Medical Benefits Management Services

Lorain County Community College 1005 N. Abbe Road Elyria, Ohio 44035 REQUEST FOR PROPOSALS Medical TPA Services Stop Loss Reinsurance Pharmacy Benefits Manager 2 (Page Intentionally Blank) 3 Contents Opportunity to Propose ............................................................................................................................................. 4 Registration Requirement ......................................................................................................................................... 4 Directory ................................................................................................................................................................... 5 Section 1: Introduction ............................................................................................................................................. 6 Section 2: General Information

................................................................................................................................ 7 Section 3: Requirements and Scope of Required Services ..................................................................................... 10 Section 4: Proposal Requirements .......................................................................................................................... 12 Section 5: Miscellaneous ........................................................................................................................................ 16 Section 6: Questions and Required Responses: ...................................................................................................... 17 Appendix A: Summary of Benefits Coverage ........................................................................................................ 24 Appendix B: Claims History / Coverage Data ....................................................................................................... 25 Appendix C: Stop Loss Premiums vs Claims ......................................................................................................... 26 4 Opportunity to Propose Medical TPA Services, Stop Loss Reinsurance, and/or Pharmacy Benefits Manager Electronic proposals must be received by 2:00 p.m., EST, on April 28, 2023. Submittal information and proposal forms may be obtained from the Lorain County Community College (LCCC or the College) website, http://www.lorainccc.edu/purchasing, or by contacting the Purchasing Office by email at rwulfhoo@lorainccc.edu. A hard copy is available for viewing only in the Purchasing Office. Note: Registration with the Purchasing Office, phone: (440) 366-4633, fax: 440-366-4648, or email (preferred): rwulfhoo@lorainccc.edu, is required in order to be notified of any addenda. By order of Lorain County Community College, Elyria, Ohio 44035 Jonathan M. Volpe Vice President for Administrative Services/Treasurer Lorain County Community College Registration Requirement Upon registration, we will provide claims data and other files needed for pricing and completing the requirements outlined in this RFP for Lorain County Community College. The following information is required: Name of Firm Primary Contact Name Street Address City, State Zip Telephone Fax Phone Email Address Plans for which you intend to submit proposals: [Medical, Pharmacy, and/or Stop-loss] http://www.lorainccc.edu/purchasing mailto:rwulfhoo@lorainccc.edu. mailto:rwulfhoo@lorainccc.edu 5 Directory OWNER: Lorain County Community College District 1005 North Abbe Rd Elyria, Ohio 44035 Evaluation Committee: Table 1: LCCC RFP Evaluation Committee LCCC External Jonathan Volpe, VP for Administrative Services/Treasurer Tracy Green, VP for Strategic and Institutional Development Keith Brown, Director, Human Resources & Organizational Development Donna Baxter, Controller & Budget Director Joshua Longo, Benefits Specialist Timothy Hess, Manager of Human Resources & Operations Joe Concheck, VP Employee Benefits Assured Partners Pamela Moreau, Operations Leader, Employee Benefits Assured Partners Steve Parsons, Actuary Parsons Risk Strategies Proposed Process Schedule: Table 2: Proposed Process Schedule Phase Date* RFP issued March 15, 2023 Last day for question submittal April 7, 2023 Register to Bid April 13, 2023 Last addenda issued April 14, 2023 Submission deadline April 28, 2023; 2:00 p.m. EST Notice of intention to negotiate June 30, 2023 Contract execution August 1, 2023 Contract begins January 1, 2024 * Key dates may be altered by the College at its discretion; any updates will be communicated via Addendum should any alteration occur. Resources: The following data will be available upon registration to assist in evaluating and underwriting this RFP • Active Employee Census Data • Summary of Benefits • Monthly Claims and Enrollment (March 2022 thru February 2023) • Stop Loss Premiums vs Claims Data • Network Repricing and Disruption Analysis files • Other information/data as requested and approved by LCCC 6 Section 1: Introduction Background and History: Established in 1963, Lorain County Community College is the first community college in Ohio with a permanent campus. For six decades, LCCC has served the diverse needs of greater Lorain County region by providing affordable access to higher education and now serves approximately 13,000 students each year in certificate, associate, bachelor’s, and master’s degree programs. Since 1963, one in four Lorain County residents have taken classes at LCCC and more than 43,000 have earned a degree. LCCC was recently ranked in the top 10% of most affordable colleges in the nation and more than 90% of LCCC graduates live and work in Northeast Ohio. 45% of Lorain County’s high school graduates earn college credits through LCCC’s high school dual enrollment programs. LCCC also partners with more than 700 employers and offers 170 industry-recognized credentials to better prepare the workforce for the future. LCCC is a dynamic, student-centered college intentionally designed to support individuals with balancing multiple roles on their path to college completion. 