Article VII. Scope of Work

9443 Capital of Texas Hwy N., Arboretum Plaza II, Ste. 500, Austin Texas 78759 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

October 14, 2016 Ms. Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 East 18th Street Austin, Texas 78701

Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated October 7, 2016

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated October 7, 2016, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.

The following provides ERS the clarification responses requested. BCBSTX considers its clarification responses confidential and proprietary in nature.

Article VII. Scope of Work

1. RFP Section VII.C.1.e. Describe the service area(s) covered by Respondent’s managed care network as of the date of submission of the Proposal.

BCBSTX’s August 11, 2016 Original Response: All confidential and proprietary information has been redacted and shown as “redacted” below. The BCBSTX service area is the entire state of Texas, which includes each of the 254 Texas counties.

To minimize any provider disruption, we have developed redacted. This redacted ensuring ERS participants have access to a broad provider network, and have flexibility and choice when selecting providers. ERS will have the redacted.

HealthSelect participants will also benefit from discounts on services from contracted non-network providers -- a cost protection feature not available with any other carrier! When participants choose out-of-network care, redacted.. It has the following advantages:

Redacted

Ms. Cyrus Walker October 14, 2016 Page 2

*BCBSTX considers its clarification responses confidential and proprietary in nature.

Extended Service Area – Nationwide

Participants living or traveling outside of our Texas service area will have access to the national Blue Cross Blue Shield (BCBS) network. The program expands the service area by providing access to providers in every state and zip code in the United States. Redacted. The program links providers through a single network for claims processing and reimbursement.

Through the national program, nearly redacted on out-of-network claims because of their scale, longstanding relationships with providers, and skillful network management.

ERS’ September 16, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.

BCBSTX’s response requires further clarification.

• Is the following a correct interpretation of the statistics provided above?

Table redacted

• Document the data and methodology used in arriving at the conclusion presented in the last paragraph of your response to Section VII.C.1.e.

• Describe how the redacted differs from redacted. Do the redacted? If not, how do they differ? • Are the provider reimbursement provisions redacted? If not, how do they differ? • Does the redacted include redacted? BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

• Is the following a correct interpretation of the statistics provided above? ERS is accurate in its interpretation. *


Statistics provided on the redacted based on actual claims data on the redacted.

• Describe how the redacted differs from redacted. Do the redacted? If not, how do they differ?

Entire response is considered confidential and proprietary and is redacted.

• Are the provider reimbursement provisions redacted? If not, how do they differ?




• Does the redacted include redacted? Yes, redacted.

ERS’ October 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.

BCBSTX’s response requires further clarification. In its Clarified Response of September 26, 2016, BCBSTX states: “redacted”.

• Are the redacted providers redacted described in your response to this clarification?

• Provide the percentages of redacted:

a. Included in redacted; and b. redacted.

• Provide the percentages of urban and rural HealthSelect participants for whom you expect

redacted.

• Would BCBSTX be redacted? Sentence redacted.

• Provide the information and data requested in RFP Article VII.C.l.l , VII.C.1.n., and VII.C.3. and Article IX.C. and D. for redacted.

• In response to ERS’ question concerning redacted, you indicate that “redacted” Describe the strategy you will pursue to prevent such action.

BCBSTX’s October 14, 2016 Clarified Response*: Entire response is considered confidential and proprietary and is redacted.

Article IX. Price Proposal

2. RFP Section IX.D.3.a. Provide the following information for arrangements with contracted non-network providers. In providing this information clearly distinguish between non-network providers with whom you contract directly and those with whom you contract indirectly through another vendor.

RFP Section IX.D.3.a.i. Summarize the key provisions of those contracts related to participant access.

BCBSTX’s August 11, 2016 Original Response:

All confidential and proprietary information has been redacted and shown as “redacted” below.



BCBSTX incorporates redacted provisions that allow for members to access contracted out of network providers without being balance billed. The provisions are as follows:

Paragraph redacted.

Paragraph redacted.

ERS’ September 16, 2016 Clarification Request:


BCBSTX’s response requires further clarification. Please explain the relevance of the redacted. Is there a similar redacted for Professional Providers? If so, please provide.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has provided the redacted in its provider contracts to display the key provision that allows participants to redacted have protections from balance billing. There is also similar provisions outlined in the redacted as listed below. Remaining response redacted. * ERS’ October 7, 2016 Clarification Request:

All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Please define the following terms used in the Professional Provider Agreement:

• Maximum Allowance; • the amount other patients are charged for the same or similar service; • the amount allowed as described in Attachment A.

