Sample Employee Confidentiality Agreement

Document Sample
Sample Employee Confidentiality Agreement Powered By Docstoc
					                                                                                      BSO RLI Questionnaire Index


References - are documents that have been provided and do not need to be completed, but are to be used to refer to
when answering specific questions.

Vendor Exhibits - are documents provided with this RLI that should be completed by the Vendor and returned to
answer specific questions. These Exhibits must be submitted in order by Section.

Vendor Attachments - are vendor created/provided materials that must be labeled with the applicable Section (A,B,C)
and Question # that they are associated with, and submitted in order by Section. Vendors may create additional
Attachments other than those suggested, however they must be labeled appropriately in order to be given
consideration.

All References, Vendor Exhibits and suggested Vendor Attachments are listed in this INDEX and also referred to
within each applicable Section. All Exhibits and Attachments returned MUST be put in order by Section and identified
properly.

If any question cannot be answered within the Vendor Response or Comments section below, and is answered on a
separate document it should be identified with the Section and Question # in order to be given full consideration.




Below is a list of the Sections of the RLI and the associated Vendor Attachments, Vendor Exhibits and References for
                                                       each Section.

Section A - General Questions & Information
                   Vendor Attachment #A-2 - Chronological History of Corporation
                   Vendor Attachment #A-3 - Corporate Leadership and Organizational Chart
                   Vendor Attachment #A-11 - Sample EOBs
                   Vendor Attachment #A-12 Company Highlights
                        Vendor Exhibit #EX-1 Submittal Section
                        Vendor Exhibit #EX-2 Book of Business Matrix
                   Vendor Attachment #A-16 Disaster Recovery Plan
                            Reference RX-1- Sample Agreement
                            Reference RX-2- Sample Insurance Certificate
                            Reference RX-3- Vendor Registration
                        Vendor Exhibit #EX-3 Statement of No Bid Form
                        Vendor Exhibit #EX-4 Drug Free Workplace Certification
                        Vendor Exhibit #EX-5 Affidavit
                        Vendor Exhibit #EX-6 Confidentiality Agreement
Section B - Plan Design & Pricing
                            Reference RX-4 - Current Plan Certificates of Coverage
                            Reference RX-5 - Current Plan Summaries
                   Vendor Attachment #B-1 - Plan Deviations
                        Vendor Exhibit #EX-7 Fully Insured Pricing Sheet


                                                     Page 1 of 24
                                                                                     BSO RLI Questionnaire Index


                       Vendor Exhibit #EX-8 Self-Insured (ASO) Pricing Sheet - Sole Provider
                       Vendor Exhibit #EX-8A Self-Insured (ASO) Pricing Sheet - Split Provider
                          Reference RX-6 - Current Census & Enrollment
                          Reference RX-7A - Current & Historical Claims - Vista
                          Reference RX-7B - Current & Historical Claims - Humana
                          Reference RX-8 - Current Employer & Employee Contributions
                          Reference RX-9 - Employee Benefit Reference Guide - contains eligibility and other
                          pertinent BSO policy and benefit plan information
                       Vendor Exhibit #EX-9 Performance Guarantee Worksheet
                       Vendor Exhibit #EX-10 Proposal Pricing Form
Section C - References
Section D - Administrative Questions
Section E - Reporting
                         Vendor Exhibit #EX-11 Standard and Custom Reporting Matrix
                    Vendor Attachment #E-2 - Report Samples
Section F - Service Delivery
Section G - Claims Adjudication
Section H - Pharmacy
Section I - Disease Management & Wellness
                    Vendor Attachment # I-1 - Disease Management/Wellness Program Materials
                    Vendor Attachment # I-26 - Sample Health Risk Assessment Questionnaire
                    Vendor Attachment # I-30 - Detail of Successful Wellness Program
Section J - Mental Health/Substance Abuse
                         Vendor Exhibit #EX-12 Template for Mental Health Statistics
Section K - Subcontractors
Section L - Marketing Materials
                    Vendor Attachment #L-1 - Marketing Samples
Section M - Implementation
                    Vendor Attachment #M-4 - Implementation Timeline
                    Vendor Attachment #M-5 - List of Implementation Transition Tasks

                  Vendor Attachment #M-7 - Transition Tasks specifically for those currently using services
Section N - Network/Provider Access
                       Vendor Exhibit #EX-13 Template for Geographic Access
                       Vendor Exhibit #EX-14 Template for Provider Disruption - Humana
                       Vendor Exhibit #EX-14a Template for Provider Disruption - Vista
                           Reference RX-10 - Humana TIN File
                           Reference RX-11 - Vista TIN File
Section O - Technology and Systems
                           Reference RX-12 - ETD Server Guidelines
                           Reference RX-13 - ETD Desktop Guidelines




                                                    Page 2 of 24
                                                                                                                                             Broward Sheriff's Office RLI Questionnaire



References - are documents that have been provided and do not need to be completed, but are to be used to refer to when answering specific
questions.