85% of LCCC students work while attending college, with majority working at least half-time. The average age of LCCC’s students is 24, and many bring life experiences that include caring for dependents, serving in the military, or completing some prior college. Over 80% of LCCC students received financial assistance through grants and scholarships, and LCCC has been nationally recognized for holistic, fully integrated services and commitment to student success. The College has a staff of over 400 full-time employees across the administrative, educational, and faculty domains of employment and offers two health plans to employees, a basic PPO and a High Deductible Health Plan (with HSA). Both plans also include a hearing benefit. LCCC is a partially self-funded employer with stop loss insurance to cover claims in excess of $500,000 per individual. The College is currently in a pooled stop loss plan and is looking for stand-alone arrangements, or a captive that would return a portion of unused risk at the conclusion of the policy year. This RFP is produced to take a serious look at the capabilities of vendors in the marketplace and is not a market-check analysis. Nature and Scope of RFP: The College is seeking proposals from interested companies capable of providing medical third-party administrator services, stop loss reinsurance, and/or pharmacy benefits management of retail, mail-order and specialty prescriptions as well as cost-containment, risk mitigation, transparency, clinical efficacy, care management, decision making tools/support, and customer service. The College intends to award either a single negotiated contract to one firm to provide the services in a bundled format under terms and conditions considered most favorable among those submissions offered or separate integrated contracts leveraging firms the College believes to be most advantageous for each component (Medical, RX, and/or Stop-loss). The selection process is based upon the evaluation of all Requests for Proposals (RFP) and the determination of the best overall value, as defined by the College. All interested firms may respond to the RFP. Additionally, interested firms may tender proposals on individual components of this RFP (for example, just pharmacy benefits management) or all three components bundled together. Submitting a response does not construe any guarantee of award by the College; evaluation of the RFP is the first step in working towards a mutually agreeable contract; however, the subsequent steps will be completed prior to initiating any form of contract. Responding to the RFP will be completed at no charge to the College. 7 Section 2: General Information 2.1 Proposal Submission, Correction, and Withdrawal Electronic Proposals must be received by 2:00 p.m., EST, on April 28, 2023, and named as Your Firm Name, RFP Medical TPA, SL_PBM 2023 and upload to RFP Medical TPA_SL_PBM_2023. The date and time recorded by the College server will be the received date and time of record. Late proposals may not be accepted or considered. There will be no public opening. • Delivery for filing is entirely the responsibility of the Respondent. The College will not be responsible for any electronic submission that is not received due to email filters or file size restrictions or other system failures. It is suggested respondents confirm their proposal has been received. • Proposals may be completely withdrawn from consideration any time prior to proposal closing time if the request for withdrawal is provided in writing via email to rwulfhoo@lorainccc.edu at the College. • Any proposal submitted may be withdrawn for amendment and re-submitted prior to the final submission deadline, but only by written notification via email to rwulfhoo@lorainccc.edu. All proposals received at the submittal date/time are valid until the work is completed, without modification, unless agreed to in writing by Lorain County Community College. • Only typed proposals signed in non-black ink, by a legally authorized representative of Respondent will be considered. • All erasures or corrections shall be initialed by the person(s) signing the proposal. • All proposals become the property of Lorain County Community College and will not be returned to the Respondents. 2.2 Inquiries Respondents are expected to carefully examine all documents included in this RFP and shall make a written request, via email to Becky George Manager, Procurement & Distribution Services for interpretation or correction of any ambiguity, inconsistency, or error herein. Also, copy both Pam Moreau, Assured Partners and Joshua Longo, Benefits Specialist. The College will respond to requests by posting an Addendum on its procurement website: Purchasing Department - Lorain County Community College (lorainccc.edu). Only a written interpretation or correction by Addenda shall be binding. Respondents are cautioned against relying upon any interpretation or correction given by any other method. Respondents must submit all requests related to this RFP no later than the date listed in the proposed process schedule. The College will not respond to any requests received after this date. All requests concerning the RFP process and/or the subject of this RFP should include the RFP title in the subject line and must be made in writing via email to: Table 3: Contact information To: Becky George - Manager, Procurement & Distribution Services rwulfhoo@lorainccc.edu Cc: Pamela Moreau - Operations Leader - Employee Benefits, Assured Partners Joshua Longo – Benefits Specialist pamela.moreau@adduredpartners.com jlongo@lorainccc.edu https://lorainccc.sharefile.com/r-r7b8684b8f27b4328978c183ed474cfae https://www.lorainccc.edu/about/purchasing-department/ https://www.lorainccc.edu/about/purchasing-department/ mailto:rwulfhoo@lorainccc.edu mailto:pamela.moreau@adduredpartners.com mailto:jlongo@lorainccc.edu 8 Respondents may withdraw their proposals by notifying the College, in writing via email to Becky George Manager, Procurement & Distribution Services at any time prior to the submission deadline. Proposals, once opened, become the property of the College and will not be returned to the Respondents. 