                                                                                                RFP 11-0111


                                                                              Exhibit 1
                                                                              Single Location: SI PPO
All questions regarding the electronic RFP questions or completion of responses in cells should be
directed to:

Consultant's Name          Lenee Goyette
Consultant's Title         Assistant Vice President
Address                    301 Commerce Street, Suite 2101
City, State, Zip           Fort Worth, TX 76102
Phone Number               817-339-2009
Cell Number                817-763-4384
Fax Number                 817-339-2016
E-mail Address             Lenee.Goyette@aonhewitt.com
                                               OR

Consultant's Name          Diana Stone

Consultant's Title         Benefit Specialist
Aon Hewitt                 Aon Hewitt
Address                    301 Commerce Street, Suite 2101
City, State, Zip           Fort Worth, TX 76102
Phone Number               817-339-2011
Fax Number                 817-339-2016
E-mail Address             Diana.Stone@aonhewitt.com


Finalists selected at the end of the vendor analysis may be asked to participate in vendor interviews.


Proposal Format
Please refer to Attachment 1 for specific instructions. You must also complete these 3 parts for the
medical administration proposal. You must print the three completed parts outlined below and
incorporate in to the format described in attachment 1 as well as save the entire workbook with your
completed responses and the worksheets to CD. You will submit 1 original and 14 copies along with the
2 sets of CDs containing the completed excel workbook and worksheets.


  Part 1: Questionnaire File: The Questionnaire and a sheet to provide Explanations are contained in this
  Excel file. You are expected to respond to the Questionnaire by entering your responses in this file.
  The majority of the questions in the Questionnaire have been structured to elicit declarative responses
  through the use of drop down boxes.

  * Click on the response cell in the Response column;
  * Click on the down arrow which appears directly to the right of the cell;

  * Click on the response that best describes your answer.

  Next to each response cell, additional space is available for a brief text explanation. However, if the
  length of the explanation is greater than 400 characters, you must go to the "Explanation" worksheet
  to provide your detailed explanation. All explanations must be numbered to correspond to the
  questions to which they pertain and should be brief.

  If you have any difficulty entering data in the appropriate cells, please contact Lenee Goyette at 817-
  339-2009.

cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012        4
Exhibit 1                                                                                                RFP 11-0111


                                                                                  Exhibit 1
                                                                                  Single Location: SI PPO

  Part 2: Financial File: A worksheet(s) to enter your financial quotation is contained within the companion
  Excel file. Generally, the types of information that you will be entering into this file are your financial
  quotation, plan design deviations, provider reimbursement data, etc., if requested. You are expected

  Part 3: Electronic File Attachments: Any attachments that you are being asked to provide about your
  organization must also be submitted electronically. Hard copy attachments will not be accepted. An
  explanation of each attachment that you are required to provide appears in the Questionnaire; please
  be sure to follow the naming conventions that are provided for each attachment.

In order to help you organize your proposal and ensure that it is complete, please review the following
list to ensure that you have provided each required item.



Part 1. Questionnaire File:


                                  Information                                        Name of Worksheet
Questionnaire                                                                      Questionnaire
Explanations, if necessary                                                         Explanation



Part 2. Financial File:
                                  Information                                        Name of Worksheet

PPO Plan Design                                                                    Plan Design (2)

PPO Self-Insured Rate Quote                                                        SQuote(2)
Hospital Network - 1-3 Plan(s)/1 Location                                          Hosp(1)
Proposed Plan Description
Provider Directories
Geo-Access Report
Management Reporting Package
Implementation Schedule
Premium (or ASO, if appropriate) Billing Description
Suggested Employer Contract
Appeal and Grievance Policies
Marketing Materials
ID Card
Annual Report
Audited Financial Report
Member Enrollment Materials




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012        5
Exhibit 1                                                                                          RFP 11-0111


                                                                                Exhibit 1
                                                                               Single Location: SI PPO
Please be sure you read and review all parts of the RFP Instructions and the Employer Provided
Requirements carefully. Incomplete proposals may be declined.
All costs associated with your proposal, including preparation and presentation, will be borne by your
Comments: Optional


Completeness
We ask that your proposal be complete and that it comply with all aspects of these specifications. Any
missing information could disqualify your proposal. Unless you note to the contrary, we will assume
that your proposal conforms to our specifications in every way.




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012     6
                                                                             RFP 11-0111 Exhibit 1
            Request for Proposal (RFP) for City of Fort Worth
            Single Location: SI PPO

            To Vendor: Use Column Q to provide a brief explanation.
            However if the length of the explanation is greater than 400
            characters, you must use the "Explanation" worksheet to
            provide your detail explanation.

            MEDICAL RFP                                                      Answer Format        Format Type            Response   Explanation

I.          GENERAL PLAN INFORMATION                                         Answer Format        Format Type            Response   Explanation
     1      Vendor Brand Name                                                     text                   Text

     2      Parent Co. Legal Entity Name                                          text                   Text

     3      d/b/a (Name in Marketplace)                                           text                   Text

     4      Year Established/Incorporated                                    Month Day, Year             Date

     5      NAIC Code                                                           numeric               Number

     6      Industry Classification                                               text                   Text

     7      Stock Ticker #                                                        text                   Text

     8      FEIN (Federal Employer Identification Number)                         text                   Text

                                                                                                      ListBox,
     9      Tax Status                                                       drop down box         ListTaxStatus

     10     Public or Privately-Held                                         drop down box      ListBox,Listrngpub

     11     Ownership/Controlling Interest Structure                              text                   Text

            Comment: Description of how the organization is structured
            (operating companies, wholly-or partially-owned subsidiaries,
     12     etc.). Provide information on all organizations with more than
            a 7.5% stake in your firm, including legal and financial
            arrangements with these organizations.