Vendor Exhibits - are documents provided with this RLI that should be completed by the Vendor and returned to answer specific questions. These
Exhibits must be submitted in order by Section.

Vendor Attachments - are vendor created/provided materials that must be labeled with the applicable Section (A,B,C) and Question # that they are
associated with, and submitted in order by Section. Vendors may create additional Attachments other than those suggested, however they must be
labeled appropriately in order to be given consideration.

All References, Vendor Exhibits and suggested Vendor Attachments are listed in the INDEX and also referred to within each applicable Section. All
Exhibits and Attachments returned MUST be put in order by Section and identified properly.

If any question cannot be answered within the Vendor Response or Comments section below, and is answered on a separate document it should be
identified with the Section and Question # in order to be given full consideration.




                                                  SECTION A - General Questions & Information
                                                                              Vendor Response                                      Comments/Explanation
                                                          ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                            if nothing is checked it will be assumed to be a No.                         comments.




        Provide the names, titles and a brief
        biography/resume of each person to include
        years of service in your employ that will be
        assigned to this account. List prior
A-1     experience, availability and office location of
        each person. Also, please indicate the
        individual's name that will have the overall
        responsibility for this account.

        Provide a Chronological history of your
        corporation including mergers, buyouts, etc.
        as Vendor Attachment #A-2.
A-2



        List your firms Corporate Leadership. A copy
        of your Organizational Chart should be
A-3     attached as Vendor Attachment #A-3.


        Provide a listing of corporate awards
        pertinent to this soliciation.
A-4


        What is your company's financial rating? (i.e
A-5     A.M. Best, S&P, etc.)

        List all plan types that your company offers
A-6     (i.e. HMO, EPO, PPO, CDHP etc.)




                                                                                      Page 3 of 24
                                                                                    Broward Sheriff's Office RLI Questionnaire



       Identify any officer, director, employee or
       agent who is also an employee of Broward
       Sheriff's Office (BSO). Disclose the name of
       any BSO employee who owns, directly or
       indirectly, an interest of 5% or more in your
       firm or any of it's subsidiaries. Also disclose
A-7
       any familial or financial relationship anyone in
       your firm may have with any employee of
       BSO or member of the family of an employee
       of BSO.


       Is your company currently in compliance with
       Florida Department of Financial Services           Yes   No
       profitability and reserves requirements? If
A-8    no, why? When was the last time it was
       reviewed.


       Explain how your plans work when a retiree
A-9    lives outside the tri-county area in the State
       of Florida and Out of State.
       Explain how your plans work when a student
       is going to school outside of the tri-county
A-10   area in the State of Florida and Out of State.
       Describe your student status verification
       process.
       Can you provide EOBs for every proposed
       plan? If yes, please provide an example as         Yes   No
A-11
       Attachment #A-11.

       Provide a one page brief summary of your
       company highlights. Please indicate why you
       think BSO should select you as the Vendor of
A-12   choice. Insert this information as
       Attachment #A-12.

       Explain your definition and how you
       administer Dependent eligibility to age 30.
       What are your guidelines for coverage?
A-13   Explain your pricing methodology as it
       pertains to the dependents in this category.
       How do you handle verification?


       As a result of the HIPAA and PHI policies,
       what restrictions, if any, do you have in
A-14   providing the customer and consultants
       reports needed to manage the plan?


       Please complete Vendor Exhibit #EX-2 to
       provide an overview of your current book of
       business nationwide, Florida, and each of the
       three Counties. Within that matrix of those
A-15   numbers how many are fully insured vs self
       insured and whether they are public or
       private.


       Please provide a copy of your Disaster
       Recovery Plan as Attachment #A-16.
A-16




                                                                     Page 4 of 24
                                                                                                                     Broward Sheriff's Office RLI Questionnaire



       Is your company accredited with the
       Utilization Review Accreditation Commission
       (URAC)? If so, which modules? AND/OR the
A-17
       National Committee for Quality Assurance
       (NCQA)?

       Do you offer Medicare carve out
       coordination? Do you offer employer                  Yes    No
       sponsored Medigap and/or Medicare
A-18
       Advantage Plans for retirees?


       Please note that Vendor Exhibit #EX
       1,Vendor Exhibit #EX 3, Vendor Exhibit #EX
       4, Vendor Exhibit #EX 5 and Vendor Exhibit
A-19
       #EX 6 must be completed and submitted
       with this RLI.

                                                         SECTION B - Plan Design & Pricing
                                                                    Vendor Response                              Comments
                                                          ALL Yes/No boxes must have one or the   If you answer "No" please provide a brief
                                                                      other selected.                     explanation in comments.
       You will be asked to quote premiums to
       duplicate the current benefit in exact detail
       for BSO. Please review BSO's current benefit
       Certificates of Coverage for each of the plans
       currently offered which is provided as
       Reference RX-4 and Benefit Summaries
       provided as Reference RX-5 Do you agree to
       match the benefit exactly as written? If not,
B-1    you must identify each benefit/detail that you       Yes    No
       cannot or will not match and state why.
       Insert in Section B and label as Attachment
       #B-1. Any benefit/detail not identified will be
       assumed to be matched and made part of the
       contract if you are selected.




