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Memorial Hermann Indemnification Agreement document sample
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City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
PROPOSAL INSTRUCTIONS
Commodity or Services Requested: Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Proposal Closing/Opening Time: Thursday, June 3, 2010 @ 2:00 P.M.
Proposal Opening Location: City Clerk's office, 801 Main, Room 125, Beaumont, TX 77701
The RFP and timeline should be reviewed in its entirety. Any questions should be submitted within the deadline; a Q&A Addendum will be released to
all carriers interested in submitting a proposal.
Proposals should be completed in the format provided within this file ("Attachments" spreadsheet). Proposals not completed in this format may be
disqualified for non-compliance.
When completing the questionnaires, answers should be summarized in short format and not exceed the allotted space within the cell(s) provided. DO
NOT add extra rows/columns--work with the allotted space. Additional information in carrier format may be submitted along with the "Attachments"
spreadsheet if a carrier would like to include "more detailed" information.
When completing the rates (for fully insured rates), enter the employee count by tier where noted. The "Assumptions" section should also be
completed.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
1 Worksheet: Tab1-Proposal Instructions
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Note: All listed tabs in this RFP file, highlighted below, must be completed, signed, and
returned as part of your proposal, in order for your quote to be considered.
Tab Name Description
Tab 1 Proposal Instructions Proposal Instructions
Tab 2 Proposal Checklist Proposal Checklist
Tab 3 Vendor Information Vendor Information
Tab 4 Exh Review Vendor Sign Exhibit Review Sign Off
Tab 5 General Questionnaire General Questionnaire
Tab 6 Performance Guarantee Performance Guarantees
Tab 7 Medical Questionnaire Medical Questionnaire
Tab 8 Med-Rx Proposed-Benefits Proposed Medical Plan Design
Tab 9 Med Deviations-Variations Proposed Medical -- Deviations/Variations
Tab 10 Med Proposed-FI Rates Proposed Fully Insured Medical Rates
Tab 11 Med Proposed-SF Fees Proposed Self-Funded Administration Fees
Tab 12 Med Proposed-SL Fees Proposed Stop Loss Fees
Tab 13 Med Proposed-Net Disc&Geo Medical Network Discounts and Geo Access Results
Tab 14 Med Disruption Analysis Medical Disruption Analysis
Tab 15 Den Questionnaire Dental Questionnaire
Tab 16 DPPO Proposed-Benefits Proposed Dental Plan Design
Tab 17 Den Deviations-Variations Proposed Dental -- Deviations/Variations
Tab 18 Den Proposed-FI Rates Proposed Fully Insured Dental Rates
Tab 19 Den Proposed-SF ASO Fees Proposed Self-Funded Dental ASO Fees
Tab 20 Den Proposed-Net Disc&Geo Dental Network Discounts and Geo Access Results
Tab 21 Den Disruption Analysis Dental Disruption Analysis
Tab 22 FSA Questionnaire FSA Questionnaire
Tab 23 FSA Proposed-Services Proposed FSA Plan Design
Tab 24 FSA Deviations-Variations Proposed FSA -- Deviations/Variations
Tab 25 FSA Proposed-Fees Proposed FSA Fees
Tab 26 COBRA Questionnaire COBRA Questionnaire
Tab 27 COBRA Prop-Services Proposed COBRA Services
Tab 28 COBRA Proposed-Fees Proposed COBRA Fees
Please provide as part of the proposal the following:
-- Current directory (Medical-PCPs, SCPS, and Mental Health/Substance Abuse providers; Dental-General Dentists,
Orthodontists, and other providers)
-- Sample experience reports
-- Sample plan documents, plan literture, forms, reports, and denial
forms/letters to employees
-- Sample implementation schedule and enrollment procedures
Signature:
Printed Name & Title:
Date:
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
2 Worksheet: Tab2-Proposal Checklist
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
3 Worksheet: Tab2-Proposal Checklist
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Primary Contact Information
Consultant Name
Title
Address (Street, City, State, Zip)
Phone #
Fax #
Email
Secondary Contact Information
Name
Title
Address (Street, City, State, Zip)
Phone #
Fax #
Email
Coverages to be Quoted (Please mark an "x" to all plan types that apply.)
Medical
Stop Loss
Dental
FSA
COBRA
Signature:
Printed Name & Title:
Date:
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
4 Worksheet: Tab3-Vendor Information
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
EXHIBIT REVIEW SIGN-OFF
I acknowledge that I have reviewed the RFP in its entirety, including the Client Specifications (in Word
format) and all information in the Exhibits file (Excel format). I have also reviewed the RFP timeline
within the Client Specifications, which includes important dates that are relevant to this RFP.
I acknowledge I have reviewed and included all Addendums, if applicable, in my proposal.
Failure to submit my proposal in the manner the RFP states and within the indicated date and time will
result in disqualification of my proposal.
Signature:
Printed Name & Title:
Date:
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
5 Worksheet: Tab4-Exh Review Vendor Sign
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
Organizational Strength Response
1 Provide the name and address of your company.
Describe the history and ownership of your
2
company.
3 How long in business under current name?
4 Is your company publicly traded?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
6 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
What is your market capitalization/financial
5
strength?
What is your company's A.M. Best rating? Please
6
also provide your Dunn & Bradstreet number.
Account Management Response
Give the name and title of the person(s) with
whom overall responsibility for planning,
5
supervising, and performing the day-to-day
administrative services for the Client will be.
Will the Client have a dedicated Account
Manager? If so, where are they located and
6
what are their standard hours? Will they have a
back-up contact?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
7 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
Please provide a summary list of all
7 administrative services your firm will perform for
our group.
In the event of contract termination, discuss the
8 transition process. Include penalties, number of
days notice, etc.
Customer Service Response
Are all customer service conversations
9 documented and/or retained for proof of
compliance?
System Processes and Technology Response
What payroll software/systems has your
10
company worked with?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
8 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
Does the platform allow clients access to reports
11
during and after enrollments?
What services will your company provide the
12 client for ongoing maintenance and support after
enrollment?
Client Specific Response
Describe the vendor/city’s responsibilities at the
13
beginning of each year and at year end process.
Describe how the benefit system integrates with
14 the payroll system. Will benefit election changes
update payroll deductions?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
9 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
Can benefit plans be set up so only a specific
15
group of employees are eligible for them?
Can benefit cost changes be future dated for a
15
future year with in the current year?
When changes occur, are premiums
16 automatically updated for age and salary benefit
calculation?
Does the system produce Employee Benefit
17 Statements and if so does it include the City’s
cost of benefits?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
10 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
Describe the vendor/city’s responsibilities at the
17
beginning of each year and at year end process.
18 Describe the online benefits enrollment process.
19 What password controls are utilized?
Please provide a sample online benefit
19
enrollment implementation plan.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
11 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
GENERAL QUESTIONNAIRE
The following questionnaire must be completed.
What staff will be offered in the field to assist
20
employees during annual enrollment?