            Mergers, acquisitions, spin-off's, significant
     13                                                                           text                   Text
            organizational changes in past 2 years.
            Anticipated changes in ownership or business
            developments, including but not limited to
     14                                                                           text                   Text
            mergers, stock issues, and the acquisition of new
            venture capital.
            Organization's core competency(ies), including
     15     significant differentiators that the organization                     text                   Text
            delivers to its customers.
            How many Legal Entities will issue policies for this
                                                                                               ListBox,ListLegalEntiti
     16     group should your organization be awarded this                   drop down box               es
            business?
     17     Legal Entity #1 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date

          b. NAIC Code                                                          numeric               Number

          c. Coverages to be underwritten by this entity                          text                   Text

     18     Legal Entity #2 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date

          b. NAIC Code                                                          numeric               Number

          c. Coverages to be underwritten by this entity                          text                   Text

     19     Legal Entity #3 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date

          b. NAIC Code                                                          numeric               Number

          c. Coverages to be underwritten by this entity                          text                   Text

     20     Legal Entity #4 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date

          b. NAIC Code                                                          numeric               Number

          c. Coverages to be underwritten by this entity                          text                   Text

     21     Legal Entity #5 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date

          b. NAIC Code                                                          numeric               Number

          c. Coverages to be underwritten by this entity                          text                   Text

     22     Legal Entity #6 - Name                                                text                   Text

          a. Year Established/Incorporated                                   Month Day, Year             Date



          cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                         7                                 RFP 11-0111
                                                                             RFP 11-0111 Exhibit 1
              Request for Proposal (RFP) for City of Fort Worth
              Single Location: SI PPO

              To Vendor: Use Column Q to provide a brief explanation.
              However if the length of the explanation is greater than 400
              characters, you must use the "Explanation" worksheet to
              provide your detail explanation.

              MEDICAL RFP                                                    Answer Format     Format Type   Response   Explanation

           b. NAIC Code                                                         numeric          Number

           c. Coverages to be underwritten by this entity                         text               Text

      23      Legal Entity(ies) - Comments                                        text               Text

      24      Home Office Location                                                text               Text

           a. Address Line #1                                                     text               Text

           b. Address Line #2                                                     text               Text

           c. City                                                                text               Text

           d. State                                                               text               Text

           e. Zip                                                                 text               Text

      25      Web Address                                                         text               Text



      26      PPO Plan Name                                                       text               Text

      27      Street Address                                                      text               Text

      28      City                                                                text               Text

      29      State                                                               text               Text

      30      Zip                                                                 text               Text

      31      Web Address                                                         text               Text

      32      PPO Operational Date                                           Month Day, Year         Date

      33      NCQA Accreditation Status                                           text               Text

      34      Last NCQA Status Date Change                                   Month Day, Year         Date

      35      URAC Accreditation
           a. Health Plan                                                         text               Text

           b. Health Network                                                      text               Text

      36      PPO Commercial Group Membership                                  number, 0        Number, 0



              Please indicate the vendor contact, should
              there be any questions concerning submitted
              responses.
      37      Primary Contact
           a. Name                                                                text               Text

           b. Title                                                               text               Text

           c. Address                                                             text               Text

           d. City                                                                text               Text

           e. State                                                               text               Text

           f. Zip                                                                 text               Text

           g. Phone Number                                                        text               Text

           h. Fax Number                                                          text               Text

           i. E-mail Address                                                      text               Text

      38      Secondary Contact
           a. Name                                                                text               Text

           b. Title                                                               text               Text

           c. Address                                                             text               Text

           d. City                                                                text               Text

           e. State                                                               text               Text

           f. Zip                                                                 text               Text

           g. Phone Number                                                        text               Text

           h. Fax Number                                                          text               Text

           i. E-mail Address                                                      text               Text



II.           PLAN DESIGN/FINANCIAL INFORMATION                              Answer Format     Format Type   Response   Explanation
              Adhere to the proposed plan design shown in
              the worksheet(s), "Plan Design" in preparing
              the quote.

           cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    8                         RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format      Format Type          Response   Explanation

       The proposal is issued in accordance with the
       specifications, assumptions and information
       included in this Request for Proposal, the
                                                                                      Listbox,ListYesNoSee
1      accompanying worksheets and standard services                  drop down box          Explain
       addressed in the Request for Information
       previously submitted. If "No", indicate deviations
       in "Explanation" column and/or worksheet.


       Plan Design                                                    Answer Format      Format Type          Response   Explanation
       Review and detail deviations from the proposed
2      plan(s) design shown in the worksheet(s), "Plan                drop down box   Listbox,ListCompleted
       Design."
       Include a concise description of how this health
       plan covers transitional conditions, such as
       pregnancy, chemotherapy, etc., if a new member
3                                                                     drop down box   Listbox,ListAttached
       is receiving treatment from a non-participating
       provider. Name the file: [Your Organization's
       Name]_TransitionalCare.

       For those employees outside of your service area,
       provide a proposed out-of-area plan design.
4                                                                     drop down box   Listbox,ListAttached
       Name the file: [Your Organization's
       Name]_OutofArea_ Plan.



       For HS A's please describe your ability to
5      integrate Rx data with a) your PBM b) an outside               drop down box   Listbox,ListAttached
       PBM




       Financial - Program Fees
       For self-insured quotes, provide your financial
6                                                                     drop down box   Listbox,ListCompleted
       quotation in the worksheet(s), "SQuote."

       Use of a specific bank is required for self-insured
7                                                                     drop down box     Listbox,ListYesNo
       coverages.


8      If yes, indicate bank name.                                        text                  Text


       For the self-insured coverages requested, the
       claim amount paid will be the negotiated amount.
       In other words, The City will pay actual negotiated
9                                                                     drop down box     Listbox,ListYesNo
       amount; none of the savings will be retained by
       your organization or shared with any other
       organization.

       Indicate if you will provide the City a transition
       fund to cover the cost of communicating the
10     vendor change and other miscellaneous costs                    drop down box     Listbox,ListYesNo
       associated with change (spds, printing). Be sure
       to include suggested amount of fund.



       Indicate below the fees that will apply to
11     process run-out claims if the contract were
       terminated for self-insured coverages:




     a. Administration/overhead




     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                     9                               RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format    Format Type        Response   Explanation


       Per Employee Per Month                                            dollar, 2        Dollar,2



       Per Claim Transaction                                             dollar, 2        Dollar,2


     b. Claim processing fees


       Per Employee Per Month                                            dollar, 2        Dollar,2


       Per Claim Transaction                                             dollar, 2        Dollar,2

     c. Network access fees

       Per Employee Per Month                                            dollar, 2        Dollar,2

       Per Claim Transaction                                             dollar, 2        Dollar,2

     d. UR fees
       Per Employee Per Month                                            dollar, 2        Dollar,2

       Per Claim Transaction                                             dollar, 2        Dollar,2

     e. Other Fees

       Per Employee Per Month                                            dollar, 2        Dollar,2


       Per Claim Transaction                                             dollar, 2        Dollar,2



       Aon Hewitt Compensation                                        Answer Format    Format Type        Response   Explanation
       The quoted rates/fees include
12     commissions/compensation requested in the                      drop down box   Listbox,ListYesNo
       Introduction Section of this RFP. (0%)

       For self-insured coverages requested, notification
       of renewal fees (to be accompanied by a detailed
13     breakdown of all administrative expense                        drop down box   Listbox,ListYesNo
       components) is to be provided at least 120 days in
       advance of the contract anniversary date.