       You are being asked to quote the plans
       identified in Reference RX-5 on a fully insured
       and self-insured basis. You are also asking to
       quote both Sole Provider and Slice Business.
       You must complete the following Exhibits for
       submission:

       Fully Insured - Exhibits EX 7 must be
       completed indicating a premium amount for
       each plan and tier indicated.

       Self Insured (ASO) - Exhibits EX 8 (Sole
B-2
       Provider) and Exhibit 8A (Split Provider)
       must be completed indicating a fee amount in
       each of the items identified.

       Note: Please refer to the following
       documents Reference RX-6, Reference RX-
       7A, Reference 7B Reference RX-8, Reference
       RX-9, as necessary to complete your Pricing
       submissions.




                                                                             Page 5 of 24
                                                                             Broward Sheriff's Office RLI Questionnaire



      You are asked to provide Performance
      Guarantees based on specific Items and
      Measurement Standards. Please provide
B-3   your submission on Vendor Exhibit #EX-9.



      You are being asked to complete and sign
      Vendor Exhibit #EX-10 -Proposal Pricing      Yes   No
      Form. Did you complete and sign this form?
B-4




                                                              Page 6 of 24
                                                                                                                                        Broward Sheriff's Office RLI Questionnaire



                                                                SECTION C - References
                                     BSO prefers references to be of similar size to BSO and a Public Sector, if possible.
                                                                         Vendor Response                                      Comments/Explanation
                                                     ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                       if nothing is checked it will be assumed to be a No.                         comments.



C-1   Current Company #1 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Insureds:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
C-2   Current Company #2 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
C-3   Current Company #3 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
C-4   Current Company #4 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:




                                                                                 Page 7 of 24
                                                         Broward Sheriff's Office RLI Questionnaire



C-5   Current Company #5 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
C-6   Former Company #1 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
      Date contract ended:
C-7   Former Company #2 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
      Date contract ended:
C-8   Former Company #3 Name:
      Address:
      Contact Person:
      Phone #:
      Total Benefit Eligible Employees:
      Total Enrolled Participants:
      Fully Insured or Self Insured:
      Sole Provider or Split Provider:
      Public Sector or Private Sector:
      Products Offered:
      Length of Contract:
      Date contract ended:




                                          Page 8 of 24
                                                                                                                                            Broward Sheriff's Office RLI Questionnaire



                                                        SECTION D - Administrative Questions
                                                                             Vendor Response                                      Comments/Explanation
                                                         ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                           if nothing is checked it will be assumed to be a No.                         comments.




      ID Cards will be generated, free of charge,
      and mailed by first class mail to the members
      home address within 10 business days from
      receipt of eligibility/change file when any of
      the following events: occur due to open
D-1   enrollment or qualifying life events:                   Yes       No
      - change in plan
      - change in coverage level
      - request for duplicate/replacement cards If
      no, why?


      At the beginning of each plan year, a new
      Welcome Kit to include ID Cards, Summary                Yes       No
      Plan Descriptions and other member
      information will be mailed by January 1st to
      the member's home address assuming
      enrollment file is delivered and accepted by
D-2
      vendor no later than the first week of
      December. The cost of preparing and
      printing of these materials will be covered by
      the Vendor and subject to pre-approval by
      BSO.

      The Vendor will notify BSO of any physicians,
      specialists and hospitals that are leaving the          Yes       No
      network. Notification to BSO will be no less
      than 30 calendar days from the effective date
      of the change. BSO shall receive these
D-3   notifications on a monthly basis and must be
      in the appropriate format for the placement
      on the BSO internet website.



      The Vendor will notify an employee who has
      identified a PCP if their selected physician is         Yes       No
      leaving the network. Notification to the
D-4   employee will not be less than 30 calendar
      days from the effective date of the change.



      The Vendor is responsible for all costs of
      printing, producing and mailing/distributing
      adequate quantities of member information
D-5   for all normal communications or marketing              Yes       No
      materials, notices, etc.



      The Vendor's Open Enrollment/New Hire Kits
      will include all materials necessary, including         Yes       No

D-6   a provider directory (if requested) or CD, to
      make a plan/physician selection.

      The Vendor must obtain approval of BSO
      prior to distribution of any member                     Yes       No
D-7
      communication materials.




                                                                                     Page 9 of 24
                                                                                                                                            Broward Sheriff's Office RLI Questionnaire



       The Vendor will be responsible for reviewing
       and updating applicable section of the annual          Yes       No
       open enrollment handbook produced by BSO
D-8    prior to distribution to ensure agreement
       with the Vendor's plan documents.