References Response
Current Clients
1
Please provide three references of current
clients and two references of clients you 2
have lost in the past two years. Ideally,
these references would be similar in size to
the Client. (Include name, phone number, 3
21 email address., and years of service)
Former Clients
1
Reason for leaving:
2
Reason for leaving:
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
12 Worksheet: Tab5-General Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
SPECIFIC REQUIREMENT CONFIRMATION OR EXPLANATION
Vendor shall assist in plan communication and
enrollment of active employees and retirees.
Vendor will assist with annual enrollment
meetings with employees who work around the
clock in various work locations throughout the
City of Beaumont. Annual enrollment during
1 October/ November is the period each year
when people insured under the City’s benefit
plans can enroll or change plans. Vendor will
provide at least two trained staff members to
help support the annual enrollment meetings
which will be held at various locations and shift
times throughout the City.
No loss/no gain: No covered employee or
covered dependent shall lose or gain benefits as
a result of a vendor change. All actively at work
and non-confinement provisions must be
2
expressly waived for the initial enrollment for
covered employees and covered dependents
who have already satisfied the limitations under
the current plan.
Administrator must be able to maintain eligibility
files and receive updates from City as required.
Administrator will make benefit eligibility
available online to City staff with appropriate
measures to protect the confidentiality and
3
integrity of the information and access to it. The
administrator must provide City staff the ability
to enter and update eligibility. The initial
eligibility information must be completed by the
vendor.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
13 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
A monthly employee eligibility/census report by
group (including COBRA) must be provided for
each type of plan administered. These reports
must include the following information:
Employee and dependent names – last, first and
middle
Employee unique ID# and gender
4 Employee and dependent date of birth
Employee address including city, state and zip
code
Effective date of coverage
Termination date
Coverage status (EO, E1, etc. with totals for
each group)
Vendor must agree to attend monthly update
5
and quarterly review meetings at the City.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
14 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
Vendor that is awarded a contract must develop,
print and make available a customized summary
plan document (SPD) booklet and plan network
directories to plan members, i.e., employees,
retirees, COBRA participants. Booklets and
directories shall be provided to the member at
the time of initial enrollment and thereafter for
new hires or other new members. Summary plan
document and updated network directory shall
6
be provided to members when changes occur.
SPD shall be reviewed and approved by the City.
Vendor will provide enrollees, prospective
enrollees, and providers access to current
information or network providers via a
searchable online directory. Detail additional
cost for printing booklets, directories for
employees, retirees, COBRA participants
on the attachment rate sheet.
The vendor must provide a single point of
contact account manager and local contact
7 medical and dental representative. This person
shall be available through a toll-free telephone
number and a direct telephone number.
The vendor that is awarded a contract must
contractually agree to provide “run-out” claims
processing services at a level of service and
8
price that are comparable to pre-termination
services, for up to 12 months at termination of
the new agreement.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
15 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
The vendor that is awarded a contract must
agree to transmit test data to a new vendor no
less than 30 days prior to the termination of a
9
contract and to provide a final verified transition
data file to the new vendor within 30 days after
the termination date.
The vendor that is awarded a contract must
10 provide the City with monthly cost reports by
section (fire, police, civilian, etc.)
The vendor, at its own cost, must provide
routine distribution of ID cards, including
printing, mailing, and postage. The Vendor, at its
own cost, will provide ID cards directly to the
participant’s (employees, retirees, COBRA
members) home address for (1) the initial
enrollment of the plan, (2) future new hires, (3)
members who change coverage category and
(4) replacement of lost cards or extra cards
11 required. The information to be printed on each
ID card will include, at a minimum, the
participant’s name and unique identification
number (not social security number), plan name,
the vendor name and toll free customer service
number. The vendor must mail ID cards to
participant home addresses within ten working
days after receiving the initial enrollment
information and within five working days of
receiving any change request.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
16 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
The vendor that is awarded a contract must
capture member and dependent information
from enrollment materials and maintain it
throughout the term of the contract. The City
requires access to an on-line computer based
updating of the eligibility data. Eligibility
software must comply with the confidentiality
and security provisions of federal law. The cost
for this service should be included as part of the
rate and should provide the following
12
capabilities:
In-house maintenance of participants’
eligibility/census;
Ability to run standard eligibility/census reports
and
Automatic update or electronic transfer of
eligibility data to the vendor
provider/administrator.
Properly staffed and supervised
customer/member service representatives must
be available to plan participants via a 1-800
13 number. Vendor will have a Web site available
24 hours everyday giving enrollees secure online
access to information on their claims and
providing secure e-mail.
The vendor that is awarded a contract shall
provide and maintain networks of qualified
providers that provide quality services on a cost-
effective basis for the health and dental plans
during the term of the contract. Each proposer
must ensure that the providers continue to meet
licensing, selection, and screening criteria and
14 that required liability insurance is maintained.
Each proposer must confirm in its response that
its proposed network will remain under
agreement throughout this proposal process.
Subsequent to submission, any material changes
must be brought to the City’s attention
immediately. Failure to do so may eliminate the
proposal from consideration.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
17 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
Dental rates quoted should be based on the
current three tier structure: employee only,
employee and one dependent, and employee
and two or more dependents in addition to a
four tier structure: employee only, employee and
15 child, employee and spouse, and employee and
family. Administrative fees should be a
composite rate. Once the City decides what rate
structure (three or four tier) will be implement,
payment will be remitted based on the monthly
enrollment (self billed).
Vendor will provide fully-funded equivalency for
16
all plan tier coverages each year.
The vendor awarded a contract will develop and
provide a summary handout/overview of plan
17
benefits for initial annual enrollment, employee
orientation and ongoing annual enrollment.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
18 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
The selected vendor shall provide the entire
COBRA administration process. The City will
provide notification of new hires, dependent
changes, and terminations to the selected
vendor who will then be responsible for all other
aspects of the process, including but not limited
to the following:
employee/dependent to home address
notification for medical, drug and dental
benefits; (general COBRA notice, COBRA
election notice, notice of unavailability of
18
COBRA coverage, COBRA termination notice
before end of maximum coverage period)
certificate of coverage for HIPAA compliance;
billing and premium collection for medical, drug
and dental benefits; and
mail identification cards and informational
materials to the member’s home; provide
monthly COBRA eligibility listing to City.
The selected vendor shall provide an actuarial
determination of COBRA rates/premiums to the
19 City on an annual basis but not later than August
1 of each year, the cost to be included a part of
the administration rate.
All services offered/provided must be clearly
identified/explained. All costs must be fully
20 detailed and summarized with exceptions or
deviations to specific requirements clearly
enumerated.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
19 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MINIMUM VENDOR REQUIREMENTS QUESTIONNAIRE
The following questionnaire must be completed. Proposals must be clearly explained and any exceptions
or deviations to specific requirements clearly identified. If you are unable to meet a condition please give
an explanation.
A specimen contract, summary plan description,
network directories showing access to Texas
21 providers, and sample eligibility/cost reports
shall be included in the proposal.
Provide strict adherence to the applicable
sections of the IRS Code and Health Insurance
21 Portability and Accountability Act of 1996
(HIPAA) regulations.
