VENDOR NAME: - North Central Texas Council of … · Web view2.2.6 Insurance Requirements - At all times during the term of this Contract, the vendor shall procure, pay for and maintain,

RFP NO. 2011-001

Request for Proposals - EAP and Self-Funded Mental Health/Substance Abuse Benefits Administration

The Public Employee BenefitsCooperative of North Texas

May 11, 2011

Proposals Due: 3:00 P.M. CT, Friday, June 10, 2011

RFP NO. 2011-001

RFP FOR MENTAL HEALTH BENEFITS

TABLE OF CONTENTS

1. GENERAL INFORMATION AND REQUIREMENTS.............................................................................................2

2. CONTRACT PROVISIONS................................................................................................................................3

3. OVERVIEW OF PEBC MEDICAL PLANS.............................................................................................................6

4. FINANCIAL REQUIREMENTS.........................................................................................................................10

5. OPERATIONAL REQUIREMENTS...................................................................................................................11

6. ELIGIBILITY AND ENROLLMENT....................................................................................................................14

7. COMMUNICATIONS REQUIREMENTS...........................................................................................................15

8. PERFORMANCE REQUIREMENTS AND PENALTIES........................................................................................16

9. TIMETABLE..................................................................................................................................................16

10. PROPOSAL EVALUATION CRITERIA..............................................................................................................17

11. PROPOSAL FORMAT...................................................................................................................................20

12. QUESTIONNAIRE........................................................................................................................................24

13. SIGNATURES..............................................................................................................................................53

14. APPENDICES...............................................................................................................................................58

A. CURRENT PLAN DESIGNS.......................................................................................................................58

B. PAID CLAIM AND ENROLLMENT EXPERIENCE.........................................................................................75

C. CENSUS.................................................................................................................................................76

D. LETTER OF UNDERSTANDING.................................................................................................................82

E. BUSINESS ASSOCIATE AGREEMENT........................................................................................................84

ENCLOSURE – PROPOSAL RESPONSE SPREADSHEETS

This Table of Contents is intended as an aid to contractors and not as a comprehensive listing of the proposal package. Contractors are responsible for reading the entire proposal package and complying with all specifications. The terms “Vendor” and “Contractor” can be used interchangeably in this RFP.

Page 1 of RFP No. 2011-001


1. GENERAL INFORMATION AND REQUIREMENTS

1.1 PEBC ORGANIZATION

The Public Employee Benefits Cooperative of North Texas (PEBC) is a coalition established through an interlocal agreement. The 2011 PEBC member groups are Dallas County, Tarrant County, Denton County, the North Texas Tollway Authority (NTTA) and Parker County. On behalf of its member governments, the PEBC keeps employee benefits affordable through common benefit plan designs and centralized administration of benefit programs. The PEBC serves as Plan Administrator for its benefit programs. The combined group’s self-funded medical plans currently consist of approximately 13,000 employees, COBRA members and under-age-65 retirees, along with an additional 11,500 covered dependents. While the groups move as a block, the PEBC is not a risk pool. Each group stands on its own, and its experience and risk is based on its own population’s costs. The benefit plan year is based on a calendar year.

The groups share a common management philosophy, structure and regulatory environment. These plans are all self-funded, non-federal governmental plans not subject to the provisions of ERISA. Each group elects, under authority of section 2722(a)(2) of the Public Health Service (PHS) Act, and 45 CFR 146.180 of Federal regulations, to exempt the plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits.

From time to time, the PEBC extends an invitation to a similar group to participate with the PEBC. A request to join does not automatically result in an invitation to participate. If a group is extended an invitation to participate, the PEBC benefit plans will extend to that group’s population as well.

The PEBC is governed by a Board of Governors and is administered under the direction of the Executive Director. Through interlocal agreement, the PEBC is located at the North Central Texas Council of Government’s (NCTCOG) offices. This RFP is jointly administered through the NCTCOG and the PEBC.

The purpose of this Request for Proposals (RFP) is to request proposals from qualified and appropriately licensed vendors to provide self-funded mental health/substance abuse benefits administration and a capitated EAP for the PEBC’s self-funded medical plans. Please see Section 3 of this RFP for detailed information on the services included in this RFP.

1.2 CONTRACTOR RELATIONSHIPS

The Executive Director of the PEBC (or Executive Director’s designee) serves as the primary contact for all external vendor/contractor contracts and relationships. As such, the Executive Director of the PEBC (or the Executive Director’s designee) must be the sole contact regarding any potential proposals or outstanding work. Contact with any PEBC Member Group directly is strictly prohibited.

1.3 CONFIDENTIALITY

All information presented in this RFP, including information which is subsequently disclosed by the PEBC during the RFP process, will be considered strictly confidential. All parties involved are expected to treat this information in a professional manner. Information should not be released to parties external to the



proposing contractor without the express written consent of the PEBC. Vendors should refer to Item 11.8 for information connected to the Texas Public Information Act and potential for post-award disclosure.

1.4 CONFLICT OF INTEREST

Contractors shall not, under penalty of law, offer or provide any gratuities, favors or anything of monetary value to any officer, member, employee or agent of the NCTCOG or the PEBC for the purpose of or having the effect of influencing favorable disposition toward their own proposal or any other proposal submitted hereunder.

No employee, officer or agent of the NCTCOG or the PEBC shall participate in the selection, award or administration of a contract if a conflict of interest, real or apparent, exists.

Contractors shall not engage in any activity that will restrict or eliminate competition. Violation of this provision may cause a contractor's bid to be rejected. This does not preclude joint ventures or subcontracts, subject to the provisions of this RFP.

1.5 ADDITIONAL INFORMATION FROM RESPONDING VENDORS

The PEBC reserves the right to request additional documentation regarding submitted proposals. Responding vendors must agree to provide any information requested.

2. CONTRACT PROVISIONS

2.1 THE CONTRACT

The Contract (and any subsequent amendments if needed) shall be in the format specified by the PEBC. While there will be one set of contractual terms, each PEBC Employer Group, as a member of the PEBC, will sign an individual contract with the successful vendor. In other words, the final result will be five (5) executed identical contracts.

The Contract will incorporate the RFP, the responding vendor’s proposal to the RFP, and any other clarifying information the responding vendor may be required to provide. Until a Contract has been executed and signed, the RFP and the selected vendor proposal will be binding. The selected vendor will be required to sign the Letter of Understanding (LOU) shown in Appendix D of this RFP as confirmation of the agreement, until the final Contract can be executed. Vendors unable to agree to each term as set forth in this RFP, including in Section 2.2, Required Contractual Provisions, and in the LOU should not submit a proposal in response to this RFP.

No Contract will be executed until the PEBC has accepted the responding vendor’s proposal and the PEBC has notified the responding vendor of its approval. The Contract will be for a two-year term beginning on January 1, 2012 and extend through December 31, 2013, to be renewed at the PEBC’S option for an additional three-year period unless terminated as provided herein or in the Contract. PEBC Employer Groups must be able to terminate the agreement at any time with 180 days notice. The Vendor cannot change contract terms or terminate the contract (without PEBC approval) during any period the contract is in force.



The PEBC and the contracting vendor shall agree and acknowledge, as applicable, that the benefits and coverage to be provided under the Contract will be provided from January 1, 2012 through December 31, 2013. However, the PEBC and the contracting vendor shall also agree and acknowledge that there are duties and obligations specified by the RFP to be performed prior to January 1, 2012 and following December 31, 2013, and the Contract will specify that the parties agree to perform all such duties and obligations. Once executed, the Contract shall comprise the complete and exclusive statement of each agreement between the PEBC Employer Group and the contracting vendor and supersede all prior or contemporaneous agreements, negotiations, course of prior dealings, and oral representations relating to the subject matter hereof.

All work performed, as herein shown under the specifications, shall be of the highest quality and shall in every respect meet or exceed the industry standards for this type service.

In the event that a contracting vendor fails or refuses to perform any of its duties or obligations as provided by the Contract, the PEBC Employer Group, without limiting any other rights or remedies it may have by law, equity or under contract, will have the right to terminate the Contract immediately. Notwithstanding such termination, certain obligations of the vendor shall survive the termination of the Contract.

2.2 REQUIRED CONTRACTUAL PROVISIONS

The PEBC has specific contracting requirements that cannot be waived or altered. All vendors should carefully review the LOU in Appendix D as well as the required provisions below. Vendors should include in their written proposals all additional requirements, terms or conditions they wish to have considered. Vendors should not assume that an opportunity exists to add such matters through the contract negotiation process. Unacceptable terms and conditions added by a vendor may cause the PEBC to reject a proposal, despite other factors of the evaluation. In addition, vendors should not strike-through or otherwise alter anything in the LOU. Submission of an altered LOU or Required Contractual Provisions under this Section 2.2 as part of a proposal may cause the PEBC to reject a proposal, despite other factors of the evaluation.

In particular, the following provisions must be in the Contract:

2.2.1 No Binding Arbitration - Each proposal must specify that the vendor will not impose a binding arbitration requirement upon a plan participant or a PEBC Employer Group. A proposal containing a requirement that plan participants and/or PEBC Employer Groups must agree to engage in binding arbitration will not be accepted and disqualifies the submitting vendor.

2.2.2 Termination – Except for breach of Contract and similar situations, the PEBC Employer Groups must be able to terminate the Contract at any time with 180 days notice. However, the contracting vendor cannot change contract terms or terminate the Contract while it is in force, except for material breach of agreement.

2.2.3 PEBC Approval of Communications/Publicity - The contracting vendor must agree not to publicize the Contract or disclose, confirm or deny any details thereof to third parties or use any photographs or video recordings of the PEBC Employer Group’s employees or use the PEBC name OR PEBC Employer Group names in connection with any sales promotion or publicity event without the prior express written approval of the PEBC.

2.2.4 No Assignment - This Contract is for the professional services provided by the vendor and the vendor’s interest in such agreement. Duties assigned to the successful vendor under



the contract may not be assigned or delegated to a third party without the advance written consent of the PEBC. Such consent shall not relieve the assignor of liability in the event of default by its assignee.

2.2.5 Indemnification – Each of the PEBC Employer Groups expressly does not waive any applicable local, State and federal rules and laws, including Sovereign Immunity. None of the PEBC Employer Groups will indemnify the vendor (or its officers, directors, employees, agents – whether employed directly or indirectly) for its negligent performance, omission or act, or non-performance of its obligations under the Contract.

2.2.6 Insurance Requirements - At all times during the term of this Contract, the vendor shall procure, pay for and maintain, with approved insurance carriers, the minimum insurance requirements set forth below, and shall require all subcontractors and sub-subcontractors performing work for which the same liabilities may apply under this contract to do likewise. The PEBC reserves the right to waive or modify insurance requirements at its sole discretion.

2.2.6.1 Workers’ Compensation: Statutory limits and employer’s liability of not less than $100,000 for each accident.

2.2.6.2 Commercial General Liability:a. Minimum Required Limits:

$1,000,000 per occurrence$1,000,000 General Aggregate

b. Commercial General Liability policy shall include:(i) Coverage A: Bodily injury and property damage(ii) Coverage B: Personal and Advertising Injury liability(iii) Coverage C: Medical Payments(iv) Products: Completed Operations(v) Fire / Legal Liability

c. Policy coverage must be on an “occurrence” basis using CGL forms as approved by the Texas Department of Insurance

d. Attachment of Endorsement CG 20 10 - additional insurede. All other endorsements shall require prior approval by the PEBC.

2.2.6.3 Comprehensive Automobile/Truck Liability: Coverage shall be provided for all owned, hired and non-owned vehicles. Minimum Required Limit: $500,000 combined single limit.

2.2.6.4 Professional Liability:

a. Minimum Required Limits:$1,000,000 Each Claim$1,000,000 Policy Aggregate

2.2.7 Payment Grace Period - All contracts must contain a payment grace period of 45 days from the later of the last day of the coverage month or receipt of an invoice (if applicable).



2.2.8 Minimum Enrollment – Minimum enrollment or minimum participation requirements by any PEBC Employer Group is not allowed.

2.2.9 Fiscal Funding - Notwithstanding anything to the contrary, the obligations of the PEBC Employer Groups are contingent upon the availability of appropriated funds. In the event of lack of sufficient funds or if no funds are appropriated to meet its obligations under the Contract, a PEBC Employer Group may terminate the Contract. To the extent it is reasonably possible, the PEBC Employer Group agrees to provide 30 days advanced written notice of termination. Vendor shall be entitled to compensation for services performed prior to the date of termination.

2.3 RIGHT TO AUDIT

At any time during the term of a Contract and for a period of four (4) years thereafter, the PEBC or a duly authorized audit representative of the PEBC, at its expense and at reasonable times, reserves the right to audit the contracting vendor’s records and books relevant to all services provided under the Contract. In the event such an audit reveals any errors/overpayments by the PEBC, the contracting vendor will be required to refund the full amount of such overpayments within thirty (30) days of such audit findings to the specific PEBC Employer Group, or the PEBC Employer Group may, at its option, reserve the right to deduct such amounts from any payments due the vendor.

2.4 HIPAA COMPLIANCE

The PEBC acts as a covered entity under the Health Insurance Portability and Accountability Act (HIPAA) with regard to its self-funded plans. The responding vendor will be required to comply with all applicable provisions of HIPAA and any regulations, rules, and mandates pertaining to the HIPAA privacy and security rules, as amended, in addition to all applicable state privacy requirements. The vendor will be considered to be the Business Associate of each participating PEBC Employer Group; however, all communication is with the PEBC. As Plan Administrator, the PEBC has access to PHI and all eligibility, payment, treatment and operation information. The successful vendor must execute a Business Associate Agreement as required by HIPAA on behalf of each PEBC Group as part of the Contract. The vendor Contract must include the PEBC Business Associate Agreement in Appendix E of this RFP.

3. OVERVIEW OF PEBC MEDICAL PLANS

3.1 CURRENT PLANS AND VENDORS

The PEBC currently offers its active and under-age-65 retirees a choice of two self-funded medical plans: an EPO and a PPO. Active employees must enroll in either the EPO or PPO Plan, and are allowed to Opt-Out of medical plan coverage only with proof of comparable coverage from another source, such as other employer coverage. Although PEBC employees reside in North Texas, both the EPO and PPO plans are national plans, available to PEBC covered members throughout the country using nationwide networks.

Mental health/substance abuse (MH/SA) benefits for the EPO and PPO (“Managed Care”) plans and an Employee Assistance Program (“EAP”) are currently provided by MHN. MHN has been the carve-out



behavioral health and EAP provider for the PEBC for over 10 years.

3.1.1 Managed Care - During 2010, the PEBC competitively bid the self-funded medical plans, and United Healthcare (UHC) was selected to administer both medical plans effective January 1, 2011. The arrangement with UnitedHealthcare does not allow access to behavioral health providers in connection with behavioral health/substance abuse services. Behavioral health and pharmacy benefit administration were not included in the medical RFP process and remained in place with the prior carve-out providers. Pharmacy benefit administration is provided by Express Scripts. Through its affiliation with Express Scripts, Curascript administers specialty drugs covered by the plans. Prescription drug administration is not a part of this RFP. Proposing vendors must confirm their ability to coordinate with UHC, Express Scripts and Curascript, to exchange patient health care information connected to payment, treatment and operations as needed.

Age-65-and-older retirees are not eligible for the self-funded EPO and PPO plans. The PEBC also manages retiree-only plans reserved for age-65-and-older retirees, and those retiree plans are not a part of this RFP.

COBRA Administration is currently outsourced to PayFlex Systems USA and is managed by the PEBC. That relationship will continue, and COBRA administration services are not included as part of this RFP.

3.1.2 EAP - All active employees and their family members are eligible to use the EAP, even if they opt out of the medical plans. The current EAP program provides clinical support, work & life services, smoking cessation coaching and other online member services.

Clinical Support: Members can access clinical support 24 hours a day, seven days a week, for assistance with marriage, family and relationship issues, stress and anxiety, depression, grief and loss, anger management, domestic violence, alcohol and drug dependency and other emotional health issues.

Up to three (3) face-to-face counseling sessions (outpatient) per member, per incident, each year at no cost to the member (MHN network providers); active employees and their family members first access services via the capitated EAP program

Telephonic consultations Web-video consultations

Work & Life Services: Members can access telephonic consultations in the following areas.

Childcare and eldercare assistance - needs assessment/referrals Financial services - budgeting, credit and financial guidance (investment

advice, loans and bill payment not included), retirement planning, and assistance with tax issues



Legal services - one free telephonic or face-to-face consultation per incident related to civil, consumer, personal and family law, financial matters, business law, real estate, and estate planning; excludes disputes or actions between member and member’s employer or MHN as well as medical malpractice assistance. After the initial visit, legal counsel can be retained at a 25% discount for subsequent visits.

Identity theft recovery services - ID theft prevention, ID theft emergency response kit, assistance from fraud resolution specialist if victimized

Daily living services - referrals to consultants and businesses to assist with tasks of every living (does not cover the cost or guarantee of vendor services)

Online Member Services: Members can access a counselor and referral (if needed), self-help programs for stress, weight management, nutrition, fitness and smoking cessation, and find additional information, tips, tools and calculators.

3.2 PROPOSALS REQUESTED FOR MENTAL HEALTH BENEFITS

The PEBC is requesting proposals for self-funded mental health/substance abuse benefits administration and an integrated/capitated EAP which will allow national coverage for both. The PEBC is seeking to secure a minimum 2-year contract effective January 1, 2012. The objective of this process is to identify the most favorable behavioral health benefits provider for the PEBC covered membership, which includes active employees, COBRA membership and under-age-65 retirees, as well as eligible covered dependents, which will combine favorable access to contracted providers plus competitive fees and aggressive network discounts for the PEBC Employer Groups. Through this RFP process, the PEBC intends to select and contract with one (1) organization to provide behavioral health services through an integrated provider network, MH/SA medical management and self-funded claims administration for both the EPO and PPO plans, along with an integrated EAP for active employees. In other words, through use of an integrated national network, a member will not be requested to change a clinician when moving from EAP to managed care services. The PEBC reserves the right to continue its existing relationships in total or in part if a favorable vendor is not identified.

The current PEBC plan designs can be found in the Appendices to this RFP. All proposed plan design features or administrative requirements are assumed to be the same as plans/contracts currently in place with existing vendors (with the acknowledgement that certain plan provisions may need to change in the future due to health care reform or PEBC cost containment strategies). To be considered, a responding vendor must submit a proposal using the current PEBC plan design and administrative processes, including applicable pricing. If the vendor cannot administer certain portions of the plan design, disclosure is required listing the specific portion(s) that cannot be administered on the Deficiencies and Deviations Form of the RFP (Section 13), along with detailed information surrounding the vendor’s substituted portion and related cost impact.