       There will be no pre-existing exclusions under
       the proposed plan for members who                      Yes       No

D-9    otherwise meet BSO's eligibility requirements.



       Proposed rates are guaranteed for the length           Yes       No
       of time specified on the pricing Exhibits.
D-10


       No commissions or remuneration of any kind
       is included in the quoted premiums or will be          Yes       No
       paid out in connection with this bid proposal -
D-11
       if Yes please explain.



       No minimum participation requirements will
       apply to any proposed plan.                            Yes       No
D-12

       Due to the unique nature of a government
       business environment, do you agree to be               Yes       No
       flexible with BSO? If administrative or
       process changes need to be made, within
D-13   reason, will you accommodate those changes
       within 14 days of the request?



       What level of your organization will be
       accessible to BSO Benefits Manager to
       discuss partnering opportunities, unique
D-14   situations to BSO, etc. Please provide Name,           Yes       No
       Title and contact information.


                                                                    Section E - Reporting
                                                                             Vendor Response                                      Comments/Explanation
                                                         ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                           if nothing is checked it will be assumed to be a No.                         comments.



       Complete Exhibit #EX-11 indicating what
       standard reporting is available for fully
       insured and self insured. Indicate frequency
       and the delivery format. Also complete the
E-1    same information for any custom/ad hoc
       reporting and include fees (if applicable)



       Provide samples of the reports listed in
E-2    Exhibit #EX-11 and insert them as
       Attachment #E-2.

       Please briefly describe the tools available to
       do any custom reporting. Please provide the
E-3    typical turn around time to receive such
       reports.




                                                                                    Page 10 of 24
                                                                                                                                           Broward Sheriff's Office RLI Questionnaire



                                                              Section F - Service Delivery
                                                                            Vendor Response                                      Comments/Explanation
                                                        ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                          if nothing is checked it will be assumed to be a No.                         comments.



       Describe your member service teams
       (numbers, titles, experience and
       qualifications). Is this a dedicated team?
       How many member service representatives
       will be on the team? Will this team answer all
F-1    questions regarding the products? Describe
       the training process and performance
       management system. What is the experience
       level of the team you are proposing?



       Please indicate the days and hours of
       operation of your member service teams, and
F-2    the number of available service days per year.

       Define the functions your member service
       unit performs. Does the member call
F-3    member services for:
       new I.D. cards, address changes, etc?

       Do you maintain a toll-free, pre-enrollment
       phone number for employees to call with               Yes       No
       questions prior to open enrollment? What
F-4    are the hours of operation and the duration
       for which this number will be accessible.


       Describe your member grievance and appeals
       process for claim denials or reductions and
F-5    pre-service denials as well as other disputes.


       Will you maintain a dedicated BSO Customer
       Service Unit?                                         Yes       No
F-6

       Will you provide a dedicated on-site service
       representative 5 days per week?                       Yes       No
F-7

       Do you offer a “paperless” Electronic Data
       Interface (EDI) for all transactions                  Yes       No
F-8
       (enrollment, reconciliation, reporting, etc.)?

       Will you provide secure web based access for
       BSO benefit administrators?                           Yes       No
F-9

       Do you have the ability to accept electronic
       applications/changes from BSO employees               Yes       No
F-10
       via a dedicated BSO internet website?




                                                                                   Page 11 of 24
                                                                                                                                          Broward Sheriff's Office RLI Questionnaire



                                                          Section G - Claims Adjudication
                                                                           Vendor Response                                      Comments/Explanation
                                                       ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                         if nothing is checked it will be assumed to be a No.                         comments.




      Has the company changed claims processing
      and adjudication systems within the last
G-1   three years? If so, describe the rationale for
      the change.

       Please indicate where claims are processed?
      Please detail by product, if different.
      a. Include details on which claim
      administration location maintains claim
      payment responsibility?
      b. Include detail on how many account
      management representatives are designated
      / dedicated for large case clients?
      c. Include detailed designation by
G-2
      department:
        i. Include an overview of organizational
      structure as well as responsibility?
        ii. Individual level of experience,
      responsibility and history with large case
      clients?




      Describe how deductibles & co-insurance are
      calculated for employees, retirees, and
      dependents -
G-3   a) that live in the service area
      b) neither live nor work in the service area

      What percentage of the total claims are auto-
G-4   adjudicated?

      How do you address the problem of providers
      requiring deductible and co-payment
      amounts at the beginning of the year that
G-5   may result in too much being collected from
      the member? How do you address the refund
      due in these type of situations?


      Describe how you would adjudicate a claim in
      a hospital setting where the member receives
      services from non-network provider which is
G-6   beyond their control.




                                                                                  Page 12 of 24
                                                                                                                                          Broward Sheriff's Office RLI Questionnaire



                                                                  Section H - Pharmacy
                                                                           Vendor Response                                      Comments/Explanation
                                                       ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                         if nothing is checked it will be assumed to be a No.                         comments.