The identification (ID) cards and directories, etc.
for the initial enrollment must be received by
each participant not later than two weeks prior
to the effective date of the contract (January 1,
22 2011). The summary plan document (SPD) must
be developed and submitted to each participant
not later than March 1, 2011 unless another
date has been agreed upon by the City.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
20 Worksheet: Tab6-Minimum Vendor Requirement
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
PERFORMANCE GUARANTEES
The following questionnaire must be completed.
Administration Response
Please include a draft of your Standard
Administrative Services Agreement. In the draft
agreement, please include performance
guarantees that you are willing to implement.
-- Description of the metrics
-- Associated monetary risks
1
-- Guarantees during plan implementation
How do you report the items back to
the client?
The guarantees are as of when?
Can you guarantee the
implementation of the file transfer?
Provide the standards for the following
performance indicators and define each.
-- Service index (claim turnover)
-- Daily average claims processed per claims
examiner
2
-- Financial/non-payment accuracy
-- Overall accuracy
-- Number of times claim "touched" to resolve
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
21 Worksheet: Tab6-Performance Guarantees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Medical Health Carriers are required to respond to all requests for information contained in this
questionnaire. All responses must be provided on a diskette and respond in a brief, bulleted format. This
questionnaire will be scored; therefore, it is necessary that you provide concise answers. Your responses
to the questions should be based on your current proven capabilities. Should there be instances where
certain questions are not applicable to your organization or its operations, please so indicate. If you are
selected to administer the Client's employee benefit plans, your responses to the questionnaire will be
considered part of your contractual responsibilities. You are also requested to return the indicated
exhibits as part of your proposal.
Organizational Strength Response
How many clients do you currently in force for
1
this line of coverage?
Customer Service Response
Please provide your customer service hours,
days of operation, time zone. Do you have
dedicated employees/unit to handle larger
2
accounts in the call center? What is the
experience level of your company’s customer
service department?
Is your customer service unit bilingual? How
often are your team members trained on the
lines of coverage supporting? What are your
3
hours of customer service unit--after hours? Is
your customer service unit outsourced? If so,
what country?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
22 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Does your company archive the actual
4
enrollment forms?
Does your company provide a customized 1-800
5 number to handle questions related to product
offerings during the enrollment period?
Are all customer service conversations
6 documented and/or retained for proof of
compliance?
System Processes and Technology Response
What are the various methods information can
be transmitted and how often? Can the platform
be fully customized to capture all feeds, and
7 upload to various payroll and eligibility systems?
State how you process and verify the eligibility
information. Identify any information you would
require in paper format.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
23 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Do you have online enrollment/eligibility
capabilities? For updating? If so, how long does
8
it take before the change / addition / deletion is
effective?
What online benefit systems has your company
9
worked with?
Describe your process for handling retroactive
10
enrollment and cancellations.
Demonstrated Qualifications/Exp Response
Has your network been reviewed and accredited
by an external agency in industry organization
11
(NCQA, AAPPO, JCAHO, etc.?) If so, please
describe.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
24 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Implementation Process Response
What initial information is required from the
employer for implementation? Is a checklist
available to provide to the client? Explain in
12 detail the steps you anticipate will be needed to
ensure a smooth implementation. Include a
timetable of events from the effective date and
including the Open Enrollment process.
Who will be assisting in the implementation
13 process? What will occur during the
implementation process?
Will you have field representatives available for
14 group meetings? What is standard timeframe for
meeting notifications for travel purposes?
Standard turnaround time for new group
15
processing? New enrollees?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
25 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
16 Do you track dependent eligibility?
17 How will terminations be handled?
Is any function of the claims process
18
outsourced?
What is your standard turnaround time for
19
claims payment?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
26 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
In the event of contract termination, discuss the
20 transition process. Include penalties, number of
days notice, etc.
How do you recommend the Client handle
transition of care issues? Be specific with respect
21
to pregnancy, hospitalization, chronic/terminal
illness, mental health and prescription drugs.
Are you willing to customize communications,
such as ID cards and SPDs? Do you agree to
allow the Client to pre-approve any
22
communication to employees that would reach a
significant portion of the Client's population?
Individualized communications are excluded.
Will your organization provide the Client with
23 hard copies of provider directories for employees
or administration? If so, how often.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
27 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
What information is available through your
24
website for the members and the group?
Are participants required to select a primary
care physician? What medical specialties are
included as PCPs? What is the process for
25
changing PCPs and how often is it allowed? Can
family members select different medical groups
and PCPs?
How will billing be set-up? Does your company
26 offer self-bill or electronic billing? Is any function
of the billing process outsourced?
Please summarize what programs you are
offering to the Client that help control cost
(utilization review, case management, condition
27 management, high performance networks, etc.).
How many of these services are currently
measuring savings? What is the percentage of
savings?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
28 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Administrative/Technical Capabilities Response
Do you have the ability to handle claims
28 administration on a local, regional and national
level?
Describe in detail your procedure for conducting
audits of your claims processing units. Include
29 who conducts the audit, what is reviewed during
the audit, and how often the audits are
conducted.
Describe the overpayment recapture process
30
and the impact on the Client's experience.
Provider Network/Utilization Mgmt Response
Describe the organizational structure of your
national and regional managed care program.
31 Briefly describe any key corporate or regional
managed care staff that would be instrumental
in servicing our account.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
29 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Identify any changes to your provider contracts
32 or contracting strategies that you anticipate over
the next three years.
Do you have the ability to profile physician for
33 prescribing patterns, administrative efficiencies,
and/or quality of care? If yes, please describe.
Identify the percentage of physicians that are
34 If quoting more than one type of plan, complete nos. 20 and 21 for each plan.
reimbursed by the following methods:
Primary Care Physician [Insert Type of Medical Plan, i.e., PPO, HMO, etc.]
Salary
Discounted fee for service w/withhold
Fee for service w/bonus
Fee schedule
Capitation
Capitation w/withhold
Capitation w/bonus
Percentage discount
Other (specify):
Total
Specialist [Insert Type of Medical Plan, i.e., PPO, HMO, etc.]
Salary
Discounted fee for service w/withhold
Fee for service w/bonus
Fee schedule
Capitation
Capitation w/withhold
Capitation w/bonus
Percentage discount
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
30 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Other (specify):
Total
Enter the percent of inpatient hospitals that are
35
reimbursed by the following methods:
Inpatient Hospitals [Insert Type of Medical Plan, i.e., PPO, HMO, etc.]
Discount
Per Diem
Capitation
DRG Case Rates
Global Fees
Other (specify):
Total
Under what circumstances would you be willing
to expand or reduce the network (service area
36
and additional hospitals and/or physicians) on
the Client's behalf?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
31 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Does your current network include providers in
37 the xxx area? If no, are you willing to expand
your network to include those area doctors?
Identify the hospitals that are considered in-
38 network within the Jefferson County area and
within a 50-mile radius.
What percent of the primary care physicians are
39 on staff at each network hospital and are
participating in the network?
How many primary care physicians are included
40 in the Jefferson County network? How many are
accepting new patients?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
32 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
How many specialists are included in the
41
Jefferson County network?