A critical factor in the choice of a successful vendor is that all services to be provided in the North Texas (Dallas/Fort Worth) area must be fully integrated and fully owned by one (1) proposing organization. This means that one organization has full ownership of all of the following components:



3.2.1 A fully owned national MH/SA provider network, including a Texas MH/SA provider network of sufficient size with particular strength in the 40 county North Texas area;

3.2.2 MH/SA case management capabilities fully owned by the proposing organization, including licensed clinicians and a licensed medical director (physician) employed by the organization;

3.2.3 Fully owned and integrated MH/SA claims payment systems and administration capabilities; AND

3.2.4 Fully owned EAP capabilities, with Critical Incident Stress Management (CISM) services readily available in the North Texas area.

To illustrate, proposals from organizations which may fully own and provide items 3.2.1 and 3.2.2, but subcontract for item 3.2.4 (listed above) will not be considered nor evaluated, as they do not meet the requirement of a fully integrated organization for this RFP, even if those subcontracted arrangements have been in place for many years.

Proposing organizations may, however, subcontract for other services needed to propose on this RFP, provided those subcontracted contractual arrangements are existing and already in place, such as additional local resources for Critical Incident debriefing in certain locations outside of North Texas. All subcontracted arrangements must be clearly disclosed and must be transparent to the PEBC from a contractual perspective.

3.3 STOPLOSS INSURANCE

The PEBC has contracted with one stoploss insurer to provide reinsurance for PEBC Employer Groups. Each PEBC Employer Group has its own level of Specific Deductible and each group has individualized premium rates. While the PEBC Employer Groups are not required to carry aggregate coverage, one of the smaller groups does carry reinsurance in the aggregate. The PEBC Employer Groups reinsure medical, prescription drug and mental health claims and currently pay based on a composite rate based on the number of employees with single coverage and those with dependent coverage. All groups benefit from the efficiency of the group purchasing arrangement and centralized PEBC plan management.

Stoploss insurance is not included as part of this RFP. However, because mental health claims are included in the current reinsurance arrangement, vendors proposing on this RFP must agree to provide the claim information needed to allow the PEBC to monitor claims effectively and maximize reimbursement.

In addition to monthly reports identifying all members with cumulative claims paid to date (including the claims paid amount) which exceed $25,000, the proposing vendor must agree to make all case management, detailed claims information, diagnosis and prognosis information and related stoploss information (including any reserves information) available to the PEBC Executive Director on a monthly basis or upon request. The vendor will report trigger diagnoses as required. PEBC stoploss coverage is based on 12 months of claims incurred during the plan year, which is also the calendar year.

3.4 LOCAL MEDICAL MANAGEMENT AND UTILIZATION REVIEW



The vendor will have an employed medical director, who is a physician licensed in the appropriate state and in good standing, with final authority on MH/SA medical necessity decisions. The vendor proposal must demonstrate interaction between the medical director and MH/SA network providers via such arrangements as protocol committees and utilization review groups. From time to time, the vendor will request review through an external review process and at vendor’s sole cost, using Board certified clinicians in the area of expertise, to supplement medical director determinations in connection with an appeal.

The vendor is responsible for cost containment procedures, which will include, but not be limited to, preauthorization and utilization review activities. Under the current PEBC medical plan designs, all outpatient and inpatient MH/SA services (with the exception of the 3 visits provided through the EAP or emergencies) must be pre-certified in advance, before treatment is received. In the case of an emergency, MHN must be notified within 48 hours of the emergency or treatment.

The vendor will have in place processes to monitor the provider network, the quality of patient care and participant satisfaction, reporting such results to the PEBC on a regular basis.

3.5 COVERAGES, LIMITATIONS, AND EXCLUSIONS

PEBC plan coverage, limitations, and exclusions must be administered in substantially the same manner as they are currently administered. Benefit Limitations and Exclusions are found in the Appendix section of the RFP.

4. FINANCIAL REQUIREMENTS

4.1 TERM

Proposed services should be for a two-year term beginning on January 1, 2012 and extending through December 31, 2013, to be renewed at the PEBC’S option for an additional three-year period unless terminated as provided herein or in the Contract.

4.2 ADMINISTRATIVE FEES

Proposed administrative fees and capitated EAP rates must be firm for two years (2012 – 2013) and cannot be contingent upon minimum participation or any other factor. If a start-up administrative fee is quoted, it must be amortized over the three year period. The administrative fee proposed by the vendor should be adequate to cover the cost incurred for the performance of all services described in this RFP for the period prior to and during the period of the Contract, and for a 12-month runout self-funded claims payment period following termination of the Contract.

The PEBC manages all eligibility for each of the PEBC Employer Groups. At approximately the 10 th of each month and for the period ending the last week of the previous month, the PEBC will forward a snapshot summary census to each PEBC Employer Group in order to facilitate “self-bill” payment of the Administrative Fees/Rates from each Employer Group. The PEBC forwards the same document to the vendor, which lists the total number of employees, retirees and COBRA participants for the previous



coverage month. This file is a summary only and does not include individual identifying information; however, the information can be tied to a specific date allowing the vendor to validate identifying information. A detailed eligibility list can be made available upon request and on a frequency not exceeding once each month.

Each PEBC Employer Group must be allowed a period of at least 45 days from the end of the applicable coverage month in which to submit payment.

4.3 BANKING ARRANGEMENTS

Currently, the PEBC member groups fund MH/SA claims on a monthly basis. The successful vendor will process and pay all claims submitted under the plan in accordance with the provisions of the plan design. In all cases, the specific PEBC Employer Group must have the ability to view the check register (or access electronic payment information) in advance of release of payments to each vendor in order to perform a final eligibility check for the date of service indicated. The check register must include claimant identifying information (Excel preferred) in order to confirm eligibility. Each individual PEBC Employer Group will fund their respective claims.

The vendor must perform monthly bank and claims reconciliation services and provide a copy of the reconciliation to the PEBC on a monthly basis. PEBC Employer Groups are not responsible for any bank service fees or banking costs connected with each account. Please refer to the Questionnaire for information regarding banking arrangements.

4.4 TAX EXEMPTION

The North Central Texas Council of Governments (NCTCOG) and the PEBC Employer Groups are local governmental entities and are exempt from all city, state, and federal sales and use taxes.

5. OPERATIONAL REQUIREMENTS

5.1 CENTRALIZED PRIMARY CONTACT

The Executive Director of the PEBC (or Executive Director’s designee) serves as the primary contact for all external vendor/contractor contracts and relationships. Further, the Executive Director serves as the PEBC Privacy Officer and Security Officer. As such, the Executive Director of the PEBC (or the Executive Director’s designee) must be the sole contact regarding eligibility, benefits, communications, contracts, claims, billing and HIPAA related issues.

5.2 USE OF PEBC DATA

PEBC Employer Group data is the property of the applicable PEBC Employer Group. The selected vendor must specifically agree that the vendor shall never use any information about PEBC employees, retirees, or covered members, regardless of source, for any marketing purpose, advertisements or to solicit other business of any type. This agreement extends to information supplied to the vendor and applicable parent company, subsidiary, affiliate or related third-party, and includes but is not limited to, detailed membership census information, summary information, written and verbal communications. This prohibition also



applies to electronic use of the information, and this prohibition applies even after termination of the Contract.

5.3 MEMBER ID CARDS, EXPLANATION OF BENEFITS (EOB) FORMS, USE OF SOCIAL SECURITY NUMBERS

Currently UHC issues medical ID cards which include the contact telephone number for MH/SA benefits. A separate MH/SA ID card is not allowed. The successful vendor must confirm its agreement to continue this process.

The vendor must be able to use a subscriber’s Benefit-ID for both the subscriber and their covered dependents as well as be able to place both the subscribers’ and dependents’ Benefit-IDs on the claims records and any electronic communication. The PEBC submits each member’s SSN to the vendor, including those of covered dependents. The vendor must communicate both the Benefit-ID and complete SSN when providing reports to PEBC. Vendors must be able to accept that the Benefit-ID will remain the identification for a subscriber even though the subscriber may become a retiree or COBRA member, or move to an alternate location. In all cases, PHI is communicated via encrypted or protected data mechanisms consistent with the attached Business Associate Agreement.

The PEBC requires pre-approval of any EOB form and its listed data prior to its use. Unless a member agrees to electronic access only, the EOB must be mailed at vendor’s sole expense to the participant at the address provided by the PEBC. Members must have the ability to view and print an EOB via a secure website.

Vendors must be able to comply with all federal and Texas state legislation applicable to the protection and use of Social Security Numbers, including the limitations placed on the use of Social Security Numbers on ID cards, EOBs and plan documents by Section 35.58 of the Texas Business and Commerce Code, CONFIDENTIALITY OF SOCIAL SECURITY NUMBER.

5.4 ADMINISTRATIVE REQUIREMENTS

The Vendor shall provide all services associated with the administration of the plans including, but not limited to, the following:

5.4.1 Customer Service

a. Toll-free telephone line available 24/7 and 365 days a year, with appropriate staffing levels and procedures to handle emergency calls;

b. The Customer Service Call Center must be located within the United States. No out-of-country call centers are allowed;

c. The vendor warrants and represents that it will provide a sufficient number of Customer Service licensed triage clinicians to meet PEBC needs, and that it will



adequately train team members to support the PEBC’s requirements; AND

d. Only licensed clinicians should make referrals, basing their decision on the caller’s identified needs and a brief assessment.

5.4.2 Self-Funded MH/SA Claims Processing and Handling of Appeals/Grievances

a. Vendor will process all required PEBC MH/SA claims incurred in connection with services rendered on or after January 1, 2012 and throughout the term of the Contract.

b. Vendor will review claims for eligibility based on covered dates of services and in accordance with the eligibility information provided by the PEBC. Any ineligible claims inadvertently paid by the vendor shall be recaptured and returned to the PEBC Employer Group in the form of a check made payable to the Group, accompanied by a report (Excel preferred) showing the original claim number, amount, date of service, and applicable member, and amount recovered, with a copy to the PEBC. Return of funds to the PEBC Employer Group via a credit against administrative fees (present or future) is not allowed.

c. In the event the vendor issues excess payments or payments for ineligible claims or participants, the vendor will take all steps necessary to recover the overpayment, including recoupment (offset) from the participants’ or providers’ subsequent claim payments. The vendor is required to assume 100% liability for incorrect payments which result from errors attributable to the vendor in whole or in part. The vendor is required to provide the PEBC with detailed reports on a monthly basis that itemize the amounts of each overpayment, the reason for the overpayment, a listing of payees with outstanding overpayment recoveries due, an account of prior balances of recoveries due, the current month overpayments, recoveries, new balances and percentage of overpayment dollars recovered, and an aging of receivables report for 30, 60, 90 and 91+ days provided in Excel format or another mutually agreeable format.

d. Vendor shall use automated systems to detect fraud and misuse of the plan, overpayments, wrongful or incorrect payments, unusual or extraordinary charges, and unnecessary treatment. The vendor will also conduct thorough, diligent and timely investigations with regard to fraudulent and suspicious claims and report monthly all such suspicious claims to the PEBC. Vendor will provide a toll free number and, if possible, an internet link for participant reporting of fraud and abuse.

e. The vendor will maintain a complete and accurate claims reporting system and provide for the retention, maintenance and storage of all payment records with provisions for appropriate reporting to the PEBC. The vendor will maintain all such



records throughout the term of the Contract and for at least three (3) years following the end of the Contract, and shall make such records accessible and available to the PEBC for inspection and audit upon PEBC request. The vendor will provide claims payment electronic records in Excel format (or other mutually agreeable format) to the PEBC upon request. In the event the vendor is scheduled to destroy payment records, the vendor must contact the PEBC for approval prior to the destruction of the payment records.

f. The vendor agrees to provide the PEBC claims information for Early Retirees and enrolled family members consistent with the requirements of the Early Retiree Reinsurance Program (ERRP) upon request and at no additional charge. Because MH/SA is a carve-out service, the claims for the entire Early Retiree population must be provided, regardless of any threshold requirement. Claims data will be provided in the HHS ERRP layout.

On a monthly basis, the vendor must provide the PEBC with a financial accounting of the PEBC claims paid (Excel), by each PEBC Employer Group, by Plan, and in total. The vendor will also provide the PEBC with other experience data, utilization data, and accounting information as the PEBC shall reasonably request and as listed in the Contract.

5.4.3 Subrogation

The PEBC manages subrogated claims in accordance with the plan’s Third Party Payments/Subrogation Language and Right of Recovery, which is included in the Appendix of this RFP. The vendor must assume a role in this process; however, the vendor is expressly prohibited from settling any claim or reducing/waiving any Notice of Lien. Vendor will dedicate a position to coordinate PEBC subrogation activities and communicate with the PEBC Executive Director on a regular basis. The Vendor will perform services including, but not limited to, those services listed below, on a regular and continued basis, regularly advising the PEBC of the status of each case. Vendor is responsible for costs associated with subrogation activities listed below, and such costs should be included in the proposed administrative fees. Contingency arrangements are not allowed.

a. Identify claims that could result in a recovery as a result of a participant’s injury for which benefits under the plan shall be or have been provided.

b. Using PEBC approved correspondence and forms, request accident reports and subrogation information from the insured/patient.

c. Obtain police reports and insurance benefits from third parties.d. Using PEBC approved notification documents, notify all involved parties of the PEBC

Employer Group’s Notice of Lien, updating the information on a regular basis.e. Track specific claims information connected with each specific case.f. Perform regular updates and follow-up as to the status of any recovery.g. Communicate information to and from third party legal counsel as appropriate.h. Provide documented call notes and file copies of each opened subrogation case to the



PEBC.i. Provide additional information upon request of the PEBC Executive Director.

5.4.4 Other Services

The vendor must provide the PEBC Executive Director with a senior level management contact who can intervene with eligibility and/or claims issues upon request and in an expedient manner, supplying her with specific information as requested, and a high-level management contact who can receive verbal or individual electronic updates (adds or terms) from the PEBC pending receipt of the weekly data file.

6. ELIGIBILITY, ENROLLMENT AND DATA

The PEBC eligibility process identifies those eligible for benefits, and transmitted data records reflect correct eligibility information. The responding vendor’s ability to accommodate PEBC data and eligibility transmission is an important consideration in this selection process. The PEBC manages all data transmission on behalf of each of its Employer Groups. The data transmission method in place today is to push data to the vendor via the use of FTP over the Internet in a fixed-length, ASCII text file. The PEBC is encrypted using Pretty Good Privacy (PGP) public key encryption. The PEBC is in the process of updating its systems so that eligibility data can be transmitted using Secure FTP (SFTP). The PEBC sends all group data via one data file with appropriate indicators to identify each group and data element.

Annual enrollment occurs in November each year, and a “baseline” full file is forwarded by mid-December each year for coverage beginning January 1. Thereafter, changes only to the baseline file are forwarded on a weekly basis for the remainder of the year with the expectation that vendor data files are updated within 24 business hours of receipt. The selected vendor must accommodate PEBC initiated emergency updates as needed. The PEBC conducts a full-file audit compare process approximately three times each year to ensure vendor and PEBC records are in synch.

Because the PEBC performs multiple tests on data prior to forwarding to each vendor, the PEBC is the only source of data update. Vendors are not to accept updates directly from a PEBC Employer Group or members. Employees must be referred to their respective Human Resources Department to update addresses and other information. By doing so, source data always initiates via the PEBC data file.

Each PEBC Employer Group owns its data. Vendors are not entitled to disclose or otherwise use any PEBC Employer Group data for any purpose whatsoever except for responding to an RFP in which case all data will be de-identified, or otherwise administering a plan benefit on behalf of a PEBC Employer Group.

The vendor will provide the PEBC with priority positioning for delivery of ad hoc system service requests and/or issue resolutions. The vendor shall designate a Technical Consultant to lead the management of all technical issues including, but not limited to PEBC service requests and items requested by the PEBC Executive Director. The vendor shall use its best effort to implement all PEBC information requests and correct all information issues as required by the PEBC. The vendor will further provide and distribute, at vendor’s expense, certain reports that are required to administer a self-funded plan including, but not limited to, IRS Form 1099.



The PEBC does utilize retroactive eligibility as it pertains to ineligible member claims. The PEBC does not adjust administrative fees for the period of ineligibility, recognizing the monthly census snapshot is a picture reflecting eligibility at the time fees are owed.

7. COMMUNICATIONS REQUIREMENTS

The PEBC Executive Director centrally controls and reviews all communication materials distributed to plan participants. The selected vendor is expressly prohibited from distributing any collateral or communication item (including correspondence) unless the item has been pre-approved by the PEBC.

Communication materials include, but are not limited to, hard-copy and electronic versions of:

Participant brochures, booklets and newsletters Scripted responses to participants and PEBC Employer Groups Claim forms Explanation of benefits (EOB) forms Provider directory Participant welcome packets or materials Any form or collateral item used in conjunction with a PEBC Employer Group

In preparation for annual enrollment each year, the vendor must supply the PEBC with electronic versions of PEBC approved plan information, including a link to provider search, no later than September 30th prior to the start of any plan year. The PEBC will order communication materials on behalf of each PEBC employer group. Additional collateral items (flyers, etc.) approved by the PEBC may be provided at vendor’s expense.

The PEBC does not currently hold employee meetings during annual enrollment. However, a representative from the selected vendor may participate in 3-4 retiree meetings each year, as a resource only, not as a speaker.

8. PERFORMANCE REQUIREMENTS AND PENALTIES

Performance guarantees are required of the successful vendor. The PEBC will conduct quarterly and annual performance reviews of the vendor for medical benefits administration services provided with any performance penalties paid annually. The performance review will consist of a review and reconciliation of the performance standards achieved based on various tracking reports and surveys. Such guarantees apply to each PEBC Employer Group separately.

Any penalties due for missed performance guarantees will be calculated and billed to the vendor and paid by the vendor annually.

9. TIMETABLE

The following table summarizes the timeframe required by the PEBC in responding to this RFP:



Task Timing

All times shown are CT

Responsibility

RFP released to qualified contractors (Via Electronic Email Release only)

May 11, 2011 (Wed) PEBC

Pre-Proposal Contractor’s Conference May 26, 2011 (Thu)

2:00 P.M. – 3:30 P.M.