       Vendor will provide routine underwriting- and
14                                                                    drop down box   Listbox,ListYesNo
       actuarial-related contract services.



       The vendor will provide a complete description of
15                                                                    drop down box   Listbox,ListYesNo
       the methodology inherent in the renewal work up.

       The vendor will provide a definition of all terms
       and an itemization of all assumptions used
       including projected claims, trend factors and the
16                                                                    drop down box   Listbox,ListYesNo
       formula involved, plus a complete explanation of
       the logic inherent in the final renewal rate/fee
       package.
       For self-insured coverages requested, the vendor
17     will provide Administrative Services Only (ASO)                drop down box   Listbox,ListYesNo
       fee and rate justification.



       The vendor will provide a comparison of old and
18                                                                    drop down box   Listbox,ListYesNo
       new rates and factors.




     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                  10                             RFP 11-0111
                                                                             RFP 11-0111 Exhibit 1
              Request for Proposal (RFP) for City of Fort Worth
              Single Location: SI PPO

              To Vendor: Use Column Q to provide a brief explanation.
              However if the length of the explanation is greater than 400
              characters, you must use the "Explanation" worksheet to
              provide your detail explanation.

              MEDICAL RFP                                                    Answer Format     Format Type          Response   Explanation

              For self-insured coverages requested, the vendor
              will provide pseudo premium rates, claim
       19                                                                    drop down box    Listbox,ListYesNo
              projections and estimated incurred but unpaid
              (IBNR and O&U) claim reserves.




III.          MEDICAL DELIVERY SYSTEM                                        Answer Format     Format Type          Response   Explanation

              Please attach a copy of the provider directory(ies)
              for all locations for which you are quoting. Name
       1                                                                     drop down box   Listbox,ListAttached
              the file: [Your Organization's
              Name]_ProviderDirectories.



            List participating Acute Care Hospitals for the
       2 a. geographic locations as shown in the                             drop down box   Listbox,ListAttached
            worksheet(s), "Hosp".




              Employees' Access to Providers                                 Answer Format     Format Type          Response   Explanation
              Has the Geo-Access reporting been completed
       3                                                                     drop down box    Listbox,ListYesNo
              using the requested parameters?
       4      Please note the geo-mapping method used:                       drop down box     Listbox,ListGeo
              Please note a Provider TIN listing has been
              provided. Have you provided an excel based
       5                                                                     drop down box    Listbox,ListYesNo
              disruption report showing which providers would
              be in or out of network?:
IV.           REPORTING (Management Reports)                                 Answer Format     Format Type          Response   Explanation

              Please indicate your willingness to comply
              with the following reporting requirements.
              Each report must reflect experience by line of
              coverage split between employees,
              dependents, and COBRA participants and
              under/over age-65 retirees (if applicable), plus
              a total for all activity. Business Unit/Divisional
              Breakdowns and Categories of Employees.

              Attach a sample management and utilization
              report(s) that would be prepared for The City.
       1                                                                     drop down box   Listbox,ListAttached
              Name the file: [Your Organization's Name]_
              MgmtRptgPkg.
              Separate reports will be provided for each of The
       2      City's strategic business units (as noted above) for           drop down box   Listbox,ListPlanType
              each plan type requested.




              Monthly Reports                                                Answer Format     Format Type          Response   Explanation



            cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    11                              RFP 11-0111
                                                                            RFP 11-0111 Exhibit 1
             Request for Proposal (RFP) for City of Fort Worth
             Single Location: SI PPO

             To Vendor: Use Column Q to provide a brief explanation.
             However if the length of the explanation is greater than 400
             characters, you must use the "Explanation" worksheet to
             provide your detail explanation.

             MEDICAL RFP                                                    Answer Format    Format Type        Response   Explanation

             Monthly reporting containing the following
     3
             information:

          a. Paid Claims                                                    drop down box   Listbox,ListYesNo

          b. Capitation (if applicable)                                     drop down box   Listbox,ListYesNo

          c. Administrative/Network Fees (if applicable)                    drop down box   Listbox,ListYesNo

          d. Premiums (if applicable)                                       drop down box   Listbox,ListYesNo

          e. Claims exceeding pooling point or stop loss levels             drop down box   Listbox,ListYesNo




          f. Monthly enrollment counts.                                     drop down box   Listbox,ListYesNo




             Quarterly Reports                                              Answer Format    Format Type        Response   Explanation
             Quarterly reporting containing the following
     4
             information:
          a. Electronic eligibility listing                                 drop down box   Listbox,ListYesNo

          b. Claims paid by $ amount increments                             drop down box   Listbox,ListYesNo

          c. Individual claims > 50% pooling/stop loss levels               drop down box   Listbox,ListYesNo

          d. Reconciliation of claim drafts to paid claims                  drop down box   Listbox,ListYesNo



             Annual Reports                                                 Answer Format    Format Type        Response   Explanation
             General claim utilization reports by major line
     5
             of coverage identifying:
          a. Claims submitted                                               drop down box   Listbox,ListYesNo

          b. Claims eligible                                                drop down box   Listbox,ListYesNo

          c. Deductible and coinsurance application                         drop down box   Listbox,ListYesNo
             Payment reductions due to network negotiated
          d.                                                                drop down box   Listbox,ListYesNo
             rates
          e. R&C cutbacks and savings                                       drop down box   Listbox,ListYesNo

          f. COB savings                                                    drop down box   Listbox,ListYesNo

          g. Ineligible expenses                                            drop down box   Listbox,ListYesNo

          h. Net benefits paid by major line of coverage                    drop down box   Listbox,ListYesNo
          Claim utilization report will show separate
     6
          experience for:
       a. Employees                                                         drop down box   Listbox,ListYesNo

          b. Dependents                                                     drop down box   Listbox,ListYesNo

          c. Non Medicare Eligible Participants                             drop down box   Listbox,ListYesNo

          d. Medicare Eligible Participants                                 drop down box   Listbox,ListYesNo

          e. COBRA Participants                                             drop down box   Listbox,ListYesNo

     7       Electronic format of claims data.                              drop down box   Listbox,ListYesNo
             Employee contested claims separated by denial
     8                                                                      drop down box   Listbox,ListYesNo
             reason.
     9       Claim lag report.                                              drop down box   Listbox,ListYesNo

     10      Network savings reports for each network offered.              drop down box   Listbox,ListYesNo

     11      Most-utilized hospitals and physicians reports.                drop down box   Listbox,ListYesNo

             A year-end financial accounting for the program
     12                                                                     drop down box   Listbox,ListYesNo
             within 90 days of the contract anniversary date.