42 How many acute care hospitals?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
33 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
MEDICAL QUESTIONNAIRE
The following questionnaire must be completed.
Wellness, Medical Plan Design/Cost Response
Please provide the Client with a brief summary
of why your proposed medical program is the
most innovative, cost effective, and best suited
43
for the Client and its employees. Be sure to
describe any unique characteristics that set you
apart from other carriers.
Describe in detail how you will support the
Client’s efforts to promote Wellness for
employees and any costs and projected savings
associated with those services. Specifically
44
indicate whether you are proposing any
dedicated wellness resources (personnel,
communication, education and physical fitness
services).
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
34 Worksheet: Tab7-Medical Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design information in the following requested
format in order for your quote to be considered. Enter only those plan design elements that
are included in your quoted rates. Please confirm that you can duplicate and administer
the current plan design. If not, please indicate differences on Medical-
Deviations/Variations.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Proposed Medical Plan Design
In-Network Out-of-Network
Deductible (CYD)
Per Participant
Family
Out-of-Pocket Maximum
Per Participant
Family
Is the deductible included in the Out-of-Pocket Maximum? Yes o No o
Does in-network or out-of-network deductible/ coinsurance
Yes o No o
cross apply?
If so, please describe.
Lifetime Maximum
Coinsurance
Physician Visit
Diagnostic Services (for lab and radiology/x-ray)
Advanced Diagnostic Services (CT Scans, Pet Scans,
MRI)
How are in-network diagnostic services handled in a
Physician's office? (i.e., included in physician copay,
deductible/ coinsurance, etc.)
Hospital Inpatient
Emergency Room
Urgent Care
Outpatient Surgery
Preventive Care
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
35 Worksheet: Tab8-Med Proposed-Benefits
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
For any benefits you cannot duplicate or administer, per the in force SPD, please indicate
on this tab. Please clearly note the differences.
Proposed Medical -- Deviations/Variations
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
36 Worksheet: Tab9-Med Deviations-Variations
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete rate information in the following requested format
in order for your quote to be considered.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Proposed Fully Insured Medical Rates
Are retirees included in fully insured rates? Yes o No o
Quote rates in the following tier structure(s): 2-Tier o3-Tier o4-Tier o
EE Counts Proposed Medical Rates
Employee Only xx
Employee + Spouse xx
Employee + Child(ren) xx
Employee + Family xx
Monthly Premiums $0
Annual Premiums $0
EE Counts Proposed Medical Rates
Employee Only xx
Employee + One xx
Employee + Family xx
Monthly Premiums #VALUE!
Annual Premiums #VALUE!
Assumptions
Employer Contribution (i.e., 75%, 50%)
Rate Guarantee
Participation Requirements
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
37 Worksheet: Tab10-Med Proposed-FI Rates
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design and rate information in the following
requested formats in order for your quote to be considered. Enter only those plan design
elements that are included in your quoted rates. List any optional coverages (along with
the approximate percentage increase to the rates) under Optional Available Riders.
Proposed Self-Funded Administration Fees
2010 2011 2012
Enrollment Assumptions
Employees
Dependents
Administrative Fee Breakdown (PEPM) 2010 2011 2012
Claims Processing
Utilization Management
Network Administration / Access Fee
Enrollment / Eligibility System Access
Schedule A Preparation
Hard Copy Directories / Fulfillment
Booklet and Contract Drafting
Booklet / Hard Copy SPD Printing & Distribution
Initial ID Cards / Replacement Cards
Banking Charges / Fees
Standard or Electronic Reporting
Subrogation
Centers of Excellence
Individual Case Management
24-Hour Nurse / Information Line
Physician Review
Employee Statements
Other (Please list)
1
2
3
4
TOTAL PEPM (Sum of Rows 16 thru 37)
TOTAL ANNUAL PREMIUMS
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
38 Worksheet: Tab11-Med Proposed-SF Fees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Other Set-Up, If Aplicable
Initial Set-Up Charges (Enter amount)
Required Banking Deposit Yes o No o
Fee Guarantee (Yes / No)
Guarantee Caveats
Assumptions
Rate Guarantee
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
39 Worksheet: Tab11-Med Proposed-SF Fees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Specific Requested Option 1 Option 2
Enrollment Assumptions
Employee Only
Employee + Dependent(s)
Total Employees
Terms
Contract Type (Incurred Mos/Paid Mos) Paid/12 12/15 18/15
Deductible $150,000 $150,000 $150,000
Covered Benefit Medical Medical Medical
Maximum Reimbursement $1,000,000 $1,000,000 $1,000,000
Premiums
Employee Only
Employee & Family
Composite
Monthly Premiums
Annual Premiums
Aggregate Requested Option 1 Option 2
Terms
Contract Type (Incurred Mos/Paid Mos) Paid/12 12/15 18/15
Covered Benefit Medical Medical Medical
Aggregate Corridore 125% 125% 125%
Aggregate Claim Liability & Run-off
Employee Only
Employee & Family
Composite
Other Provisions
Average Claim Value
Minimum Point of Attachment
Premiums
Employee Only
Employee & Family
Composite
Monthly Premiums
Annual Premiums
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
40 Worksheet: Tab12-Med Proposed-SL Fees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must this information in the following requested formats in
order for your quote to be considered. Enter only the networks that are included in
your quoted rates.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Medical Network Discounts
Please provide your organization's self reported discounts within the xx area for:
Hospital Inpatient %
Hospital Outpatient %
Physician %
Geo Access Results
Please provide full detailed reports for the medical GEO access within your formal proposal.
Primary Care Acute Care
Measurement Specialists
Physicians Hospitals
# of Employees / Zip Codes Evaluated
Providers
# of Providers
# of Locations
X Providers within X Miles 2 / 10 2 / 15 1 / 20
% of Employee WITH access % % %
# of Employees WITH access
% of Employee WITHOUT access % % %
# of Employees WITHOUT access
Average distance to 2 providers for employees
WITH desired access
Average distance to 2 providers for employees
WITHOUT desired access
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
41 Worksheet: Tab13-Med Proposed-Net Disc&Geo
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
42 Worksheet: Tab13-Med Proposed-Net Disc&Geo
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete the disruption analysis for each network
quoted in the following requested formats in order for your quote to be
considered.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Medical Disruption Analysis
In Network?