Attendance Optional

PEBC

Proposing contractor questions related to RFP due to the PEBC

June 1, 2011 (Wed)

By 5:00 P.M.

Contractors

Responses to questions released to proposing contractors

June 3, 2011 (Fri) PEBC

Proposals due June 10, 2011 (Fri)

By 3:00 P.M.

Contractors

Proposal opening June 10, 2011 (Fri)

By 3:15 P.M.

PEBC

On-site visits and/or finalist presentations (at discretion of PEBC)

June 29, 2011 – July 15, 2011

Contractors/PEBC

Award notification date Target date July 29, 2011 PEBC

Implementation Start Date Target date July 29, 2011 Contractor/PEBC

Effective Date January 1, 2012 Contractor/PEBC

10. PROPOSAL EVALUATION CRITERIA

10.1 OPENING OF PROPOSALS

A public opening of the proposals will be held on Friday, June 10, 2011, at 3:15 P.M. CT at the North Central Texas Council of Governments, Centerpoint Two, 616 Six Flags Drive, Arlington, TX 76011. Only the names of the respondents will be read aloud. No other information concerning the proposal will be provided.

Proposals shall be opened so as to avoid disclosure of contents to competing vendors and kept confidential during the process of negotiation. However, all proposals that have been submitted shall be open for public inspection after the contract is awarded. After proposals are opened, the proposals will be evaluated using the process and scoring criteria shown in this RFP.



10.2 EVALUATION PROCESS

Proposals will be evaluated by the PEBC with the assistance of its consultants, Towers Watson, and the PEBC will retain responsibility for the final selection of the contractor. Vendors should not contact Towers Watson in connection with this RFP, but should follow the instructions included in the RFP. Each contractor will be reviewed in the context of the PEBC’s philosophy and objectives. The PEBC reserves the right to reject any and all proposals for any reason at its sole discretion.

An on-site visit and/or finalist presentation may be requested by the PEBC as part of its evaluation. The purpose of these meetings, if requested, is to substantiate proposal representations, increase the PEBC’s understanding of the services and operations of the proposing organization, and meet the individuals who will have a significant role in servicing the PEBC. However, the PEBC reserves the right to make a selection decision based on proposal responses alone, without on-site visits or additional presentations.

Consulting firm Towers Watson currently provides actuarial assistance to the PEBC and may assist with the financial analysis of proposals received. The PEBC Board of Governors must approve selection of a vendor. Once the PEBC has identified the successful contractor, all responders will be notified in writing via email.

10.3 SCORING CRITERIA

The criteria used in selecting a contractor will be as outlined in the chart below. Note that the scoring criteria below correspond to the questions in the Questionnaire section of this RFP.

Criteria Maximum Points

A. MH/SA provider network composition and access; MH/SA medical and case management capabilities and experience; EAP benefits 30 points

B. References 10 points

C. Cost, including administrative fees, EAP rates, provider network discounts, and performance guarantees 30 points

D. Ability to administer benefits in accordance with PEBC contractual requirements, data requirements and administrative requirements; experience with administration of self-funded group medical benefits to employers with more than 10,000 employees; EAP resources; MH/SA and EAP experience with a large public employer plan; organization financial stability, and ability to provide solid, responsive customer service to the PEBC and to member groups’ covered employees, retirees and their dependents.

30 points



TOTAL POINTS 100 points

Please note: There is an additional Section in the Questionnaire, Section E, which contains questions regarding current practices for benefit plan coverage and management of autism cases and related services, including applied behavioral therapy (ABA). The questions in Section E do not count towards the scoring of the RFP. These questions are designed to gather current information on what major MH/SA managed care organizations and their self-funded, non-federal governmental employer clients (who are not subject to ERISA) are doing with regard to managing these cases, and to examine the specific plan design in connection with that coverage. Please disclose if the client elects to exempt its plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits. If you do not have any self-funded, non-federal governmental clients, please disclose and do not respond to Section E. If you do have clients in this category, we appreciate your response. You should not assume or conclude that the PEBC groups will cover additional services in connection with questions asked in Section E. This is an information gathering section only and will not be scored. Responses received in Section E are subject to the same open records requirements shown in Section 11.8 of this RFP.

10.4 ALTERNATIVE BENEFIT DESIGNS/FINANCIAL ARRANGEMENTS

Alternative benefit design or financial arrangements, other than as requested herein, will not be considered unless fully disclosed on the Deficiencies and Deviations Form (Section 13) as described in this RFP. However, the PEBC reserves the right to revise the benefits and/or financial arrangements should that become necessary due to legislative, budgetary, or other factors. The purpose of this RFP and the subsequent review process is to select the vendor that the PEBC considers to be most qualified to provide the most effective, efficient and high-quality services, supplies and products to the PEBC Employer Groups and covered plan participants. The PEBC views the relationship with the vendor as a cooperative one, and nothing contained in this RFP, nor any action taken in the review and approval process, shall prevent the PEBC from continuing negotiations with the selected vendor after the selection is made or to consider quantified innovative design factors. The vendor must agree to act in good faith in connection with all such negotiations and in performing all of its services, duties, and provisions of coverage related to this RFP.

10.5 RESERVED RIGHTS

The PEBC retains the right to reject any and/or all proposals submitted and/or call for new proposals. The PEBC is not required to select the proposal with the lowest administrative fee, but shall take into consideration other factors as described herein. The PEBC reserves the right to enter into discussions and negotiations with one or more vendors selected at its discretion to determine the best and final terms. The PEBC is not under obligation to hold these discussions or negotiations with each responding vendor that submits a proposal. The PEBC is under no legal obligation to execute a Contract on the basis of this RFP or upon receipt of a proposal. The PEBC reserves the right to reject any and all proposals received. The PEBC specifically reserves the right to revise any or all RFP or Contract provisions set forth at any time prior to the execution of a Contract where the PEBC deems it to be in the best interests of the PEBC Plans and its participants. The PEBC reserves the right to audit/validate all materials and responses submitted with the vendor’s proposal.



10.6 REJECTION/DISQUALIFICATION OF PROPOSALS

Proposals will be considered irregular if they show any omissions, alterations of form, additions or conditions not called for, unauthorized alternate proposals, or irregularities of any kind. The PEBC reserves the right to waive any irregularities and to make the award in the best interest of the PEBC.

Proposals may be rejected, among other reasons, for any of the following reasons:

a. proposals received after the time set for receiving proposals as reflected on the cover pageb. proposal containing any irregularitiesc. unbalanced value of any itemsd. improper or insufficient guarantye. where the contractor, any subcontractor or supplier, or the surety on any bond given, or to be

given, is in litigation with the PEBC or with Dallas County, Tarrant County, Denton County, the North Texas Tollway Authority (NTTA) or Parker County, or where such litigation is contemplated or imminent.

Contractors may be disqualified and their proposals not considered, among other reasons, for any of the following specific reasons:

a. belief that collusion exists among the contractors;b. where the contractor, any subcontractor or supplier, or the surety on any bond given, or to be

given, is in litigation with the PEBC or with Dallas County, Tarrant County, Denton County, the NTTA, or Parker County, or where such litigation is contemplated or imminent, in the sole opinion of the PEBC;

c. the contractor being in arrears on any existing contract or having defaulted on a previous contract;d. lack of competency as revealed by pertinent factors, including, but not limited to, experience, a

financial statement and questionnaires;e. insufficient resources, which in the judgment of the PEBC will prevent or hinder the prompt

providing of additional services if awarded.

10.7 NEWS RELEASES

Advance written approval by the PEBC Executive Director is required prior to any issuance of any news releases or other public communication regarding a contract awarded to a responding vendor.

10.8 PROCUREMENT DISPUTE RESOLUTION PROCESS

The NCTCOG is the responsible authority for handling complaints or protests regarding the proposal selection process. This includes, but is not limited to, disputes, claims, protests of award, source evaluation or other matters of a contractual nature. Matters concerning violation of law shall be referred to such authority as may have proper jurisdiction.

Once the PEBC has agreed upon selection(s), all contractors will be notified in writing of the results. Any protest regarding this process must be filed in accordance with the following procedure:

The NCTCOG would like to have the opportunity to resolve any dispute prior to the filing of an



official complaint by the protester. The protester should contact the NCTCOG’s Deputy Executive Director of Administration at (817) 695-9121, P.O. Box 5888, Arlington, Texas 76005-5888, so that arrangements can be made for a conference between the NCTCOG and the protester. Copies of the appeal process will be made available to the protester.

11. PROPOSAL FORMAT

11.1 QUESTIONS REGARDING THIS RFP

Interested contractors will have the opportunity to ask questions to clarify information found in this RFP through attendance at the Pre-Proposal Contractor’s Conference:

Date: Thursday, May 26, 2011Time: 2:00 P.M. – 3:30 P.M. CTLocation: Metroplex Conference Room

North Central Texas Council of GovernmentsCENTERPOINT TWO616 Six Flags DriveArlington, TX 76006-5888

Attendance at the Pre-Proposal Contractor’s Conference is optional.

Following the Contractor’s Conference, questions must be submitted in written form via e-mail, fax, or hard copy and received by the PEBC no later than 5:00 P.M. CT, Wednesday, June 1, 2011 to:

Diana Kongevick, Executive Director PEBCP.O. Box 5888Arlington, TX 76006-5888E-mail: [email protected]: (817) 695-9104

Questions received by the due date and time shown above will be answered and responses will be sent to all interested contractors.

Interested contractors should NOT contact any of the Employer Groups of the PEBC directly regarding this RFP. Direct contact with PEBC Employer Groups may cause disqualification from this process.

Except for the Pre-Proposal Contractor’s Conference, no oral explanation in regard to the meaning of the proposal specifications will be made, and no oral instructions will be given before the award of the contract.

11.2 PROPOSAL CONTENT

Your proposal should consist of only the answers to the questions in Section 12, Questionnaire, and Section 13, Signatures, including completion of the required forms and exhibits exactly as shown on the enclosed Proposal Response Spreadsheet. Please do not include extraneous marketing or other materials.



Proposals must be valid for a minimum period of 180 days.

11.3 PROPOSAL FORMAT

Proposals must be submitted with clear indications as to the name of the submitting company and contact person. All proposals must be received in a sealed envelope, clearly marked “PEBC Mental Health Benefits - to be opened 3:15 P.M. CT, June 10, 2011 .”

All proposal response forms and questionnaires must be fully completed and included in your response. Detailed pricing exhibits and administration specifications have been provided in the enclosed Proposal Response Spreadsheet, and any deviations or exceptions must be referenced in the designated response sheets.

Vendors should submit three (3) signed hard copy originals of the proposal and an electronic version on CD (with your responses to the Questionnaire in the acceptable electronic formats described below, including the Proposal Response Spreadsheet, GeoAccess reports, provider network information, and other exhibits as requested in this RFP). Acceptable electronic formats are Office 2007 Word and Excel (or lower versions) and GeoAccess.

Proposals should be delivered to:

PEBCc/o Diana Kongevick, Executive DirectorCenterpoint Two Building 616 Six Flags DriveArlington, TX 76011

Faxed or e-mailed responses are not acceptable and will not constitute delivery of your proposal.

It is the responsibility of the contractor to ensure all proposals are received no later than 3:00 P.M. CT on June 10, 2011. All proposals become the property of the PEBC and will not be returned to the contractor, except that any proposal received after the date and/or hour set for proposal submission will be returned to the vendor, unopened. Respondents using U.S. mail or delivery services should take precautions to ensure that their proposal is received by the due date and time.

The PEBC and its member groups assume no responsibility for delays caused by any mail or delivery service or any other factor contributing to a contractor’s delay in delivery of these proposals. The PEBC is located in close proximity to the Texas Rangers Ballpark and Cowboys Stadium in Arlington. Deadline dates may be on scheduled game/event days. Respondents are encouraged to take precautions to avoid delays in delivery of these proposals.

Alterations may be made before the official opening time provided such alterations are provided in writing and signed by the proposing company certifying authenticity. Proposals may be withdrawn at any time prior to the official opening with written notice.

Proposals may not be withdrawn after proposals have been opened, and the contractor, in submitting the same, warrants and guarantees that its proposal has been carefully reviewed and checked and that it is in



all things true and accurate and free of mistakes, and that such proposal will not and cannot be withdrawn because of any mistake committed by the contractor.

11.4 ORDERING OF PROPOSAL RESPONSES

The content of all responses submitted must be ordered to correspond with the specifications as they appear in the RFP. Unless a deviation is specifically noted in the response, it will be assumed that the responding vendor agrees to meet all specifications exactly as set forth in this RFP.

This proposal may not be divided into sections or bid by multiple contractors. This does not prohibit sub-contracting as described herein. One proposal, inclusive of all provider network, MH/SA case management, EAP, and claims administration services, and subject to the requirements of this RFP, must be submitted.

Financial proposals must be itemized by service as requested in the Questionnaire. Failure to itemize the proposal using the provided exhibits may result in disqualification of the proposal.

11.5 NON-RESPONSIVE CRITERIA

The PEBC will not accept for consideration any proposals that do not comply with the criteria set forth herein. Failure to address any of the RFP requirements may result in rejection of a proposal.

11.6 VENDOR REQUIREMENTS

To be considered for selection, responding vendors must be licensed in good standing from the Texas Department of Insurance as an insurance company or third party administrator to provide MH/SA benefits services in the State of Texas at all times throughout the RFP process. The PEBC will consider all applicable factors in determining which proposal best serves its interests.

11.7 AGENT OF RECORD / COMMISSIONS

The PEBC and its Groups shall not designate an Agent of Record or any other such company, employee or commissioned representative to act on behalf of the PEBC, the Vendor or the PEBC Employer Groups. All requests to provide such designation will be rejected. Vendors are specifically instructed to submit proposals directly to the PEBC. Proposals submitted through a third party agent will not be accepted.

All proposals must be submitted without any commissions payable to any agent or agency, broker or brokerage. Further, each proposing contractor must fully disclose payments to any individual(s) or company (ies) other than compensation paid to active regular direct employees of the contractor earned in the course of carrying out their regular duties in providing contracted services to the PEBC.

11.8 CONFIDENTIAL STATUS – DISCLOSURE OF PROPOSAL CONTENTS

Unless required to release such information by applicable law or court order, proposals submitted by organizations will be deemed confidential until any announcement regarding the selection or rejection of a proposal has been made. However, once a proposal has been received, it becomes subject to release in accordance with the provisions of Chapter 552 of the Texas Government Code (The Public Information Act,



“the Act”). In order to permit the responding vendor to protect confidential information submitted by the vendor in support of a proposal, the responding vendor must conspicuously label any information it believes to be exempt from disclosure under the Act as “Confidential Proprietary Information.” The responding vendor acknowledges and agrees that the PEBC and its Employer Groups shall have no liability to the responding vendor or any other person or entity for disclosure of information in accordance with the Act. It is the responding vendor’s sole obligation to advocate the confidential or proprietary nature of any information it provides in its proposal. Responding vendors should understand and be aware that the Texas Attorney General may determine that all or part of the claimed confidential or proprietary information should be disclosed. The PEBC shall not advocate the confidentiality of the responding vendor’s material to the Texas Attorney General or to any other person or entity. For the purpose of asking the Attorney General to determine whether an exception to disclosure exists for information a vendor deems to be proprietary, PEBC will submit to the Attorney General only that information the vendor has specifically labeled "Confidential Proprietary Information."

11.9 VENDOR EXPENSES

The PEBC and the NCTCOG will not be liable under any circumstances for any expenses incurred by any service provider in connection with preparation of a proposal or for any part of the RFP process. All proposals become the property of the PEBC and will not be returned to the service provider.

The only purpose of this RFP is to ensure uniform information in the selection of proposals and procurement of services. This RFP is not to be construed as a purchase agreement or contract, or as a commitment of any kind, nor does it commit the NCTCOG or the PEBC to pay for costs incurred prior to the execution of a formal contract unless such costs are specifically authorized in writing by the PEBC.

* * * * *



12. QUESTIONNAIRE

Be certain that all questions are answered completely and accurately. Include the question in your response. If the service you can provide involves subcontracting to or working through any other organizations, you must disclose all contractual relationships. If you are uncertain about this requirement, please err on the side of disclosing all information.

In responding to the following questions, please provide only information relative to this project. If your information reflects information other than what is requested, your proposal may be removed from consideration, since the PEBC will not be able to make a fair comparison of potential service contractors.

A. MH/SA PROVIDER NETWORK AND MH/SA MEDICAL MANAGEMENT (30 points)

Proposals must indicate that the responding vendor can provide all required services in the proposed provider network areas for PEBC employer group employees, retirees, and their covered dependents.

1. Provide the following information to demonstrate your experience with MH/SA provider networks in North Texas:

a. Year the MH/SA network was established in North Texas and length of time network has been in place.

b. Name(s) and brief description of the network(s) you are proposing for the PEBC (MH/SA and EAP).

c. Confirmation that your organization fully owns and controls these provider network(s).

d. Total MH/SA covered members (insured or self-funded) for the North Texas network(s) proposed on January 1, 2011.

Response:

2. For North Texas, are your contracts primarily with large groups and/or facilities or with individual providers? Please disclose the percentage of North Texas contracts with individual providers and with groups/facilities.

Response:

3. Although all PEBC employees are located in the North Texas area, the covered population includes retirees and dependents that may reside throughout the country. Please:

a. Confirm you can provide all required services in the proposed provider network areas for PEBC



employer group employees, retired employees, and their covered dependents listed on the census provided.

b. Describe your network arrangements for national coverage (e.g., if you lease networks in other areas of the country, for how long has the arrangement been in place, etc.)

Response:

4. What do you require for a provider to become "credentialed" in your network? When is the process first completed and when is it re-verified? Be sure to include any professional liability requirements.

Response:

5. How do your contracts and provider search processes address providers who are not accepting new patients?

Response:

6. Provide the turnover rate for your MH/SA network providers in the North Texas area over the last two years (2009 and 2010).

Response:

7. What contractual provisions apply to a provider who decides to leave your network or change groups? Please address lead times, patient notification, and continuation of care for patients.

Response:

8. Do you have any reason to believe there will be upcoming changes to your MH/SA provider network in North Texas due to terminations by high volume providers or groups, or providers, including hospitals, challenging your pricing in certain locations or specialties? If not, please disclose if you have had material terminations as described in the past three years, providing the specific provider type and year of termination.