2.3 Proposal Disclosure The College is governed by the Ohio “Open Records Law” and all responses and supporting data shall be subject to disclosure under Ohio Revised Code Section 149.43. Respondent will fully indemnify and protect the College from any costs (including attorney’s fees) that may be incurred as a result of the College’s possession or release of information. Respondents must clearly identify any proprietary information that the firm does not want disclosed to the public. Respondent must invoke, in writing, the exemptions to disclosure provided by law in their response to the RFP by providing the specific statutory authority for claimed exemptions, identifying the data or other materials to be protected, and stating the reasons why such exclusion from public disclosure is necessary. The College reserves the right to make an award to the Respondent offering a proposal in the best interests of the College. The successful Respondent shall be awarded a contract for up to three (3) years from the start date of the contract, which may be renewable by mutual agreement of the parties annually for one (1) year. Option for renewal will only be exercised upon mutual written agreement and with all original terms, conditions and unit prices adhered to with no deviations. Any renewal will be subject to appropriation of funds by the College. The College, in its sole discretion, reserves the right to negotiate terms and conditions with the successful Respondent. 2.4 Addenda If revisions or clarifications to the RFP become necessary, the College will post a written Addendum on the College’s website and notify, via email, all registered firms, which will include Delivery and Read receipt confirmations. 2.5 Oral Presentations and/or Interviews At its sole discretion, the College may invite short-listed Respondents to conduct oral presentations or interviews. Presentations or interviews provide an opportunity for Respondents to clarify their proposals for the College. The College will schedule any such presentations or interviews. 2.6 Acceptance or Rejections of Proposals The College, in its sole discretion, reserves the right to waive all technicalities or irregularities, to reject any or all proposals, including any portion thereof, to award to a single Respondent or to divide the award between Respondents, and/or re-solicit in whole or in part. The College further reserves the right, in its sole discretion, to award a contract to the Respondent whose proposal best serves the interests of the College. 9 When a proposal appears to contain an obvious error or otherwise where an error is suspected, the circumstances may be investigated by the College and then be considered and acted upon. Any action taken shall not prejudice the rights of the public or other Respondents. Where proposals are submitted substantially in accordance with the RFP but are not entirely clear as to intent or to some particular fact or where there are other ambiguities, clarification may be sought and accepted provided that, in doing so, there is no substantial change to the proposal. The purpose of seeking clarification is to clarify existing information, not to allow additional information to be added. Basis for rejections may include, but not be limited to, the following: • The proposal being deemed unsatisfactory as to quantity, quality, delivery, price or services offered. • The proposal not complying with conditions of the RFP or with the intent of the proposed contract. • Lack of competitiveness by reason of collusion or knowledge that reasonably available competition was not received. • Error in specifications or indication that revision would be to the College's advantage. • Cancellation or changes in the intended project or other determination that the proposed requirement is no longer needed. • Limitation or lack of available funds. • Circumstances which prevent determination of the lowest responsible or most advantageous offer. • Any determination that rejection would be to the best interest of the College. 2.7 Development Costs Neither the College nor its representatives shall be liable for any expenses incurred in connection with the preparation, submission, or presentation of a response to this RFP. 2.8 Code of Ethics If any Respondent violates or is a party to violation of the Code of Ethics of the State of Ohio with respect to this RFP, such Respondent may be disqualified from performing the work described in this RFP or from furnishing the goods or services for which the proposal is submitted and may be further disqualified from bidding on any future work, goods, or services for the College. 2.9 Conflicts of Interest Respondents must disclose with their proposal the name of any officer, director, or agent who is an elected official, appointed or contracted official or an employee of the College. Further, Respondents must disclose the name of any elected official, appointed or contracted official or employee of the College, who owns directly or indirectly, any interest in the Respondent’s firm or any of its branches. Respondents must complete this section by indicating “No Conflicts to Disclose” if they have no conflicts. 