Provider Code Provider Name City and State
(Y/N)
1. 640523657 CHRISTUS HOSPITAL BEAUMONT, TX
2. 640523657 CHRISTUS HOSPITAL BEAUMONT, TX
MEMORIAL HERMANN BAPTIST BEAUMONT
3. 57310455 BEAUMONT, TX
HOSPITAL
4. 17728034 THE METHODIST HOSPITAL HOUSTON, TX
MEMORIAL HERMANN BAPTIST BEAUMONT
5. 57310455 BEAUMONT, TX
HOSPITAL
6. 569869586 MD ANDERSON CANCER CENTER HOUSTON, TX
7. 815572832 THE MEDICAL CTR OF SOUTHEAST TX LP PORT ARTHUR, TX
8. 628918645 MEM HERMANN HOSPITAL HOUSTON, TX
9. 17728034 THE METHODIST HOSPITAL HOUSTON, TX
10. 260752583978001 CREIGHTON ST JOSEP OMAHA, NE
11. 815572832 THE MEDICAL CTR OF SOUTHEAST TX LP PORT ARTHUR, TX
12. 845953862 TEXAS CHILDRENS HOSPITAL HOUSTON, TX
13. 95480482 BEAUMONT BONE JOINT INSTITUTE BEAUMONT, TX
14. 530933751 KATE DISHMAN REHAB HOSPITAL BEAUMONT, TX
15. 49303065 QUEST DIAGNOSTIC CLINICAL LAB INC IRVING, TX
16. 16353033 KINDRED HOSPITAL HOUSTON HOUSTON, TX
THE ENDOSCOPY CENTER OF SOUTHEAST
17. 445458479 BEAUMONT, TX
TEXAS LP
BIOTRONICS KIDNEY CENTER OF BEAUMONT
18. 241710260 BEAUMONT, TX
INC
19. 162049180 BEAUMONT SURGICAL AFFILIATES LLC BEAUMONT, TX
20. 538650116 FOUNDATION SURGICAL HOSPITAL BELLAIRE, TX
21. 85361120 TEXAS ORTHOPEDIC HOSPITAL HOUSTON, TX
22. 20909037 DIAGNOSTIC HEALTH BEAUMONT BEAUMONT, TX
23. 568574588 KESHAVA REDDY BEAUMONT, TX
24. 845953862 TEXAS CHILDRENS HOSPITAL HOUSTON, TX
25. 569869586 MD ANDERSON CANCER CENTER HOUSTON, TX
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
43 Worksheet: Tab14-Med PPO Disrupt Analysis
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete the disruption analysis for each network quoted in
the following requested formats in order for your quote to be considered.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Medical Disruption Analysis
In Network?
Provider Code Provider Name City and State
(Y/N)
1 640523657 CHRISTUS HOSPITAL BEAUMONT, TX
2 640523657 CHRISTUS HOSPITAL BEAUMONT, TX
3 323783341 CLEAR LAKE REGIONAL MEDICAL CENTER WEBSTER, TX
4 57310455 MEMORIAL HERMANN BAPTIST BEAUMONT HOSPITAL BEAUMONT, TX
5 57310455 MEMORIAL HERMANN BAPTIST BEAUMONT HOSPITAL BEAUMONT, TX
6 569869586 MD ANDERSON CANCER CENTER HOUSTON, TX
7 569869586 MD ANDERSON CANCER CENTER HOUSTON, TX
8 6804024 OPTIONCARE BEAUMONT, TX
9 241710260 BIOTRONICS KIDNEY CENTER OF BEAUMONT INC BEAUMONT, TX
10 95480482 BEAUMONT BONE JOINT INSTITUTE BEAUMONT, TX
11 640523657 CHRISTUS HOSPITAL BEAUMONT, TX
12 815572832 THE MEDICAL CTR OF SOUTHEAST TX LP PORT ARTHUR, TX
13 815572832 THE MEDICAL CTR OF SOUTHEAST TX LP PORT ARTHUR, TX
14 20909037 DIAGNOSTIC HEALTH BEAUMONT BEAUMONT, TX
15 189744206 SOUTHWEST AIR AMBULANCE SERV EL PASO, TX
16 845953862 TEXAS CHILDRENS HOSPITAL HOUSTON, TX
17 698464723 CHRISTUS DUBUIS HOSPITAL BEAUMONT BEAUMONT, TX
18 162049180 BEAUMONT SURGICAL AFFILIATES LLC BEAUMONT, TX
19 5946155 CLARUS IMAGING BEAUMONT LP BEAUMONT, TX
20 374549392 SAVITHRI BONTHALA WEBSTER, TX
HEALTHSOUTH REHABILITATION HOSPITAL OF
21 99254116 BEAUMONT, TX
BEAUMONT
22 17728034 THE METHODIST HOSPITAL HOUSTON, TX
23 197372245 ERWIN LO BEAUMONT, TX
24 57310455 MEMORIAL HERMANN BAPTIST BEAUMONT HOSPITAL BEAUMONT, TX
25 856455988 CURTIS THORPE BEAUMONT, TX
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
44 Worksheet: Tab14a-Med HMO Disrupt Analys
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
DENTAL QUESTIONNAIRE
The following questionnaire must be completed.
Dental Carriers are required to respond to all requests for information contained in this questionnaire. All
responses must be provided on a diskette and respond in a brief, bulleted format. This questionnaire will
be scored; therefore, it is necessary that you provide concise answers. Your responses to the questions
should be based on your current proven capabilities. Should there be instances where certain questions
are not applicable to your organization or its operations, please so indicate. If you are selected to
administer the Client's employee benefit plans, your responses to the questionnaire will be considered
part of your contractual responsibilities. You are also requested to return the indicated exhibits as part of
your proposal.
Organizational Strength Response
How many clients do you currently in force for
1
this line of coverage?
How long have you been providing dental
2
administration?
General Response
3 Location of Claim Payment Operations
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
45 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Will you provide annual actuarial services to
4
provide COBRA rates for participants?
Customer Service Response
Please provide your customer service hours,
days of operation, time zone. Do you have
dedicated employees/unit to handle larger
5
accounts in the call center? What is the
experience level of your company’s customer
service department?
Is your customer service unit bilingual? How
often are your team members trained on the
lines of coverage supporting? What are your
6
hours of customer service unit--after hours? Is
your customer service unit outsourced? If so,
what country?
Does your company archive the actual
7
enrollment forms?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
46 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Does your company provide a customized 1-800
8 number to handle questions related to product
offerings during the enrollment period?
Are all customer service conversations
9 documented and/or retained for proof of
compliance?
System Processes and Technology Response
What are the various methods information can
be transmitted and how often? Can the platform
be fully customized to capture all feeds, and
10 upload to various payroll and eligibility systems?
State how you process and verify the eligibility
information. Identify any information you would
require in paper format.
Do you have online enrollment/eligibility
capabilities? For updating? If so, how long does
11
it take before the change / addition / deletion is
effective?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
47 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
What online benefit systems has your company
12
worked with?
Describe your process for handling retroactive
13
enrollment and cancellations.
Providers/Networks Response
Can employees nominate their dentist to
become part of your network? Do you actively
pursue member recommendations? What % of
14
member referrals join the network? What is the
average timeframe from referral to network
contract?
Do you provide directories? If so, how frequently
15 are provider directories updated? How often are
website directories updated?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
48 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Implementation Process Response
What initial information is required from the
employer for implementation? Is a checklist
available to provide to the client? Explain in
16 detail the steps you anticipate will be needed to
ensure a smooth implementation. Include a
timetable of events from the effective date and
including the Open Enrollment process.
Who will be assisting in the implementation
17 process? What will occur during the
implementation process?
Will you have field representatives available for
18 group meetings? What is standard timeframe for
meeting notifications for travel purposes?