Response:



9. Is any MH/SA provider compensation related to utilization levels? If so, explain the methodology.

Response:

10. Is your organization NCQA accredited or certified? If so, provide proof of such certification.

Response:

11. Using the Excel spreadsheet included with this RFP, complete the two tabs marked 11A and 11B (Facility and Provider Match), indicating whether each physician or MH/SA provider shown is currently under contract in your network for the given specialty. These lists contain information pertaining to providers currently utilized by PEBC membership based on PEBC claims data. Note that these lists include both in-network and out-of-network providers utilized; they are not intended to replicate the current provider networks. The file returned with your proposal must be in Excel format and follow the included format to allow for comparison of proposals. No other format will be accepted. All required data fields must be filled in or your proposal will be considered incomplete.

(Respond on Excel spreadsheet)

12. Based on the census information contained in Appendix C, please provide a MH/SA network provider GEOAccess report for the North Texas area based on the specifications below, addressing both professional providers and behavioral health facilities. In the table below, provide a summary of the match for the PEBC, giving the percentage of employees whose access meets the specifications provided.

When running GEOAccess reports, distance to providers should be measured by driving distance. Rivers, lakes, etc. should be taken into consideration when determining distance. Also, the GEOAccess methodology should exclude closed practices (those not accepting new patients or no longer in business.)

(Respond with hard copy GEOAccess reports plus an electronic version on CD, plus completion of the exhibit below)

Specification – Professional Providers MD Ph.D. Masters RN

Urban: 2 professional providers within 10 miles

Suburban: 2 professional providers within 20 miles



Specification – Professional Providers MD Ph.D. Masters RN

Rural: 1 professional provider within 30 miles

Specification – Facilities Behavioral Health Facility

Urban: 1 behavioral health facility within 20 miles

Suburban: 1 behavioral health facility within 30 miles

Rural: 1 behavioral health facility within 40 miles

Your proposal response should include hard-copy reports as part of your hard-copy proposals as well as an electronic version of the GEOAccess reports on CD.

13. Provider Count – North Texas

To demonstrate that your network contains a sufficient number of providers to service participants, please complete the chart shown below and on the enclosed spreadsheet, Question 13 (Provider Count), providing counts for each of the following specialties in the North Texas area. Include only those providers with signed contracts in place at the time of proposal submission. Please also provide three (3) hard-copies of your most recent regional provider directory which includes the North Texas service area.

For purposes of this question, please define the North Texas area as follows: Counties of Collin, Dallas, Denton, Ellis, Erath, Hood, Hunt, Johnson, Kaufman, Palo Pinto, Parker, Rockwall, Somervell, Tarrant, Wise in the Total Column. In addition, please disclose the specific provider count for the Counties of Collin, Dallas, Denton, Parker and Denton, the sum of which is included in the Total Column.

You may count multiple offices or addresses for an individual provider separately in your response to this question.

(Respond on Excel spreadsheet plus hard copy directories)

Specialty TOTAL – 15

Counties

Collin Count

y

Dallas Count

y

Denton

County

Parker Count

y

Tarrant County

Behavioral Health Facility



Specialty TOTAL – 15

Counties

Collin Count

y

Dallas Count

y

Denton

County

Parker Count

y

Tarrant County

Psychiatrists - MDs

Psychologists - PhDs

Masters Level Clinicians

14. Will you commit to recruiting other key providers who are critical to the current PEBC covered membership, if they are not already part of your network? What timetable and guarantees can you provide?

Response:

15. What processes do you have in place to improve provider compliance with evidence-based medicine?

Response:

16. Identify the Medical Director who will be involved with the PEBC, including his/her working location, the length of time he/she has been employed by your organization, and his/her Board Certification specialty.

Response:

17. The current PEBC plan design requires pre-authorization of any and all MH/SA services other than the first 3 EAP visits. To access the EAP, the member must contact MHN. Give a brief overview of your standard pre-authorization processes. Can you support the current PEBC model?

Response:

18. Describe your care management approach for all levels of care for mental health and substance abuse treatment. Please be specific in terms of initial admission and concurrent review along with requests for outpatient services.

Response:



19. Describe your ability to coordinate and deliver on-site crisis services and Critical Incident Stress Management (CISM) services and debriefing at the request of the PEBC, including:

a. Do you provide these services directly, or do you use subcontractors?

b. Can you provide CISM services within a 24- to 72- hour turnaround?

c. What are your response times for telephonic versus on-site CISM?

d. Briefly describe how your firm defines “on-site crisis services and Critical Incident Stress Management services” including any minimum attendance requirements.

Response:

B. REFERENCES (10 points)

20. Provide three current client references, similar in size and complexity to the PEBC, for self-funded MH/SA benefits administration services. At least one reference must be from a public sector client (e.g., city, county, university, etc.) preferably in Texas. Complete the reference information for each of the three references you provide. By responding to this request, the vendor (1) authorizes the PEBC to contact the employers to discuss the services the vendor has provided for these employers; (2) authorizes the employers to provide such information to the PEBC; and (3) agrees to release the PEBC and its Employer Groups from any liability from the employer’s actions.

a. Reference 1: Public Sector Client

Customer name and address:Response:

Contact person’s name, title, e-mail address and telephone number:Response:

Services provided and years performed:Response:

Number of covered employees / covered members:Response:

b. Reference 2:







c. Reference 3:





21. Provide one client reference for an organization, either similar in size or complexity to the PEBC, who has terminated similar services (self-funded MH/SA benefits administration) within the last 18 months. Please provide, if possible, a client that terminated services following a competitive bid or request for proposal process, and not due to merger/acquisition. By responding to this request, the vendor (1) authorizes the PEBC to contact the employer to discuss the services the vendor has provided; (2) authorizes the employer to provide such information to the PEBC; and (3) agrees to release the PEBC and its Employer Groups from any liability from the employer’s actions.

a. Reference 1: Terminated Client





Services provided and years performed, including termination date:Response:


22. Provide one client reference, current or recent, for the Account Manager you plan to assign to the PEBC. By responding to this request, the vendor (1) authorizes the PEBC to contact the employer to discuss the services the vendor has provided; (2) authorizes the employer to provide such information to the PEBC; and (3) agrees to release the PEBC and its Employer Groups from any liability from the employer’s actions.

a. Reference 1: Account Manager Reference





C. PRICING AND PERFORMANCE GUARANTEES (30 points)

23. Complete the table below with your actual and projected trend rates used for your self-funded MH/SA customers.



Response:

Location Self-funded MH/SA

2010 Actual 2011 Projected

North Texas area

National

24. Complete the table below with your current average MH/SA network discount percentages from billed charges (billed charges are defined as provider submitted charges less ineligible charges before application of fee schedules and contracted reimbursement provisions) without weighting data for employer utilization patterns.

Response:

Location MH/SA Network

North Texas National

Inpatient Facility MH/SA

Outpatient Facility MH/SA

Professional/Physician

TOTAL

25. CPT Code Negotiated Rates

Using the spreadsheet included in this RFP (Question 25 CPT), please complete the chart provided below with your current (2011) outpatient negotiated/allowable rate for the North Texas 3-digit zip codes shown.

(Respond on Excel spreadsheet; chart shown below for reference))



CPT Code 3-digit Zip Code

750 751 752 760 761 762

90806 – Psychiatrists (MDs)

90806 – Psychologists (PhDs)

90806 – Masters Level Clinicians

90862 – Psychiatrists (MDs)

26. Provide your average, negotiated inpatient facility psychiatric daily reimbursement rate (excluding chemical dependency and detoxification) for the North Texas (Dallas/Fort Worth) area.

Response:

27. Please outline your proposed network discount guarantees. Note that any proposed performance guarantees may not result in additional fees due from or payable by the client.

Response:

28. Complete the chart on the enclosed spreadsheet, Question 28 Fees, providing a single, 24 month administrative fee for self-funded MH/SA plan administration (for EPO and PPO medical plan participants), and a separate capitated EAP rate for a 3-visit model for active employees only, beginning on January 1, 2012 and ending December 31, 2013. All fees/rates should be provided on a Per Employee/Retiree Per Month basis (PEPM) and must be guaranteed/fixed for a minimum of 2 years and disclosed if guarantee can survive the entire five year period (including renewal period of three years). Fees cannot be contingent on minimum membership participation by group. The fees proposed must be “mature”, including 12 months of runout claims administration should the contract terminate. Please note that additional administrative fees are not allowed. Additional fees that are known up-front, such as start-up or implementation fees, should be built into the proposed fees/rates, unless they are specifically excluded as a special service and outlined in the next question below (Question 29).

These administrative fees will apply for each PEBC Employer Group, regardless of the size of the individual group.

Please note that ASO fees may not be dependent upon a percentage of savings. While performance guarantees related to network savings are acceptable (see Question 27), your proposed ASO fee for MH/SA administration must be a stand-alone, pre-set, flat maximum monthly fee that will be



budgeted for and paid by the client.


29. On the enclosed spreadsheet, please complete Question 29 (shown below), confirming whether or not the proposed MH/SA administrative fees and capitated EAP rates, proposed above in Question 28, include the following services. If No, please provide an explanation of the extra service and the cost of that service.




Service Included in MH/SA Fees? Yes/No (if No please outline)

Start-up or Implementation Fees (incl. data file set-up, banking set-up, etc.)

MH/SA Claims Fiduciary Liability – handle 1st level appeals

MH/SA Claims Fiduciary Liability – handle 2nd level and External appeals process

Case Management (beyond that included in Question 28) or non-network claims negotiations

Collection and Reimbursement of Claim Overpayments

ERRP format claims data provided on a quarterly basis for all early retirees and their enrolled dependents, regardless of ERRP threshold

Subrogation

Interfacing with medical carrier (UHC)

Regular provision of information for stop-loss carrier

Ad-hoc reporting (per hour)

Other:

Other:



Service Included in Capitated EAP Rate? Yes/No (if No please outline)

Up to three (3) face-to-face counseling sessions per member, per incident, each year at no cost to the member

Telephonic clinical counseling available 24 hours/day, 7 days/week, at no cost to the member

Telephonic counseling for childcare and eldercare as shown in Section 3.1.2 of this RFP

Telephonic counseling for financial services as shown in Section 3.1.2 of this RFP

Telephonic counseling for legal services as shown in Section 3.1.2 of this RFP

Telephonic counseling for identity theft recovery as shown in Section 3.1.2 of this RFP

Telephonic counseling for daily living services as shown in Section 3.1.2 of this RFP

Online counseling and access to referrals

Up to 21 hours per year of onsite training (e.g., brown bag lunches) per Employer Group

Other

30. Please confirm the administrative fees proposed include 12 months of run-out claims administration (i.e., they are mature fees) should your contract to provide services terminate.

Response:

31. Please provide the name, title, telephone number and email address for the actuarial/financial personnel responsible for preparation of this administrative fee.

Response:

Name: _______________________



Title: _______________________

Telephone: ___________________

Email: _______________________

32. Performance Guarantees: Performance guarantees are required if selected as the network/claims administrator for the PEBC. Such guarantees apply to each PEBC Employer Group and will include the following:

Performance Standard Measurement Frequency

Amount at Risk (per PEBC member group)

Claims Administration

99% of clean claims processed within thirty (30) days

Quarterly

Financial Accuracy of paid claims of 99.0% Annually

Maximum Penalty Per Year – Claims Admin Annually

Telephone Calls

Vendor’s average time in queue (waiting time) cannot exceed 30 seconds

Quarterly

Vendor’s average abandonment rate cannot exceed 2%

Quarterly

Maximum Penalty Per Year Annually

Communications

Confirmation that no employee communications were released without prior PEBC Executive Director approval

Annually

Annual Enrollment - providing access to Website (provider search) and electronic materials

Annually

Data Management

Confirmation that data records are updated within 24 business hours of receipt

Quarterly



Performance Standard Measurement Frequency

Amount at Risk (per PEBC member group)

Audit comparisons completed within ten business days of receipt

Up to 3 times each year

Timely delivery of plan reports (final content and schedule to be confirmed during Implementation)

Quarterly

Maximum Penalty Per Year – Data Management Annually

TOTAL AMOUNT AT RISK ANNUALLY

Please confirm your willingness to agree to these Performance Standards and Measurement Frequency, and provide the Amounts at Risk that will become a part of each PEBC Employer Group’s contract.

Response:

33. Please describe any innovations or approaches unique to your organization for which you can quantify results, generating short- or long-term cost savings, which could benefit the PEBC and its covered membership. The PEBC may request further details on these programs for vendors selected as finalists.

Response:

D. ADMINISTRATION, CUSTOMER SERVICE, AND ORGANIZATIONAL INFORMATION (30 points)

General Information

34. Define the organization(s) that are participating in your proposal and explain the relationship of any material subcontracted service (e.g., outside contracting for Critical Incident debriefing in the North Texas area.) For each subcontracted service, provide the length of time the current arrangement has been in place, and explain how the service is integrated into your systems and processes.

Response:

35. Provide a brief overview of the ownership of your company, including the number of years you have been in business and the nature of the financial relationship (e.g., publicly traded on major stock exchange, privately held by whom, any holding company arrangements, etc.) Be sure to specifically



address:

a. Type of organization or incorporation (for profit, not-for-profit, etc.)

b. Publicly or privately owned

c. State of incorporation

d. Number of years in business

e. Provide a copy of your Certificate of Authority or registration to conduct business within the State of Texas

Response:

36. Provide a copy of a valid license for performing third party administration services for medical (MH/SA) claims in the State of Texas for your organization.

Response:

37. Have there been any changes in your organization’s ownership structure (e.g., merger, acquisition, etc.) in the last 24 months, or are any contemplated or expected? If so, please describe them in detail and address the impact these changes may have related to the provision of services as described in this RFP.

Response:

38. Describe any pending litigation that could impact your provider network(s) or your ability to provide service to the PEBC and the PEBC Employer Groups.

Response:

39. Describe any notifications to Health and Human Services (HHS) by your firm or your parent company in connection with breach of confidential data (include date and number of records), including your firm’s corrective action taken and current status if not resolved.

Response:



40. Do you currently, or have you recently (within the last two years) provided any PEBC Employer Group benefit plan services through a self-funded or fully-insured arrangement, even if through an affiliated or acquired company? If you answered yes, please answer the following questions.

a. List all types of Plans contracted (HMO, PPO, Senior Supplement, Medicare Advantage) and the last date for which you provided coverage.

b. Who is/was the senior account manager for that block of business?

c. Is your firm still providing these services? Why or why not?

d. Explain why (or why not) the PEBC should refer to this experience and relationship as an indicator of future success with your firm.

Response:

41. In the past 12 months, have you had any workforce reductions/consolidations, or are you planning, any workforce reductions/consolidations that could affect your organization’s ability to provide services as proposed?

Response:

42. Provide a copy of the most recent audited financial statement, including auditor’s notes, for your organization. Please provide a copy of the statement and auditor’s notes only – not the full annual report.

Response:

43. Please respond to the following regarding your MH/SA administration book of business for self-funded customers only:

a. Number of self-funded MH/SA plan administration customers

b. Total number of covered members in your self-funded MH/SA plan administration programs

c. Number of customers with more than 10,000 covered employees nationally

d. Number of customers with more than 10,000 employees based in the North Texas area (i.e., with account management, customer service and claim administration assigned to your North Texas service teams)

Response:Page 41 of RFP No. 2011-001


44. Describe your experience advising plan sponsors and administering benefit plans for organizations such as the PEBC, which are not subject to ERISA, and not subject to all Texas Department of Insurance regulations, but which are subject to other legislation (e.g., Public Health Service Act, Texas Serious Mental Illness required benefits, health care reform.) Please disclose if the organization elected to exempt the plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits.

With regard to this issue, please address:

a. Legal/compliance resources available

b. Training for Account Managers specifically regarding legislation/compliance and benefit design

c. Provide examples of other similar customers (non-ERISA, self-insured) with whom you currently work.

Response:

45. Provide an organizational chart identifying the personnel who will be responsible for the administration and management of your organization’s contract with the PEBC, on behalf of the PEBC Employer Groups.

Response:

46. Please clearly identify the senior level person in your organization who would be assigned to work with the PEBC Executive Director, as well as the key day-to-day contact for working with the PEBC day-to-day items (if different). Provide each person’s years of service with your organization as well as the total number of accounts directly managed.

Response:

47. Occasionally PEBC service providers are contacted by interested third parties (e.g., the media) requesting information about the PEBC and its member groups. Please confirm your agreement not to disclose any information about the PEBC’s covered population or utilization, even in aggregate, with any outside third parties. Press releases or any other communications or requests must be pre-approved by the PEBC Executive Director.

Response:



Plan Design

48. The current medical and MH/SA plan designs are shown in Appendix A.

a. Are you able to administer the PEBC EAP and MH/SA plan designs exactly as currently written, in all states (note: this is notwithstanding any plan design changes that may be required as a result of health care reform)? Please specify Yes or No.

b. Identify any current PEBC plan design provisions or specifications that you cannot administer, or which would require special or manual processing with your system, in particular with regard to the following procedures:- EAP visit definitions- Inpatient Hospital copays – per day copays with maximum limits- Preauthorization requirements- Exclusions

Please be sure to list any plan design provisions or specifications also in Section 13.Signatures-4, “Deficiencies and Deviations” Form, providing your alternative approach in detail, including any cost impact.

Response:

49. In the event the PEBC added a consumer-driven or account-based medical plan (such as an HRA) in the future, describe the resources and experience you have to support this type of plan design.

Response:

50. Please describe transition benefits and the process you would follow (in detail, based on the current plan designs) for those plan participants in a course of treatment prior to January 1, 2012 and through completion of a course of treatment beyond January 1, 2012. Please disclose if you are willing to provide a financial transition allowance (if applicable) and describe.

Response:

Claims Administration and Customer Service

51. From what office location will claims be paid?

Response:



52. For the claims office that will be processing claims for the PEBC, provide the following statistics for all claims paid by the vendor for calendar year 2010.

Measurement Company Standard 2010 Actual

Claims payment accuracy

Claims processing accuracy

Financial accuracy

Average turnaround time

Percentage of claims processed within 10 business days of receipt

Percentage of claims received electronically (EDI)

Auto-adjudication percentage

53. Do you outsource any claim payment or customer/member services function overseas?

Response:

54. What is the lag between when you receive an eligibility update file and when the information is "online" in member services and claims?

Response:



55. The PEBC provides links to certain portions of vendor websites via its information website. Please confirm links can be provided via the PEBC website. Describe your current website capabilities (links potential) for employees and employers. Include:

a. What is your website address?

b. Do you maintain your website in-house, or is your website outsourced? To whom?

c. How often do you update your online provider directory?

d. Please complete the chart below with currently operational capabilities that would be available to PEBC membership.