       Please provide the estimated rebates and
H-1    timing of the rebate payments.
       What method of contracting is used (if
H-2    applicable) – Lock-In pricing or Pass-Through
       pricing?
       What percentage of the Average Wholesale
H-3    Price (AWP) do you retain (if applicable)?


       Do you adjudicate claims (including self-
       administered specialty drugs) using NDC-11?          Yes       No
H-4

       Please provide the amount of rebates
H-5    retained by the carrier.


       Do you adjudicate claims using NDC-11?
                                                            Yes       No
H-6

        Do you own and operate you own mail order
       facility?                                            Yes       No
H-7

       List your customized Utilization Management
H-8    programs.


       What Utilization Management Tools do you
H-9    employ?


       List guaranteed Return on Investment (ROI)
       for all proposed Utilization Management and
H-10
       cost management programs.

       Identify the source for your Maximum
H-11   Allowable Cost (MAC) list.


       Can you customize your network?
                                                            Yes       No
H-12

       Do you offer incentive programs for
       pharmacists at mail and retail?                      Yes       No
H-13

       How do you ensure that the retail network
H-14   has enough inventory on hand to fill
       prescriptions without any delays?
        How is your formulary determined? How
H-15   often are changes made to your formulary?


       What specialty drugs are covered under your
H-16   formulary?




                                                                                  Page 13 of 24
                                                                                                                                             Broward Sheriff's Office RLI Questionnaire



                                                 Section I - Disease Management and Wellness
                                                                              Vendor Response                                      Comments/Explanation
                                                          ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                            if nothing is checked it will be assumed to be a No.                         comments.




       Please provide an overview of your Disease
       Management services. Please provide
       additional program details and any other
I-1    pertinent information to adequately present
       your Disease Management programs as
       Attachment #I-1.


       Is your Disease Management Program in-                  Yes       No
       house? If No please identify your
       subcontractor(s), list any Performance
I-2    Guarantees, and explain how your
       subcontractors are paid.


       Please list the # of your Staff dedicated to the
       Disease Management Program (if
       subcontracted, list # dedicated to your
I-3    clients) and provide an overview of their
       professional experience and qualifications.


       What was the ROI on your Disease
       Management Programs for 2008? Please
I-4    provide statistics broken down by public
       sector vs. private sector.
       What is your definition of Disease
I-5    Management?

       What is your definition of Case Management
       and how does it differ in programs and
I-6    services from your Disease Management
       services?

       What is the engagement of your Disease
I-7    Management identified members?


       What is the engagement of your Case
I-8    Management identified members?

       What steps do you take to make sure that
       members identified for Disease Management
I-9    are compliant. How does this affect ROI?


       Please describe how you tailor your program
       to meet the needs of your client
I-10
       organizations and their specific populations.

       Please provide a description of your member
       outreach strategies, including the types of
I-11   interventions you perform and how
       frequently they occur.
       Describe your enrollment model (e.g., opt-in
       or opt-out) and identify why you believe it is
I-12
       the best approach.

       What on line capabilities do you have for
I-13   members? For doctors? For employers?




                                                                                     Page 14 of 24
                                                                                      Broward Sheriff's Office RLI Questionnaire



       What elements would you say are essential
I-14   for a successful DM program?


       How do you keep individuals engaged in the
I-15   programs?

       Please describe how you use data (claims,
       pharmacy and other) to maximize
I-16   participation in disease management
       programs.
       Please describe your call center operations.
       Are nurses located on-site or virtually? Can
I-17   call center representatives and nurses speak
       Spanish and other languages?

       Provide the types of support and/or
       recommendations in coordinating wellness
I-18   programs with events such as breast cancer
       awareness, etc

       Describe the channels and controls in place to
       alert providers to emerging health risks and
       to provide them with educational services to
       better prepare them to address these risks.
       Provide examples of recent alerts you have
I-19
       disseminated to your provider network.
       Please also summarize the feedback you
       received to these sample alerts.


       Provide a brief overview of your wellness
       program/resources. Please include your
I-20   programs goals and objectives.


       What is your guarantee and ROI on the
I-21   Wellness Programs that you offer?
       Detail your organizations’ standard approach
       to measuring program success and explain
I-22   how it is similar or different than that of other
       wellness programs.

       Do you use incentive programs or other
       active or passive tools that enhance results of     Yes   No
I-23   such programs (please provide specific
       examples)?
       Do you have the ability to use previous Health
       Risk Assessment data or an Health Risk              Yes   No
I-24   Assessment from other vendors?

       Do you currently offer any incentive                Yes   No
       programs for Wellness. If so, please give
I-25   details on the programs.

       Will you agree to provide reporting of those        Yes   No
       members who complete the biometric
       screening and Health Risk Assessment so that
       BSO can award incentives? If yes are there
I-26   any restrictions? Please submit a sample of
       your HRA questionnaire as Attachment #I-26.