Standard turnaround time for new group
19
processing? New enrollees?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
49 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
20 Do you track dependent eligibility?
21 How will terminations be handled?
Is any function of the claims process
22
outsourced?
What is your standard turnaround time for
23
claims payment?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
50 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
In the event of contract termination, discuss the
24 transition process. Include penalties, number of
days notice, etc.
Do you provide ID cards? How soon do
25 employees receive ID cards prior to the effective
date of coverage?
Are you willing to customize communications,
such as ID cards and SPDs? Do you agree to
allow the Client to pre-approve any
26
communication to employees that would reach a
significant portion of the Client's population?
Individualized communications are excluded.
Will your organization provide the Client with
27 hard copies of provider directories for employees
or administration? If so, how often.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
51 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
What information is available through your
28
website for the members and the group?
How will billing be set-up? Does your company
29 offer self-bill or electronic billing? Is any function
of the billing process outsourced?
Plan Design Response
What schedule and percentage is your UCR data
based upon? Is UCR based on the carrier's or
30 other data? If own data, is UCR based on ALL
submitted charges or only network dentists
charges?
What is the basis for out-of-network benefits
reimbursement:
31
1) UCR, 2) network fee schedule, and 3) other?
Please explain.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
52 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Claims Payment Response
What procedures are in place for insuring proper
32
COB?
For an ASO account, are you responsible for
33 overpayments? If not, how is the Client
compensated for your errors?
In the event that the relationship terminates,
34 how is work-in-process handled? What about
members in the midst of orthodontia treatment?
For an ASO account, are you willing to submit to
35
audits conducted by the Client or its agents?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
53 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Are claim forms necessary for all services? Any
36
services?
How long do you maintain dental claims
37
records?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
54 Worksheet: Tab15-Den Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design information in the following requested
format in order for your quote to be considered. Enter only those plan design elements
that are included in your quoted rates. Please confirm that you can duplicate and
administer the current plan design. If not, please indicate differences on Dental-
Deviations/Variations.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Proposed Dental Plan Design
Is quoted plan an open or closed list of services? Yes o No o
If a closed list, please provide a detailed list of covered services and any services not included.
How is your dental plan set up? Calendar Year o Plan Year o
Is there a 4th quarter carryover provision? Yes o No o
What are your plan frequency limitations based on? Calendar Year o Consecutive Months o
In-Network Out-of-Network
Deductible (CYD)
Per Participant
Family
Out-of-Pocket Maximum
(Per person, per calendar year)
Preventive
Number of preventive cleanings covered
Basic Services
Are composite fillings covered?
Major Services
Orthodontic Services
Benefit Percentage
Age Limitations
Orthodontic Lifetime Maximum
Basis of reimbursement
UCR percentile, in-network fee schedule, or other fixed
dollar schedule?
If UCR, what percentile?
What level of service is Periodontic services covered?
What level of service is Endodontic services covered?
What is the eligibility or benefit waiting periods for new
enrollees or late entrants?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
55 Worksheet: Tab16-DPPO Proposed-Benefits
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Frequencies
Please provide frequency and service category (i.e., preventive, basic, major) for each service listed:
Frequency Service Category
Periodic Oral Evaluation
Genetic test for susceptbility to oral diseases
Intraoral complete Series or Panoramic X-rays
Bitewing X-Rays
Dental Prophylaxis
Topical Flu
Bitewing X-Rays
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
56 Worksheet: Tab16-DPPO Proposed-Benefits
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Dental Prophylaxis
Topical Fluoride Treatment
Sealants
Space Matainers
Periodontal Maintenance (Prophy)
Inlays and Onlays
Crowns
Endodontic endosseous implants
Dentures
Fixed Bridges
Plan Specific Questions
Major Services
Is treatment (crown/root canal) started prior to coverage eligible for benefits? Yes o No o
Please explain how transfer of benefits are paid.
Orthodontic
Is coverage limited to active treatment or active treatment and retention? Active Treatment o Active Treatment & Retention o
Is treatment started prior to coverage eligible for benefits? Yes o No o
Please explain how transfer of orthodontic benefits are paid.
Plan Design
Yes o No complex endo?)
Are endodontic and periodontal services combined or split into separate service categories (surgical and non-surgical perio, simple ando
If separated, please list on the deviations/variations tab.
Are simple and surgical extractions combined or split into separate service categories? Yes o No o
Are "naturally functioning" or "asymptomatic" tooth provisions in effect? Yes o No o
If terms are defined, please list on the deviations/variations tab.
Out-of-Network Benefits
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
57 Worksheet: Tab16-DPPO Proposed-Benefits
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
For any benefits you cannot duplicate or administer, per the in force SPD, please indicate
on this tab. Please clearly note the differences.
Proposed Dental -- Deviations/Variations
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
58 Worksheet: Tab17-Den Deviations-Variations
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete rate information in the following requested format
in order for your quote to be considered.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Proposed Fully Insured Dental Rates
Are retirees included in fully insured rates? Yes o No o
Quote rates in the following tier structure(s): 2-Tier o3-Tier o4-Tier o
EE Counts Proposed Dental Rates
Employee Only xx
Employee + Spouse xx
Employee + Child(ren) xx
Employee + Family xx
Monthly Premiums $0
Annual Premiums $0
Assumptions
Employer Contribution (i.e., 75%, 50%)
Rate Guarantee
Participation Requirements
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
59 Worksheet: Tab18-Den Proposed-FI Rates
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design and rate information in the following
requested formats in order for your quote to be considered. Enter only those plan
design elements that are included in your quoted rates. List any optional coverages
(along with the approximate percentage increase to the rates) under Optional
Available Riders.
Proposed Self-Funded Dental ASO Fees
With $x,xxx Benefit With $x,xxx Benefit
Administrative Fees
Employee Only $ pepm $ pepm
Employee + Spouse $ pepm $ pepm
Employee + Child(ren) $ pepm $ pepm
Employee + Family $ pepm $ pepm
Other Fees
Startup $ $
SPD (draft, production & distribution) $ $
Reporting $ $
Subrogation $ $
Coordination of benefits $ $
Other fees $ $
Assumptions
Employer Contribution (i.e., 75%, 50%)
Rate Guarantee
Participation Requirements
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
60 Worksheet: Tab19-Den Proposed-SF ASO Fees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must this information in the following requested formats in
order for your quote to be considered. Enter only the networks that are included in
your quoted rates.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Dental Network Discounts
Please provide your organization's self reported discounts within the Beaumont area for:
General Dentists %
Specialist Dentists %
Orthodontists %
How are discounts calculated? Average Charge oUCR Percentile o
Geo Access Results
Please provide full detailed reports for the medical GEO access within your formal proposal.
Measurement General Dentists Specialist Dentists Orthodontists
# of Employees / Zip Codes Evaluated
Providers
# of Providers
# of Locations
X Providers within X Miles 2 / 10 2 / 15 1 / 20
% of Employee WITH access % % %
# of Employees WITH access
% of Employee WITHOUT access % % %
# of Employees WITHOUT access
Average distance to 2 providers for employees
WITH desired access
Average distance to 2 providers for employees
WITHOUT desired access
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
61 Worksheet: Tab20-Den Proposed-Net Disc&Geo
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete the disruption analysis for each network quoted in the
following requested formats in order for your quote to be considered.