10 2.10 Non-Collusion By submitting and signing a proposal, the Respondent certifies that its proposal is made without prior understanding, agreement, or connection with any corporation, firm or person submitting an offer for the same materials, services, supplies, or equipment and is in all respects fair and without collusion or fraud. No premiums, rebates, or gratuities are permitted, either with, prior to, or after any delivery of material or provision of services. Any violation of this provision may result in contract cancellation, return of materials, or discontinuation of services and possible removal from the College’s Vendor/Bid List (s). 2.11 Subcontracting Respondents submitting proposals may subcontract portions of the engagement to another firm. If this is to be done, that fact, and the name of the proposed subcontracting firms must be clearly identified in the proposal. However, following award of a contract, no additional subcontracting or changes in subcontractors will be allowed without express prior written consent of the College. Section 3: Requirements and Scope of Required Services 3.1 Specific Requirements Proposals should provide a full analysis of firm capabilities and proposed pricing to begin as of 1/1/2024 if the contract is awarded. We are seeking alternative bid proposals for the following: 1. Medical Third-Party Administration (TPA) services 2. Stop Loss Reinsurance to include medical and pharmacy to mirror current Summary Plan Description and to provide coverage for all high-cost claims in excess of $500,000 per individual. 3. Pharmacy Benefit Management (PBM) to include sample contract, fee and rebate structure as well as no interface fees for outside stop loss or Medical TPA Provider. Covered pharmaceuticals and related products may be dispensed at participating network pharmacies or at other pharmacies. Respondent must be able to accommodate the pharmaceuticals and products criteria identified in the “Resources” section and provide expertise in formulary management assistance and support services. 3.2 Special Provisions A. Compliance with Laws/Permits/Licenses Successful Respondent shall comply with all federal, state, and municipal laws, ordinances, rules, statutes, regulations, codes, and orders of any public authority bearing on the performance of the contract including, but not limited to, the laws referred to in this RFP. Upon request, Respondent shall furnish to the College copies of any licenses or permits required to comply with these laws, orders, ordinances, rules, statutes, regulations, and codes. The successful Respondent shall be responsible for obtaining all necessary permits and licenses required for performance under any contract resulting from this RFP. 11 B. Insurance and Liability The successful Respondent shall maintain, at its sole cost and expense, insurance with limits not less than those prescribed below: (a) Workers’ Compensation Insurance with limits meeting or exceeding statutory requirements. (b) Certificates of Insurance evidencing required coverage as stated in this RFP within ten (10) days following the decision to award contract to Respondent. Throughout the term of the contract, successful Respondent shall submit original Certificates of Insurance reflecting the coverage herein upon request by the College. (c) The College shall be named as an additional named insured party and a waiver of subrogation in favor of the College shall be issued on all policies of insurance, as its interest may appear in paragraphs (a) and (b) above. The College shall be provided with thirty (30) days advance written notice prior to any termination, cancellation or material change to said insurance policies. 3.3 Geographical Location of Members Please provide GeoAccess or similar network analysis to include the following zip codes. PCP, Hospital, ER, Cardiologist, Gynecologist, Pediatrician: Table 4: Listing of Zip Codes for GeoAccess 02825 44028 44053 44090 44113 44130 44143 44224 44310 44851 44001 44035 44054 44092 44116 44134 44145 44236 44313 44870 44011 44036 44055 44094 44118 44136 44146 44253 44721 44889 44012 44039 44060 44106 44120 44138 44147 44256 44839 49024 44017 44044 44070 44107 44122 44140 44149 44273 44839 44022 44050 44074 44109 44125 44141 44202 44275 44846 44024 44052 44089 44111 44126 44142 44212 44280 44847 3.4 Plan Coverage Details --For plan coverage details refer to the following: Appendix A: Summary of Benefits Coverage Appendix B: Claims History / Coverage Data Appendix C: Stop Loss Premiums vs Claims 12 3.5 Medical Networks Utilized The Plan is currently using the Medical Mutual Super Med Plus local network, and the Cigna PPO for Shared Administration to process claims. https://www.supermednetwork.com/SiteNavigation/Default.aspx Section 4: Proposal Requirements 4.0 Proposal Requirement The proposal must name all persons or entities interested in the proposal as principals. In each proposal by an individual or firm, there shall be stated the name and address of every person having an interest in the proposal; in the case of a corporation, state the names and addresses of its officers. Proposals shall be signed by the person or member of the firm making the proposal, and in the case of a corporation, by an authorized officer or agent subscribing the name of the corporation and his or her own name. The proposal must declare that it is made without collusion with any other person or entity submitting a proposal pursuant to this RFP. Specifically, be sure to include: 1. The names and number of years the firm has been in business under current or previous names or additional assumed business names. 2. The name and title of the person authorized to execute a contract on behalf of the firm. 3. A statement outlining any exceptions to the College’s requirements or clarifications to the requirements. 4. The caption, cause number, Court, Counsel, and general summary of any litigation pending, or judgment rendered within the past 3 years against the proposer. 