V.           ADMINISTRATIVE AND OPERATIONAL ISSUES                          Answer Format    Format Type        Response   Explanation
             Implementation Services



          cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                   12                             RFP 11-0111
                                                                     RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
      Single Location: SI PPO

      To Vendor: Use Column Q to provide a brief explanation.
      However if the length of the explanation is greater than 400
      characters, you must use the "Explanation" worksheet to
      provide your detail explanation.

      MEDICAL RFP                                                    Answer Format     Format Type          Response   Explanation

     Prepare a detailed schedule and time frame to
     implement this program by the effective date.
     Please indicate the implementation
1                                                                    drop down box   Listbox,ListAttached
     responsibilities of your organization, The City and
     Aon Hewitt. Name the file: [Your Organization's
     Name]_Implementation.
     Indicate your willingness to provide the
2
     following services, if required:
     Design, submit for The City's approval, and print
  a. forms with The City's logo for claims submission,               drop down box    Listbox,ListYesNo
     where required.
     Provide network service area zip codes and
  b. electronic directories for The City's voice                     drop down box    Listbox,ListYesNo
     enrollment system.
     Load, audit and insure clean eligibility data at least
  c.                                                                 drop down box    Listbox,ListYesNo
     5 days prior to program effective date.
     Indicate your willingness to provide the
3
     following pre-implementation services:

       [AonHewitt, on behalf of The City, will conduct a
       quality review of the plan design to be loaded in
       the claims system(s) prior to implementation (or
       as soon thereafter as reasonably possible). As the
       selected carrier or administrator, you agree to pay
       the cost of this review, up to $[Variable #1]. You
       will provide all necessary support to enable Aon
    a. Consulting, Inc., on behalf of The City, to review            drop down box    Listbox,ListYesNo
       claims in a test environment that mirrors the plan
       information present in the "live" claims processing
       system. If this review cannot be supported
       remotely and requires an on-site review, you will
       be responsible for travel costs up to $[Variable
       #2]. All costs associated with this review shall not
       be included in The City retention fee.]



      Other Services                                                 Answer Format     Format Type          Response   Explanation



      List the location(s) of your service centers that
      would be servicing The City's employees and the
4     corresponding geographic areas/regions covered
      by the respective location. Use the "Explanation"
      column and/or worksheet if you need more space.




    a. Service Center 1
      Location 1                                                         text                 Text

      Geographic Region(s) Covered 1                                     text                 Text



    b. Service Center 2


      Location 2                                                         text                 Text

      Geographic Region(s) Covered 2                                     text                 Text

    c. Service Center 3
      Location 3                                                         text                 Text

      Geographic Region(s) Covered 3                                     text                 Text

      Indicate whether the following additional
5     services are provided and the associated
      costs.
    a. COBRA: List Box: Attached, Not Attached


    cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                   13                               RFP 11-0111
                                                                         RFP 11-0111 Exhibit 1
          Request for Proposal (RFP) for City of Fort Worth
          Single Location: SI PPO

          To Vendor: Use Column Q to provide a brief explanation.
          However if the length of the explanation is greater than 400
          characters, you must use the "Explanation" worksheet to
          provide your detail explanation.

          MEDICAL RFP                                                    Answer Format      Format Type          Response   Explanation

          Service Provided?                                              drop down box     Listbox,ListYesNo

          Associated Cost                                                   dollar, 2          Dollar,2

     b. COBRA: List Box: Attached, Not Attached
          Service Provided?                                              drop down box     Listbox,ListYesNo

          Associated Cost                                                   dollar, 2          Dollar,2

     c. HIPAA Administration: List Box: Attached, Not
        Attached
        Service Provided?                                                drop down box     Listbox,ListYesNo

          Associated Cost                                                   dollar, 2          Dollar,2

     d. Other: List Box: Attached, Not Attached
          Service Provided?                                              drop down box     Listbox,ListYesNo

     Associated Cost                                                        dollar, 2          Dollar,2
     Indicate which conversion plans are offered
6    post-COBRA coverage; if offered, indicate the
     name of insuring entity.
  a. PPO
                                                                                         Listbox,ListNameInsur
     b. Offered/Not Offered?                                             drop down box           eEntity
     c. Name of Insuring Entity                                               text                 Text



          Are in network Chiropractors included in the Fort
     d.                                                                  drop down box     Listbox,ListYesNo
          Worth area?



        Are mental health/substance abuse providers
     e. considered a separate network or part of your                    drop down box     Listbox,ListYesNo
        owned network in the Fort Worth area?

        Please provide a listing of the Centers of
     f. Excellence in the DFW area and for the state of                  drop down box   Listbox,ListAttached
        Texas. List each center's sepciality.

          The City has one on-site Customer Service
          Representative from the health plan administrator.
     g.                                                                  drop down box     Listbox,ListYesNo
          Please indicate your willingness to duplicate this
          service.


          Attach a description of premium or administrative
          fee billing procedures. Include information on the
          timing of billing, billing-payment reconciliations
7                                                                        drop down box   Listbox,ListAttached
          and ability to provide for the City's self-billing.
          Name the file: [Your Organization's
          Name]_PremiumBilling.

          The plan will contain the birthday rule and will
8         have group to group coordination of benefits                   drop down box     Listbox,ListYesNo
          provision.
          To the extent permitted under state law, no fault
          auto insurance, governmental plans coordination
9                                                                        drop down box     Listbox,ListYesNo
          and negligent third party subrogation will be
          administered.

          All claim records and eligibility data used by the
          carrier in its role as claim administrator shall
10                                                                       drop down box     Listbox,ListYesNo
          remain the property of The City as Plan Sponsor
          and Plan Administrator under ERISA.




     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                       14                               RFP 11-0111
                                                                       RFP 11-0111 Exhibit 1
        Request for Proposal (RFP) for City of Fort Worth
        Single Location: SI PPO

        To Vendor: Use Column Q to provide a brief explanation.
        However if the length of the explanation is greater than 400
        characters, you must use the "Explanation" worksheet to
        provide your detail explanation.

        MEDICAL RFP                                                    Answer Format      Format Type           Response   Explanation


        Vendor agrees to monitor federal and state
        legislation affecting the delivery of medical
11      benefits under the plan and to report to The City              drop down box     Listbox,ListYesNo
        on those issues in a timely fashion prior to the
        effective date of any mandated plan changes.


        Address deductibles fully or partially met through
12                                                                     drop down box   Listbox,ListYesExplain
        the date of termination.