COMPLETE THIS TAB FOR EACH PLAN QUOTED.
Dental Disruption Analysis
In Network?
Provider Code Provider Name City and State
(Y/N)
1 0000742048323 WEAVER/RICHARD E DDS BEAUMONT, TX
2 0000760382551 CASCIO/GERARD A DDS BEAUMONT, TX
3 0000760357336 BAXLEY/WILLIAM K DDS BEAUMONT, TX
4 0000760675414 COPLEY HARPER/REBA DDS BEAUMONT, TX
5 0000141860826 BEAUMONT DENTAL ASSOCIATES BEAUMONT, TX
6 0000742101849 MATHERNE/ROBERT C DDS BEAUMONT, TX
7 0000451028736 ROSE/FRANK R DDS BEAUMONT, TX
8 0000760065161 COLEMAN/ALAN B DDS BEAUMONT, TX
9 0000760618962 DUKE/ANDY B DDS BEAUMONT, TX
10 0000760522395 COURVILLE BESS PARTNERSHIP DDS BEAUMONT, TX
11 0000760628321 K DILEO & E GREEN DILEO DDS PC ORANGE, TX
12 0000760230188 CITRANO/RONALD DDS BEAUMONT, TX
13 0000746176002 BITAR/KAMAL C DDS BEAUMONT, TX
14 0000464154420 HAGLER/TIMOTHY H DDS VIDOR, TX
15 0000760505666 LUMBERTON DENTAL LUMBERTON
16 0000760437652 NELAMS/H DAVID DDS LUMBERTON
17 0000462713976 ARGUELLES/ALANNA K DDS BEAUMONT, TX
18 0000741677616 LEAVINS/JERRY D DDS VIDOR, TX
19 0000741745935 DRS LAUGHLIN & PHILLIPS DMD BEAUMONT, TX
20 0000742144454 WARE/EDWARD M DDS BEAUMONT, TX
21 0000263322621 OLSON/KATHERINE E DDS BEAUMONT, TX
22 0000201249597 SCOTT/GEORGE G DDS PORT ARTHUR
23 0000760212883 BOSTWICK/PHILLIP A DDS BEAUMONT, TX
24 0000454802239 DYER/CHARLES E DDS BEAUMONT, TX
25 0000320178544 BARTLETT/MICHAEL SCOTT DDS PORT NECHES, TX
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
62 Worksheet: Tab21-DenDisruption Analysis
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
FLEXIBLE SPENDING ACCOUNT (FSA) QUESTIONNAIRE
The following questionnaire must be completed.
Flexible Spending Account (FSA) carriers are required to respond to all requests for information contained
in this questionnaire. All responses must be provided on a diskette and respond in a brief, bulleted format.
This questionnaire will be scored; therefore, it is necessary that you provide concise answers. Your
responses to the questions should be based on your current proven capabilities. Should there be instances
where certain questions are not applicable to your organization or its operations, please so indicate. If
you are selected to administer the Client's employee benefit plans, your responses to the questionnaire
will be considered part of your contractual responsibilities. You are also requested to return the indicated
exhibits as part of your proposal.
Your Organization Response
How long have you been providing FSA
1
administration?
How many clients do you currently in force for
2 this line of coverage? What is the average
number of employees per plan?
Plan Design Response
How is discrimination testing performed? How
3
often is this done?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
63 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please provide a list of all services that your
4
company would provide.
Implantation / Account Management Response
What initial information is required from the
employer for implementation? Is a checklist
available to provide to the client? Explain in
5 detail the steps you anticipate will be needed to
ensure a smooth implementation. Include a
timetable of events from the effective date and
including the Open Enrollment process.
Who will be assisting in the implementation
6 process? What will occur during the
implementation process?
Provide descriptions of staff who will direct and
provide services for the Client's account. Is there
7
a dedicated account manager assigned for the
client/consultant?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
64 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Will you have field representatives available for
8 group meetings? What is standard timeframe for
meeting notifications for travel purposes?
Standard turnaround time for new group
9
processing? New enrollees?
Please list all descriptive literature, enrollment
forms, direct deposit forms, other essential
10 forms used for intial set-up, during the year and
during annual enrollment that will be provided to
the Client.
11 How will terminations be handled?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
65 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
In the event of contract termination, discuss the
12 transition process. Include penalties, number of
days notice, etc.
How will billing be set-up? Does your company
13 offer self-bill or electronic billing? Is any function
of the billing process outsourced?
Customer Service and Reports Response
Are utilization reports available? At what
frequency? Will the Client receive reports
necessary for the administration of the Flexible
Spending Account Plan including a.) periodic
report by employee showing amounts credited
14
to the employee’s account, the amount paid
from the account and the account balance; b.)
end of plan year report showing, by employee,
amounts left unexpended? What is the cost for
customized reports?
15 Are your standard reports available online?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
66 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
How often are statements sent to the employee
16 indicating claims received, payments made, and
the account balance?
Please provide your customer service hours,
days of operation, time zone. Do you have
dedicated employees/unit to handle larger
17
accounts in the call center? What is the
experience level of your company’s customer
service department?
Is your customer service unit bilingual? How
often are your team members trained on the
lines of coverage supporting? What are your
18
hours of customer service unit--after hours? Is
your customer service unit outsourced? If so,
what country?
19 What languages and TDD services are available?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
67 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Communications and Web Tools Response
Is the Internet access available to employees
and employer? What are your online capabilities
20
for employees? Can the employee view the
balance online?
Provide the description of how the Client
employees will receive information on their Flex
21 plans. What will be the effective date of when
employees can access information regarding
plan.
What types of employee communication pieces
22
are available?
Are communication pieces customized with client
23
logo/information?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
68 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Is someone available to attend an enrollment
24
health fair in the Fall?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
69 Worksheet: Tab22-FSA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design information in the following
requested format in order for your quote to be considered. Enter only those plan
design elements that are included in your quoted rates. Please confirm that you can
duplicate and administer the current plan design. If not, please indicate differences
on EAP-Deviations/Variations.
Proposed FSA Services
Services
Debit Card? Yes o No o
Plan Documents? Yes o No o
Discrimination Testing? Yes o No o
Employee Communication Materials? Yes o No o
Reporting (Please list standard and any other reports)
1
2
3
4
5
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
70 Worksheet: Tab23-FSA Prop-Services
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
For any benefits you cannot duplicate or administer, per the in force SPD, please indicate
on this tab. Please clearly note the differences.
Proposed FSA -- Deviations/Variations
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
71 Worksheet: Tab24-FSA Deviations-Variations
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete rate information in the following requested format
in order for your quote to be considered.