BCBSTX’s October 14, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below.

• Maximum Allowance

“Maximum Allowance” means the redacted.

• the amount other patients are charged for the same or similar service A published amount redacted.

• the amount allowed as described in Attachment A.

Attachment A is a rate attachment that outlines redacted.



3. RFP Section IX.D.3.a.ii. Describe the reimbursement arrangements applicable to contracted non-network providers. Quantify the difference in reimbursement between (i) the level provided under these arrangements, and (ii) the network reimbursement for similar specialties in the same geographic region. BCBSTX’s August 11, 2016 Original Response: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX employs redacted, fee schedules.


BCBSTX’s response requires further clarification. The information provided is insufficiently responsive to the request to “quantify redacted”. BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

Table redacted. ERS’ October 7, 2016 Clarification Request:


BCBSTX’s response requires further clarification. Please explain the meaning of the factors in the chart above. Use an example in your explanation.


4. RFP Section IX.D.3.a.v. Provide the tables requested in Section VII.C.3. for contracted non-network providers. BCBSTX’s August 11, 2016 Original Response:

Confirmed.

ERS’ October 7, 2016 Clarification Request: BCBSTX’s response requires further clarification. BCBSTX shall provide two additional provider files for contracted non-network providers for the following specialties: Radiologists, Anesthesiologists, Pathologists, and Emergency Medicine specialists. One file shall contain only the primary address for each provider; the other shall contain all practice locations for each provider. Use the following codes to denote each specialty.



Two-Digit Code Specialty AN Anesthesiology EM Emergency Medicine

RAD Radiology PTH Pathology

*This information is considered confidential and proprietary.

BCBSTX’s October 14, 2016 Clarified Response*:

Please find the requested files for contracted, non-network providers (ParPlan)

• Contracted Non-Network Providers Rpt 1_Primary • Contracted Non-Network Providers Rpt 2_All

We appreciate the opportunity to provide clarification to our proposal. Please do not hesitate to contact me at (512) 795-5908 or [email protected] with any further questions.

Sincerely,

Cyrus Walker Sales Strategy Executive

cc: Keith Barnes, Vice President, Enterprise National Accounts Enclosures (All enclosures include confidential and proprietary information and are redacted.)


November 7, 2016 Ms. Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 East 18th Street Austin, Texas 78701

Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated November 3, 2016

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated November 3, 2016, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.


Article VI. Legal Requirements and Regulatory Compliance

1. RFP Section VI.A.5. Performance Guarantees. The Contract will include Performance Guarantees (as attached to the RFP as Appendix F) and other legal remedies to ensure proper administration of the Plans. Performance Guarantees may include, but are not limited to, provisions in Articles I through IX of the RFP. Respondent shall refer to Appendix F for a comprehensive listing of the Performance Guarantees. Respondent may submit deviations to the Performance Guarantees. If deviations are submitted, they must include specific language rather than vague suggestions that certain provisions require discussion. Such specific language should be shown as redlined changes. Any such deviations will be considered by ERS; however, ERS will not be obligated to accept or agree to any such deviations.


CONFIDENTIAL AND PROPRIETARY Entire response is considered confidential and proprietary and is redacted.

ERS’ October 4, 2016 Clarification Request:

Ms. Ginger Grissom November 7, 2016 Page 2


All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall redacted to the Performance Guarantees that are attached as Appendix F to the RFP.

BCBSTX’s October 11, 2016 Clarified Response:


ERS’ November 3, 2016 Clarification Request:

All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall: (a) BCBSTX shall redacted. (b) In accordance with Section VI.A.5.a. of the RFP, ERS has redacted. BCBSTX shall redacted.

BCBSTX’s November 7, 2016 Clarified Response:


2. RFP Section VII.D.4.j. Describe Respondent’s preauthorization process, if applicable.


CONFIDENTIAL AND PROPRIETARY All confidential and proprietary information has been redacted and shown as “redacted” below. Preauthorization determines medical necessity and appropriateness of the physician’s plan of treatment and is critical to cost containment. Three sentences redacted. Preauthorization Process Paragraph redacted. As part of the clinical review process to preauthorize care, redacted. This system makes the review redacted. Sentence redacted: • Redacted. Paragraph redacted. Preauthorization Extensions If an extension of the initial preauthorization is needed, the provider contacts the plan and must communicate sufficient clinical detail to make a determination of medical necessity and appropriateness of stay. Two sentences redacted.



