P-364 ATTACHMENT 2

MEDICAL MINIMUM REQUIREMENTS

ALL VENDORS MUST COMPLETE THIS SECTION.

The following are proposal specifications. Please complete the following chart by responding in the right-hand column. If you disagree with any of the criteria, you may not be considered. If the criteria do not apply to the services you are quoting, please indicate “N/A.”

ENTER VENDOR NAME:

1. You must be able to provide a fully integrated medical and prescription drug solution along with a comprehensive network, utilization/cost management services and wellness tools/resources.

Agree Disagree

2. You have reviewed and accept the Plan’s eligibility provisions outlined in the RFP.

Agree Disagree

3. You must be licensed in New Mexico or willing to obtain a license in New Mexico.

Agree Disagree

4. Self-funded Quotes: ASO fees must be guaranteed for a minimum of two (2) years from the effective date. A third year rate guarantee is preferred. Fees must be the same for Years 1 and 2.

Agree Disagree

5. Fully Insured Quotes: Medical rates must be guaranteed for 1 year.

Agree Disagree

6. The rates/fees/premiums should be calculated NET of commissions.

Agree Disagree

7. Renewal rates and fees must be submitted 120 days prior to the contract renewal date.

Agree Disagree

8. You have included detailed plan summaries for all quoted plans.

Agree Disagree

9. You currently have a provider network in Albuquerque, NM. Agree Disagree

10. You completed the network analysis sections (Attachments 6 Hospital Discount Data, 7 Medical Professional Discount Data and 8 Medical Provider Disruption Data) in their entirety, in the format requested.

Agree Disagree

11. The vendor will be responsible for producing the Booklet/Certificate of Coverage / Summary Plan Description/Summary of Benefits and Coverage. The client

Agree Disagree

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P-364 ATTACHMENT 2

MEDICAL MINIMUM REQUIREMENTSreserves the right to review/revise the Booklet/COC/SPD/SBC prior to finalization.

12. Vendor agrees to provide a booklet draft within 60 days of the effective date.

Agree Disagree

13. Vendors may be required to attend open enrollment meetings.

Agree Disagree

14. Vendor agrees to provide all standard reports to the client. Agree Disagree

15. The client must be able to access reports online. Agree Disagree

16. Insured coverage must be provided on a no-loss/no-gain basis for all covered participants so the current group does not suffer a loss of benefit solely due to the transfer of coverages to your firm.

Agree Disagree

17. You must agree to waive the “actively at work” provision for the currently enrolled. The master contract will reflect the elimination of the actively at work restriction or deferred effective date for all initially enrolled active or inactive employees and dependents. This will include only initial eligibles (those eligible on the effective date of the contract) including COBRA continuees.

Agree Disagree

18. You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security requirements.

Agree Disagree

19. With regard to the Patient Protection and Affordable Care Act (PPACA) please confirm your understanding and agreement with the following:

Agree Disagree

Vendors must agree to be in compliance with, and able to administer, PPACA’s required administration processes and reporting requirements (e.g., nondiscrimination testing, etc.), as outlined in the law.

Agree Disagree

Vendors must agree to be in compliance with, and able to administer, PPACA’s claims appeal process (both internal and external) and must be willing to take the steps necessary to ensure that the client/plan is in full compliance. This includes your agreement to contract with at least three (3) URAC-accredited IROs (Independent Review Organizations).

Agree Disagree

20. Your contract must require no more than a 30-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off

Agree Disagree

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P-364 ATTACHMENT 2

MEDICAL MINIMUM REQUIREMENTSanniversary.

21. Vendor agrees to provide performance guarantees. Provide details within your proposal.

Agree Disagree

22. You have specifically listed all deviations from the RFP and coverage requirements on Attachment 11, Deviations from RFP Terms and Conditions and Coverage Requirements. NOTE: Deviations MUST be listed; you cannot simply make a “general” reference to section(s) of the proposal.

Agree Disagree

23. You completed all questionnaires and exhibits in full and in the format requested (e.g., Word or Excel – not PDF).

Agree Disagree

24. Insurance premium tax does not apply to public entity employers including, but not limited to, cities, counties, school districts, etc.  If selected, premium tax will not be charged.

Agree Disagree

25. If your medical proposal includes both a SOLE carrier and SLICE carrier quote, you have indicated any costs differences on Attachments 4A and 4B.

Agree Disagree

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P-364 ATTACHMENT 2

GENERAL QUESTIONNAIRE

ALL VENDORS MUST COMPLETE THIS SECTION.

