ARE REFERRALS REQUIRED IN THIS PLAN? No referrals in this plan No deviations will be considered. MANDATED BENEFITS All mandated benefits, unless otherwise directed by the State. No deviations will be considered. HOSPITAL INPATIENT SERVICES (Preauthorization Required) Inpatient Care 90% of allowed benefit 70% of allowed benefit after deducible Hospitalization 90% of allowed benefit 70% of allowed benefit after deductible Acute Inpatient Rehab for Stroke and Traumatic Brain Injury Patients when Medically Necessary 90% of allowed benefit Not covered Anesthesia* 90% of allowed benefit 70% of allowed benefit after deductible Surgery 90% of allowed benefit 70% of allowed benefit after deducible Acute Inpatient Rehab (pre-cert required, must be medically necessary) 90% of allowed benefit Not covered Organ Transplant 90% of allowed benefit 70% of allowed benefit after deductible HOSPITAL OUTPATIENT SERVICES (Preauthorization Required) Chemotherapy/ Radiation 90% of allowed benefit 70% of allowed benefit after deductible Diagnostic Lab Work and X-rays** 100% of allowed benefit 70% of allowed benefit after deductible Outpatient surgery 90% of allowed benefit 70% of allowed benefit after deductible Anesthesia* 90% of allowed benefit 70% of allowed benefit after deductible Observation – up to 23 hours and 59 minutes - presented via Emergency Department 100% of allowed benefit after $75 facility copay and $75 physician copay 70% of allowed benefit after deductible Observation – 24 hours 90% of allowed 70% of allowed
medically necessary. Flu Shots 100% of Allowed Benefit Not covered No deviations will be considered. Mammography Preventive 100% of allowed benefit 70% of allowed benefit after deductible Screening: one mammogram per plan year (35+). No deviations will be considered. Mammography Diagnostic 90% of allowed benefit 70% of allowed benefit after deductible No age/frequency limitation on diagnostic mammogram. No deviations will be considered. Physical Exams 100% of allowed benefit 70% of allowed benefit after deductible One exam per plan year for all members and their dependents age 3 and older. No deviations will be considered. Well Baby Care 100% of allowed benefit 70% of allowed benefit after deductible Birth – 36 months: 12 visits total No deviations will be considered. STI Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benefit Not Covered Counseling and screening for sexually active women as mandated by PPACA. No deviations will be considered. Norplant Surgery Only 90% of allowed benefit 70% of allowed benefit after deductible Allergy Testing 100% after $15 copay – PCP; $30 copay – Specialist 70% of allowed benefit after deductible EMERGENCY TREATMENT Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit Ambulance Services – Non-Emergency Transport 90% of allowed benefit 70% of allowed benefit Emergency Room (ER) Services –In and Out of Network 100% of allowed benefit after $75 facility copay and $75 physician copay 100% of allowed benefit after $150 combined copay Copays are waived if admitted. No deviations will be considered. If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the two $75 copays.
rehabilitation is not covered. Family Planning and Fertility Testing6 90% of allowed benefit 70% of allowed benefit after deductible Contraception and Contraceptive Counseling 100% of allowed benefit Not Covered In-Vitro Fertilization (IVF) and Artificial Insemination (per MD mandate) 90% of allowed benefit 70% of allowed benefit after deductible IVF and AI benefits are limited to 3 attempts of Artificial Insemination, and 3 attempts of IVF per live birth. Not covered following reversal of elective sterilization. No deviations will be considered. Hospice Care 90% of allowed benefit 70% of allowed benefit after deductible Home Healthcare 90% of allowed benefit 70% of allowed benefit after deductible Home Healthcare benefits are limited to 120 days per plan year No deviations will be considered. Medical Supplies 90% of allowed benefit 70% of allowed benefit after deductible Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law. No deviations will be considered. MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES Inpatient Hospital Care 90% of allowed benefit 70% of allowed benefit after deductible No deviations will be considered. Partial Hospitalization Services 90% of allowed benefit 70% of allowed benefit after deductible Outpatient Services (Including Intensive Outpatient Services) 100% after $15 copay 70% of allowed benefit after deductible Residential Crisis Services 90% of allowed benefit 70% of allowed benefit after deductible