All utilization management determinations are communicated to the participant and the requesting provider in writing. The letter includes information about their appeal rights and the process.

[DIAGRAM PROVIDED BY BCBSTX NOT INCLUDED] ERS’ October 4, 2016 Clarification Request: BCBSTX’s response requires further clarification. What services fall under "physical health requests"? What services do BCBSTX typically require PA for both at the in-network provider level and out-of-network provider level (i.e., which standard services is a network physician required to obtain PA for vs. which services is a member required to obtain PA for)? BCBSTX’s October 11, 2016 Clarified Response:


ERS’ November 3, 2016 Clarification Request: BCBSTX’s response requires further clarification. BCBSTX shall provide a list of all of its procedures and services, including mental health services, which are subject to preauthorization.

BCBSTX’s November 7, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. *Below ERS will find those items that require preauthorization for redacted. Our utilization management program redacted. Remaining response redacted.

3. RFP Section VII.D.5.l.i. What Wellness Services does Respondent offer? BCBSTX’s August 11, 2016 Original Response: Entire response is considered confidential and proprietary and is redacted.


All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. What health trackers does BCBSTX offer and what types of information do they track? What incentives does BCBSTX provide? Is there wellness coaching for any additional topics other than weight management and tobacco cessation? Other than reduced redacted, what does BCBSTX's redacted program entail--is there an education or health coach aspect involved? Is weight tracking involved? With BCBSTX's wellness example, who redacted? Three sentences redacted.





What health trackers does BCBSTX offer and what types of information do they track? Entire response redacted. What incentives does BCBSTX provide? Entire response redacted. Is there wellness coaching for any additional topics other than weight management and tobacco cessation? Entire response redacted. Other than reduced redacted, what does BCBSTX's redacted program entail--is there an education or health coach aspect involved? Entire response redacted. Is weight tracking involved? With BCBSTX's wellness example, redacted? Entire response redacted.

Clarification request redacted? BCBSTX response redacted. Clarification request redacted? BCBSTX response redacted. ERS’ November 3, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s original response requires clarification. BCBSTX shall provide the following: (a) In its October 11, 2016 clarification response, BCBSTX mentioned redacted. BCBSTX shall

provide a detailed response with regards to redacted, including the following:

(i) Redacted

(ii) Redacted ability to opt out of this program if desired.

(b) Additionally, in its October 11, 2016 clarification response, BCBSTX elaborated on their ability to allow redacted. With regard to this, please provide the following:



(i) Redacted

(ii) Redacted

BCBSTX’s November 7, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. (a) *Redacted

(i) Redacted offers a standard redacted for all participants. Two sentences redacted.

(ii) Redacted.

(b) * Redacted (i) Redacted (ii) Redacted.

4. RFP Section VII.E.3.c. Please describe in detail any ACO or other demonstration projects that Respondent has in Texas. BCBSTX’s August 11, 2016 Original Response: Entire response is considered confidential and proprietary and is redacted.



BCBSTX’s response requires further clarification. Who are BCBSTX's redacted and where are they located? What services are covered under the redacted model and how does BCBSTX determine the target cost that should be utilized?


All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has partnered with CMS in the deployment of redacted that aims to improve the quality, cost, and coordination of redacted. BCBSTX has agreed to participate in redacted along with redacted. BCBSTX’s redacted program includes redacted. Three sentences redacted. ERS’ November 3, 2016 Clarification Request: BCBSTX’s response requires further clarification. BCBSTX shall confirm the following: (a) BCBSTX shall confirm the number of ACOs that will be made available to ERS at the

beginning of the Contractual period (September 1, 2017).



(b) In addition, BCBSTX shall confirm that on a regular basis they will employ a process whereby it will compare their active ACOs with the HealthSelect medical homes to determine which of these initiatives provides the greatest cost savings to the HealthSelect Plan.

BCBSTX’s November 7, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

(a) *Redacted.

(b) * Redacted.

5. RFP Section VII.E.4.a. Is Respondent capable of working with ERS in the establishment of a remote

health program for Participants? Yes No


CONFIDENTIAL AND PROPRIETARY

Yes No Entire response is considered confidential and proprietary and is redacted.