ENTER VENDOR NAME:

Firm / Organization Questions1. Do you carry an Errors & Omissions policy? Yes No

2. Do you carry a comprehensive general liability policy?

Yes No

3. Does your company carry a fidelity bond? Yes No

4. Will you agree to offer a Performance Guarantee with financial penalties?

Yes No

If yes, include your proposed performance guarantee in your proposal, including the total amount you are willing to put at risk.

5. Please provide the following information. (New Mexico public sector employers or higher education organizations are preferred.)

Three (3) current client references At least one of these references should be from a

client of similar size. Provide - Client Name Contact Contact’s email address Address Telephone number Type of coverage (e.g., medical, life) Approximate # of employees covered by

each contract

6. Please provide the following information. (New Mexico public sector employers or higher education organizations are preferred.)

Two (2) former clients, who may be contacted. Provide -

Client Name Contact Contact’s email address Address Telephone number Type of coverage (e.g., medical, life) Approximate # of employees covered by

each contract Reason for termination

Implementation, Enrollment, Eligibility and Maintenance Questions

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P-364 ATTACHMENT 2

GENERAL QUESTIONNAIRE7. What is the normal lead-time required to implement a

group?

8. What mediums do you accept for plan enrollment?

9. Do you offer online eligibility maintenance for all clients?

Yes No

If so, is there a charge? Is there a charge for hard copy maintenance?

10. Finalists will be required to provide a formal and detailed implementation plan.

Agree Disagree

General Administration Questions11. For insured coverages: for the first and each renewal

year, what periods of time will be used as the basis for determining renewal recommendations?

12. When are premiums/fees due under your policy?

What is the grace period? If premium is paid after the grace period, is a

penalty and/or interest charge assessed? Yes No

If yes, explain in detail.Customer Service / Satisfaction Questions13. Do you complete customer service surveys? Yes No

How frequently do you conduct satisfaction surveys?

What percentage of participants is surveyed? What is your performance standard for patient

satisfaction survey results?14. Will you provide a foreign language interpreter service for

participants as needed? Yes No

Are there any charges associated with this service? If so, specify.

15. Describe your company’s client management team structure.

16. Describe how your company handles client management responsibilities and transition when a member of the team:

Goes out on extended leave (more than 2 weeks)

Leaves the company17. Provide a brief bio detailing the experience and

background of each individual that would be assigned to the CNM account.

18. Provide the office location (city) that each member of the account management team works from.

19. Does your company have a local office in the

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P-364 ATTACHMENT 2

GENERAL QUESTIONNAIREAlbuquerque area?

If not, what is the closest office?20. How many onsite meetings does the account team

commit to attending throughout the year for: Implementation Ongoing account management and reporting Open enrollment Health and Wellness Fair

21. Will CNM be assigned a dedicated representative? How many other accounts will this individual

service? What amount of time will the representative’s

time will be available to service the CNM account?

Technology Questions22. Which of the following tasks can members and plan

sponsor representatives perform online? You may indicate N/A if not applicable to the line of coverage you are quoting.

Members Plan Sponsors Enrollment (New Hires and Open Enrollment) Changes in Status Billing (Plan Administrators only) N/A Claim inquiry Provider search Access provider directories Physician/provider cost and quality comparison ID card request Electronic EOB Terminations Other

23. Is there an additional cost for online services? Yes No

If yes, describe.24. What percentage of claims is auto-adjudicated

through your system?25. BRIEFLY describe the services you offer to support

the client’s human resources / benefits team.Reporting Questions26. Are you able to provide data that benchmarks the

client’s experience against the following : Your book of business Yes No National norms Yes No Similar sized municipalities Yes NoPlease provide cost to provide benchmark reports, if any.

27. Provide a list of all standard and optional reports available and associated costs (if any). Please provide sample reports.Report Frequency Additional Cost? If

so, indicate amount.Standard?Optional?

Comments

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P-364 ATTACHMENT 2

GENERAL QUESTIONNAIRE

28. What is the lag time on reports from your firm?

29. Does the client/consultant have the ability to access your database in real time for purposes of:

Tracking plan experience Yes No Utilization patterns Yes No Other available plan information Yes No

How is this ability provided? Is there an additional charge to the client? Yes No

If so, what is the charge?

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P-364 ATTACHMENT 2

MEDICAL QUESTIONNAIRE ENTER VENDOR NAME:

1. Concisely identify and comment on any major claim, eligibility, and / or reporting system changes or upgrades planned in the next 12 to 24 months, along with the intended outcome.