        Address amounts applied toward out-of-pocket
13 a.                                                                  drop down box   Listbox,ListYesExplain
        maximums through the date of termination.


14      The health plan will pay for printing costs for:


     a. ID Cards                                                       drop down box     Listbox,ListYesNo



        Performance Benchmarks                                         Answer Format      Format Type           Response   Explanation

        Focusing specifically on the claim office(s)
        that would be used for The City, indicate if
        performance from January 2011 through
15      January 2011 did or did not meet the specified
        standards below. If more than six Service
        Centers proposed, provide requested data in
        "Explanation" column and/or worksheet.

     a. Service Center #1

        Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

        Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet


        90% of claims were processed in 10 business
                                                                       drop down box   Listbox,ListMetNotMet
        days or less.


        At least 90% of telephone calls to member
                                                                       drop down box   Listbox,ListMetNotMet
        services were answered within 20 seconds.

     b. Service Center #2

        Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

        Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet

        90% of claims were processed in 10 business
                                                                       drop down box   Listbox,ListMetNotMet
        days or less.
        At least 90% of telephone calls to member
                                                                       drop down box   Listbox,ListMetNotMet
        services were answered within 20 seconds.
     c. Service Center #3

        Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

        Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet

        90% of claims were processed in 10 business
                                                                       drop down box   Listbox,ListMetNotMet
        days or less.
        At least 90% of telephone calls to member
                                                                       drop down box   Listbox,ListMetNotMet
        services were answered within 20 seconds.
     d. Service Center #4

        Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

        Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet

        90% of claims were processed in 10 business
                                                                       drop down box   Listbox,ListMetNotMet
        days or less.


     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                     15                                RFP 11-0111
                                                                           RFP 11-0111 Exhibit 1
            Request for Proposal (RFP) for City of Fort Worth
            Single Location: SI PPO

            To Vendor: Use Column Q to provide a brief explanation.
            However if the length of the explanation is greater than 400
            characters, you must use the "Explanation" worksheet to
            provide your detail explanation.

            MEDICAL RFP                                                    Answer Format      Format Type          Response   Explanation

            At least 90% of telephone calls to member
                                                                           drop down box   Listbox,ListMetNotMet
            services were answered within 20 seconds.
          e. Service Center #5

            Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

            Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet

            90% of claims were processed in 10 business
                                                                           drop down box   Listbox,ListMetNotMet
            days or less.
            At least 90% of telephone calls to member
                                                                           drop down box   Listbox,ListMetNotMet
            services were answered within 20 seconds.
          f. Service Center #6

            Financial Dollar Accuracy was 99% or greater.                  drop down box   Listbox,ListMetNotMet

            Procedural Accuracy was 98% or greater.                        drop down box   Listbox,ListMetNotMet

            90% of claims were processed in 10 business
                                                                           drop down box   Listbox,ListMetNotMet
            days or less.
            At least 90% of telephone calls to member
                                                                           drop down box   Listbox,ListMetNotMet
            services were answered within 20 seconds.


VI.         PERFORMANCE GUARANTEES                                         Answer Format      Format Type          Response   Explanation
            The City is considering negotiating
            performance standards on financial and
            service performance results with the selected
            vendor to encourage the vendor to provide
      1
            superior performance. Vendor's failure to
            meet the performane guarantee(s) would result
            in a financial penalty. Please indicate your
            concurrence below.
            The penalty for failure to meet any agreed
      2     performance standard will be determined
            during negotiations.
            A penalty of % of for failure to meet any of
      3     the agreed performance standards is being
            considered.


            Guaranteed Discounts                                           Answer Format      Format Type          Response   Explanation
            Indicate the guaranteed discount percent off of
      4     normal charges for the designated locations
            for the following service categories.

          a. Metropolitan/Geographic Location 1                                 text                 Text

            Network Name                                                        text                 Text

            Hospital Inpatient Discount                                      percent, 1          Percent,1

            Hospital Outpatient Discount                                     percent, 1          Percent,1

            Physician Discount                                               percent, 1          Percent,1

            Other Services Discount                                          percent, 1          Percent,1

          b. Metropolitan/Geographic Location 2                                 text                 Text

            Network Name                                                        text                 Text

            Hospital Inpatient Discount                                      percent, 1          Percent,1

            Hospital Outpatient Discount                                     percent, 1          Percent,1

            Physician Discount                                               percent, 1          Percent,1

            Other Services Discount                                          percent, 1          Percent,1

          c. Metropolitan/Geographic Location 3                                 text                 Text

            Network Name                                                        text                 Text

            Hospital Inpatient Discount                                      percent, 1          Percent,1

            Hospital Outpatient Discount                                     percent, 1          Percent,1

            Physician Discount                                               percent, 1          Percent,1




          cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    16                               RFP 11-0111
                                                                     RFP 11-0111 Exhibit 1
      Request for Proposal (RFP) for City of Fort Worth
      Single Location: SI PPO

      To Vendor: Use Column Q to provide a brief explanation.
      However if the length of the explanation is greater than 400
      characters, you must use the "Explanation" worksheet to
      provide your detail explanation.

      MEDICAL RFP                                                    Answer Format    Format Type        Response   Explanation

      Other Services Discount                                          percent, 1        Percent,1

    d. Metropolitan/Geographic Location 4                                 text               Text

      Network Name                                                        text               Text

      Hospital Inpatient Discount                                      percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    e. Metropolitan/Geographic Location 5                                 text               Text

      Network Name                                                        text               Text

    f. Hospital Inpatient Discount                                     percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    g. Metropolitan/Geographic Location 6                                 text               Text

      Network Name                                                        text               Text

      Hospital Inpatient Discount                                      percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    h. Metropolitan/Geographic Location 7                                 text               Text

      Network Name                                                        text               Text

    i. Hospital Inpatient Discount                                     percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    j. Metropolitan/Geographic Location 8                                 text               Text

      Network Name                                                        text               Text

      Hospital Inpatient Discount                                      percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    k. Metropolitan/Geographic Location 9                                 text               Text

      Network Name                                                        text               Text

      Hospital Inpatient Discount                                      percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1

    l. Metropolitan/Geographic Location 10                                text               Text

      Network Name                                                        text               Text

      Hospital Inpatient Discount                                      percent, 1        Percent,1

      Hospital Outpatient Discount                                     percent, 1        Percent,1

      Physician Discount                                               percent, 1        Percent,1

      Other Services Discount                                          percent, 1        Percent,1



      Implementation                                                 Answer Format    Format Type        Response   Explanation
      Meeting deadlines set forth in Implementation
5                                                                    drop down box   Listbox,ListYesNo
      Schedule.