ERS’ October 4, 2016 Clarification Request: BCBSTX’s response requires further clarification. Is the MDLIVE telemedicine program available to participants in all 50 states? Are interactions telephonically or is a video component included as well? What types of conditions can MDLive treat and does the participant have the ability to send the provider a picture or video of their complaint/symptom to be used in their diagnosis? Are there any limitations regarding the types of illness/injuries that can be treated by this telemedicine visit? BCBSTX’s October 11, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. Yes, the Virtual Visits offering is available to all participants across the United States dependent upon local state regulations including but not limited to the (a) availability and (b) communication channels of virtual visits. We continue to monitor these regulations and ensure ongoing compliance and the best participant experience. Availability: All states except Arkansas currently allow telehealth. Please note: Legislation is close to being passed that would open up Arkansas for video access, which is being closely monitored. In the interim, participants living in Arkansas will have the benefit and can utilize it when they are physically located in a different state. Communication Channels: The communication channel is dependent upon the state regulations for where the participant is physically located at the time of the consult. For example, Texas typically



has access to telephone consultations; Oklahoma, Idaho, and Montana have access to video consultations, and all other states (besides Arkansas) have access to both telephone and video consultations. Sentence redacted. It should be noted that we will work with ERS to determine communication channels appropriate for its participants. Virtual Visits includes acute non-emergency medical conditions such as redacted. Virtual visits are also available for redacted. Virtual Visits is meant to augment primary care, not replace it, nor is it meant to be used as a crisis hotline or a replacement for a true emergency such as a heart attack. Participants can also redacted to the physician during the virtual visit. ERS’ November 3, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. The Texas Medical Board promulgated telemedicine rules pursuant to the Texas Medical Practice Act to ensure medicine is practiced consistent with public health and welfare. These rules address the requirements which include that in all cases a prior physician-patient relationship be established. BCBSTX shall describe how its proposed telehealth program, specifically the partnership with MDLIVE to deliver a telemedicine solution via redacted, will meet the Texas telemedicine requirements.

BCBSTX’s November 7, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. *BCBSTX believes that the proposed virtual visit benefit, which limits virtual visits in Texas to redacted meets the requirements of the current Texas Medical Board (TMB) rules as impacted by the pending TMB litigation. Specifically, in the current litigation, TMB has been enjoined from enforcing the most recently amended version of section 190.8(1)(L) of the Texas Administrative Code (“New Rule”), which prohibits prescription of any “dangerous drug or controlled substance” without first establishing a “defined physician-patient relationship” which “must include,” in pertinent part, “documenting and performing” a “physical examination that must be performed by either a face-to-face visit or in-person evaluation” elsewhere defined as requiring the provider and patient to be in the same physical location or at an established medical site. Previously, section 190.8 (“Old Rule”) simply said that the prescription of any “dangerous drug or controlled substance” without first establishing a “proper professional relationship” was prohibited and the proper professional relationship required, in pertinent part, “establishing a diagnosis through the use of acceptable medical practices such as patient history, mental status examination, physical examination, and appropriate diagnostic and laboratory testing.” Nothing in the Old Rule mentioned anything about face-to-face or in person visits. The TMB tried to interpret the Old Rule (without expressly amending the written text) to mean face-to-face or in-person visits were required prior to prescription and this interpretation was blocked in a previous litigation. The TMB has also adopted separately regulations in 2004 specifically governing “telemedicine.” 22 TEX.ADMIN. CODE §§ 174.1, et seq. Effective October 2010, the TMB amended its telemedicine



regulations, restricting the definition of “telemedicine” to consultations using “advanced telecommunications technology that allows the distant site provider to see and hear the patient in real time.” 22 TEX. ADMIN. CODE § 174.2. The amended regulations also made clear that, to establish a “proper physician-patient relationship,” telemedicine providers were required to conduct a physical examination of a patient. Id. § 174.8. The current injunction only prohibits enforcement of section 190.8(1)(L) and is silent regarding section 174.1, et. seq. BCBSTX, and its vendor, MDLIVE, have conservatively limited the virtual visit benefit and services to interactive audio only because this would fall outside of the definition of telemedicine in Section 174.2 (since the distant site provider cannot see and hear the patient in real time). While the TMB has been enjoined from enforcing face-to-face or in-person requirements under one regulation, it has not been enjoined under section 174.1, et. seq., which is the reason for the interactive audio only limitation.

6. RFP Section VII.E.4.c.iv. What incentives does Respondent use to encourage participation in its

remote health program?