Response:

Website capabilities Currently operational? Yes/No

Can members access the full provider directory?

Can members search for a provider by name?

Can members print a map to a provider’s office?

Do you offer a live chat with a nurse?

Can members see their specific benefit plan?

Can members submit out-of-network claims?

Can members check claim status and view EOBs?

Can members access legal consultation services?

Can members access financial consultation services?

Does the site have a self-assessment tool that addresses depression?

Does the site have a self-assessment tool that addresses alcohol/drug abuse?

56. Provide the following regarding your customer service/member services phone line and team:



a. Office location

b. Hours of operation

c. Confirm you will provide a toll-free number. Will this number be unique to the PEBC?

d. Confirm the line is available 24 hours/day and 365 days/year, with no busy signals

e. Will the PEBC have the ability to customize the phone tree?

f. Will you provide warm transfers to other PEBC vendors (e.g., UHC)?

Response:

57. Do you record all calls to customer/member services? When are these calls purged?

Response:

58. Confirm that you have specific, written procedures for handing emergency calls both during and after hours. Do you have special procedures for handling cases of potential violence?

Response:

59. Please provide the following statistics for the customer/member services site that will service the PEBC account:

Response:

Measurement Company Standard 2009 Actual

Call abandonment rate

Average speed to answer (in seconds)

First call resolution rate

Member satisfaction rate *

* Defined as the combined percentage responding “Completely Satisfied” or “Very Satisfied” on customer satisfaction surveys. Neutral responses should not be counted.



60. EAP - Do you presume eligibility for EAP services for all members that contact you? If not, how is eligibility handled?

Response:

61. EAP - What are the minimum qualifications for those answering calls to the EAP? Please confirm that only clinicians may make referrals under your model.

Response:

62. EAP - Is follow-up provided on all EAP and work/life cases? If yes, please describe how the follow-up is completed and by what level of staff.

Response:

63. EAP - Please provide information on how your EAP legal and financial counseling services work. Please be sure to indicate the number of telephone and in-person counseling sessions available for both legal and financial counseling sessions, as well as the length of each session. Are there any instances where additional costs would apply?

Response:

64. EAP - Please provide information describing the turn-key EAP services your organization provides which are included in the EAP PEPM rate. Please include any limits or additional pricing information.

Response:

65. Describe your ability to coordinate services with the PEBC’s current medical plan and prescription drug providers, UHC and Express Scripts, respectively, including:

a. Coordination of high-cost inpatient cases

b. Coordination of cases with depression as a co-morbidity

c. Coordination with disease management programs

Response:



66. Explain the process used by customer/member services to assist members in locating a specialty provider who is able to assist with needed care if emergency care or a specialty provider is needed. Under what circumstances, if any, do you use "non-contract" providers to provide services to members?

Response:

67. EAP – Currently, each PEBC Employer Group receives up to 21 hours of onsite training annually (e.g. brown bag lunches) on a variety of topics at no additional cost. Please confirm your ability to provide onsite training services on a regular basis as requested. Please also supply a list of the various topics available for this purpose noting those circumstances where additional cost may apply.

Response:

68. EAP - Describe the value-added, no cost resources and tools you can make available with regard to wellness programs for PEBC Employer groups.

Response:

69. The PEBC requires Employer plan management reports in electronic format (Excel or text file and .pdf) with a hard-copy printed version. Please provide a list of your standard Employer plan management reports. Specify the frequency of production and availability following the close of the reporting period, and confirm that the information can be provided in Excel or text file and .pdf.

a. Reports for the EAP

EAP Reports Included?

Open and closed case by type of problem

Number of face-to-face sessions

Book of business/peer group comparisons on all reporting

Follow-up provided

Supervisory referrals



EAP Reports Included?

Number of hits to the website

Utilization of work/life resources

b. Reports for self-funded MH/SA benefits – please list standard reports and provide frequency

MH/SA Reports Included?

Comprehensive utilization statistics for inpatient, alternative levels of care, and outpatient (ALOS, days/visits per 1000, etc.)

Reporting on readmission rates

Reporting on percentage of enrollees terminating treatment prior to completion of treatment plan

Book of business/peer group comparisons on all reporting

Response:

70. Do you offer on-line reporting functionality? Is there an additional fee for this service?

Response:

71. Please confirm your willingness to take 100% financial responsibility for your own claims processing mistakes (e.g., if you pay claims on a member whose coverage has been terminated and forwarded to you in a timely manner and the claim was funded by the PEBC Employer Group.)

Response:



72. Any refunds due to claims processing should not be credited against administrative fees; they must be returned to the applicable PEBC employer group via check accompanied by a report showing the claim number, amount, date of service, and applicable member. Please confirm your agreement to administer this arrangement.

Response:

73. Please clearly confirm whether or not you can accommodate each of the funding/banking arrangements listed below, and identify any additional costs to administer the program in that manner, if applicable:

a. Each PEBC Employer Group owns the positive pay disbursement bank account with vendor’s check stock, branded with the PEBC logo and the Employer group name, and the vendor agrees to provide reconciled bank account documents on a monthly basis, including but not limited to outstanding and void checks.

b. Vendor owns the individual PEBC Employer Group positive pay disbursement bank account with vendor’s check stock, branded with the PEBC logo and the Employer group name, and vendor agrees to provide reconciled bank account documents on a monthly basis, including but not limited to outstanding and void checks.

c. Vendor funds and releases checks on vendor owned positive pay disbursement account, and the PEBC Employer Group funds presented checks only on a daily or weekly basis. Vendor agrees to fund positive pay checks in advance of reimbursement and must be prepared to fund claims from vendor’s resources for a period up to two weeks before PEBC Employer Group reimbursement is made.

d. Other (explain arrangement)

e. Please confirm you can provide a check register/electronic report in advance of check release for all options.

f. Please describe any security and fraud-prevention features built into your check release and cash management process.

Response:

74. The PEBC Executive Director must approve any and all communication materials distributed to PEBC covered members prior to their release. Confirm your ability and willingness to meet this standard. Note that it will be a Performance Guarantee standard for the PEBC.

Response:



75. Comment on your organization’s HIPAA compliance. Is your organization fully compliant with the HIPAA Privacy, Security, Breach Notification, and other regulations?

Response:

76. The PEBC serves as the Plan Administrator (not the ERISA definition) for the self-funded medical plans for each of the PEBC Employer Groups. Thus, as Plan Administrator, the PEBC Executive Director is entitled to receive Protected Health Information (“PHI”) as defined under HIPAA statutes for health care operations purposes, without an authorization from the covered employee. Please confirm your understanding of these provisions and your willingness to share PHI with the PEBC Executive Director as needed and requested for health care operations purposes.

Response:

Required Provisions and Forms

77. Confirm your agreement to meet the following Contractual requirements of this RFP (see Section 2 for more detail):

Contractual Requirements Meets PEBC Requirement Yes/No

Two year contract (January 1, 2012 – December 31, 2013) with PEBC optional 3-year extension (without rate increase)

Firm carries Professional Liability insurance meeting ALL the requirements in Section 2

Contract WILL NOT contain a Binding Arbitration provision

PEBC Member Groups may terminate contract with 180 days notice

Selected vendor may not terminate contract during the contractual term

Selected vendor may not assign contract



Contractual Requirements Meets PEBC Requirement Yes/No

Contract will contain language consistent with the Indemnification provisions in Section 2.2.5 of this RFP

Payment grace period of 45 days

Selected vendor will sign the Letter of Understanding shown in Appendix D of this RFP

Selected vendor will sign the PEBC Business Associate Agreement as shown in Appendix E of this RFP

78. If applicable, complete the Historically Underutilized Businesses Only form (13.Signatures - 1) and attach a copy of your HUB certification. Does this form apply to you?

Response: Yes/No

79. Complete and sign the Certificate of Compliance Page (13. Signatures - 2).

80. Complete and sign the Signature Page (13. Signatures - 3).

81. Complete and sign the Deficiencies and Deviations Form (13. Signatures - 4) clearly identifying any deviations to the requirements of this RFP.

82. Complete and sign the Disclosure of Third-Party Payments (13. Signatures - 5), clearly identifying any payments to be made to other organizations as a result of this contract.

E. REQUEST FOR INFORMATION – AUTISM BENEFITS (0 points)

Note: This Section seeks information on how your organization manages benefits and services requested for treatment of autism and related conditions, including applied behavioral analysis therapy (ABA). Your responses to this section will not count towards the scoring of the RFP. These questions are designed to gather current information on what major MH/SA managed care organizations and their self-funded, non-federal governmental employer clients (who are not subject to ERISA) are doing with regard to managing these cases, and to examine the specific plan design in connection with that coverage. If you do not have any self-funded, non-federal governmental clients, please disclose and do not respond to this section. If the



client also elects to exempt its plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits, please indicate. If you have clients in this category, we appreciate your response. You should not assume or conclude that the PEBC groups will cover additional services in connection with questions asked in this Section. This information is requested for informational purposes only.

Please see Section 11.8 of this RFP for information on public records requests which may include your responses to this section of the RFP. You are not required to disclose your client’s name when responding to this RFP. Please be aware of the potential for public records requests, in particular if you include customer-specific examples in your responses.

The State of Texas has mandated coverage of ABA therapy (with age limits, etc.) for those plans which are under State oversight, such as a fully-insured HMO plan, but that mandate does not apply to self-funded governmental plans such as those offered by the PEBC. To reiterate, the PEBC is also not subject to ERISA, and all PEBC Employer Groups elect to exempt the plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits.

The PEBC currently covers the following services related to Autism Spectrum Disorder (ASD): Office Visits Speech Therapy Physical Therapy Occupational Therapy Prescription Drug Management.

The PEBC medical plan excludes coverage for educational services. Examples of services that are not covered by the PEBC medical plans include:

Sensory integration Applied behavioral analysis (ABA) Lovaas therapy Music therapy.

When answering the questions below, please respond in connection with coverage connected to a group similar to the PEBC (e.g. self-funded, non-federal governmental plan, not subject to ERISA, and elects to exempt the plan from the requirements of Title XXVII of the PHS Act including parity in the application of certain limits to mental health benefits). If you do not have a self-funded client that fits this description, please provide information for the closest match client available, disclosing the type of client. You are not required to disclose your client’s name when responding to this RFP.

83. What is your organization’s standard or recommended approach to covering pervasive development disorders? We are requesting specific language describing services typically covered and not covered, including any coverage or cost limitations.

Response:



84. What is your organization’s standard or recommended approach regarding treatments often recommended for ASD, including ABA? Please provide a copy of your clinical policy or practice bulletin, along with a summary of how and by whom that document was prepared.

Response:

85. Please provide any cost information you have collected on providing coverage for ABA and/or similar therapies (per unit, per 15 minutes, per visit, etc.)

Response:

86. Do you have self-funded MH/SA customers (similar to PEBC) that have chosen to cover ABA and/or other autism therapies on a voluntary basis (meaning the customer made the decision; not because of a legislative requirement)? If so,

a. What percentage of your self-funded clients nationally cover ABA therapy?

b. What percentage of your self-funded clients headquartered in Texas cover ABA therapy?

c. How is ABA coverage distinguished from other educational services in your claim and other systems, since specific CPT codes do not exist?

d. What has been the annual cost history and cost projections for customers electing to cover ABA therapy?

Response:

87. Please provide examples, as specific as possible, of the benefit plan design for customers which have voluntarily chosen to cover ABA therapy. For example: What copays/coinsurance apply? Are there limits on the number or cost of services? Is pre-authorization required? Do age limits apply? Are members required to use certain providers? What exclusions continue to apply? Case studies or specific customer examples would be extremely helpful if available.

Response:

88. Do you have contracted network providers for ABA and/or similar treatment therapies as part of your network in North Texas? Your national network? If so,



a. What are the credentialing standards for these providers?

b. What level of network discounts (on a percentage basis) are you typically able to achieve from these providers?

Response:

89. What alternatives, approaches or other resources do you offer to members requesting coverage for ABA and/or similar therapies?

Response:

90. Are there any other factors other than those mentioned above which your ASO customers considered regarding plan design related to covering pervasive developmental disorders?

Response:



13. SIGNATURES - 1HISTORICALLY UNDERUTILIZED BUSINESSES, MINORITY OR WOMEN-OWNED OR DISADVANTAGED

BUSINESS ENTERPRISES

Historically Underutilized Businesses (HUBs), minority or women-owned or disadvantaged businesses enterprises (M/W/DBE) are encouraged to participate in the RFP process. Representatives from HUB companies should identify themselves and submit a copy of their Certification.

NCTCOG recognizes the certifications of both the State of Texas Program and the North Central Texas Regional Certification Agency. Companies seeking information concerning HUB certification are urged to contact:

State of Texas HUB ProgramTexas Comptroller of Public AccountsLyndon B. Johnson State Office Building111 East 17th StreetAustin, Texas 78774(512) 463-6958http://www.window.state.tx.us/procurement/prog/hub/

Local businesses seeking M/W/DBE certification should contact:

North Central Texas Regional Certification Agency624 Six Flags Drive, Suite 100Arlington, TX 76011(817) 640-0606http://www.nctrca.org/certification.html

Proposer must include a copy of its minority certification documentation as part of this RFP.

If your company is already certified, attach a copy of your certification to this form and return it with the proposal.

Indicate all that apply:______Minority-Owned Business Enterprise______Women-Owned Business Enterprise______Disadvantaged Business Enterprise


http://www.nctrca.org/certification.html


13. SIGNATURES - 2 CERTIFICATE OF COMPLIANCE

Equal Opportunity Clause: (applies to federal contractors and sub-contractors for contracts of $10,000 or more) – Contractor is aware and fully informed of its responsibilities under Executive Order 11246, as amended, and agrees to be bound by its provisions

Affirmative Action Compliance Program: (applicable to federal contractors and sub-contractors for contracts of $50,000 or more, if contractor has 50 or more employees) – Contractor certifies to NCTCOG and to the United States government that since NCTOCG is a federal contractor, proposer will, if appropriate: a) file with the appropriate federal agency a complete and accurate report on Standard Form 100 (EEO-1) within 30 days after the signing of this certificate (unless such a report has been filed in the last 12 months), and continue to file such reports annually, on or September 30,or as otherwise provided by law or regulations; and b) develop and maintain a written affirmative action compliance program in accordance with the regulations of the Office of Federal Contract Compliance Programs promulgated under Executive Order 11246, as amended.

Employment of the Disabled: (applicable to federal contractors and sub-contractors for contracts of $10,000 or more – Executive Order 11758) – Contractor acknowledges that if applicable, it is bound by the Affirmative Action for Disabled Workers Clause set forth in Section 60-741.4 of Title 41 C.F.R., promulgated under Section 503 of the Rehabilitation Act of 1973 and that the clause is incorporated by reference into this Certificate of Compliance.

Employment of Disabled Veterans and Veterans of the Vietnam Era and Veterans Serving Active Duty During a War or in a Campaign or Expedition for Which a Campaign Badge Has Been Authorized: (applicable to federal contractors and subcontractors for contracts of $25,000 or more). Contractor acknowledges that if applicable, it is bound by the Affirmative Action for Disabled Veterans of the Vietnam Era Clause, as set forth in Section 60-250.4 of Title 41 C.F.R., promulgated under the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 and the Veterans Employment Opportunity Act of 1998 and that the clause is incorporated by reference into this Certificate of Compliance.

General: Contractor understands and agrees that this Certification does not create any enforceable rights hereunder for any firm, organization, or individual. The undersigned agrees that the provisions of this Certificate of Compliance are hereby incorporated in every non-exempt contract or purchase order between NCTCOG and Contractor currently in force, or that may be issued during a one-year period from the date of execution of this Certificate.

_____________________________________ ___________________________________Contractor’s name Authorized Signature

_____________________________________ ___________________________________Address Printed name

_____________________________________ ___________________________________Title of Authorized Representative

_____________________________________



Date of Execution13. SIGNATURES - 3 SIGNATURE PAGE

The undersigned agrees this proposal becomes the property of the PEBC after the official opening.

The undersigned agrees, if this proposal is accepted, to furnish any and all items/services upon which prices are offered, at the price(s) and upon the terms and conditions contained in the Specifications. The period for acceptance of this Proposal will be 180 calendar days unless the contractor notes a different period.

The undersigned affirms that he/she is duly authorized to execute this proposal, that this proposal has not been prepared in collusion with any other contractor, nor any employee of the PEBC, the NCTCOG, the Counties of Tarrant, Dallas, or Denton, Parker County nor the NTTA, and that the contents of this proposal have not been communicated to any other contractor or to any employee of the PEBC, the NCTCOG, the Counties of Tarrant, Dallas or Denton, Parker County nor the NTTA prior to the official opening of this proposal.

The contractor hereby assigns to purchaser any and all claims for overcharges associated with this proposal which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq.

The undersigned, being of management level, affirms and declares that they have read and understand the specifications and any attachments contained in this proposal package, and further affirms and declares that this proposal is executed and signed by contractor/proposer with full knowledge and acceptance of the provisions of the products or services described, proposed schedule and special needs and conditions as stated, which will be made of part of the contract.

NAME AND ADDRESS OF COMPANY: AUTHORIZED REPRESENTATIVE:

___________________________________ Signature ___________________________

___________________________________ Date _______________________________

___________________________________ Name ______________________________

___________________________________ Title _______________________________

Contact Name _______________________ Telephone __________________________

Telephone __________________________ FAX ______________ E-mail ___________

Fax ______________ E-mail_____________

COMPANY IS:

Business included in a Corporate Income Tax Return? ______YES ______NO

_____Corporation organized and existing under the laws of the State of __________________

_____Partnership consisting of __________________________________________________

_____Individual trading as ______________________________________________________



_____Principal offices are in the city of ____________________________________________



13. SIGNATURES - 4 DEFICIENCIES AND DEVIATIONS FORM

Following is a listing of ALL deficiencies and deviations from the requirements and/or provisions as outlined in this Request for Proposals. Please reference the specific section, question and/or page number to which the deviation or deficiency applies. Unless specifically listed here, your proposal will be considered to be in FULL compliance with the RFP. Contractor assumes the responsibility of identifying all deficiencies and deviations and if not identified, all requirements of the RFP stipulated must be fulfilled at no additional expense to the PEBC or the NCTCOG.