5. Please do not include any direct or indirect broker compensation in your proposal. 4.1 Mandatory Requirements A prospective Respondent who does not meet all the mandatory requirements is not considered a Responsible Bidder and, in the College’s sole discretion, may be deemed ineligible to submit a proposal for consideration. Respondents must: • Have no conflicts of interest with the College, its Board of Trustees, nor with regard to any other work performed by the Respondent for the College. • Adhere to the instructions in this RFP document for the preparation and submittal of a proposal. • Be registered to conduct business in the State of Ohio. https://www.supermednetwork.com/SiteNavigation/Default.aspx 13 4.2 Mandatory Forms/Attachments Title Page: Title page must show the RFP title, Respondent's legal business name, local address and phone number and the due date of the proposal. Transmittal Letter Respondent shall submit a letter that briefly addresses its commitment to perform the work described within this RFP, and a statement explaining why the Respondent believes itself to be best qualified to perform the required work. Respondent shall set forth the anticipated number of employees or persons who will be retained by Respondent for performance of the work described in this RFP. Respondent shall also describe its service facilities including IT capabilities. Names of all persons authorized to make representations on behalf of the Respondent, including the titles, addresses and phone number of each person shall be documented in the transmittal letter. The Respondent shall certify that its firm is duly qualified, capable, and an otherwise bondable business entity, is not in receivership and does not contemplate it, and has not filed for bankruptcy. Further, the Respondent must certify that neither the firm nor any of its shareholders, officers, directors or other principals is currently delinquent with respect to payment of property taxes within Lorain County. An authorized agent of the Respondent must sign the transmittal letter, indicating the agent's title or authority. The transmittal letter shall not exceed three (3) pages. 4.3 Technical Proposal Each proposal must set forth, in detail, the Specific Requirements and address the ability to meet each requirement set forth in this RFP. If a section not applicable to your proposal, indicate (N/A). A. Qualifications and Experience Respondent shall furnish the College a detailed description of the qualifications and experience of the firm, its officers, and key personnel, including, but not limited to, managers and supervisors that will be providing the goods or services herein, which description shall include experience in similar work. The Respondent must also provide the name and resume of each individual assigned to this project and the individual assigned to back up the primary person in his/her absence and similar information concerning each individual to be provided by subcontract. B. Proposed Implementation Time Frame Each Respondent shall furnish the College a detailed description of their proposed implementation process and schedule from contract finalization to the contract start date of January 1, 2024. C. Covered Pharmaceuticals and Products Respondent should document how they are able to accommodate the pharmaceuticals and products criteria identified and their expertise in formulary management and support services. 14 D. Participating Medical Provider Network, Pharmacy Network and Formulary The Respondent must be able to communicate network changes to the College and impacted participants at least 30 days prior. E. Billing and Payment of Claims Respondent must confirm that they have the capability to export formulary lists in Microsoft Office Excel format directly from the claims processing system in real time. This capability must be available at the go-live date. The Respondent must provide weekly MAC lists in Microsoft Office Excel format. Respondent should document how they are able to accommodate the billing and payment of claims criteria identified. F. Reports and Records Respondent should document how they are able to accommodate the reports and records criteria identified. G. Rebates Respondent should document how they are able to accommodate the rebates criteria identified. H. Payment for Services Respondent should acknowledge agreement with the requirements. I. Prior Authorization Software Respondent should document how they are able to accommodate the prior authorization software criteria identified. J. HIPAA, Statutory, and other Legal Compliance Respondent should acknowledge agreement and show compliance for all HIPAA, statutory, and all legal compliance. K. Performance Guarantees and Proposed Thresholds Respondent will specify Performance Guarantee thresholds and metrics under the categories of Customer Service, Clinical Quality, Cost Containment, and Account Management. List specific guarantee along with measure, timing and plan credit for not meeting. L. Implementation Services & Credits List any special services to support implementation (e.g., Project Management, Participant support/communications, disruption support and communications, etc.) or credits to offset additional expenses incurred by the college and outside audit fees. M. Describe your data integrity and auditing process concerning computer interfaces, eligibility/enrollment information, claim system setup, and other systems that support claims administration and client/customer support. 