CONFIDENTIAL AND PROPRIETARY



All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Is MDLive a contracted provider who provides virtual visits or merely the platform for actually accessing telemedicine visits? Since BCBSTX mentions that members redacted? Sentence redacted. If so, are there any limitations to this prescribing?


All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has contracted with MDLIVE to provide redacted. However, in Texas, redacted. For Texas providers redacted. Prescriptions are available to participants using virtual visits and can be sent electronically to a pharmacy of their choice. Controlled substances are not offered through virtual visits.

ERS’ November 3, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.



BCBSTX’s response requires further clarification. BCBSTX shall provide the following:

(a) BCBSTX has indicated that the cost to the participant for a virtual visit is redacted? Is there a different claim cost assessed if redacted?

(b) Describe how the MDLIVE program is accessed by the participants to utilize for providers who redacted.

(c) BCBSTX explained redacted. What has been the level of acceptance redacted? What is the target level of telemedicine participation redacted?

(d) Describe how BCBSTX would work to educate participants about the availability of this benefit.

(e) BCBSTX should confirm how long telemedicine as described in RFP (through MDLive) has been provided to clients. If the telemedicine program has been in effective for longer than six (6) months, BCBSTX shall describe the level of utilization of this platform across the applicable client base.


(a) *Virtual Visits provided through our vendor partner, MDLive, are redacted. Sentence redacted. (See BCBSTX’s September 26, 2016 Clarified Response for more details on behavioral health claims fees.)

MDLive also offers redacted. In the event a redacted.

Below ERS will find the average reimbursement rates redacted.

Table redacted.

In collaboration with ERS, we recommend that we develop a telemedicine redacted strategy that drives participants to the most effective, cost efficient, and convenience solution to reduce unnecessary visits to the emergency room or other higher levels of care.

(b) *Typically, when a provider offers telemedicine services to his or her practice, it is communicated to patients by the physicians practice. For example, communicated with office hours, services offered, and after hour availability. For information on Texas regulation related to video telemedicine, please see question 5 above.

(c) *Provider education is a key component of redacted. Four sentences redacted.

Paragraph redacted.

(d) *We will educate HealthSelect participants about the availability of this benefit throughout their experience with us. We know that understanding where to go for care can be difficult, and we want to make information available across every channel and touchpoint so that participants have it readily available when they need it.



Remaining response redacted.

(e) *BCBSTX has been partnering with MDLive since redacted. Our average book of business utilization is redacted. Three sentences redacted. During implementation, our redacted will collaborate with ERS to clearly redacted that offers convenience and cost savings to participants.

7. RFP Section VII.H.4.hh. Are the updates real-time and how quickly can a provider view the

enrollment update? BCBSTX’s August 11, 2016 Original Response:



All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall confirm that if redacted, BCBSTX will proactively redacted.


All confidential and proprietary information has been redacted and shown as “redacted” below. Paragraph redacted. This applies to situations redacted. Additionally, our redacted.


All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Sentence redacted. In other words, when BCBSTX loads an eligibility file received on Saturday, are the enrollment changes viewable redacted, or redacted?

BCBSTX’s November 7, 2016 Clarified Response: Entire response is considered confidential and proprietary and is redacted.



8. RFP Section VII.H.5.a. Audits. ERS may contract with one or more auditing firms to conduct periodic audits of Respondent. Respondent shall cooperate with and support the efforts of the auditors. Neither ERS nor the auditors will be required to indemnify Respondent for any costs incurred in connection with these audits. Article 15 of the Contractual Agreement has additional requirements regarding audits. BCBSTX’s August 11, 2016 Original Response:



BCBSTX’s response requires further clarification. ERS will not indemnify BCBSTX, and cannot require its auditors to indemnify BCBSTX. BCBSTX shall withdraw requested indemnification requirements from its response.




BCBSTX’s response requires further clarification. BCBSTX shall describe its internal process to ensure that ERS’ compliance auditor has sufficient and timely access to thoroughly reviewed claims data, source documents, and provider contracts specific to the administration of the HealthSelect Plan.

BCBSTX’s November 7, 2016 Clarified Response:

* Entire response is considered confidential and proprietary and is redacted.

