Table 1.2.1 HCA Current Plan Summary (as of 2016 Coverage Year) For UMP Plans UMP Classic Premiums Deductibles Out-of-Pocket Limits Provider Networks Network Reimbursement Out-of-Network Reimbursement Prescription Drugs Facility/Hospital Charges Special Highest of UMP Plans Medical: $250 per person, $750 family maximum for three (3) or more Prescription drug: $100 per person, $300 family maximum for three (3) or more Medical: $2,000/$4,000 family maximum Medicare retirees $2,500/$5,000 family maximum Prescription drugs: $2,000 per person, no family maximum Currently Regence BlueShield network within Regence Service Area. BlueCard affiliates outside service area Plan pays 85% of allowed amount, Member pays 15%. Preventive care: Specific services covered in full, not subject to medical deductible Plan pays 60% of allowed amount. Member pays 40% remaining, plus any amount billed by the provider over the allowed amount. Preventive care: Not subject to medical deductible, but still pay out-of-network coinsurance. Based on tier system; for most generic drugs, the Member doesn’t pay the prescription drug deductible. Member pays more for certain generic and drugs. For preferred facilities: Member pays $200 per Day, up to $600 annually for inpatient facility charges. For Members: The inpatient copay is $200 per Day, with a maximum of $600 per inpatient stay (up to the medical out-of-pocket limit). Professional providers bill separately from the facility, and are paid according to the provider’s network status. Only UMP plan that regularly offers coverage to Members. Emergency care: Members pay a $75 copay. May participate in medical flexible spending arrangement under the PEBB. primary primary
1 TRANSFORMATION VISION & EXPECTATIONS 100 500 2 CLINICAL MANAGEMENT 100 500 3 ADMINISTRATIVE SERVICES 100 500 4 PROVIDER NETWORK 50 250 6 TECHNICAL DATA REQUIREMENTS 25 125 7 MARKET PRESENCE 25 125 COST ELEMENTS 3,000 8 CLAIMS PRICING 250 1,250 9 TREND GUARANTEE 150 750 10 PSPM 200 1,000 REFERENCES 177 885 Maximum Points Possible 5,885 Oral Presentation and Reference Scoring Methodology Table 3.2.4 Description Discussion 5 Far Exceeds Requirements The Bidder has provided an innovative, detailed, efficient approach or established, by presentation of material, far superior capability in this area. 4 Exceeds Requirements The Bidder has demonstrated an above-average capability, approach, or solution and has provided a complete description of the capability, approach, or solution. 3 Meets Requirements The Bidder has an acceptable capability of solution to meet this criterion and has described its approach in sufficient detail to be considered “as substantially meeting the requirements”. 2 Below Requirements The Bidder has established some capability to perform the requirement but descriptions regarding their approach are not sufficient to demonstrate the Bidder will be fully able to meet the requirements. 1 Substantially Below Requirements The Bidder has not established the capability to perform the requirement, has marginally described its approach, or has simply restated the requirement. 0 No value The Bidder has omitted any discussion of this requirement or the information provided is of no value. BEST AND FINAL OFFER
Submit an example of the Bidder’s complex Case Management satisfaction tool or similar tool. Submit an example of a quarterly summary complex Case Management report. Provide two (2) Case Management summaries: One case with a member with a primary Behavioral Health condition, including Case Management assessment, care plan, Case Management interventions for both Behavioral Health and physical health issues, and a description of the outcomes from the Case Management interventions. One case with a member with a primary physical health condition, including Case Management assessment, care plan, Case Management interventions for both Behavioral Health and physical health issues, and a description of the outcomes from the Case Management interventions. Evaluation and Scoring Insight None. Bidder Response Not to exceed sixteen (16) pages, excluding Required Accompanying Documents. Exhibit 2.4 Chronic Condition Management Overview The HCA requires a chronic condition management program that is embedded whenever possible into Primary Care practices. The management program should demonstrate how it incorporates the tenets of the Chronic Care Model and Patient Centered Medical Home (PCMH). The ASB must use HCA evidence-based medical policies and guidelines, when available, as well as available Bree Collaborative recommendations in the chronic condition management care planning and decision-making processes. The ASB must use its own criteria for chronic condition management when there are no HCA criteria. The HCA requires the ASB to conduct chronic condition management for physical health and Behavioral Health. Any chronic condition management programs the ASB provides to its Book-of-Business, must be offered to the HCA at no additional cost, but must be approved by the HCA before implementation. The ASB will update the HCA quarterly on all Clinical Management programs, including but not limited to chronic condition management programs. The Bidder must provide chronic condition management programs for UMP Plans, grounded in the tenets of the Chronic Care Model, evidence-based practice, patient self-management and Shared Decision Making, facilitate timely and appropriate referrals for physical health and Behavioral Health services, coordinates care across the healthcare delivery system, and provide positive patient and provider experiences. The ASB will provide a chronic condition management business function that identifies Members with multiple, persistent, severe healthcare needs to ensure: Incorporation of the tenets of the Chronic Care Model and PCMH. If telephonic process is used, please describe how the Bidder works with patient’s Primary Care team to integrate as much as possible.