2. If you quoted fully insured rates, do the rates include any amount for the PPACA Insurer fee? Yes No

If yes, provide the amount that is included in the rate. Express as a percentage or as a dollar amount PMPM.

3. Do your fully insured rates or ASO fees include any amount for the PPACA Transitional Reinsurance fee? Yes No

If yes, provide the amount that is included in the rate or fee. Express as a percentage or as a dollar amount PMPM.

4. Do your fully insured rates include any amount for the PPACA Comparative Effectiveness Research fee? Yes No

If yes, provide the amount that is included in the rate or fee. Express as a percentage or as a dollar amount PMPM.

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P-364 ATTACHMENT 2

SELF-FUNDED PLANS – ASO/TPA CLAIMS ADMINISTRATION QUESTIONS

ENTER VENDOR NAME:

1. Will you agree to offer services on a co-exist (slice) basis? Yes No

2. Do ASO fees paid while the contract is active cover the cost of run-out administration, or are additional fees due during run-out administration?

____ Covered by fees paid when contract is active

____ Additional fees are due during run-out administration

3. If additional fees are due during run-out administration, precisely identify how run out fees will be calculated, and for what time period fees will be charged.

4. How long after contract termination will you perform claim run-out administration?

Will you administer run-out longer than your standard time, if requested by the client?

Yes No

6. At termination, after the run-out period, how will you handle the following claims incurred prior to termination date:

Claims in house before end of run-out period, but not processed?

Claims submitted after the run-out period?

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P-364 ATTACHMENT 2

FULLY INSURED MEDICAL PLAN QUESTIONNAIRE

ENTER VENDOR NAME:

1. Will you agree to offer coverage on a co-exist (slice) basis? Yes No

2. Which of the following arrangements did you quote? Pooled

Experience rated / participating

Experience rated / non-participating

3. What pooling point are you quoting?

4. For the first renewal, and each subsequent renewal, what periods of experience will be used as the basis for calculating the renewal?

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P-364 ATTACHMENT 2

PROVIDER NETWORK QUESTIONS ENTER VENDOR NAME:

1. Does your network plan require a referral from the PCP to a specialist?

Yes No

2. Do your contract directly with the providers in your network? Yes No

3. Do you use a “leased” provider network in New Mexico? Yes No

4. Does your proposal include E-Visit, or Telehealth services? Yes No

5. Are you participating in the CMS Comprehensive Primary Care program? If yes, please answer the following:

Yes No

What is your timeframe for deployment?

What are the PMPM care coordination payments, and how are they calculated?

What are the Shared Savings payments, and how will they be calculated?

What reports will be provided to the client and consultant to substantiate the calculation of Care Coordination and Shared Savings fees and bonuses? When, and how frequently, will such reports be provided?

How will a self-funded client’s share of costs for any shared savings bonuses be calculated?

What mechanism will be used for self-funded clients pay for the program?

Separate bill? Claim charge? Other? (describe):

When will Shared Savings charges be assessed to the client?

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P-364 ATTACHMENT 2

PROVIDER NETWORK QUESTIONS

6. Do you offer a separate “high value” provider network, similar to but separate from the Comprehensive Patient Care program sponsored by CMS? If yes, please answer the following?

Yes No

Is participation optional for the client?

Are there quality / cost of care measurements that participating providers must meet?

What is your timeframe for deployment?

What are the PMPM care coordination payments, and how are they calculated?

What are the Shared Savings payments, and how will they be calculated?

What reports will be provided to the client and consultant to substantiate the calculation of Care Coordination and Shared Savings fees and bonuses? When, and how frequently, will such reports be provided?

What discounts will be applied to the stop loss rates you quote, for participating in the program?

Are provider bonuses calculated on the performance of the individual group, or are they based on a “pooled” book of business?

Identify performance metrics used to measure provider success.

7. How are physicians who are part of your “high value” network reimbursed?

Check ALL that apply:SalaryPer CapitaDiscounted fee for serviceOther (Describe)

8. Do you currently offer Patient Centered Medical Homes? Yes No

If no, are you developing one, and when will it be offered to clients?

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P-364 ATTACHMENT 2

WELLNESS PROGRAMS QUESTIONNAIRE

ENTER VENDOR NAME:

1. List any accreditations or certifications that your wellness program currently has available.

2. If your program offers biometric screening, are you able to aggregate data and provide consolidated reports to clients that include results of tests administered by both your firm and any outside contractors hired by your firm?

Yes No

3. Is any onsite biometric screening done by an outside vendor?

If yes, please identify.