9. RFP Section VII.H.7.h. Provide a detailed description of Respondent’s claims processing procedures.







BCBSTX’s response requires further clarification. In its response, BCBSTX explained that it accurately auto-adjudicates redacted claims. With respect to its claims processing, BCBSTX shall provide the following: (a) Describe the controls that BCBSTX has in place to ensure that manually-processed claims

are processed accurately and timely. (b) Describe the controls that BCBSTX has in place to mitigate the risk of duplicate claims. (c) Fully describe its process to proactively identify and actively manage high dollar claims. (d) Provide details to any strategic initiatives that will target increase the auto-adjudicate rate

to be redacted. (e) Describe its internal review process to audit the self-adjudication logic post

implementation.


(a) Describe the controls that BCBSTX has in place to ensure that manually-processed

claims are processed accurately and timely. * Entire response is considered confidential and proprietary and is redacted.

(b) Describe the controls that BCBSTX has in place to mitigate the risk of duplicate claims.


(c) Fully describe its process to proactively identify and actively manage high dollar

claims. * Entire response is considered confidential and proprietary and is redacted.

(d) Provide details to any strategic initiatives that will target increase the auto-adjudicate

rate to be redacted. * Entire response is considered confidential and proprietary and is redacted.

(e) Describe its internal review process to audit the self-adjudication logic post implementation.




10. RFP Section VII.J.1.d. Before 8:00 a.m. CT on each business day, Respondent shall notify ERS electronically of the balance of the DDA that is pending for reimbursement. ERS will instruct its custodian bank to transfer the funds via Fedwire to the DDA to settle the claim reimbursement on the same day if it is a business day on which ERS is fully open for business and if it is at all reasonably practicable to do so. Although Respondent shall be responsible for maintaining sufficient funds to provide for the cost incurred, Respondent shall not be responsible for the sufficiency or collection of Plan contributions. Due to the timing of the claims reimbursements, Respondent may be required to advance up to three (3) days (or more, depending on the applicable State holiday schedule) of its own resources for claims payments. Three (3) days of claims payments is projected to average around $20 million.


CONFIDENTIAL AND PROPRIETARY All confidential and proprietary information has been redacted and shown as “redacted” below.


BCBSTX’s response requires further clarification. BCBSTX shall confirm that filing claim reimbursements from ERS is based on check presentment, not on check issuance. For example, a provider filed a claim from BCBSTX and BCBSTX issued a check to BCBSTX for settlement of the claim on October 1, 2015. The provider cashed the check on October 15, 2015. BCBSTX would file the claim reimbursement from ERS on October 15, 2015, not on October 1, 2015.




All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall confirm the following: (a) According to ERS’ discussion with BCBSTX on October 31, 2016, BCBSTX shall confirm

that it agrees to the following funding arrangement for claims reimbursements to BCBSTX:

(i) BCBSTX will open a DDA to pay any claims from the service providers that are originated from the HealthSelect program. BCBSTX will have the ownership of this DDA.

(ii) BCBSTX will send ERS the summary of funding requests by 8 am CST, through e-mail notification, for the claims from the previous business day or weekend that have been paid through the DDA.



(iii) ERS will instruct the custodian bank to wire the claim reimbursement to BCBSTX on the same day the funding request is submitted to ERS.

(iv) When it is a State holiday but the bank is open, BCBSTX will provide ERS the estimated fund needed for the State holiday. BCBSTX should indicate this additional fund in the regular funding request for the day before the State holiday. ERS will wire the total to BCBSTX the day before the State holiday.

(b) As part of the Pay on Presentment methodology, BCBSTX confirms that it will work in

good faith during implementation to develop a custom monthly report which will be utilized to reconcile the funds requested to paid claims. At a minimum, this custom monthly report will contain unique claim payment identification numbers (i.e., check payment numbers or direct deposit reference numbers) and the corresponding claim numbers. This report will be delivered to ERS monthly and will be subject to the Monthly Reporting Requirements stipulated within the attached Performance Guarantees.

BCBSTX’s November 7, 2016 Clarified Response: (a) *BCBSTX confirms the following:

(i) Confirmed. BCBSTX confirms that will open, and have ownership of a DDA to pay any claims from service providers that are originated from the HealthSelect program.

(ii) Confirmed. BCBSTX confirms it will send ERS a summary of funding requests by 8 a.m. CST, via e-mail notification for the claims from the previous business day or weekend that have paid through the DDA.

(iii) Acknowledged. BCBSTX acknowledges its understanding that ERS will instruct the custodian bank to wire the claim reimbursement to BCBSTX on the same day the funding request is submitted to ERS.