Report Name Report Frequency Due Date to the HCA Content 1 Medical Management OPS Report Monthly 30th of the following month Case management count of open bariatric and transgender cases. Medical Policy updates and ABA Participation Spreadsheet. 2 OPS Report Monthly 30th of the following month PowerPoint deck to include: Claims inventory; customer service call volumes and top 5 reasons for calling; escalations report and Appeals/Complaints reports; pre-authorization reasons; ABA summary; detailed summary of annual service hours used to date 3 Paid Claims Weekly Email to HCA Contract Manager of Claims paid 4 Erroneous Payments Quarterly 15 Days following end of quarter Overpayments that have not been recovered; any money recovered will be credited to the HCA at the time of recovery. 5 Description of Clinical Management Program Annually May 1 Written description of Clinical Management program, which has been approved by the ASB’s Medical Director 6 Changes in Medical Policy Variable 30 Days prior to change Notice of changes in medical policy that materially affect Plan payments 7 Clinical Management Program Statistics By request By request Detailed program statistics, including disease type, Case Manager work, outcomes, and other information as determined by the HCA 8 IRO Decisions Variable 7 Days after final decision Copies of each IRO decision
9 Account Management Team Notification Annually; and upon request January 1 Memo identifying the Account Management Team 10 Performance Outcomes Quarterly April 30 July 31 October 31 January 31 Performance; key features of Plan operations; presentation of analyses and recommendations in response to reported performance outcomes 11 Executive Report Quarterly April 30 July 31 October 31 January 31 Utilization and cost by overall payments; PSPM payments; discount rates; payments by type of service (inpatient, outpatient, ambulatory surgical center, or professional); second-level Appeals summaries; credit balance recovery report, including total dollars recovered that will be credited to the HCA Eligibility and Claims Report By Request By Request Separate and combined reports for and Medicare risk groups; Correct reporting of Medicare risk group Members including those who have Medicare as their primary coverage, and all other Members included in the risk group 13 Standard Key and Ad Hoc Reports By request By request Standard key reports and ad hoc reports; accurate and adhering to dates and response times 14 SOC1 Type II Audit Results By request By request SOC1 Type II audit results, upon request 15 Service Hours/Project Report Monthly 30th of each month Requested project details; number of hours remaining in the Pooled Hours for Work Orders
Ensure that all communications sent will relate directly to UMP Plans. The Bidder may not send, help or allow any other person or entity to send any communications to Subscribers, Members, or Enrollees except those relating directly to the UMP Plans, unless authorized in writing in advance by the HCA. Note its intent to provide HCA Communications with a PDF file each month with UMP Plan coverage criteria that meets the requirements of RCW 41.05.074(3). Required Accompanying Documents Provide an example of an EOB form. Identify which areas of the form are customizable, and if there are additional fees for customization. Provide an example of a member identification card. Identify which areas of the card are customizable, and if there are additional fees for customization. Provide examples of in-house designed COCs, welcome packets, and other informational materials. Evaluation and Scoring Insight Preference will be given to Bidders who agree to perform all of the functions mentioned in this Exhibit without exception, and can offer flexibility regarding customization of documents at no additional cost. Bidder Response Not to exceed twelve (12) pages, excluding Required Accompanying Documents. Exhibit 3.13 Online Services Overview The HCA desires a web team that provides Members and UMP Plan shoppers with access to a robust, accurate, and up-to-date array of web-based tools and information. The ASB’s online services must at all times meet or exceed the following Washington State Information Technology Standards, or their replacements or successors: The HCA intends to support the current and next most recent versions of each of the four major browsers: Internet Explorer, Safari, Firefox, and Chrome. The ASB will be expected to perform each of the following: Provide ongoing maintenance of the UMP Plan websites as part of the Administrative Fee. Website maintenance will include updates to content both (i) as benefits and plans are updated and (ii) upon HCA request. Provide Member access to the UMP Plan websites twenty-four (24) hours a Day, seven (7) Days a week, except for scheduled downtime. Ensure that information on the website is up-to-date, accurate, and complies with the ADA and associated regulations, such as HIPAA. Respond to all Member emails by the end of the next Business Day.