                                                                      Page 15 of 24
                                                                                  Broward Sheriff's Office RLI Questionnaire



       Will you agree to provide an annual Biometric   Yes   No
       Screening and on-line Health Risk Assessment
       to each employee at no additional cost to
I-27   BSO? Would there be an additional cost to
       also provide to each adult dependent? If yes
       please provide the fee per person.


       Can you offer Fecal Occult Blood Tests (FOBT)   Yes   No
       for employees? If so under what
       conditions/criteria would you agree to
I-28   include this as preventive within the medical
       plan?


       Can you offer Fecal Occult Blood Tests (FOBT)   Yes   No
       for adult dependents? If so under what
       conditions/criteria would you agree to
I-29   include this as preventive within the medical
       plan?


       Please provide a reference for a successful
       wellness program you have implemented
       with a major employer. Include a brief
       description of the methods used, what
       specific programs were put in place,
I-30   employee participation rate, the results, and
       exactly how the results were measured.
       Please submit your response in detail as
       Attachment #I-30.


       Wellness Reference Company Name:
       Address:
       Contact Person:
       Phone #:




                                                                  Page 16 of 24
                                                                                                                                             Broward Sheriff's Office RLI Questionnaire



                                                Section J - Mental Health and Substance Abuse
                                                                              Vendor Response                                      Comments/Explanation
                                                          ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                            if nothing is checked it will be assumed to be a No.                         comments.



      Do you provide Mental Health and Substance
      Abuse treatment services directly, through
      your own contracted and credentialed panel
      of providers and facilities, or do you
J-1   subcontract these services to a third party
      entity? If the latter, please indicate the third
      party and describe the contracting and
      compensation arrangement in place.


      Do enrollees call one telephone number for
      all Mental Health / Substance Abuse needs,
      including claims issues, benefit questions,
J-2   network availability and                                 Yes       No

      referral/authorization for care?

      Is an Employee Assistance Program a
      component of your Mental Health/Substance
      Abuse Benefits? If Yes list what additional
J-3   services are available and provide costs for             Yes       No
      basic EAP with any additional costs broken
      out.

      How many visits are available for Mental
      Health/Substance Abuse Services without
J-4   prior authorization? (i.e., three, five)


      When enrollees call for a referral, what
      screening questions are asked to ensure they
      are referred to the appropriate provider
J-5   type? Are all self-referrals screened for
      possible substance abuse?

      In geographic areas that present access
      challenges, what is your standard process for
      the following situations?

      a) Enrollee lives in urban area, but has a full-
      time student child away at school in a rural
      area that has limited provider access. Child
      has been treated for an eating disorder but
      the illness has progressed to the extent that
      child needs to be admitted to an in-patient
      facility. Closest contracting in-patient facility
      is 80 miles away from where the child is going
J-6   to school/living. However, there is a non-par
      facility only 30 miles from the school.

      b) Spouse of enrollee self refers because of
      domestic violence. Spouse needs out-patient
      counseling, but because of trust/fear issues
      only wants to see a female provider. There
      are two network providers in the local area,
      but both are male.




                                                                                     Page 17 of 24
                                                                                    Broward Sheriff's Office RLI Questionnaire



       What are your Mental Health/Substance
       Abuse Customer Service hours?
J-7

       How do you administer split claims, when
       part of the services are medical and part
J-8    Mental
       Health/Substance Abuse?

       Do you have a 24-hour crisis line? If so, who
       is it staffed by and what is their level of
J-9    training and expertise? How are callers
                                                         Yes   No
       triaged?
       Who are your on-site clinicians and what are
J-10   their credentials?
       How do you ensure patient confidentiality?
J-11
       Please include a sample of your standard
J-12   utilization reporting. When are these reports
       available?

       Please include samples of your
J-13   communications. When are these
       communications distributed?

       Describe your emergency admission process
J-14   for Mental Health/Substance Abuse issues.

       What is your process for developing a
J-15   transition plan for in- & out-patient care from
       current vendor?
       Describe your aftercare monitoring and
J-16   relapse prevention following intensive
       treatment.
       Please provide the number of employer
       clients, noting the number of enrollees, which
       you are currently providing Mental
       Health/Substance Abuse treatment services
J-17
       by completing Exhibit #EX - 12. Please
       provider by public sector vs. public sector.


       Describe your experience and philosophy
       regarding the role of these services in
J-18   supporting return to work and disability
       management efforts.

        Describe follow-up counseling for clients,
       post-substance abuse and/or mental health
J-19   treatment, including work re-entry.


       Do you provide counseling for adolescents? If
       yes, please provide the criteria and explain
J-20   how it differs from adult counseling.
                                                         Yes   No


       Do you have specialists in adolescent
       counseling? If yes please provide a listing of
J-21   these specialists and their geographic
                                                         Yes   No
       location.