(iv) Confirmed. BCBSTX confirms that when it is a State holiday but the bank is open, it will provide ERS the estimated fund needed for the State holiday. BCBSTX will indicate this additional fund in the regular funding request for the day before the State holiday. BCBSTX acknowledges its understanding that ERS will wire the total to BCBSTX the day before the State holiday.

(b) *Confirmed. As part of the Pay on Presentment methodology, BCBSTX confirms that it

will work in good faith during implementation to develop a custom monthly report which will be utilized to reconcile the funds requested to paid claims. At a minimum, this custom monthly report will contain unique claim payment identification numbers (i.e., check payment numbers or direct deposit reference numbers) and the corresponding claim numbers. This report will be delivered to ERS monthly and will be subject to the Monthly Reporting Requirements stipulated within the attached Performance Guarantees.



We appreciate the opportunity to provide clarification and welcome additional questions that provide ERS clarity to any outstanding questions. Under separate cover, I will send responses to items BCBSTX staff captured as requiring follow-up from our Face-to-Face Interview. To avoid duplication, I will send this after receiving the next round of questions from the breakout sessions, as I believe many of the items my team captured are included in ERS’ next clarification request. Please do not hesitate to contact me at (512) 795-5908 or [email protected] with any further questions.

Sincerely,


cc: Keith Barnes, Vice President, Enterprise National Accounts

Enclosures (All enclosures include confidential and proprietary information and are redacted.)



Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated November 14, 2016 – Operations

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated November 14, 2016 for Operations, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.


Article VI. Legal Requirements and Regulatory Compliance 1. RFP Section VI.A.5. Performance Guarantees. The Contract will include Performance Guarantees (as

attached to the RFP as Appendix F) and other legal remedies to ensure proper administration of the Plans. Performance Guarantees may include, but are not limited to, provisions in Articles I through IX of the RFP. Respondent shall refer to Appendix F for a comprehensive listing of the Performance Guarantees. Respondent may submit deviations to the Performance Guarantees. If deviations are submitted, they must include specific language rather than vague suggestions that certain provisions require discussion. Such specific language should be shown as redlined changes. Any such deviations will be considered by ERS; however, ERS will not be obligated to accept or agree to any such deviations.

BCBSTX’s August 11, 2016 Original Response: CONFIDENTIAL AND PROPRIETARY Entire response is considered confidential and proprietary and is redacted.




BCBSTX’s response requires further clarification. BCBSTX shall withdraw its deviations to the Performance Guarantees that are attached as Appendix F to the RFP. BCBSTX’s October 11, 2016 Clarified Response:


ERS’ November 3, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall: (a) BCBSTX shall redacted. (b) In accordance with Section VI.A.5.a. of the RFP, ERS has redacted. BCBSTX shall redacted.


ERS’ November 14, 2016 Clarification Request: Entire response is considered confidential and proprietary and is redacted.


2. RFP Section VI.D.3.a. Provide Respondent’s Texas Franchise Tax Account Status report and, if not

incorporated or formed in Texas, evidence of good standing in its jurisdiction of incorporation or formation. BCBSTX’s August 11, 2016 Original Response:

Acknowledged. Please refer to TAB B-6 Texas Franchise Tax Account Status.

ERS’ August 18, 2016 Clarification Request:

BCBSTX’s response requires further clarification. BCBSTX’s Texas Franchise Tax Report indicates “Franchise Tax Ended.” BCBSTX shall explain why the franchise tax has ended. BCBSTX’s August 25, 2016 Clarified Response:



As described below, pursuant to Section 171.052, Subchapter B. Exemptions, Blue Cross and Blue Shield of Texas, a division of Health Care Service Corporation, a Mutual Legal Reserve Company, is exempted from paying Franchise Tax.

TAX CODE TITLE 2. STATE TAXATION

SUBTITLE F. FRANCHISE TAX CHAPTER 171. FRANCHISE TAX

SUBCHAPTER B. EXEMPTIONS

Sec. 171.052. CERTAIN CORPORATIONS.

a) Except as provided by Subsection (c), an insurance organization, title insurance company, or title insurance agent authorized to engage in insurance business in this state that is required to pay an annual tax measured by its gross premium receipts is exempted from the franchise tax.

ERS’ November 14, 2016 Clarification Request: BCBSTX shall provide evidence of good standing in Illinois. Additionally, BCBSTX shall provide its Certificate of Incorporation (with current amendments) or equivalent charter documents from Illinois.