________________________________ _____________________________Proposing Company Signature of Authorized Representative

________________________________Date



13. SIGNATURES - 5 DISCLOSURE OF THIRD-PARTY PAYMENTS

Following is an itemization of parties who will receive payment from our company if we are the successful contractor. Please indicate the party involved (i.e., agent) and the amount of the proceeds each will receive if this proposal is successful.

________________________________ _____________________________Proposing Company Signature of Authorized Representative

________________________________Date



APPENDIX ACURRENT PLAN DESIGNS

Please base your proposal on the current plan designs, although there may of course be plan adjustments made due to health care reform or other legislation. Any deviations from the current design which you cannot administer must be clearly listed in the Questionnaire, Section 12, Question 48, AND in Section 13.Signatures – 4, on the “Deficiencies and Deviations Form”.

The following information is provided in this section: Quick Reference Guide – EPO Medical Plan – 2011 (full medical and MH/SA plan design for EPO plan) Quick Reference Guide – PPO Medical Plan – 2011 (full medical and MH/SA plan design for PPO plan) Summary Plan Description text – Managed Care Plans



A Quick Reference Guide ToEPO Medical Plan Benefits

Revised for the Plan Year Beginning January 1, 2011Please note: only one copay will be required for covered services performed on the same date by the same provider. Keep in mind that this section is only a quick reference summary of benefits of the EPO Plan provided for your convenience. You should rely on the EPO Plan Booklet (Summary Plan Description) for additional details concerning any benefits listed below. Care is coordinated through your Primary Care Physician (“PCP”), although referrals to specialists are not required. Services are covered only if provided by in-network providers, and there are no out-of-network benefits, except in an emergency situation. Always check the EPO Plan Booklet for notification requirements which may apply.

COVERED SERVICE(must be Medically Necessary)

In-Network(coinsurance is based on Network Allowable Amounts)

You Pay Plan Pays(after copays)

PHYSICIAN SERVICES

Office Visits- PCP (Family Practice, General Practice, Internal

Medicine, Pediatrics, OB/GYN for well woman care only)

$25 copay 100%

- Specialist $30 copay 100%

Hospital (Inpatient/Outpatient) Professional Fees No copay (hospital admission or outpatient surgery copay applies)

100%

PREVENTIVE SERVICES – subject to health care reform rules for covered preventive services and billing. If your provider bills an Office Visit separately and in certain other cases, the applicable copay shown above will apply.

Adult Health Assessments and Immunizations (age 18 and older)

$0 100%

Well Child Care and Childhood Immunizations (birth through age 17)

$0 100%

Annual Well Woman Examination(1 per year, includes pap smear)

$0 100%

Routine Screening Mammography(1 per year, age 35 and older)

$0 100%

Routine Prostate Screening(1 per year)

$0 100%

Routine Screening Colonoscopy $0 100%

Routine Speech and Hearing Exam(1 per year in doctor’s office only)

$0 100%

Preventive Minor Lab/X-ray $0 100%

ALLERGY CARE SERVICES

Testing and Evaluations $25 PCP / $30 Specialist

100%

Injections and Serum $25 PCP / $30 Specialist (or 100%






actual cost if less)

MATERNITY SERVICES

Prenatal and Postnatal Visits $25 PCP / $30 Specialist copay for 1st visit only

100%

Delivery in Hospital $200 copay per day, limit $800 per admission

100%

Newborn Care in Hospital 0% for admission at birth 100%

OUTPATIENT SERVICES

Outpatient Surgery (including physician/professional services, facility charges, and all related surgical services)

$300 copay per procedure 100%

Lab & X-rays (performed by a physician’s office, participating laboratory or radiological provider)- Minor non-preventive- Major diagnostic (CT, PET, MRI, Nuclear)

$25 PCP / $30 Specialist

100%

Diagnostic Scopic procedures, Radiation Oncology, IV Chemotherapy, Dialysis, IV Infusion, Diagnostic Mammograms

10% 90%

Rehabilitation Services and Therapy (Physical, Occupational and Speech Therapy only, limited to 60 visits per calendar year for all therapy combined)


100%

INPATIENT HOSPITAL SERVICES

Inpatient Care (semi-private room & board, surgery, physician and professional services, medications, lab & x-ray, anesthesia and therapy)

$200 copay per day, limit $800 per admission

100%

EMERGENCY MEDICAL SERVICES

Emergency Room Services(Copay waived if admitted)

$100 copay 100%

Urgent Care Center $30 copay 100%

Physician Services in Emergency Room $0 100%

Ambulance Services – Emergency $0 100%

SKILLED NURSING, HOME HEALTH & HOSPICE SERVICES

Skilled Nursing Facility(up to 60 days paid by the Plan per calendar year)

10% 90%

Home Health Care(up to 120 days paid by the Plan per calendar year)

10% 90%

Hospice 10% 90%

Custodial Care Not covered






OTHER SERVICES

Durable Medical Equipment 10% 90%

Prosthetic Devices (when medically necessary) 10% 90%

Family Planning Services

- Office visits $25 PCP / $30 Specialist 100%- All other services 10% outpatient 90% outpatient

Infertility Services (up to $20,000 lifetime maximum benefit. Infertility drug therapies are not covered. Refer to the Exclusions and Covered Medical Services and Expenses sections of the Plan booklet.)- Office visits $25 PCP / $30 Specialist 100%

- All other services 10% outpatient 90% outpatient

Chiropractic Care(limited to 20 visits per calendar year)

$30 copay 100%

MAXIMUM OUT-OF-POCKET

(Note that Copays do not apply towards the Maximum Out-of-Pocket)

Per Year - Per Individual $1,750

Per Year - Per Family $3,500

ANNUAL PLAN MAXIMUM $2,000,000 per individual combined for the EPO and PPO Plans

LIFETIME PLAN MAXIMUM Does Not Apply

DEDUCTIBLES Does Not Apply

COINSURANCE (for other services not specified above)

You pay 10%, Plan pays 90%

PREEXISTING CONDITION LIMITATIONS Does Not Apply

MENTAL HEALTH SERVICES MHN National Network

Outpatient Visits(20 visits per calendar year)

Up to 3 EAP visits free, then $25 copay

100%

Inpatient Hospital Days and Day Treatment (30 days inpatient or 60 day treatment days per calendar year)


100%

Chemical Dependency / Substance Abuse (limited to 3 episodes of care per lifetime)

- Outpatient Visits (20 visits per calendar year)


100%

- Inpatient Hospital Days and Day Treatment (30 days inpatient or 60 day treatment days per calendar year)


100%

Serious Mental Illness Covered as any other illness






PHARMACY Express Scripts Nationwide NetworkYou Pay Plan Pays

Retail (30-day supply)

Generic $15 copay 100% after copay

Preferred brand name $25 copay 100% after copay

Non-preferred brand name $50 copay 100% after copay Mail Order (90-day supply)



Non-preferred brand name $100 copay 100% after copay



A Quick Reference Guide ToPPO Medical Plan Benefits

Revised for the Plan Year Beginning January 1, 2011Please note: Deductibles and coinsurance apply to most services. You must satisfy the deductible before coinsurance applies, unless the service is subject to a copay. Only one copay will be required for covered services performed on the same date by the same provider. Keep in mind that this section is only a quick reference summary of benefits of the PPO Plan provided for your convenience. You should rely on the PPO Plan Booklet (Summary Plan Description) for additional details concerning any benefits listed below. Always check the PPO Plan Booklet for notification requirements which may apply.

COVERED SERVICE (must be Medically Necessary)

In-Network(coinsurance is based on Network

Allowable Amounts)

Out-of-Network(coinsurance is based on allowable

amounts*)You Pay Plan Pays You Pay Plan Pays

DEDUCTIBLES

Per Year - Per Individual $250 $500

Per Year - Per Family $500 No limit

COINSURANCE (applies after you meet the Deductible)

You pay 20%, Plan pays 80% You pay 40%, Plan pays 60%

MAXIMUM OUT-OF-POCKET

Per Year - Per Individual $2,750 No limit

Per Year - Per Family $5,500 No limit

ANNUAL PLAN MAXIMUM $2,000,000 per individual combined for the PPO and EPO Plans

LIFETIME PLAN MAXIMUM Not applicable

PREEXISTING CONDITION LIMITATIONS

Not applicable

PHYSICIAN SERVICES

Office Visits

- PCP (Family Practice, General Practice, Internal Medicine, Pediatrics, OB/GYN for well woman care only)

$25 copay 100% 40% 60%

- Specialist $30 copay 100% 40% 60%

Hospital (Inpatient/Outpatient) Professional Fees

20% 80% 40% 60%





Allowable Amounts)



PREVENTIVE SERVICES - subject to health care reform rules for covered preventive services and billing

Adult Health Assessments and Immunizations(age 18 and older)

(Note: If your provider bills an Office Visit separately and in certain other cases, the applicable copay shown

above will apply.)

$0 100% 40% 60%

Well Child Care and Childhood Immunizations(birth through age 17)

$0 100% 40% 60%

Annual Well Woman Examination(1 per year, includes pap smear)

$0 100% 40% 60%

Routine Screening Mammography(1 per year, age 35 and older)

$0 100% 40% 60%

Routine Prostate Screening(1 per year)

$0 100% 40% 60%

Routine Screening Colonoscopy

$0 100% 40% 60%

Routine Speech and Hearing Exam(1 per year in doctor’s office only)

$0 100% 40% 60%

Preventive Minor Lab/X-ray $0 100% 40% 60%

ALLERGY CARE SERVICES

Testing and Evaluations $25 PCP / $30 Specialist

100% 40% 60%

Injections and Serum $25 PCP / $30 Specialist (or actual

cost if less)

100% 40% 60%

MATERNITY SERVICES

Prenatal and Postnatal Visits 20% 80% 40% 60% Delivery in Hospital 20% 80% 40% 60% Newborn Care in Hospital 20% 80% 40% 60%

OUTPATIENT SERVICES

Outpatient Surgery (including all related surgical services)

20% 80% 40% 60%

Diagnostic Lab & X-rays (performed by a physician’s office, laboratory, or radiological provider)

- Minor non-preventive

- Major diagnostic (CT, PET, MRI, Nuclear)


100% 40% 60%





Allowable Amounts)



Diagnostic Scopic procedures, Radiation Oncology, IV Chemotherapy, Dialysis, IV Infusion, Diagnostic Mammograms

20% 80% 40% 60%

Rehabilitation Services and Therapy (Physical, Occupational and Speech Therapy only, limited to 60 visits per calendar year for all therapy combined)


100% 40% 60%

INPATIENT HOSPITAL SERVICES

Inpatient Care (semi-private room & board, medications, surgery, lab & x-ray, anesthesia and therapy)

20% 80% 40% 60%

EMERGENCY MEDICAL SERVICES

Emergency Room Services(Copay waived if admitted)

$100 copay 100% $100 copay 100%

Urgent Care Center $30 copay 100% 40% 60% Physician Services 20% 80% 40% 60% Ambulance Services 20% 80% 40% 60%

SKILLED NURSING, HOME HEALTH & HOSPICE SERVICES

Skilled Nursing Facility (up to 60 days paid by the Plan per calendar year)

20% 80% 40% 60%

Home Health Care(up to 120 days paid by the Plan per calendar year)

20% 80% 40% 60%

Hospice 20% 80% 40% 60%

Custodial Care Not covered Not covered

OTHER SERVICES

Durable Medical Equipment 20% 80% 40% 60%

Prosthetic Devices (when medically necessary)

20% 80% 40% 60%

Family Planning Services

- Office visit $25 PCP / $30 Specialist

100% 40% 60%

- All other services 20% 80% 40% 60%





Allowable Amounts)



Infertility Services (up to $20,000 lifetime maximum benefit. Infertility drug therapies are not covered. Refer to the Exclusions and Covered Medical Services and Expenses sections of the Plan booklet.)- Office visits $25 PCP / $30

Specialist100% 40% 60%

- All other services 20% 80% 40% 60%

Chiropractic Care (limited to 20 visits per calendar year)

$30 copay 100% 40% 60%

MENTAL HEALTH SERVICES MHN National Network

Outpatient Visits (20 visits per calendar year)


100% 50% 50%

Inpatient Hospital Days and Day Treatment (30 days inpatient or 60 day treatment days per calendar year)

20% 80% 40% 60%

Chemical Dependency /Substance Abuse (limited to 3 episodes of care per lifetime)- Outpatient Visits (20 visits per calendar year)


100% 50% 50%

- Inpatient Hospital Days and DayTreatment (30 days inpatient or 60 day treatment days per calendar year)

20% 80% 40% 60%

Serious Mental Illness Covered as any other illness Covered as any other illness

PHARMACY Express Scripts Nationwide Network Out-of-Network

You Pay Plan Pays

Retail (30-day supply)You Pay network copays plus the

difference between the non-network pharmacy’s charge and the network

allowed amount



Non-preferred brand name $50 copay 100% after copay

Mail Order (90-day supply)

Generic $30 copay 100% after copay Not applicable

Preferred brand name $50 copay 100% after copay Not applicable

Non-preferred brand name $100 copay 100% after copay Not applicable



SUMMARY PLAN DESCRIPTION TEXT – Managed Care Plans

The 2011 SPDs have not yet been finalized due to the change to UHC for medical plan administration. The following text regarding mental health and substance abuse benefits is an excerpt from the EPO Plan SPD. The text for the PPO Plan is similar (EAP benefits are the same), but the PPO includes out-of-network benefits as outlined in the Quick Reference Guide.

* * * * *

Mental Health and Substance Abuse TreatmentMHN administers the Plan’s mental health and substance abuse treatment benefits, including the Employee Assistance Program.

The Employee Assistance Program (“EAP”)The EAP offers two types of services to you and your family members: 24-hour phone counseling for assessment and emergencies at no cost to you. Up to three face-to-face counseling sessions per member, per incident, each year at no cost to you.

To reach the EAP, call MHN. Counselors are available 24 hours a day, seven days a week. Please refer to your ID card, check the PEBC website, or check with your Employer’s Human Resources Department for phone numbers.

When you call the EAP, your counselor may recommend face-to-face, short-term counseling as part of your action plan. If you choose to take advantage of the EAP’s counseling services, you pay nothing for up to three sessions.

At any time during the three sessions, you and your counselor may decide that you require more than three sessions or sessions with a counselor outside of the EAP. In some cases, you may continue to work with your EAP counselor (if they participate in the network) when you require more than three sessions.

To receive the free counseling sessions, you must use the EAP’s network of preferred providers.

If you require services beyond the scope of the EAP, your EAP counselor may refer you for other mental health treatment, as described below.

The EAP also has other services available to you and your family members. For more information about the EAP’s other services, refer to your EAP pamphlet or call MHN at the number shown on your ID card.

Please note: while the EAP offers legal counseling services, you may not use this service for employment-related matters.

The care you receive through the EAP is confidential. MHN provides information only to the provider who delivers your treatment. In addition, MHN and your provider will not disclose any information to anyone without explicit written instructions from you, except where required within federal and state guidelines.



Other Outpatient Mental Health Services

To receive benefits for other outpatient mental health treatment, you must have MHN pre-certify all care before you receive it. The MHN network of providers must be used for in-network benefits to apply. It is your responsibility to contact MHN for pre-certification.

When you see an in-network provider, the Plan covers outpatient treatment at 100% after you pay a $25 copay for each visit. For out-of-network providers, the Plan pays 50%, and you pay 50% of eligible covered expenses. The Plan covers up to 20 office visits per calendar year. The 20 visits can include individual treatment, couple visits, or family visits.

Inpatient/Day Treatment Mental Health ServicesTo receive benefits for inpatient or day treatment mental health services, you must contact MHN to pre-certify all care before you receive it. If you fail to have your treatment pre-certified by MHN, no benefits will be paid. You will be responsible for paying all costs incurred for the care you receive.

When you use in-network facilities for treatment pre-certified by MHN, you pay a $200 copay per day, up to $800 maximum. Benefits are limited to 30 inpatient days per calendar year for each covered person OR to 60 days of treatment per calendar year for care and services provided by a psychiatric day treatment facility, crisis stabilization unit, or residential treatment center for children. The Plan covers expenses for a semi-private room. Private room charges are covered only when medically necessary and when MHN has pre-certified these charges.

If you have a mental health or substance abuse-related emergency admission, call MHN within 48 hours of the admission to have the treatment approved. If you are unable to call, have a family member or a facility staff member call MHN for you. If the admission is not medically necessary, the Plan pays no benefits for the treatment.

Substance Abuse/Chemical Dependency TreatmentTo receive benefits for substance abuse or chemical dependency treatment, you must have MHN pre-certify all care before you receive it. If you fail to have your treatment pre-certified by MHN, no benefits will be paid. You will be responsible for paying all costs incurred for the care you receive.

For outpatient substance abuse treatment, the Plan covers 100% of expenses after you pay the $25 copay per visit to an in-network provider. The Plan covers up to 20 office visits per calendar year. For inpatient treatment, the Plan covers expenses for necessary care and treatment for detoxification and/or rehabilitation. You pay a $200 copay per day up to $800 at in-network facilities. Benefits are limited to 30 inpatient days per calendar year for each covered person OR to 60 days of treatment per calendar year for care and services provided by a psychiatric day treatment facility, crisis stabilization unit, or residential treatment center for children.

The Plan limits all substance abuse treatment (inpatient and outpatient combined) to three episodes of care in a covered person’s lifetime.

Serious Mental IllnessesAs required by Texas State law, the Plan covers serious mental illnesses in the same manner as any other illness. This means that the separate mental health care annual and lifetime maximums do not apply to treatment of a



serious mental illness.

Currently, these conditions are defined as “serious mental illnesses” under Texas State law: Schizophrenia; Paranoid and other psychotic disorders; Bipolar disorders (hypomaniac, manic, depressive, and mixed); Major depressive disorders (single episode or recurrent); Schizo-affective disorders (bipolar or depressive); Pervasive developmental disorders; Obsessive-compulsive disorders; and Depression in childhood and adolescence.

Benefits covered under this Plan may change in accordance with any changes made to the Texas State law.

Exclusions and Limitations

The EPO and PPO Medical Plans do not cover:

Health services and care which are not medically necessary.

Charges which exceed the Plan’s maximum benefit amounts.

Expenses for inpatient admissions or alternative treatment (residential care, day treatment, partial day care) not authorized by the Utilization Review Manager or MHN.

Care for which other coverage is required by Federal, State or Local Law to be purchased or provided through other arrangements including Workman’s Compensation, no fault auto insurance or similar legislation.