                                                                    Page 18 of 24
                                                                                                                                            Broward Sheriff's Office RLI Questionnaire
                                                              Yes       No


       Describe how you would handle the following
       cases:

       a) management referral of a senior executive
       in severe denial about their addiction,
J-22   b) self-referral of a suicidal employee,
       c) spousal referral of a battered child and/or
       abused spouse, and
       d) adolescent with conduct disorder, court-
       ordered to inpatient treatment

       Under what circumstances might the
       assessing counselor ever become the treating
J-23   clinician if the client is referred for further
       counseling?
       Please describe your compliance with the
       Mental Health Parity Act and what you
J-24   anticipate the cost will be for BSO to comply
       as of 1/1/2010.

       What providers will be offering mental
       health/substance abuse services for children?
J-25


       Do you provide updated provider lists every
       month or every quarter which identify new
J-26   and deleted providers? The listing should
       also include added or deleted treatment
       programs
       Will you provide a mental health/emergency
       triage service (where members in crisis can
       contact insurance provider number and be
J-27   provided an urgent appointment with a local
       provider)?

       Please describe your Employee Assistance
       Plan that is offered in conjunction with the
J-28   Medical Plan. What services are covered as
       part of the medical premium?

       Non-par providers – Are you willing to write
       one time (single service) user agreements
J-29   with programs?

       What benefits are included in your Substance
       Abuse Benefits? Requesting services to
       include: detoxification services, inpatient
J-30   (sometimes referenced as residential),
       outpatient, partial hospitalization and after-
       care services.


                                                               Section K - Sub-Contractors
                                                                             Vendor Response                                      Comments/Explanation
                                                         ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                           if nothing is checked it will be assumed to be a No.                         comments.



       Is your firm using any sub-contractors?
K-1                                                           Yes       No

       If so, please list the name of any
K-2    subcontractor used.
       What are the scopes of services the sub-
K-3    contractors will perform?




                                                                                    Page 19 of 24
                                                                                 Broward Sheriff's Office RLI Questionnaire



      What are the reasons you are sub-contracting
K-4   these services?
      What is the benefit of sub-contracting these
K-5   services?
      What is the depth of experience of the sub-
K-6   contractor performing these services? How
      do you monitor quality assurance.
      How have you evaluated the subcontractors?
      If yes, please provide a brief description of   Yes   No

K-7   your evaluation process including frequency
      of evaluations and ratings used, etc.


      Why have you selected this sub-contractor to
      perform these services?
K-8

      Please list in detail any Performance
      Guarantees you have with your
K-9   Subcontractors (identified and broken by
      Subcontractor).




                                                                 Page 20 of 24
                                                                                                                                          Broward Sheriff's Office RLI Questionnaire



                                                          Section L - Marketing Materials
                                                                           Vendor Response                                      Comments/Explanation
                                                       ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                         if nothing is checked it will be assumed to be a No.                         comments.




      Please provide hard copy samples as
      Attachment #L-1 of standard marketing
      materials that have been sent to new client
      enrollees within the past year.

      Additionally, note how much latitude BSO has
      in personalizing materials. In this regard,
      please include samples of personalized
      materials from other clients such as the
L-1   following:

      Brochures, Post Cards, Tip Sheets, Preventive
      Screen Reminders, Email Messages,
      Promotional/Health Text, Voicemail Blasts,
      Letters, Targeted Outreach, Newsletters,
      Posters, Flyers, Give-always




      Please describe, in detail, collaborative
      marketing efforts you have undertaken to
      support new employer clients in health plan
      transition during the past two years. Detail
      the manpower (expressed as Full Time
      Employee-FTE), time and financial resources
      you committed to each endeavor undertaken
L-2
      with a client at least as large and diverse as
      BSO. Please indicate the percentage of cost
      associated with a marketing campaign of this
      scope which you are prepared to invest in
      such a collaborative effort.


      Please indicate the specific resources you are
L-3   willing to invest in this marketing enterprise


                                                            Section M - Implementation
                                                                   Vendor Response                                               Comments
                                                         ALL Yes/No boxes must have one or the                    If you answer "No" please provide a brief
                                                                     other selected.                                      explanation in comments.
      Provide the name, address and phone
      number of the person with primary
M-1   responsibility for implementation of The BSO
      account.


      Provide the names, titles, address and phone
      numbers of the team members who would
      perform any additional work for BSO after a
M-2   contract is awarded. Also provide the major
      responsibilities and accountabilities for each
      person.

      What are your expectations of BSO in
      relation to staffing this project (resources,
      needs, roles/responsibilities, percentage of
M-3   dedicated time, project management, etc.)?




                                                                                  Page 21 of 24
                                                                                                                                          Broward Sheriff's Office RLI Questionnaire



      Provide a timeline for a new client
      implementation, including key milestones,
      deliverables and responsible parties, if the
      contract is awarded no later than 7/31/2009
      noting that all ID cards have to be mailed by
      12/15/2009. Open Enrollment will take place
      10/1 - 10/31/09. Please make sure the
      timeline includes a plan for a "positive"
M-4
      electronic enrollment to include retirees
      residing outside of Florida. Please note that
      the initial electronic enrollment of all
      enrollees are to be generated by vendor (with
      the format defined by BSO).Provide the
      timeline as Attachment #M-4.