Proposed FSA Fees
Proposed FSA Fees
FSA Administration Fee (PEPM)
Debit Card Fee (PEPM)
Implementation/Set Up Fee
Annual Renewal Fee
Employee Communication Material(Please List)
1
2
3
4
5
Other (Please List)
1
2
3
4
5
Monthly Premiums
Annual Premiums
Assumptions
Participation Requirements
Rate Guarantee
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
72 Worksheet: Tab25-FSA Proposed-Fees
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
COBRA QUESTIONNAIRE
The following questionnaire must be completed.
COBRA carriers are required to respond to all requests for information contained in this questionnaire. All
responses must be provided on a diskette and respond in a brief, bulleted format. This questionnaire will
be scored; therefore, it is necessary that you provide concise answers. Your responses to the questions
should be based on your current proven capabilities. Should there be instances where certain questions
are not applicable to your organization or its operations, please so indicate. If you are selected to
administer the Client's employee benefit plans, your responses to the questionnaire will be considered
part of your contractual responsibilities. You are also requested to return the indicated exhibits as part of
your proposal.
Your Organization Response
Please provide information about your company,
1 including ownership and structure. How long
have you been in business?
Please describe any mergers, acquisitions, or
2
name changes in the last five years.
Has your company been involved in litigation in
3
the past three years? If so, please describe.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
73 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please provide your customer service hours/days
4
of operation/time zone.
5 What is your organization's target market?
6 Location of COBRA Operations.
7 Number of years providing COBRA services.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
74 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Which carriers do you share data feeds for
8
eligibility?
Administrative Response
Describe your administrative process(include
qualifying events notices, billing, premium
payments, eligibility confirmation, coordination
9
of benefits confirmation, disability extensions,
conversions, cancellations, disbursement of
premiums received, etc.)
Please confirm your ability to customize letters
sent to participants. Please also describe any
10
associated additional fees related to
customization.
Please describe your reporting capabilities.
Include the method by which the plan sponsor
11 and outsource vendor can request reports,
delivery methods, timelines for ordering reports
and any extra fees associated with reports.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
75 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please provide samples of your reports available
to the plan sponsor and outsource eligibility
vendor. Please describe and label each sample,
12
and indicate the format(s) available for each
report. Please also indicate which reports are
included in your standard reporting package.
When are monthly reports available for the plan
sponsor? How are requests for ad hoc reports
13
handled and what is the typical turnaround time
for additional reports requested?
Does your website offer access to customized
14
reports for COBRA on a real time basis?
What payment options are available? Do you
15 offer online payment options? Do you offer the
ability to pay via credit or debit card?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
76 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please describe how your company insures and
16 monitors participant and plan sponsor
confidentiality.
Describe your system for protecting information
17
and ensuring HIPAA compliance.
Please describe your initial and ongoing training
requirements for your customer service
18
employees. How is performance tracked and
monitored?
Describe how your organization monitors and
complies with changes in government
19
regulations. Please provide and label samples of
plan sponsor compliance and advisory materials.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
77 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
What audit processes do you use to insure the
20
accuracy and timeliness of data in your system?
Please describe your emergency update and
21
changes capability for both Client and their TPA?
Can your process/system accommodate
immediate changes to eligibility and enrollment?
22
Can you also immediately confirm those changes
to the vendor?
How often do you send files to the vendors and
23 on what days of the week are those files sent?
Can Client and/or consultant choose the days?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
78 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please describe in detail your annual enrollment
support capabilities. Will you partner with the
24
Sample Client annual enrollment vendor to
provide communications?
Please describe, in detail, your transition plan for
25
Sample Client.
Please provide a proposed implementation plan
26
and schedule.
Will you provide a “test” environment in order
27
for the client to test implementation?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
79 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please provide and label a sample COBRA
28
Service Agreement.
29 Please provide and label a sample BAA.
Please provide and label a sample third party
30
agreement.
Please provide and label a sample
31
indemnification agreement.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
80 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
COBRA Response
Please list the standard services provided under
32
COBRA administration.
How is COBRA eligibility tracked? If the service
33 is provided through a different vendor, can you
provide a COBRA eligibility interface?
Please describe the process for handling
34 initial/general COBRA notifications and what
data is required from the client?
Please describe where and how your processes
35 for COBRA administration and services are
documented and monitored.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
81 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Please provide a sample of your standard
COBRA communication and administration
36 forms, including initial COBRA notices, COBRA
rights, billing, past due, and termination forms.
Please describe and label each sample.
Can you accommodate reissuing any of these
37
notices and forms?
How are spouse and/or dependent records
associated with the qualifying employee handled
38
if only spouse and/or dependent elects COBRA
coverage?
How does your system differentiate between the
39
various COBRA qualifying events?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
82 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
How does your system handle secondary COBRA
40
qualifying events?
Describe your process for reviewing status
41
changes, death, and divorce events?
How does your system track and report
42
severance arrangements?
Describe your process for handling unpaid
43 premiums and related benefit coverages during
the COBRA premium grace period.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
83 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
What method is used to communicate elections,
44 changes and terminations and what is the
frequency?
Are transactions audited to ensure that all
45 transactions have been reported to the carrier
accordingly?
Describe your ability to transmit and receive
46 COBRA data electronically (eligibility and invoice
reconciliation.)
Describe how COBRA participants can contact
47 your organization with questions /issues/ or
concerns.
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
84 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Do you provide web access to view account
status, enrollment, and premium payments?
48
What participant friendly features are available
on your website?
Is any part of your COBRA administration
49 outsourced currently? If not, do you have any
plans to outsource any portion in 2010?
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
85 Worksheet: Tab26-COBRA Questionnaire
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete plan design information in the following
requested format in order for your quote to be considered. Enter only those plan
design elements that are included in your quoted rates. Please confirm that you can
duplicate and administer the current plan design. If not, please indicate differences
on COBRA-Deviations/Variations.
Proposed COBRA Services
Services
Able to customize letters and reporting? Yes o No o
Ability to receive and load a weekly new hire/term/QE report? Yes o No o
Agree to allow Client to pull their own reports from system? Yes o No o
Ability to provide annual enrollment support? Yes o No o
Allow payment via a bank draft or mail in check? Yes o No o
Ability to adjust COBRA premium schedule? Yes o No o
Allow Client direct access to COBRA website? Yes o No o
Real Time updating? Yes o No o
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
86 Worksheet: Tab27-COBRA Prop-Services
City of Beaumont
Request for Proposal
Medical, Stop Loss, Dental, Flexible Spending Accounts, and COBRA
Carrier Name
Please note that you must complete rate information in the following requested format
in order for your quote to be considered.
Proposed COBRA Fees
Proposed COBRA Fees
Proposed Fees (PEPM)
COBRA Administration
Implementation Fee
Takeover Continuants Fee
Qualifying Event Fee
Monthly COBRA Participant Fee
Do you retain 2% of COBRA premium?
Open Enrollment Coordination Fee
Initial Rights to New Hires Fee
Any Other Additional Fees (Please list and describe)
1
2
3
4
5
Assumptions
Length of Fee Guarantee
Commissions Net
Other
Holmes Murphy Associates, Inc. -- CONFIDENTIAL
Prepared: 11/14/2010
87 Worksheet: Tab28-COBRA Proposed-Fees
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