Services provided for the care or treatment of any work-related injury or illness.

Care for which you are not legally obligated to pay or charges made only because you have coverage under this Plan.

Free services, free supplies, and charges covered by Medicare.

Care or services you receive before Plan coverage begins or after it ends.

Care that the Utilization Review Manager or MHN considers not to be medically necessary or appropriate for your condition.

Care for family members who do not meet the Plan’s “dependent” definition.

Care provided or paid for by federal government or its agencies; except for care provided by:



the United States Veterans Administration, for a veteran with a disability which is not service-connected;

a United States military hospital or facility, for a retiree (or dependent of a retiree) from the armed services;

Care, treatment, services or supplies provided or paid for by any other governmental plan or law not restricted to the government’s civilian employees and their dependents; or

Medicaid.

Care for an illness or injury which results from an act of declared or undeclared war or armed aggression.

Care for an illness or injury incurred while on active duty or training in the Armed Forces, National Guard, or Reserves of any state or country.

Services rendered by a physician or provider with the same legal residence as a covered person or who is a member of a covered person’s family including spouse, brother, sister, parent or child.

Acupuncture treatment (except when used as an anesthetic agent for covered surgery), hypnotherapy, naturopathy, holistic or homeopathic care, aromatherapy, massage therapy and other forms of alternative medicine.

Anti-smoking treatment or treatment for nicotine addiction.

Appetite control, food addiction treatment, or eating disorder treatment (except for documented cases of bulimia or anorexia that present significant symptomatic medical problems) or any treatment of obesity, including surgery for morbid obesity.

Care and treatment of the teeth and gums, except for oral surgery for tumors or jaw bone injuries and the initial stabilization of acute accidental injury to sound natural teeth as described earlier.

Charges for duplication of medical records or completion of forms.

Charges for missed or broken appointments.

Chelation therapies except for acute arsenic, gold, mercury, or lead poisoning.

Convenience, personal, or comfort items or services for you, your family, caretaker, physician, or other medical provider.

Custodial care, respite care, developmental care, convalescent care, or domiciliary care.

Devices used specifically as safety items or to affect performances primarily in sports-related activities; all expenses related to physical conditioning programs such as athletic training, body-building, exercise, fitness, flexibility diversion or general motivation;

Disposable or consumable outpatient supplies.



Durable medical equipment expenses over $500 that are not pre-certified by the Utilization Review Manager.

Education, training (unless specifically allowed in the Plan booklet), or development of skills needed to cope with an injury or sickness. Examples of services that are not covered by the PEBC medical plans include sensory integration, applied behavioral analysis (ABA) therapy, Lovaas therapy and music therapy.

Elective pregnancy termination (treatment for complications of pregnancy termination is covered).

Expenses for any drug, device, procedure or treatment that are experimental, investigative, not proven safe and effective, or not provided in accord with generally accepted professional medical standards. Experimental or investigative expenses are defined as expenses for any drug, device, procedure or treatment that requires FDA approval, but for which such approval has not been granted, or expenses for any drug, device, procedure or treatment which has been conditionally approved by the FDA for limited diagnosis or treatment of conditions other than those for which the member is receiving service, supply or treatment.

Expenses for reports, evaluations, including evaluations for employment, camp, insurance or sports participation, court-ordered testing, or examinations that are not medically necessary and not required for health reasons.

Eyeglasses, contact lenses, and any other items or services for vision correction, subject to other Plan provisions.

Fertility services, other than artificial insemination, for conception by artificial means and donor semen and donor eggs used for such services. Non-covered services include, but are not limited to, invitro-fertilization, ovum and embryo transplants, gamete intrafallopian transfer (“GIFT”), zygote intrafallopian transfer (“ZIFT”) and the cost of donor semen. Infertility drug therapies are not covered.

Health services and associated expenses for cosmetic surgery or procedures including salabrasion, skin abrasion, procedures associated with the removal of tattoos or scars.

Health services or any treatment related to sexual dysfunction, including prescription drugs (such as Viagra) and penile implants.

Hearing aids, batteries, and fitting examinations.

Orthopedic shoes, orthotics, or other supportive devices for the feet.

Physical therapy, occupational therapy, or other rehabilitation services that exceed 60 days of treatment per episode of care on an inpatient basis, or that exceed 60 visits per calendar year on an outpatient basis.



Prescription drug products for outpatient treatment except as described under “Prescription Drug Benefits” and except for infusion therapy and supplies necessary for therapy provided under the Home Health Care benefit.

Prosthetic appliances not listed in the Plan booklet.

Radial keratotomy or other radial keratoplasties.

Reconstructive surgery, except to repair defects which result from surgery while covered under this Plan or for repair of congenital defects or birth abnormalities of newborn children, and except for reconstructive surgery for craniofacial abnormalities for dependent children younger than 18 years old covered under the Plan, when deemed medically necessary.

Remedial education and evaluation, behavior training, and employment, vocational, or marriage counseling, except as may be covered under the EAP or mental health plan benefits.

Routine foot care.

Supplies and equipment not specifically listed in the Plan booklet.

Surrogate parenting, non-medically necessary amniocentesis or ultrasound including procedures solely to determine the gender of a fetus, and reversal of surgical sterilization.

Transportation (except for ground/air transportation as described in the Plan booklet).

Transsexual surgery, sex transformations or any treatment or counseling related to this surgery.

Treatment of adolescent behavior disorders, including conduct disorders and oppositional disorders, except as may be covered under the EAP or mental health plan benefits.

Treatment of mental retardation and mental deficiency.

Third Party Payments/Subrogation and Right of Recovery

The Medical Plan will be subrogated to you or your eligible covered dependent's right of recovery against any person or insurer in connection with injuries sustained by you or your dependent, whether or not the covered injury is the result of an act or omission of a third party. This plan may exercise this right to the extent of the benefits provided under the plan connected to those injuries. The Medical Plan will have a right of reimbursement from the proceeds of any full or partial recovery whether by settlement, judgment, or otherwise for the reimbursement of medical costs paid by the Plan. The plan’s rights of subrogation and reimbursement are not subject to the “made whole” doctrine and repayment must be made to the plan even if you or your eligible dependent have not been fully compensated for any loss. Further, the plan’s rights of subrogation and reimbursement are not subject to the “common fund” doctrine, and repayment to the plan shall be made without reduction for attorney fees. This subrogation and reimbursement provision includes, but is not limited to, any recovery from any individual or group



automobile or liability insurance policy, including any uninsured/underinsured motorist coverage and any personal injury protection coverage you or a covered dependent may have. If the injured person is a minor, any amount recovered by the minor, the minor's trustee, guardian, parent or other representative shall be subject to this provision regardless of whether the minor's representative has access to or control of the recovered funds.

If you or a covered dependent is injured because of another party's act or omission, the plan will pay benefits for the injury only if you and your dependent follow these rules:

You must not take any action which would prejudice the plan's subrogation rights.

You must cooperate in doing what is reasonably necessary to assist the plan in any recovery, including signing any documents requested by the plan and furnishing any information as requested by the plan.

If it becomes necessary for the Medical Plan to enforce its rights of subrogation and/or reimbursement by initiating any action against you or your covered dependent, then you agree to pay the plan’s attorney fees and costs associated with the action.

Right of Recovery

If for some reason a benefit is paid which is larger than the amount allowed by the plan, the plan has a right to recover the excess amount from the person or agency that received it. The person receiving benefits must produce any instruments or papers necessary to ensure this right of recovery, unless prohibited by law.



APPENDIX BMEDICAL PAID CLAIM AND ENROLLMENT EXPERIENCE

Please see the attached Excel file “RFP MHSA Claims Information” for monthly paid claim and enrollment experience which includes the information listed below

Note: The fully-insured HMO Plan was discontinued December 31, 2009, with the HMO population transitioned into the self-funded EPO or PPO Plans effective January 1, 2010.

PEBC Self-funded Medical PlansBy PEBC Employer GroupSelf-funded ClaimsEmployee Census by Month (does not include dependents)For each calendar year 2007, 2008, 2009, 2010, and Q1 2011 and by Class/Month:

Medical Claims by Month Prescription Drugs by Month Mental Health Claims by Month Total By Year

HMO Fully-insured Medical PlansBy PEBC Employer GroupFully-insured Claims (HMO)By Class and in TotalEmployee Census by Month (does not include dependents)For each calendar year 2007, 2008, 2009 and 2010 Run-out and by Class/Month:

Medical Claims by Month (includes mental health claims through Magellan) Prescription Drugs by Month Total By Year

Parker County OnlyParker County joined the PEBC effective January 1, 2010. Claims data is provided in Pre-PEBC and PEBC 2010 format. Before joining the PEBC, the County offered an open-access PPO Plan only with both in-network and out-of-network benefits via the Texas True Choice network. For purposes of this RFP only, assume the plan design was comparable to the PEBC plans.

EAP Summary StatisticsCombined all PEBC Employer GroupsFor each calendar year 2009 and 2010Managed Care Census = sum of EPO/PPO Active Employees (see PEBC Self-funded Medical Plans above)EAP Census 2009 = sum of EPO/PPO Active Employees plus HMO and medical plan OPT-OutsEAP Census 2010 = sum of EPO/PPO Active Employees plus medical plan OPT-Outs

EAP Clinical Cases EAP Employer Services EAP Health and Wellness EAP Life management Services EAP Clinical Face-to-Face Visits Compared to EAP Cases



Managed Care Cases Opened (those exceeding EAP Cases)



APPENDIX CCENSUS

The attached file contains a current PEBC census at April 1, 2011 (Excel format) with the following data elements.

Data Element Format / Comments

Column A - Entity Identifier DC = Dallas County

DN = Denton County

PC = Parker County

TC = Tarrant County

TW = North Texas Tollway Authority

Column B - Class AC = Active Employee

UR = Under-age-65 Retiree

CO = COBRA PQB

Column C - Date of Birth YYYYMMDD

Column D - Gender M = Male

F = Female

Column E - Zip Code 5 digit zip code

Column F - Plan ID – Medical Plan Selection

EPO = EPO Plan (Self-Funded)

PPO = PPO Plan (Self-Funded)

OPT = Opt-Out with Comparable Coverage Through Another Source

Column G - Coverage Tier Level 1 = Single Coverage

2 = Single + Spouse

3 = Single + Child(ren)

4 = Single + Family

Historical Census Information

In addition to the current de-identified census, enclosed are 5 spreadsheets, one for each PEBC Employer Group, providing historical census information for the past 5 years (2007 – 2011). Each spreadsheet is a “snapshot” census providing enrollment counts as of April in the given year. These files begin with the name “App C – Historical Census” and end with the abbreviation for the PEBC Employer Group name using the abbreviations shown in the chart above.



The census information shown is separated using these parameters: By Class (Active, COBRA, Pre-age 65 Retirees) By Plan (HMO, EPO, PPO, OPT) – the HMO was discontinued effective December 31, 2009 By Tier (Tier 1, Tier 2, Tier 3, Tier 4)

Each spreadsheet (one per PEBC Employer Group) contains the following worksheet tabs: Sequence 1 (Active Employees, COBRA participants, Pre-age 65 Retirees) Dependent Counts (does not include the Sequence 1 – but is provided by Tier) TOTAL LIVES: the sum of both tabs = total number of lives/membership

If there are any differences in census between the full de-identified census and the “snapshot” counts provided, they are timing only and can be ignored.



Sample File Layout for Ongoing Transfer of Eligibility Information

FIELD DESCRIPTION2011 PEBC LOCATION

2011 PEBC LENGTH

2011 PEBC BRIDGE 2 STANDARD DESCRIPTION

2011 PEBC BRIDGE 2 STANDARD VALUES

RECORD-TYPE 1-1 1 Literal EMASTER CARRIER CODE 2-5 4 Literal A4 or Spaces

SUB-CARRIER-CODE 6-9 4 Literal “PEB “ or SpacesEMPLOYEE / RETIREE SSN 10-18 9 Employee / Retiree SSN (Sequence 1

SSN)9 digit numeric

Reserved 19-20 2 FILLER 21-25 5 SEQUENCE MODIFIER 26-27 2 If accompanies 03 or greater

sequence codes = Grandchild (GR)Alpha/numeric

SEQUENCE CODE 28-29 2 Indicates Employee/Retiree/COBRA Member, Spouse or Dependent sequence number. Dependent sequence number cannot be re-used once assigned. See Seq Modifier for grandchildren (GR).

01 = Employee; 02 = Spouse; 03-70 = Dependent (seq 03-70 use GR seq mod to indicate grandchild); ESI only - 00 = Employee; 99 = Spouse or Dep; CMS Only: 01=self; 02=spouse; 03=other

FILLER 30-30 1 Spaces SpacesLAST NAME 31-50 20 Last name AlphaFIRST NAME 51-60 10 First name AlphaFILLER 61-65 5 Spaces SpacesMIDDLE INITIAL 66-66 1 Middle initial AlphaADDRESS LINE 1 67-106 40 Employee address Alpha NumericADDRESS LINE 2 107-146 40 Employee Address Alpha NumericCITY 147-161 15 City AlphaSTATE 162-163 2 State Alpha - All caps ZIPCODE 164-172 9 Zip Numeric (truncates at 5 digit) no

spaces, no dashes

Reserved 173 1 Reserved 174-185 12 Reserved 186-193 8 Reserved 194-201 8 Reserved 202-202 1 DATE OF BIRTH 203-210 8 Date of birth Alpha/Numeric - CCYYMMDD

GENDER 211-211 1 Gender Alpha /Numeric: M=Male; F=Female; CMS ONLY: 0=unknown, 1=male; 2=female

BENEFIT EFFECTIVE DATE 212-219 8 Benefit coverage effective date is 1st day of calendar month following eligibility rules. Exception 1: Newborns effective date of birth in year of birth; Exception 2 Adoption (or placed for adoption). This is not the hire date. Also used for benefit effective date following change of status.

Alpha/Numeric CCYYMMDD

BENEFIT END - EXPIRATION DATE

220-227 8 Benefit coverage always ends last day of calendar month. This is not the employment termination date. CMS ONLY: If coverage ongoing - must populate with 99999999


Reserved 228-235 8



COMPANY INDICATOR (1/1/05) 236-236 1 1 = Dallas County 2 = Tarrant County 3 = NTTA 4 = Denton County 5 = Unassigned 6 = Parker County

Alpha Numeric

FILLER 237-242 6 Spaces SpacesSTATUS CODE 243-244 2 AC = Active Employee

UR = Under age 65 Retiree RT = Age 65 + Retiree CO = COBRA Member

Alpha

PLAN ID 245-247 3 Medical Plans -EPO, PPO, OPT; PSS; PSD; PMA; PMD Dental Plans - ANT, PEB Flex Plans - FXM, FXD, ERM, ERD, FXW Life - GLF, TLF, DGL Note - not all plans are available to all groups/classes Vision - VIS

HICN 248-259 12 CMS Only - populate all spaces required

Spaces

FILLER 260-262 3 Spaces SpacesReserved 263-264 2 "01" refers to "dependent or spouse"

coverage Numeric (ESI)

FILLER 265-266 2 ESI REQUIREMENT SpacesFILLER 267-304 38 Spaces SpacesReserved 305-307 3 Reserved 308-327 20 Reserved 328-337 10 Reserved 338-338 1

Reserved 339-345 7 Reserved 346-352 7

FILLER 353-383 31 Spaces SpacesReserved 382-388 7 Reserved 391-399 9

FILLER Spaces SpacesReserved 400-400 1 DEPENDENT SSN 401-409 9 Dependent SSN NumericMH ONLY; GROUP-CODE 410-415 6 Literal or Spaces PPO, EPO=004542; ELSE =004624

MH ONLY; PLAN GROUP 416-418 3 Literal or Spaces EPO = W44 PPO = W45 ELSE = 00X

MH ONLY; SUB GROUP 419-421 3 Literal or Spaces Dallas County:AC=001, RT=801, UR=805, CO=901;Tarrant County:AC=002, RT=802, UR=806, CO=902; NTTA:AC=003, RT=803, UR=807, CO=903; Denton County: AC=004, RT=804; UR=808; CO=904; Frisco: AC=005, RT=809, UR=810, CO=905

MULTIPLE GROUP INDICATOR 422-423 2 TC = Tarrant County DC = Dallas County DN = Denton County

Alpha



TW = North Texas Tollway Authority PC = Parker County

CLERICAL-ERROR 424-424 1 Y or Space - If populated, indicates the record should not have been sent in the first place. Benefit effective date and expiration date will = each other. DO NOT PROCESS AS A TERMINATED RECORD.

Alpha

RETIREE TIER MODIFIER 425-426 2 Identifies correct Retiree premium. See Retiree Modifier chart.