      Production and distribution of current up-to-date
6     provider directories to The City offices prior to the          drop down box   Listbox,ListYesNo
      enrollment period.




    cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                  17                             RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
        Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format      Format Type          Response   Explanation

       Production and distribution of ID cards prior to
 7     effective date with accuracy equal to data                     drop down box     Listbox,ListYesNo
       provided by The City.

       Appropriate members of account team to perform
 8     a service and operational audit for The City within            drop down box     Listbox,ListYesNo
       the first three months of the program.


       Provide The City with a benefits and financial
 9                                                                    drop down box     Listbox,ListYesNo
       contract 90 days prior to the effective date.


       Meet or exceed the City's subjective assessment
10                                                                    drop down box     Listbox,ListYesNo
       of satisfaction with program implementation.




        If the answer to the preceding question is "no",
        for all plans/products quoted in this RFP for which
        the required state insurance department filing
     a.                                                                   text                  Text
        requirements have not been met, please specify
        the applicable plan/product and corresponding
        state
11     Vendor is bonded.                                              drop down box   Listbox,ListYesExempt

     a. If not, please explain amount of coverage.                        text                  Text

12     Liability insurance covers:
                                                                                      Listbox,ListYNNANoEx
     a. Medical management decisions.                                 drop down box            plain
                                                                                      Listbox,ListYNNANoEx
     b. Professional malpractice                                      drop down box            plain
                                                                                      Listbox,ListYNNANoEx
     c. Provider contracting                                          drop down box            plain
       Please describe any judgment or settlement
       during the past three years or pending litigation
13                                                                        text                  Text
       that could result in judgments or settlements in
       excess of $100,000.
       If self-funded option is offered, vendor will act as                           Listbox,ListYNNANoEx
14                                                                    drop down box            plain
       plan fiduciary, if requested.
       The vendor maintains executed contracts with all                               Listbox,ListYNNANoEx
15                                                                    drop down box            plain
       providers participating in the network.
       The vendor provider contracts do not provide for
       any type of remuneration to your organization,                                 Listbox,ListYNNANoEx
16                                                                    drop down box            plain
       such as commission, finder's fee, rebate, or other
       financial benefit.
       Your organization is not a creditor of any provider                            Listbox,ListYNNANoEx
17                                                                    drop down box            plain
       in the network.


       Contractual                                                    Answer Format      Format Type          Response   Explanation
                                                                                      Listbox,ListYNNANoEx
18     The contract will be issued in Texas                           drop down box            plain
      January 1 will be the first contract anniversary                                Listbox,ListYNNANoEx
19                                                                    drop down box            plain
      date.
      The vendor agrees not to appoint any agent,
      general agent, or broker, nor authorize payment of                              Listbox,ListYNNANoEx
20                                                                    drop down box            plain
      any kind to a party not approved in writing by The
      City.
      We understand that terminology and contract
      provisions may vary among the involved vendors.
                                                                                      Listbox,ListYNNANoEx
21 a. We will permit such alternative language provided               drop down box            plain
      benefit payment levels are not adversely
      impacted.




     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    18                               RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format      Format Type           Response   Explanation

       No statement of health or medical evidence will be
                                                                                      Listbox,ListYNNANoEx
22     imposed upon the [initial group of covered                     drop down box            plain
       participants].

       Please include a copy of a sample employer
       contract that includes all exclusions and
23     limitations that the vendor expects will apply to              drop down box   Listbox, ListProvideNA
       "&fmClientName & ". Name the file: [Your
       Organization Name]_Sample Employer Contract.




       Future Contract Termination                                    Answer Format      Format Type           Response   Explanation
       The City shall have the right, in its sole and
       absolute discretion and without the payment of
                                                                                      Listbox,ListYNNANoEx
24     any penalty, to terminate the contract in whole or             drop down box            plain
       in part at any time during the term thereof upon 30
       days prior written notice to vendor.


       The vendor selected during this proposal process
       will be responsible for incurred claims up to the
       termination date of the contract, regardless of paid
       date, in the event the contract awarded during this                            Listbox,ListYNNANoEx
25                                                                    drop down box            plain
       marketing is subsequently terminated. The
       replacement vendor will have the responsibility
       pay claims incurred after the termination date of
       the contact.(Applicable to fully-insured coverages)


       The vendor selected during this proposal process
       must agree to transfer to City of Fort Worth, within
       60 days of notice of termination, all required data
       and records necessary to administer the
                                                                                      Listbox,ListYNNANoEx
26     plan(s)/program(s), subject to state and federal               drop down box            plain
       confidentiality considerations. The transfer may
       be made electronically, in a file format to be
       determined based on the mutual agreement
       between City of Fort Worth and the vendor.

       Vendor agrees that it will honor repayment
       demands or requests for reimbursement that are                                 Listbox,ListYNNANoEx
27                                                                    drop down box            plain
       made within the 3-year period for Medicare to
       recover improper payments.

       The vendor agrees to comply with the Department
       of Labor's final claims procedure regulations,
                                                                                      Listbox,ListYNNANoEx
28     including the appropriate timeframes for                       drop down box            plain
       adjudicating claims and notice of appeal
       decisions.
       Vendor will provide participants with annual notice
                                                                                      Listbox,ListYNNANoEx
29     that the plan provides for coverage for breast                 drop down box            plain
       reconstruction following mastectomy.




       Compliance, HIPAA                                              Answer Format      Format Type           Response   Explanation


       You maintain a dedicated individual or staff                                   Listbox,ListYNNANoEx
30                                                                    drop down box            plain
       responsible for resolving HIPAA issues.
       Vendor certifies that it will comply with the
31     interim final rules on nondiscrimination in the
       group health market, including:



     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    19                                RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
        Request for Proposal (RFP) for City of Fort Worth
        Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

        MEDICAL RFP                                                   Answer Format      Format Type          Response   Explanation