15 4.4 Cost Proposal Each proposal must contain all cost information relative to the cost of goods or services to be provided. The format for submitting the cost proposal shall include the following: Total unit price of the services in the RFP and Total Anticipated Plan Costs (All-inclusive) based on provided data and necessary assumptions. Also, confirm whether proposal is a transparent/pass- thorough arrangement with no spread pricing. If warranted, you may also provide multiple pricing offers based on both your broadest network and a targeted network. If applicable, the itemized cost of additional services all prices stated within a proposal shall include: 1. Plan implementation (one-time cost) (a) Plan sponsor training & participant communications (b) Enrollment support (e) Clear notation that proposal prices are conditioned upon the College’s acceptance of the entire package as proposed (if pricing is based upon the College accepting the entire package as proposed, the Respondent must clearly state such condition in its proposal) 2. Outline of all fees, charges and any costs for administration and operation of plan. Include both required fees and itemized options. 4.5 References Respondent shall furnish the College a list of at least three (3) former clients within the last five (5) years to serve as references. Each reference must include the business name, address, and the name of at least one (1) contact person with their contact information (email and telephone number). 4.6 Supplemental Information Respondent shall furnish the College the following information: 1. List of all subcontractors that Respondent intends to utilize in connection with the work performed in response to this RFP. Also include a brief description of the services each sub- contractor provides. 2. A summary of any litigation filed against the Respondent in the past three (3) years that relates to the products or services that Respondent provides in the regular course of business. The summary shall state the nature of the litigation, a brief description of the case and its outcome (actual or projected). 3. Audited financial statements for the past two (2) years and annual reports or similar evidence of Respondent’s financial stability for the respondent and any relevant subcontractors 4. System and Organization Controls (SOC) reports for the respondent and any relevant subcontractors 5. Identify any contract terms and/or conditions Respondent requires. 6. Any additional information Respondent determines relevant for consideration by the College (optional). 16 Section 5: Miscellaneous 5.1 Review of Proposals If College staff is not successful in negotiations with the highest-ranking Respondent, the College reserves the right for the College to terminate negotiations with the highest-ranking Respondent and proceed to the next highest ranked Respondent and so forth until College staff successfully negotiates a contract with a ranked Respondent. 5.2 Ownership of Proposal The College shall retain all proposals submitted and reserves the right to use any idea in a proposal regardless of whether that proposal is selected. Further, all representations in the proposal of the successful Respondent shall be incorporated by reference into the executed contract. 5.3 Evaluation Criteria Mandatory Requirements Respondents and Subcontractors must: • Have no conflicts of interest with the College, its Board of Trustees, nor regarding any other work performed by the Respondent for the College. • Adhere to the instructions in this RFP document for preparation and submittal of a proposal. • Be registered to conduct business in the State of Ohio. • Be subject to all Ohio laws. 5.4 Oral Presentation At its sole discretion, the College may require Respondents to make oral presentations before the evaluation committee and/or the approval authority. 5.5 Selection Process The selection process described may be changed as needed to accommodate College requirements. Any change in the evaluation criteria will require the College to issue an Addendum and possibly extend the submittal period in accordance with this RFP. 5.6 Right to Reject Proposals The College reserves the right to reject any and all proposals when (1) such rejection is in the best interest of the College; or (2) if the proposal contains any irregularities; provided, however, that the College reserves the right to waive any minor irregularities and to accept the most responsive and responsible proposal as determined by the College. The College also reserves the right to withdraw this RFP at any time and/or to solicit and re-advertise for other proposals. 17 Section 6: Questions and Required Responses: 6.1 Firm Overview 1. What is the name, location, and ownership structure of your company and describe your company’s history, years in business and professional affiliations. 2. Provide key account executive and eligibility team assigned. 3. Please provide your AM Best Rating if available and other indicators of financial strength/solvency. 4. Is there a dedicated service team for the employees of LCCC to obtain claim and benefit assistance? Please describe. 5. Which services do you use in-house, and which do you out-source? Please Describe. 6. Do all your business processes and people reside in the US? If not, please explain locations and responsibilities. 7. Are you independently audited? If so, who conducts the audits and describe nature of these audits. 8. Explain how you will ensure transparency in all transactions related to vendor contracts and rating methodology and describe support for periodic claims auditing. 9. Do you offer third party recovery, including overpayments? 10. Will you be a claim fiduciary? 6.2 Network (Medical and/or PBM) 1. Please provide your network footprint (i.e.: national, local, regional) and GeoAccess or similar report. 2. If you do not provide a national network, do you provide a wrap network? What is the cost of your wrap network? 3. Please provide a network disruption analysis. 4. What assistance and communications do you provide to communicate the change in networks for those. 