FA1 Attachment S-4: Participating Physicians Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. Instructions: Please define your organization’s criteria for designating high quality, high efficiency and low cost (QEC) physicians (e.g., tiered or centers of excellence, “providers of distinction,” “premium providers,” Patient-Centered Medical Homes): Please provide the total number of participating physicians by specialty and, of those physicians, the number designated as high quality, high efficiency and low cost (QEC): County/ Metro Area Category Family Practice, General Practice General Internal Medicine General Pediatrics Obstetrics/ Gynecology All Other Specialists Total Physicians Central Maryland Anne Arundel County Total # of physicians # of QEC physicians Baltimore City # of physicians # of QEC physicians Baltimore County # of physicians # of QEC physicians Carroll County # of physicians # of QEC physicians Harford County # of physicians # of QEC physicians Howard County # of physicians # of QEC physicians Eastern Shore Caroline County # of physicians # of QEC physicians Cecil County # of physicians # of QEC physicians Dorchester County # of physicians # of QEC physicians Kent County # of physicians # of QEC physicians Queen Anne's County # of physicians # of QEC physicians Somerset County # of physicians # of QEC physicians Talbot County # of physicians # of QEC physicians Wicomico County # of physicians # of QEC physicians Worcester County # of physicians # of QEC physicians Southern Maryland Calvert County # of physicians # of QEC physicians Charles County # of physicians # of QEC physicians
FA1 Attachment S-6: Access to Pediatricians Amendment 2 Instructions: Provide access two ways: (1) all employees and retirees currently in PPO and POS and (2) all employees and retirees. Matches must be determined based on criteria outlined in Section III Participants Access to Providers in "Attachment S-1: Plan Information.” A. For Response Attachment S-1: GeoAccess® GeoNetworks® Report, please provide the following report format for Access to Pediatricians: Zip Code Average Distance to Adult PCPs Total Number of Employees / Retirees Employees Matched Employees Not Matched Number Percent Number Percent B. Also provide subtotals for (1.) All employees and retirees currently in PPO and POS by County of residence and by region of residence as shown in the table below: Metropolitan/ Geographic Area (Subtotal by County) Average Distance to Adult PCPs Total Number of Employees / Retirees Employees Matched Employees Not Matched Number Percent Number Percent Anne Arundel County 6829 Baltimore City 12871 Baltimore County 14533 Carroll County 2460 Harford County 2570 Howard County 3412 Central Maryland 42675 Caroline County 493 Cecil County 865 Dorchester County 651 Kent County 501 Queen Anne's County 708 Somerset County 782 Talbot County 528 Wicomico County 2181 Worcester County 740 Eastern Shore 7449 Calvert County 705 Charles County 636 St. Mary's County 901 Southern Maryland 2242 District of Columbia 1023 Montgomery County 3955 Prince George's County 5367 Washington Metro 10345
must be or for only the service center handling the State account. Quarter. (Report Card to be submitted by the Offeror). Frequency of report: Quarterly Processing of Enrollment Eligibility Update Information Plan will process electronic interchange of State enrollment information by 5:00 PM of the second business day after receipt. If tape is received after 12 noon, record as having been received as of the next business day. Time over which standard is measured: Quarter Report Card - Vendor to maintain log for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each calendar day, or portion thereof, of delay Accuracy of Processing Enrollment Eligibility Information Plan will process electronic interchange of State enrollment with at least 98% accuracy. Time over which standard is measured: Quarter Report Card - Vendor to maintain log and system generated reports for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each percentage point, or fraction thereof, under 98%. Contractor attendance at State-sponsored Open Enrollment meetings. Attendance by plan representatives trained on State of Maryland plan benefits at 100% of meetings scheduled by the State, for 100% of the meeting's duration. Representative must arrive early enough to have their table set-up prior to meeting start time. Display must be organized and include appropriate covering of table. Representative must have detailed plan knowledge, interact with members, and Sign-in sheets at meetings or minutes of State meetings. Frequency of report: Annually 0.05% of fees for each scheduled meeting date that vendor fails to attend.