        Coverage for self-inflicted injuries for persons who
                                                                                      Listbox,ListYNNANoEx
     a. suffer from medical conditions (such as                       drop down box            plain
        depression)
        Coverage for persons who are hospital-confined
                                                                                      Listbox,ListYNNANoEx
     b. or not actively at work when coverage would                   drop down box            plain
        otherwise take effect.
32      The vendor will not use or further disclose
        protected health information (PHI) other than as                              Listbox,ListYNNANoEx
                                                                      drop down box            plain
        permitted or required by the Business Associate
        Agreement or as required by law.
33      The vendor agrees to use appropriate safeguards
        to prevent the unauthorized use or disclosure of
                                                                                      Listbox,ListYNNANoEx
        the PHI. Vendor agrees to report to the plan                  drop down box            plain
        sponsor any unauthorized use or disclosure of the
        PHI.
34      The vendor agrees to mitigate, to the extent
        practicable, any harmful effect that is known to
                                                                                      Listbox,ListYNNANoEx
        vendor of a use or disclosure of PHI by vendor in             drop down box            plain
        violation of the requirements of the federal privacy
        rule.
35      The vendor agrees to ensure that any agent,
        including a subcontractor, to whom it provides PHI
        received from, or created or received by the                                  Listbox,ListYNNANoEx
                                                                      drop down box            plain
        vendor agrees to the same restrictions and
        conditions that apply to vendor with respect to
        such information.
36      The vendor agrees to provide access to PHI in a
                                                                                      Listbox,ListYNNANoEx
        "designated record set" in order to meet the                  drop down box            plain
        requirements under 45 CFR §164.524.
37      The vendor agrees to make any amendment(s) to
                                                                                      Listbox,ListYNNANoEx
        PHI in a "designated record set" pursuant to 45               drop down box            plain
        CFR §164.526.
38
        The vendor agrees to document such disclosures
        of PHI and information related to such disclosures
                                                                                      Listbox,ListYNNANoEx
        as would be required to respond to a request by               drop down box            plain
                                                                                                                Yes
        an individual for an accounting of disclosures of
        PHI in accordance with 45 CFR §164.528.

39
        The vendor agrees to (i) implement administrative,
        physical, and technical safeguards that reasonably
        and appropriately protect the confidentiality,
        integrity, and availability of the electronic PHI that
        it creates, receives, maintains, or transmits, (ii)
        report to the plan sponsor any security incident
                                                                                      Listbox,ListYNNANoEx
        (within the meaning of 45 CFR § 164.304) of                   drop down box            plain
        which vendor becomes aware, and (iii) ensure that
        any vendor employee or agent, including any
        subcontractor to whom it provides PHI received
        from, or created or received by the vendor agrees
        to implement reasonable and appropriate
        safeguards to protect such PHI.




        Officer                                                       Answer Format      Format Type          Response   Explanation



        Vendor's completed proposal contains the form
        (included in the worksheet, "Officer"), signed by a                           Listbox,ListOffWkshee
40                                                                    drop down box              t
        company officer, attesting to compliance with RFP
        specifications and the accuracy of all responses.


     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                    20                               RFP 11-0111
                                                                              RFP 11-0111 Exhibit 1
               Request for Proposal (RFP) for City of Fort Worth
               Single Location: SI PPO

               To Vendor: Use Column Q to provide a brief explanation.
               However if the length of the explanation is greater than 400
               characters, you must use the "Explanation" worksheet to
               provide your detail explanation.

               MEDICAL RFP                                                    Answer Format      Format Type         Response   Explanation


VII.           OTHER INFORMATION                                              Answer Format      Format Type         Response   Explanation
               Please provide the following information in
               electronic format and name the file as
               specified:
               The City has assigned an MWBE goal to the
                                                                                              Listbox,ListYNNANoEx
        1      Medical Administration project. Have you                       drop down box            plain
                                                                                                                       Yes
               reviewed and provided response?
               The City will require a copy of your SAS 70 report
                                                                                              Listbox,ListYNNANoEx
        2      annually. Please indicate if you are willing to                drop down box            plain
                                                                                                                       Yes
               provide with no additional charge?

               The City retains the right to conduct an audit of
               claims paid, systems and general administration
               of the health plan. The City will choose the audit                             Listbox,ListYNNANoEx
        3                                                                     drop down box            plain
                                                                                                                       Yes
               firm. The audit may be a statistically valid audit
               consisting of 400 claims. Please indicate your
               acceptance of this number of claims.

               The City Audit and Finance Department retains
               the right to conduct an audit of claims paid,
               systems and general administration of the health                               Listbox,ListYNNANoEx
        4                                                                     drop down box            plain
                                                                                                                       Yes
               plan that may be a separate audit from the
               Statistical audit. The audit may review 100% of
               claims paid. Please indicate your acceptance.

               Please include a copy of the procedures used for
        5                                                                     drop down box   Listbox,ListAttached
               correcting overpayments and underpayments.

               The vendor must be able to electronically
               exchange data with the City's PeopleSoft system
        6                                                                     drop down box   Listbox,ListAttached   Attached
               for purposes of eligibility. Please provide a copy
               of your eligibility/data file format.

               A copy of your most recent audited financial
        7      statement. Name the file: [Your Organization                   drop down box   Listbox,ListAttached
               Name]_Audited Financial Statement.

               A description of the health plan's conversion
        8      plan(s) and associated costs. Name the file:                   drop down box   Listbox,ListAttached
               [Your Organization Name]_Conversion Services.

               A copy of the health plan's appeal and grievance
               policies, if not specified in the Suggested
        9                                                                     drop down box   Listbox,ListAttached
               Employer Contract. Name the file: [Your
               Organization Name] _Appeal_Grievance Policies.

               A copy of the health plan's appeal and grievance
               policies, if not specified in the Suggested
       10                                                                     drop down box   Listbox,ListAttached
               Employer Contract. Name the file: [Your
               Organization Name] _Appeal_Grievance Policies.

             Current marketing materials that would be of
             assistance to Aon Hewitt and The City in
       11 a.                                                                  drop down box   Listbox,ListAttached
             evaluating your program. Name the file: [Your
             Organization Name]_MarketingMaterials.
             Sample ID Card and description of elements that
       12 a. may be customized. Name the file: [Your                          drop down box   Listbox,ListAttached
             Organization Name]_IDCard.

               Current member enrollment materials that the
               health plan feels would be of assistance to Aon
       13                                                                     drop down box   Listbox,ListAttached
               Hewitt in evaluating your program. Name the file:
               [Your Organization Name]_EnrollmentMaterials.