5. Confirm you will pass through to LCCC all provider-negotiated savings and that will not retain any difference between billed charges and contracted fees as a variable network access charge or additional form of compensation. If so, certify that you will. If not, please explain. 6. Confirm willingness to allow LCCC to provide preferred home infusion companies or physician infusion offices. 7. Explain in detail how you will guarantee a discount level. 8. Describe how transition of care issues will be handled for both medical and mental health. 9. Is Telehealth / Telemedicine provided? Describe? 18 6.3 Reporting and Technology (Medical and/or PBM) 1. Provide an overview of your claims adjudication system, how data is protected, disaster recovery protocols, and other pertinent features and processes to ensure data continuity and integrity. 2. Describe your ongoing development and maintenance of your platform/systems and do you anticipate any changes to these systems in the next three years? 3. Please confirm you can integrate with stop loss reporting, eligibility reporting, and pharmacy reporting systems. 4. Describe your standard reporting offerings and provide a sample of your quarterly reporting package. 5. Describe the reporting and analytical tools that are available to the plan administrator to assist in understanding the performance and cost drivers of the respective plan(s). Also, what benchmarking, and reference data is accessible in your system to allow comparisons other than historical performance? 6. Describe any reporting offered that integrates medical, pharmacy, human resource, demographic, or other social determinants data, especially in the areas of predictive modeling. 7. 6.4 Case Management, Disease Management and Large Claims Management (Medical) 1. Please provide details on your case management and large claim management processes. 2. Will you allow LCCC to carve out case management to a third party? 3. Will you permit carve out on expensive prescription drugs being infused and processed under the medical plan (Medical Drug Care Out) to achieve savings through the PBM? 4. Provide full description of the pre-certification and utilization review process. 5. How are gaps in care defined and managed? 6. Confirm PBM data is integrated in care management and large claim management. 7. Will you put fees at risk for failure to effectively manage large claims? 6.5 Claims Repricing (Medical) 1. Medical claims repricing is required. Upon submission, we will provide instructions and requirements for the claims repricing. 19 6.6 Fees: (Medical) Table 5: TPA Fees for 3-year Quote Administration & Access Fees Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Medical claims Network access fee Utilization Management/High Claimant Mgmt. Chronic Condition Care Mgmt. Maternity Program Nurse Line Telemedicine/Teladoc Reporting and Finance Bank Fees Other fees, charges or cost items not mentioned above to be considered. Please provide details. 6.7 Member Support (Medical and/or PBM) 1. Describe your member support, call center, and services including hours of operation, average hold times when calling for customer service, first-touch call resolution rates, customer satisfaction scores including net promoter scores, and other items you feel differentiate your customer services from your competitors. 2. Describe available self-service tools, mobile and web-based services, education tools for members, and other resources for members to find support, information, and resources on effective utilization of their plans(s). 3. Describe locations and employment status (employee/contractor) make-up (full- and part-time), and average length of service of your customer service team. Are they all based in the US? And will there be a dedicated service representative for LCCC’s account? 4. What sort of credentials have and what training and ongoing education do your customer service representatives receive? Specifically, how will they be educated about LCCC’s plan specifics, changes and culture? 5. For PBM plans, Confirm education and certification requirements of customer service staff (e.g. CPhT) and their average length of service working in a managed care pharmacy. 6. For PBM plans, Do customers have access to a Registered Pharmacist? And if so, what is the average wait time to speak with a Pharmacist when needed/requested? 20 6.8 Stop Loss 1. Stop Loss Rates (Assumes a $500k specific attachment point per current coverage) for Employee, Employee+ Spouse, Employee + Child(ren), and Family. 2. Confirm stop loss coverage for all medical and prescription drug claims including specialty and gene cell therapy drugs mirroring the plan contracts. 3. Based on plan claims history, what recommendations do you have for limits other than the current $500k? Please provide rationale and projected savings, additional costs or change to risk profile. 4. Please provide details on your case management and large claim management processes. 5. Will you allow LCCC to carve out case management to a third party? 6. Are you able to offer a rate cap and/or NNL (No New Laser Guarantee)? 7. Are you able to offer Advanced Funding? 8. Describe any unique approaches or claims management techniques your company uses that differentiates you from your other competitors and provides value for LCCC and its members. 6.9 Pharmacy Benefit Manager (PBM) 1. Please confirm and provide your proposed lower of logic for drug pricing and adjudication purposes. Describe your understanding and experience using National Average Drug Acquisition Cost (NADAC) as a pricing source. Are you willing to use NADAC as the primary basis for claims pricing and adjudication using AWP only in select circumstances where NADAC is not available? And please specify the source (e.g., MediSpan) for the AWP utilized to price claims. 