Alpha, Numeric

COBRA-FLAG 427-427 1 Indicates individual is covered as COBRA UDC

“Y” indicates COBRA; Spaces= Not Cobra

HOME-PHONE 428-437 10 Home telephone number (ACTIVE FIELD)

10 digit numeric; area code and number

FILLER 1 1 Spaces SpacesReserved 438-446 9 TIER-LEVEL 448-449 2 Tier 01 = Subscriber (single)

Tier 02 = Subscriber + Spouse Tier 03 = Subscriber + Child(ren) Tier 04 = Subscriber + Family

Numeric; 01, 02, 03, 04

FILLER 450-457 8 Date rate effectiveFILLER 458-462 5 Active, Retiree, COBRAQMCSO-FLAG 463-463 1 Y indicates sequence 3 or higher

Medical Support Order.Alpha

ORIGINAL HIRE DATE (If retiree or COBRA - first coverage date)

464-471 8 CCYYMMDD-the actual hire date of the Employee


Reserved 472-479 8 Reserved 480-491 12 Reserved 492-492 1 MARITAL STATUS 493-493 1 I = Single;

M = Married; U = Unmarried/Unknown

Alpha

Reserved 494-494 1 SPONSORED/SURVIVING SPOUSE/DEPENDENT FLAG

495-495 1 Y or N Alpha

SSN ORIGINAL RETIREE OR EMPLOYEE OF SPONSORED/SURVIVING SPOUSE/DEPENDENT

496-504 9 Must be populated if location 495 populated with Y

Numeric

Reserved 505-513 9 Reserved 514-522 9 EMPLOYMENT TERMINATION DATE

523-530 8 Date employment ends (not date benefits end)


Reserved 531 1 Reserved 532-538 7

FILLER 539-540 2 Spaces Spaces

Reserved 541-547 7

Reserved 548-549 2

Reserved 550-556 7

Filler 557 1 Spaces Spaces

Reserved 558-565 8



Reserved 566-573 8 Reserved 574-581 8 FILE SENT DATE 582-589 8 Date record sent to PEBC Vendor

(Bridge 2 & 4) Alpha/Numeric CCYYMMDD

Reserved 590-597 8

Reserved 598-599 2 TRAILER 600 1 “X”TOTAL 600



APPENDIX DLETTER OF UNDERSTANDING

Between[Vendor] and

[Each Specific PEBC Employer Group]

WHEREAS, this Letter of Understanding (“LOU”) is by and between [Vendor Name “Vendor”] and [PEBC Employer Group “Group”], as a member of the Public Employee Benefits Cooperative of North Texas (“PEBC”); and

WHEREAS, Vendor and the Group (collectively, the “Parties”) have determined to enter into an Administrative Service Agreement (the “Agreement”) effective January 1, 2012 (the “Effective Date”) for the Vendor to provide behavioral health administrative, network management, disease management and utilization review services for the Group’s EPO and PPO Medical Plans (“the Plans”), which are self-funded non-federal governmental plans not subject to the provisions of the Employee Retirement Security Act of 1974 (“ERISA”) as amended; and

WHEREAS, Vendor and the Group have determined to enter into an Agreement for provision of an Employee Assistance Plan (EAP); and

WHEREAS, Vendor and the Group agree and understand that the Agreement will incorporate the Request for Proposal (“RFP”) dated May 11, 2011, Vendor’s response to the RFP (including clarifying information provided as part of the RFP process), and the required provisions set forth under Section 2 of the RFP dated May 11, 2010; and

WHEREAS, the Parties agree and understand that the purpose of this Letter of Understanding (LOU) is to confirm that the services described in the RFP (including the terms and conditions of those services) timely commence; and, further, that the Group shall approve and pay administrative fees as shown below and fund claims in accordance with its internal approval process, until such time the Agreement is finalized and at which time the provisions of the Agreement shall prevail; and

WHEREAS, pursuant to the RFP, until the Agreement is executed, the Parties agree and understand that the RFP and the Vendor’s RFP response will serve as the Parties’ agreement and understanding regarding the terms and conditions of the behavioral health administrative, network management, disease management, and utilization review services for the Group’s self-funded medical plans; and further, shall be binding on the Parties effective January 1, 2012; and

WHEREAS, the Parties agree and understand that this LOU is not intended to capture each of the terms to be included in the final Agreement; and

WHEREAS, pursuant to the terms of the RFP, the Parties agree and understand that this LOU is not intended by the Parties, nor does it, change the services, or the terms or conditions of those services as set



forth in the RFP, the Vendor’s response to the RFP (including other clarifying information provided as part of the RFP process); and

WHEREAS, the Group appoints the Public Employee Benefits Cooperative of North Texas (“PEBC”) as Plan Administrator, to serve as an agent of Group and authorized to act on behalf of Group in all aspects of plan administration, including eligibility reporting, data management and transfer, billing, plan design, plan management and operations, performance and savings guarantees, HIPAA privacy and security matters, and other matters as required, except that the PEBC does not serve as a fiduciary of Group; and

WHEREAS, Exhibit A – Business Associate Addendum To Letter of Understanding is made a part of this LOU and incorporated herein, ensuring compliance with the provisions of HIPAA, and allowing Vendor to release Protected Health Information (“PHI”) to the PEBC per the terms of the Business Associate Addendum; and

WHEREAS, the Parties agree and understand that subsequent to this LOU being executed, the Parties will continue in good faith to expedite, and to take such steps as necessary to enter into a signed Agreement; NOW, THEREFORE, it is agreed that:

The Parties agree to the provisions described herein. Once the Agreement is negotiated and signed, all duties required in this LOU terminate.

Mental Health/Substance Abuse Managed Care Administrative fees effective January 1, 2012 are:

EAP premium effective January 1, 2012 is:

The Parties agree to enter into this LOU as set forth herein, effective as of January 1, 2012.

The undersigned parties hereto have caused this Letter of Understanding to be executed in multiple originals by their duly authorized officers, to be effective January 1, 2012.

Group Vendor

Authorized Signature Authorized Signature

Print Name: Print Name:

Print Title: Print Title:



Date: Date:



APPENDIX EBUSINESS ASSOCIATE AGREEMENT

I. Definitions

(a) Business Associate. “Business Associate” shall mean [Vendor].

(b) Plan Sponsor. “Plan Sponsor” shall mean the [PEBC Employer Group]. (c) Individual. “Individual” shall have the same meaning as the term “individual” in 45 CFR 164.501 and

shall include a person who qualifies as a personal representative in accordance with 45 CFR 164.502(g).

(d) Privacy and Security Rules. “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E. “Security Rule” shall mean the Security Standards for the Protection of Electronic Protected Health Information at 45 CFR part 64, subpart C.

(e) Protected Health Information. “Protected Health Information”, or “PHI” shall have the same meaning as the term ``protected health information'' in 45 CFR 160.103, limited to the information created or received by the Business Associate from or on behalf of the Plan.

(f) Required By Law. “Required By Law” shall have the same meaning as the term “required by law” in 45 CFR 164.501.

(g) Secretary. “Secretary” shall mean the Secretary of the Department of Health and Human Services or his designee.

(h) Plan. “Plan” shall mean the applicable component of the [PEBC Employer Group] Self-funded Medical Plans for which [Vendor] provides administrative services, which is/are a Covered Entity(ies) subject to the Privacy and Security Rules, and the Breach Notification Rules.

(i) PEBC. “PEBC” shall mean the Public Employees Benefits Cooperative of North Texas, which acts as an agent of the Plan Sponsor as administrator of the Plan.

(j) Security Incident. “Security Incident” means the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system, as defined in §164.304 of the Security Rule.

(k) Administrative Safeguards. “Administrative Safeguards” are administrative actions, and policies and procedures, to manage the selection, development, implementation, and maintenance of security measures to protect electronic protected health information and to manage the conduct of the covered entity’s workforce in relation to the protection of that information.



(l) Physical Safeguards. “Physical Safeguards” are physical measures, policies, and procedures to protect a covered entity’s electronic information systems and related buildings and equipment, from nature and environmental hazards, and unauthorized intrusion.

(m) Technical Safeguards. “Technical Safeguards” means the technology and the policy and procedures for its use that protect electronic protected health information and control access to it.

(n) Electronic Protected Health Information. “Electronic Protected Health Information” is protected health information that is (i) transmitted by electronic media; or (ii) maintained in electronic media.

(o) Breach Notification Rules. “Breach Notification Rules” shall mean the Standards for Notification in the Case of Breach of Unsecured Protected Health Information at 45 CFR part 164 subpart D.

II. Obligations and Activities of Business Associate

(a) Business Associate agrees to not use or disclose Protected Health Information other than as permitted or required by this BA Agreement, the Administrative Services Agreement (the Agreement) or as Required By Law.

(b) Business Associate acknowledges that it is obligated to comply with the standards set forth in §§164.502(e) and 164.504(e) of the Privacy Rule in the same manner that such sections apply to the Plan. Business Associate further acknowledges that §§164.308, 164.310, 164.312, and 164.316 of the Security Rule apply to the Business Associate in the same manner that such sections apply to the Plan.

(c) Business Associate hereby represents that any Protected Health Information it shall seek from the Plan shall be the minimum necessary, as set forth in the Privacy Rule, for the Business Associate’s stated purposes in its agreements with the Plan Sponsor and acknowledges that the Plan shall rely upon such representation with respect to any request by the Business Associate for PHI.

(d) With respect to the use, disclosure, or request of Protected Health Information, Business Associate shall limit such PHI, to the extent practicable, to the limited data set as defined in 45 CFR §164.514(e)(2), or if needed, to the minimum necessary to accomplish the intended purpose of such use, disclosure, or request, respectively.

(e) Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Agreement. Business Associate further agrees to implement appropriate administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of Electronic Protected Health Information that it creates, receives, maintains, or transmits on behalf of Plan Sponsor. Such safeguards are to be consistent with the safeguards described in the Security Rule at §§164.308 through 164.312.



(f) Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the requirements of this BA Agreement.

(g) Business Associate agrees to report to the Plan Sponsor and the PEBC, on behalf of the Plan, any use or disclosure of Protected Health Information not provided for by this BA Agreement of which it becomes aware. Business Associate agrees to report to the Plan Sponsor and the PEBC, on behalf of the Plan Sponsor, any Security Incident of which it becomes aware, except that for the purposes of this Agreement a Security Incident shall not include any “scans” or “pings” that are stopped by the Business Associate’s firewall. Business Associate shall notify the Plan Sponsor and the PEBC:

(1) Promptly and without unreasonable delay upon the Business Associate’s becoming aware of any use or disclosure of the Plan’s PHI or ePHI, not provided for by this Agreement or otherwise required by law, or

(2) Promptly and without unreasonable delay, but in no event more than forty-eight (48) hours of confirming any Security Incident involving the Plan’s ePHI.

(h) Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides Protected Health Information received from, or created or received by Business Associate on behalf of the Plan, agrees to the same restrictions and conditions that apply through this BA Agreement to Business Associate with respect to such information. Business Associate shall further ensure that any such agent or subcontractor to whom Business Associate provides any such ePHI agrees in writing to implement reasonable and appropriate safeguards to protect such information; such safeguards are to be consistent with the safeguards described in the Security Rules at §§164.304 through 164.316.

(i) Business Associate agrees to provide access, at the request of the Plan, and in a timely manner, to Protected Health Information in a Designated Record Set, including access to and transmission of PHI that is used or maintained as an electronic health record, to the Plan; to a representative of the Plan, including the PEBC or the Plan Sponsor, as directed by the Plan; or to an Individual in order to meet the requirements under 45 CFR 164.524, as amended.

(j) Business Associate agrees to make any amendment(s) to Protected Health Information in a Designated Record Set that the Plan directs or agrees to pursuant to 45 CFR 164.526, as amended, at the request of the Plan or an Individual, and in a timely manner.

(k) Business Associate agrees to restrict disclosures of PHI, at the request of the Plan or an individual, and in a manner designated by the Plan, in a timely manner, in accordance with §164.522 of the Privacy Rule, as amended, when the Plan or the individual notifies the Business Associate of the request.

(l) Business Associate agrees to make internal practices, books, and records, including policies and procedures, documentation of safeguards, and Protected Health Information, relating to the use and disclosure of Protected Health Information received from, or created or received by Business



Associate on behalf of, the Plan available to the Plan, or to the Plan’s designated representative, including the PEBC, or to the Secretary, in a timely manner or as otherwise designated by the Secretary, for purposes of the Secretary determining the Plan’s compliance with the Privacy and Security Rules.

(m) Business Associate agrees to document such disclosures of Protected Health Information and information related to such disclosures as would be required for the Plan to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528, as amended.

(n) Business Associate agrees to provide to Plan, or its representative as directed by the Plan, including the PEBC, or an Individual, in a timely manner, information collected in accordance with Section II.m. of this BA Agreement during the six (6) years preceding the date of the request, or three (3) years with respect to a request for an accounting of payment, treatment or health care operations (except for disclosures occurring before the effective date of this Agreement), to permit the Plan to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528, as amended, including with respect to an accounting of disclosures through an electronic health record.

(o) Following the discovery of a Breach of unsecured PHI, Business Associate shall notify the Plan and the PEBC of such Breach. The term “Breach” has the meaning set forth in 45 CFR §164.402.

(1) A Breach shall be treated as discovered by the Business Associate as of the first day on which such Breach is known to the Business Associate or, by exercising reasonable diligence, would have been known to Business Associate. Business Associate shall be deemed to have knowledge of a Breach if the Breach is known, or by exercising reasonable diligence would have been known, to any person, other than the person committing the Breach, who is an employee, officer, or other agent of Business Associate.

(2) Except as otherwise provided for in the Breach Notification Rules, Business Associate shall provide the notification to the Plan and the PEBC promptly and without unreasonable delay; provided, however, that in no case shall the notification be made later than ten (10) calendar days after the discovery of a Breach. The notification shall include, to the extent possible, the following information:

(i) identification of each individual whose unsecured PHI has been, or is reasonably believed by Business Associate to have been, accessed, acquired, used or disclosed during the Breach;

(ii) the date of discovery of the Breach;

(iii) description of the information Breached;

(iv) any steps the individuals should take to protect themselves;

(v) the steps Business Associate (or its agent) is taking to investigate the Breach, mitigate



losses, and protect against future Breaches; and

(vi) a contact person and telephone number for more information.

(3) At the same time that Business Associate notifies the Plan and the PEBC of the Breach, or as promptly thereafter as information becomes available to Business Associate, Business Associate shall provide the Plan with any other available information that the Plan is required to include in its notification to the individual.

(4) If requested by the Plan or the PEBC, Business Associate shall, in accordance with §164.404 of the Breach Notification Rules, notify the individuals whose PHI was involved in the Breach, or shall reimburse the Plan for any costs associated with the Plan making such notifications.

(p) Business Associate shall not receive, directly or indirectly, any remuneration in exchange for any PHI of an individual, unless Business Associate has obtained from the individual, in accordance with §164.508 of the Privacy Rule, a valid authorization that includes a specification that the PHI can be further exchanged for remuneration by the entity receiving the PHI of that individual.

III. Permitted Uses and Disclosures by Business Associate

A. General Use and Disclosure Provisions

Except as otherwise limited in this BA Agreement, Business Associate may use or disclose Protected Health Information to perform functions, activities, or services for, or on behalf of, the Plan as specified in the Agreement with the Plan Sponsor, provided that such use or disclosure would not violate the Privacy and Security Rules if done by the Plan or the minimum necessary policies and procedures of the Plan.

B. Specific Use and Disclosure Provisions

(a) Except as otherwise limited in this BA Agreement, Business Associate may use Protected Health Information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate.

(b) Except as otherwise limited in this BA Agreement, Business Associate may disclose Protected Health Information for the proper management and administration of the Business Associate, provided that such disclosures are Required By Law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required By Law or for the purpose for which it was disclosed to the person, and the person notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

(c) Except as otherwise limited in this BA Agreement, Business Associate may use Protected Health Information to provide Data Aggregation services relating to the health care operations of the Plan as permitted by 45 CFR 164.504(e)(2)(i)(B).



(d) Business Associate may use Protected Health Information to report violations of law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1).

IV. Obligations of Plan and Plan Sponsor

(a) Plan Sponsor, on behalf of the Plan, shall notify Business Associate of any limitation(s) in its notice of privacy practices of the Plan in accordance with 45 CFR 164.520, to the extent that such limitation may affect Business Associate's use or disclosure of Protected Health Information. The Plan may meet this obligation by providing Business Associate with a copy of the Notice of Privacy Practices which the Plan produces in accordance with the Privacy Rule.

(b) Plan Sponsor, on behalf of the Plan, shall notify Business Associate of any changes in, or revocation of, permission by Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate's use or disclosure of Protected Health Information.

(c) Plan Sponsor, on behalf of the Plan, shall notify Business Associate of any restriction to the use or disclosure of Protected Health Information that the Plan has agreed to in accordance with 45 CFR 164.522, to the extent that such restriction may affect Business Associate's use or disclosure of Protected Health Information.

V. Permissible Requests by the Plan

The Plan shall not request Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy and Security Rules if done by the Plan, except that Business Associate may use and disclose protected health information for data aggregation and management and administrative activities of Business Associate as provided herein.

VI. Term and Termination

(a) Term. The Term of this BA Agreement shall be effective as of June 30, 2011, and shall terminate upon the later of (1) the termination of the Agreement; or (2) when all of the Protected Health Information provided by the Plan or Plan Sponsor to Business Associate, or created or received by Business Associate on behalf of the Plan, is destroyed or returned to the Plan or its representative, or, if it is infeasible to return or destroy Protected Health Information, protections are extended to such information, in accordance with the termination provisions in this Section.

(b) Termination for Cause. Upon the Plan’s or Plan Sponsor's knowledge of a material breach by Business Associate, the Plan Sponsor, on behalf of the Plan, shall either:

(1) Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this BA Agreement and the Agreement if Business Associate does not cure the breach or end the violation within the time specified by Plan Sponsor;

(2) Immediately terminate this BA Agreement and the Agreement if Business Associate has breached a material term of this BA Agreement and cure is not possible; or



(3) If neither termination nor cure is feasible, Plan Sponsor, on behalf of the Plan, shall report the violation to the Secretary.

(c) Business Associate shall have the same obligations as the Plan, as provided for in Section VI (b) above, with respect to a material breach by the Plan.

(d) Effect of Termination.

(1) Except as provided in paragraph (2) of this section, upon termination of this BA Agreement or the Agreement, for any reason, Business Associate shall return to the Plan or its designated representative or destroy all Protected Health Information received from the Plan or the Plan Sponsor, or created or received by Business Associate on behalf of the Plan. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of Business Associate. Business Associate shall retain no copies of the Protected Health Information.

(2) In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible, Business Associate shall provide to the Plan notification of the conditions that make return or destruction infeasible. Business Associate shall extend the protections of this BA Agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Business Associate maintains such Protected Health Information.

VII. Miscellaneous

(a) Regulatory References. A reference in this BA Agreement to a section in the Privacy and Security Rules, or to the Breach Notification Rules, means the section as in effect or as amended.

(b) Amendment. The Parties agree to take such action as is necessary to amend this BA Agreement from time to time as is necessary for the Plan to comply with the requirements of the Privacy and Security Rules under the the Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, as amended, and the Health Information Technology for Economic and Clinical Health Act, part of the American Recovery and Reinvestment Act of 2009 (Pub. L. 111-5).

(c) Survival. The respective rights and obligations of Business Associate under Section VI.(d) of this BA Agreement shall survive the termination of this BA Agreement.

(d) Interpretation. Any ambiguity in this BA Agreement shall be resolved to permit the Plan to comply with the Privacy and Security Rules, and the Breach Notification Rules. The terms and conditions of this BA Agreement shall override and control any conflicting terms and conditions in any agreement between parties related to the Privacy and Security of PHI or ePHI.



(e) Relationship of the Parties. The relationship between the Plan and Business Associate is that of independent contracting entities. Neither party is the agent or representative of the other, nor shall either party be liable for the acts or omissions of the other, its agents, or its employees.


Documents

VENDOR NAME: - North Central Texas Council of … · Web view2.2.6 Insurance Requirements - At all times during the term of this Contract, the vendor shall procure, pay for and maintain,