               Does your proposed network have a “premium” or
               “gold” designation program that indicates
       14                                                                     drop down box     Listbox,ListYesNo
               providers and facilities that achieve quality of care
               and cost containment metrics?


            cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                     21                              RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format     Format Type          Response   Explanation

       What is the estimated savings differential for
15                                                                        text                 Text
       utilizing premium providers and facilities?
       On what basis is that savings derived?
16                                                                        text                 Text
       (Regionally specific, nationally, etc).
       Provide the number of such designated providers
17                                                                      numeric             Number
       by specialty in Tarrant County.
       Provide listing of Premium designated facilities
18                                                                    drop down box   Listbox,ListAttached
       and their specialty in Tarrant County.
       What % of the Tarrant County Providers are
19                                                                      numeric             Number
       Premium Designated?
       What is the estimated savings differential for City
20     of Fort Worth for utilizing premium providers and                numeric             Number
       facilities?
       On what basis is that savings derived?
       (Assumption that all services available through
21                                                                    drop down box   Listbox,ListAttached
       Premium Designation program are utilized, or
       “open access” – no hard steerage).
       How is your organization linking technology with
22                                                                    drop down box   Listbox,ListAttached
       the provider community?
       Attach description of technology enhancements
23     and how this benefits the provider, the City, and              drop down box   Listbox,ListAttached
       the patient?

       Are patient/participant medical records available
24                                                                    drop down box    Listbox,ListYesNo
       electronically throughout your provider network?

       The City has a significant retiree population with
       50% of that population in Non-Medicare eligible
       and 50% in Medicare eligible plans. What is your
25                                                                    drop down box   Listbox,ListAttached
       organization doing to incent the Medicare
       providers to continue to accept new Medicare
       patients?
       Please provide your organizations last four years
26     NCQA Accreditation Rankings in the following
       areas
27     Calendar Year 2007
28     Health Plan Accreditation (HPA)                                  numeric             Number

29     Wellness & Health Promotion (WHP)                                numeric             Number

30     Managed Behavioral Health (MBHO)                                 numeric             Number

31     New Health Plans (NHP)                                           numeric             Number

32     Disease Management (DM)                                          numeric             Number

33     Quality Plus                                                     numeric             Number

34     Calendar Year 2008
35       Health Plan Accreditation (HPA)                                numeric             Number

36       Wellness & Health Promotion (WHP)                              numeric             Number

37       Managed Behavioral Health (MBHO)                               numeric             Number

38       New Health Plans (NHP)                                         numeric             Number

39       Disease Management (DM)                                        numeric             Number

40       Quality Plus                                                   numeric             Number

41     Calendar Year 2009
42       Health Plan Accreditation (HPA)                                numeric             Number

43       Wellness & Health Promotion (WHP)                              numeric             Number

44       Managed Behavioral Health (MBHO)                               numeric             Number

45       New Health Plans (NHP)                                         numeric             Number

46       Disease Management (DM)                                        numeric             Number

47       Quality Plus                                                   numeric             Number

48     Calendar Year 2010
49       Health Plan Accreditation (HPA)                                numeric             Number

50       Wellness & Health Promotion (WHP)                              numeric             Number

51       Managed Behavioral Health (MBHO)                               numeric             Number



     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                   22                               RFP 11-0111
                                                                      RFP 11-0111 Exhibit 1
       Request for Proposal (RFP) for City of Fort Worth
       Single Location: SI PPO

       To Vendor: Use Column Q to provide a brief explanation.
       However if the length of the explanation is greater than 400
       characters, you must use the "Explanation" worksheet to
       provide your detail explanation.

       MEDICAL RFP                                                    Answer Format     Format Type          Response   Explanation

52       New Health Plans (NHP)                                         numeric             Number

53       Disease Management (DM)                                        numeric             Number

54       Quality Plus                                                   numeric             Number
       Does your organization have a Patient-
55     Centric/Medical Home program developed in                      drop down box    Listbox,ListYesNo
       Tarrant County?
       Provide details on how many providers and what
       specialties are represented in the Patient
56                                                                    drop down box   Listbox,ListAttached
       Centric/Medical Home program for Tarrant
       County.

       Please provide outline of a health plan structure
       designed to reduce the City’s overall claims spend
57                                                                    drop down box   Listbox,ListAttached
       by 5-10% pepm. Provide multi-year strategy to
       maintain flat PEPM spending in year 1 through 3.




     cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012                                   23                               RFP 11-0111
              Request for Proposal (RFP) for City of Fort Worth
              Explanation
              This worksheet should be used to provide additional explanations for any questions for which a "See Explanation
              was given. Explanations must be numbered to correspond to the question to which they pertain and they must b

              State the number of questions you addressed with further explanation:

              Section/
              Question #




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012    24                                           RFP 11-0111
              Request for Proposal (RFP) for City of Fort Worth
              Explanation
              This worksheet should be used to provide additional explanations for any questions for which a "See Explanation
              was given. Explanations must be numbered to correspond to the question to which they pertain and they must b

              State the number of questions you addressed with further explanation:

              Section/
              Question #




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012    25                                           RFP 11-0111
                                              RFP 11-0111 Exhibit 1
t for Proposal (RFP) for City of Fort Worth

heet should be used to provide additional explanations for any questions for which a "See Explanation" response
 Explanations must be numbered to correspond to the question to which they pertain and they must be brief.

number of questions you addressed with further explanation:

                                                      Explanation




            cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012      26                                            RFP 11-0111
                                              RFP 11-0111 Exhibit 1
t for Proposal (RFP) for City of Fort Worth

heet should be used to provide additional explanations for any questions for which a "See Explanation" response
 Explanations must be numbered to correspond to the question to which they pertain and they must be brief.

number of questions you addressed with further explanation:

                                                      Explanation




            cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls 8/29/2012      27                                            RFP 11-0111
                     Request for Medical Proposal (RFP) for City of Fort Worth
                     RFP 10-0385 Exhibit 1
                     Officer Certification
                     Please have an Officer review and sign this worksheet to confirm the information is valid.
                     Please include the completed form with your proposal.

                                                                     OFFICER'S STATEMENT
                     Medical Vendor Legal Name
                     Medical Vendor Marketing Name
                     Street Address
                     City
                     State
                     Zip
                     Phone Number
                     Fax Number
                     Web Address
                     Name of Officer completing statement
                     Title of Officer completing statement
                     Phone Number of Officer completing statement
                     Email Address of Officer completing statement

                     I certify that our response to Aon Consulting's RFP (Request for Proposal) is complete and accurate to the b
                     knowledge and contains no material omissions or misstatements. I acknowledge that Aon Consulting's clien
                     upon the information included in our response to make decisions concerning the medical services that are o
                     their employees.



                     Officer's Signature


                     Date Signed




cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls Officer 8/29/2012   28                                           RFP 10-0385
y of Fort Worth



firm the information is valid.


TATEMENT




for Proposal) is complete and accurate to the best of my
ents. I acknowledge that Aon Consulting's clients will rely
ons concerning the medical services that are offered to




             cc399cb0-eabb-4cba-a7e7-7e2c67dfbb70.xls Officer 8/29/2012   29   RFP 10-0385

								
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