2. Provide a brief description of your Prior Authorization programs. Detail program costs (if any), anticipated savings, and provide a listing of the prior authorization protocols available to LCCC. 3. Provide descriptions of other Utilization Management programs you are offering to LCCC (e.g., step therapy, quantity limitations, dose/duration of therapy edits, drug compliance/adherence monitoring, and concurrent and retro-drug utilization review programs). Detail program costs (if any), and anticipated savings, and provide a listing of the targeted drugs/therapy classes. 4. What formulary are you offering LCCC and why? 5. Describe your formulary management approach. Does the first tier of your formulary contain all generic drugs as set forth in First Databank’s National Drug Data File or MediSpan’s National Drug Data File, or such other nationally recognized source. If not, please explain. 6. Do you accept manufacturer funding for placement on your formulary? If so, please explain. 7. Does your rebate strategy influence your decisions regarding clinical programs and formulary development? Please explain. 21 8. Please provide a benchmark of your book of business measuring the percentage of specialty drugs to the total costs of drugs 9. Confirm mandatory mail is not assumed as part of your organization’s pricing proposal and auto- refill at mail order will not be mandatory. 10. What manufacturer Co-pay Assistance Programs are available to help both the participant and LCCC pay for expensive specialty and gene cell therapy drugs? 11. What type of programs or processes can protect LCCC given the development of expensive gene/cell therapy drugs in the pipeline? 12. Will you permit carve out of specialty drug management to a third-party Specialty Drug PBM? 13. Given rebates are achieved by higher cost prescription drugs, please provide your ability to achieve savings through all sources and provide an example where you achieved higher savings by the holistic approach vs simply chasing rebates. 14. Formulary and Manufacturer Rebates: Please confirm that 100% of all manufacturer rebates related to Lorain County Community College’s utilization will be passed through to LCCC. 15. Are all claims eligible for rebate payment (i.e., all paid claims for brand and generics) regardless of days’ supply, and are your quoted or guaranteed rebates based on actual days’ supply? 16. How do you engage patients when you determine that a patient is not on the most appropriate drug for their clinical situation? 17. Do you encourage Biosimilars? If so, how? Please provide examples. 18. Describe and highlight any programs, services or competencies not addressed in any of the requests in this proposal that set your company apart from your competitors, especially those items that will help the College and its employees maximize clinical outcomes and overall, wellbeing, and minimize costs, unnecessary care, and services. 19. Pharmacy claims repricing is required. Upon submission, we will provide instructions and requirements for the repricing. 20. Please provide a network provider and a formulary disruption analysis. 6.10 Pharmacy Benefit Manager (PBM) Details Table 6: PBM Administration Fees Administration Fees Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Per Retail Brand Claim Per Retail Generic Claim Per 90-Day Retail Brand Claim Per 90-Day Retail Generic Claim Per Mail Brand Claim Per Mail Generic Claim Per Specialty Claim Per Member Per Month (PM/PM) 22 Administration Fees Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Per Employee Per Month (PE/PM) Per Member Submit / Paper Mach Claim If proposing an administrative fee on a per claim basis, confirm the fee is charged only on paid claims – not on a reversed or rejected claims. Confirm that an administrative fee is based on a full pass-through of network discounts and dispensing fees. Other fees, charges or cost items not mentioned above to be considered. Please provide details. Table 7: PBM Retail Network Information Retail Network Information Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Retail Network Name Number of Pharmacies in this Network List major retail chains excluded from this network Provide your source of AWP (First DataBank, Medispan, etc.) Table 8: PBM Specialty Drug Pricing Specialty Drug Pricing Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Provide an exhibit to indicate the discounts and dispensing fees associated with specialty drugs through both the retain network and your specialty pharmacy. Confirm vendor agrees specialty medications are limited to those indicated in this exhibit. (Provide electronically; paper copy not required) The AWP used to price the claim will be the one associated with the actual NDC-11 submitted by the pharmacy and used to fill the prescription at the specialty [pharmacy. Confirm that specialty medications are limited to no more than 30 days except for those specialty medications only available in larger days’ supply. 23 Table 9: PBM Other Questions Other Year 1 1/1/24 Year 2 1/1/25 Year 3 1/1/26 Are there any instances when a drug would be considered a brand drug for discount reconciliation purposes and a generic drug for application of copay (or vice versa)? Please explain. Are you willing to provide minimum discount and dispensing fee guarantees? If so, please explain. Should you miss network discounts, dispensing fee, or applicable rebate guarantees, explain both the extent of payout and the process for payout reconciliation? 24 Appendix A: Summary of Benefits Coverage See attached file: FURNISHED UPON REGISTRATION Note: We also offer a single-member carve-out plan that has no cost share that is not captioned here. rwulfhoo Highlight 25 Appendix B: Claims History / Coverage Data See attached file: FURNISHED UPON REGISTRATION rwulfhoo Highlight 26 Appendix C: Stop Loss Premiums vs Claims See attached file: FURNISHED UPON REGISTRATION rwulfhoo Highlight