Yes No

4. Please indicate if the wellness services you are quoting include the following (check all that apply).

Health Coaching (telephonic and/or online) Yes No

Customized health risk assessment Yes No

Premium web content and tools Yes No

Advanced communications materials Yes No

Discounted gym memberships Yes No

Outbound calling to top 5% of high risk population

Yes No

Comprehensive reporting, including incentive reporting

Yes No

Comprehensive promotion and communications materials and campaign support

Yes No

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P-364 ATTACHMENT 2

WELLNESS PROGRAMS QUESTIONNAIRE

5. Please indicate if your Biometric Screening services include the following (check all that apply).

Onsite screening events Yes No

Includes clinical and educational staff Yes No

Includes all travel considerations Yes No

Educational materials and resources Yes No

Includes all reports and data Yes No

Integrates with Coaching and HRA Yes No

Measures taken include Cholesterol, Blood Glucose, Blood Pressure, Body Fat and Tobacco Use

Yes No

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P-364 ATTACHMENT 2

DISEASE MANAGEMENT QUESTIONNAIRE

MEDICAL VENDORS MUST COMPLETE THIS QUESTIONNAIRE

ENTER VENDOR NAME:

1. Are your services local, national or international? (Check [X] only ONE.)

Local onlyNational, some statesNational, all statesNational, all states + international

▪ From what location(s) are services provided?

2. Does your DM program have an accreditation separate from your provider network?

Yes No

▪ If yes, check all that apply Expiration DateURAC ____________NCQA ____________Other ____________

3. Are the following reports available at no additional cost to the client? If so, indicate frequency next to your response.

▪ Cost savings reports Yes NoFrequency:________________________

▪ Utilization reports Yes NoFrequency:________________________

4. Provide three (3), DM service references.

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P-364 ATTACHMENT 2

DISEASE MANAGEMENT QUESTIONNAIRE

5. Do you proactively contact potential DM candidates without waiting for them to contact you?

Yes No

▪ If so, how? (check ALL that apply) TelephoneEmailLetter

Text

6. What DM interventions does your organization propose to provide? (Check [X] ALL that apply)

Written communicationsGroup educationOne-on-one interventionsTelephone monitoringClinical interventionsOther proposed interventions (describe)

7. Is your DM program developed internally, or provided through an outside vendor?

Internally Outside Vendor Both

▪ If an outside vendor, indicate the name(s) and location(s) of the firm(s), and indicate the length of time this relationship has been in place.

8. Is the use of any in-state, or out-of-state Centers of Excellence required by your plans?

Yes No

▪ If yes, provide details on the providers and locations.

9. What is the frequency of your program reports? MonthlyQuarterlySemi-annuallyAnnuallyOther _________________

10. To what degree can you customize reporting?

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P-364 ATTACHMENT 2

DISEASE MANAGEMENT QUESTIONNAIRE

11. How do you report a Return on Investment?

12. It is desired to establish ROI guarantees relative to disease management performance, whereby demonstrable savings will be measured and compared to a minimum threshold. Please respond to the following items:

▪ Confirm your ability and willingness to enter into a ROI guarantee. This metric would be expected to be measured / assessed annually.

Agree Disagree

▪ Indicate the level of savings that you will be willing to guarantee, in the form of a ratio of savings (ROI) to disease management fees.

▪ Provide a brief description of the methodology that you will use in the measurement of savings, along with an external validation of that methodology.

13. Are you willing to provide detailed data reports to the client’s consultant to perform an independent ROI analysis?

Agree Disagree

14. Can you provide a case study that demonstrates your DM program’s ROI?

Agree Disagree

15. Have the empirical results of your DM program been published in any publication?

Yes No

▪ If yes, what publication and date?

16. Has your DM program been audited by any outside firm for effectiveness?

Yes No

▪ If yes, by whom and what date?

17. Number of your DM programs currently in effect?

▪ Nationally

▪ New Mexico

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P-364 ATTACHMENT 2

DISEASE MANAGEMENT QUESTIONNAIRE

18. Would you agree to integrate your DM program with the client’s PBM?

Yes No

Are there additional costs for this? (all costs must be reflected on the Medical Cost Exhibits 3B).

19. Briefly describe how your DM process can help support and/or be integrated with Value Based benefits.

20. What Value Based benefits do your currently support?

21. Briefly describe how you identify DM candidates, including all standard and optional data points.

22. Explain the DM identification process for Diabetes.

23. Explain the DM identification process for Cardiac.

24. Explain the DM identification process for Respiratory.

25. List all DM programs you currently administer.

26. What DM programs do you anticipate supporting?

27. Briefly describe what type of DM program you have for Depression.

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