      Specifically list your implementation
      transition tasks and timeline related to
      healthcare services, mental health and
M-5   substance abuse given a 1/1/2010 effective
      date. Provide task list as Attachment #M-5.


      How will you communicate with BSO
      regarding the progress of the conversion and
M-6   implementation effort?


      How will enrollees be affected during the
      conversion process? Please provide a full
      transition process for medical, mental health
M-7   and substance abuse services that are
      currently undergoing care. Provide
      attachment as Attachment #M-7.

      Describe what additional efforts you are
      willing to take responsibility for to educate
M-8   enrollees and ensure a smooth and timely
      transition.

                                                       Section N - Network/Provider Access
                                                                           Vendor Response                                      Comments/Explanation
                                                       ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                         if nothing is checked it will be assumed to be a No.                         comments.




      A Geographic Accessibility Analysis Template
      in Microsoft Excel is attached as Exhibit #EX-
      13. Completion of this analysis is required.
      (Please also attach your standard Geo Access
      Report) . The analysis submitted must be at a
      State, City and five (5) digit zip code level.
      Reports submitted in any other format will be
      viewed as non-responsive. The desired
      access-to-care standards for the Template
N-1   are:

      2 PCP's within 10 miles
      2 Specialists within 10 miles
      2 OB/GYN's within 10 miles
      2 Pediatricians within 10 miles
      1 Hospital within 15 miles




                                                                                  Page 22 of 24
                                                                                    Broward Sheriff's Office RLI Questionnaire



      Please complete Exhibits #EX-14 and #EX-14a
      determining the level of provider disruption
      in moving from the incumbent’s networks to
N-2   yours. Please note there are two current
      providers that must be analyzed.

      Are all hospital-based physicians (emergency,
      pathology, anesthesia and radiology)               Yes   No
      affiliated with network hospitals contracted?
N-3   If not, list any hospital physician group(s) not
      contracted. Please
      include the hospital affiliation.

      Does your proposed network include
      “Centers of Excellence”? If yes, please            Yes   No

N-4   indicate the diseases or procedures included
      and the facility associated.

       Is utilization of your “Centers of Excellence”
N-5   voluntary or mandatory?
      What percentage of your network physicians
      offer expanded office hours? How is this
N-6
      information communicated to members?

      What percentage Geographic match will you
      commit to have in force by 1/1/2010 for each
      of the following - PCP, Specialty and Hospital
N-7
      ? (list each commitment separately)


      Do provider contracts reward hospitals,
      facilities and/or physicians for quality and       Yes   No
N-8
      efficiency? If yes, describe.




                                                                    Page 23 of 24
                                                                                                                                           Broward Sheriff's Office RLI Questionnaire



                                                        Section O - Technology and Systems
                                                                            Vendor Response                                      Comments/Explanation
                                                        ALL Yes/No boxes must have one or the other selected;    If you answer "No" please provide a brief explanation in
                                                          if nothing is checked it will be assumed to be a No.                         comments.



      Please detail your e-technology strategy,
      current and for the next 3 to 5 years including
      any specific system upgrades or any new
0-1   system implementations including but not
      limited to Claims Adjudication, Telephone,
      Customer Service, etc.


      Describe your system capability to provide
      claims, financial and enrollment reports
      detailing monthly activity separated by line of
      business, location, benefit plan and enrollee
      grouping. Indicate the level of data detail
0-2   available and the methods by which the
      output may be accessed (e.g., on-line,
      Compact Disc (CD), download to Excel, hard
      copy, etc.)

      What web capabilities will employees and
      BSO have to view benefit details, claim
0-3   information, Explanation of Benefits, billing
      data and to request ID cards?


      You will be required to provide monthly
      electronic claim extract files. These may be
      sent to third parties who assist in data
      management and analysis. Please identify
      what data elements are included in the file
0-4   and the additional fees, if any, which will be
      necessary to produce the extract file. Please
      indicate when the file will be available (i.e.,
      how many days following the month end).




      Please refer to Reference RX 12 for BSO's              Yes       No
0-5   Enterprise Technology Server Requirements.
      Do you agree to comply with these
      requirements?

                                                             Yes       No
      Please refer to Reference RX 13 for BSO's
0-6   Enterprise Technology Desktop
      Requirements. Do you agree to comply with
      these requirements?
      Describe your system capabilities to receive
      ongoing electronic enrollment files to include,
0-7   but not limited to, new hires, changes and
      terminations

      Please provide your technical security
      requirements as they apply to an electronic
0-8   data interface (including PGP encryption and
      FTP transmission of files).




                                                                                   Page 24 of 24

				
DOCUMENT INFO
Description: Sample Employee Confidentiality Agreement document sample