exhibit professional appearance and behavior. Time over which standard is measured: Annual Delivery of Quarterly Utilization, Case Management, Wellness Activity and Disease Management Data Reports to State's Consultant Delivery to the State by 6:00 pm on the following dates**: Documentation of receipt by State's Benefit Consultant, i.e., date-stamp of mailing package for data information and verification of completeness. (All required fields must be filled in correctly.) Frequency of report: Quarterly 0.20% of fees for each week, or fraction thereof, the data report is not received or is incomplete. First Quarter (Jan – Mar) Due: May 1st Second Quarter (Apr – Jun) Due: August 1st Third Quarter (Jul – Sep) Due: November 1st Fourth Quarter (Oct – Dec) Due: February 1st Delivery of Rate Renewal Reports Delivery to the State and to the State's actuarial consultant of reports required for annual rate renewal process by 6:00 pm March 1 of each contract year. At a minimum, the renewal reports must include (but not be limited to) the following: Date-stamp of receipt by the State and verification of completeness of required documentation. Frequency of report: Annually 0.20% of fees for each week, or fraction thereof, that the rate renewal reports are not received or are incomplete. Projection of incurred claim costs for renewal year. Estimate of IBNR reserves at end of current year; including the most recent 36 months of incurred/paid triangular reports. Complete documentation of the methodology and
assumptions utilized to develop the projected costs. Disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc. Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees. Explanations for any unusual trend results (high relative to the market, low relative to the market). Claims Standards: Financial Accuracy Measures the gross dollars paid incorrectly (overpayments) plus underpayments) subtracted from total paid claim dollars, divided by total paid claim dollars within the audit sample 99% of claim dollars processed accurately. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 2.00% of fees if below 99% but at least 97%. 4.00% of fees if less than 97%. Claims Standards: Payment Accuracy Measures the number of incorrect drafts of payments made on behalf of the State, subtracted from the total draft or payments transactions, 97% of claims w/ benefit payments are processed accurately. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal 2.00% of fees if below 97% but at least 95%. 4.00% of fees if less than 95%.
divided by the total draft or payment transactions. places. Claims Standards: Processing Time 95% of all claims are adjudicated within 10 business days; and 98% of all claims are adjudicated within 20 business days. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 3.00% of fees if performance is less than standards. Provision of claims and eligibility data to third party vendors. Delivery of agreed-upon claims and eligibility data to third party vendors in the format and frequency required by the applicable vendor(s). Date-stamp of receipt by the third-party vendor and verification of completeness of required documentation. One-half of a Unit Point for each calendar day the data is not received or is incomplete. Annual Hospital Records Claims Audit Conduct hospital records (including clinical and billing issues) audits for every admission with paid claims in excess of $25,000, subject to a minimum of 2% of all hospital claims. Audits are to be conducted to ensure accuracy of billed charges in relation to the clinical services delivered. Provide quarterly reporting of the number of audits conducted, the amount of recoveries to the State. 3.00% of fees if performance is less than standards. Employee Satisfaction – Satisfactory Satisfactory or better results from an annual State-conducted Participant satisfaction survey. Time over which standard is measured: Annual 90% of members Survey results Frequency of report: Annually 1% of fees if performance is less than standards
indicate satisfied or very satisfied Time over which standard is measured: Quarter Pre-admission outreach call 95% of members meeting criteria for receiving a preadmission outreach call will receive a call. Documentation of outbound call. 1.00% of fees if performance is less than standards. Disease Management Outreach Call 95% of members meeting criteria for receiving an outreach call (and have a telephone number in the eligibility system) will have documentation of all outreach call attempts. Documentation of attempted member contact. 1.50% of fees if performance is less than standards. Complex Case Management Program 95% of member meeting criteria for participation in the complex case management program will have document of attempted member and physician contact. Documentation of attempted contacts. 1.00% of fees if performance is less than standards. Provision of Draft Plan Documents Certificate/ Evidence of Coverage for plans and Summary Plan Description for the fully-insured plans Draft Plan Document (Certificate/Evidence of Coverage or Summary Plan Description as appropriate by plan) including all required updates is provided to the State at least three months prior to the first day of the plan year. For example if the plan year effective date January 1st, the vendor must provide the State the draft by October 1st of the prior year. Receipt date as documented by vendor and confirmed by State $500 per day for the first three calendar days that the draft document is not received. $1,000 per calendar day for each day the draft document is not received for the fourth calendar day and beyond. Provision of Final Plan Documents Final Plan Document (Certificate/Evidence of Coverage or Summary Receipt date as documented by vendor and $500 per day for each calendar day the draft plan