54 5 64 15 74 35 84 75 55 6 65 16 75 38 85 80 56 7 66 17 76 41 86 85 57 8 67 18 77 44 87 90 58 9 68 19 78 47 88 95 59 10 69 20 79 50 89 100 The total score across all measures will be calculated for each performance year. Tables 3.16.8-2 and 3.16.8-3, below, describe the subset of clinical and Member experience performance measure targets that the HCA will use. Table 3.16.8-2 Performance Measure Benchmark Source Benchmark Target Clinical Performance Measures (for UMP Classic, Non-Medicare/UMP CDHP population) Adult Body Mass Index Assessment Quality Compass (PPO) 90th percentile Antidepressant Medication Management – Effective Acute Phase Treatment* Quality Compass (PPO) 90th percentile Antidepressant Medication Management – Effective Continuation Phase Treatment* Quality Compass (PPO) 90th percentile Breast Cancer Screening* Quality Compass (PPO) 90th percentile Cervical Cancer Screening* Quality Compass (PPO) 90th percentile Childhood Immunization Status (Combo 10) Quality Compass (PPO) 90th percentile Chlamydia Screening in Women Quality Compass (PPO) 90th percentile Comprehensive Diabetes Care: Blood Pressure Control Quality Compass (PPO) 90th percentile Comprehensive Diabetes Care: Eye Exam Quality Compass (PPO) 90th percentile Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Quality Compass (PPO) 90th percentile Controlling High Blood Pressure Quality Compass (PPO) 90th percentile Medication Management for People with Asthma (Asthma Medication Ratio) Quality Compass (PPO) 90th percentile Statin Therapy for Patients with Cardiovascular Disease (Received Statin Therapy) Quality Compass (PPO) 90th percentile CAD Statin Adherence Measure Washington Health Alliance 90th percentile Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life Quality Compass (PPO) 90th percentile Table 3.16.8-3
Table 7.1 Experience Managing Self-funded PPOs Self-Insured Client Name and Contact Information Plan Type* Plan Member Geography** If “yes,” Number of WA Counties Served Public or Private Sector Plan Number of Covered Lives Services Provided (Limit of 15 services) Year Began Services Year Ended Services Number of lives within an ACN? (A) (B) (C) (A) (B) (C) (A) (B) (C) (A) (B) (C) (A) (B) (C) (A) (B) (C) (A) (B) (C) (A) (B) (C) *Please select a Plan Type from the following: Self-Funded PPO, Fully-Insured PPO. **List the number of Members (A) within Washington State, (B) outside Washington State (indicate state(s)), and (C) outside the United States.
APPENDIX 6 INCORPORATED ATTACHMENTS Attachment 1 - RFP Checklist Attachment 2 – Draft Contract (to be provided by Amendment to the RFP) Attachment 3 – PEBB Members by County, by Plan Attachment 4 – UMP Classic 2017 Certificate of Coverage Attachment 5 - UMP CDHP 2017 Certificate of Coverage Attachment 6 - UMP Plus Puget Sound High Value Network 2017 Certificate of Coverage Attachment 7 - UMP Plus UW Medicine 2017 Certificate of Coverage Attachment 8 – UMP Operations Manual Attachment 9 – HCA Value-based Roadmap Attachment 10 – PEBB Performance Quality Measures Attachment 11 – Example Work Order Attachment 12 – Data Exchanges Attachment 13 – Health Benefits K-12 Reporting Attachment 14 –K-12 Document Employee Benefits Report Attachment 15 – ACN Operations Manual Attachment 16 - ACN - Network Consent for Non-Network and Out of Network Services Attachment 17 – ACN - Sample UMP Plus Business Rules Attachment 18 - ACN – Adding ACN Affiliate or ACN Partner Providers Attachment 19 - ACN – Adding TIN Provider to Partner or Affiliate Attachment 20 - ACN – Provider Data End to End Process Attachment 21 - ACN – HCA Review Monthly Provider Attachment 22 - ACN – Remove ACN Affiliate or ACN Partner Provider Attachment 23 - ACN – Monthly Provider Change Roster Attachment 24 - Paying for Value Survey Attachment 25 – Completion Dates for Quarterly Eligibility Reconciliation Attachment 26 – Common Measure Set Attachment 27 – Administrative Fees Attachment 28 – Proposal Scoring and Weights Attachment 29 – WA Provider Network Analysis Attachment 30 – Repricing of Claims Summary