BCBSTX’s November 15, 2016 Clarified Response: Attached is a copy of a recent ‘Certificate of Compliance’ issued to HCSC in June of this year by the Illinois Department of Insurance. Article VII. Scope of Work

3. RFP Section VII.F.1.h. Provide copies of your generic communications used for plans similar to the Plans. Respondent’s response should include, but not be limited to, enrollment marketing packets. BCBSTX’s August 11, 2016 Original Response: Agreed. ERS’ November 14, 2016 Clarification Request: BCBSTX shall confirm that it will use infographics and icons within its communication materials when requested to do so by ERS. BCBSTX’s November 15, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. *Redacted.



4. RFP Section VII.F.6.a.ii. Participant and Consumer Information Sources. Respondent shall provide a

variety of tools and information sources for Participants. This includes, but is not limited to, the following:

• New Participant and SE/FE information; • Interactive web-based benefit “cost estimator tools” to allow cost modeling of GBP

program choices (HealthSelect v Consumer Directed HealthSelect v HMO); • Examples of cost scenarios to help Participants understand how the health plan

works; • Comprehensive Provider Directory; • Sample cost information for the most common physician, hospital and pharmacy

services in Texas; • Participant information services (including web-based) to track deductible,

coinsurance and out-of-pocket maximum status; and • Non-web information similar to web tools for those without web access.

BCBSTX’s August 11, 2016 Original Response: Agreed. ERS’ November 14, 2016 Clarification Request: BCBSTX shall confirm that it is willing to add additional enhancements to its participant and consumer information sources and communication materials when requested to do so by ERS, and that ERS will have full access to update the plan site with any necessary coordinator resources and videos to assist the participants (i.e., such as educational videos and job aids for coordinators to assist with explaining benefits to employees). BCBSTX’s November 15, 2016 Clarified Response: Entire response is considered confidential and proprietary and is redacted.

5. RFP Section VII.F.6.a.x. Link to Wellness Services to include the following information:

• List those Wellness Services currently provided; • Provide a description for each Wellness Services referenced; • Provide a Health Risk Assessment form; • Indicate how Participant may get more information on any offered program(s); • Provide enrollment information/form; and • Provide separate section for Wellness coordinators at State Agencies.

BCBSTX’s August 11, 2016 Original Response: Agreed.



ERS’ November 14, 2016 Clarification Request: BCBSTX shall confirm that ERS will be able to update the plan site with the coordinator resources and videos to assist participants with wellness issues (i.e., such as educational videos and job aids for coordinators to assist with explaining benefits to employees). BCBSTX’s November 15, 2016 Clarified Response: * Entire response is considered confidential and proprietary and is redacted.

6. RFP Section VII.H.3.g. Respondent shall provide ERS access to a dedicated reporting and analytical

team to advise and support ERS to include, but not be limited to: • Provide claims specific information and files; • Create statistical reports; • Develop templates for ERS data; • Benchmarking analysis; • Trend analysis; • Provide data for a regional map on the website; and • Develop, review, and fact check ERS publications (i.e., Cost Containment and Fraud

Report). A sample of the Cost Containment and Fraud Report is located at: http://www.ers.state.tx.us/About_ERS/Reports/.

BCBSTX’s August 11, 2016 Original Response: Entire response is considered confidential and proprietary and is redacted.

ERS’ November 14, 2016 Clarification Request: BCBSTX shall confirm that the reporting and analytical team can provide HEDIS reporting. BCBSTX shall further specify what information such reports are expected to contain. BCBSTX’s November 15, 2016 Clarified Response: * Entire response is considered confidential and proprietary and is redacted.

7. RFP Section VII.H.4.hh. Are the updates real-time and how quickly can a provider view the enrollment update?

BCBSTX’s August 11, 2016 Original Response: CONFIDENTIAL AND PROPRIETARY Entire response is considered confidential and proprietary and is redacted

http://www.ers.state.tx.us/About_ERS/Reports



ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall confirm that if redacted, BCBSTX will proactively redacted. BCBSTX’s October 11, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. Paragraph redacted. This applies to situations redacted. Additionally, our redacted. ERS’ November 3, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Sentence redacted. In other words, when BCBSTX loads an eligibility file received on Saturday, are the enrollment changes viewable redacted, or redacted? BCBSTX’s November 7, 2016 Clarified Response: Entire response is considered confidential and proprietary and is redacted.

ERS’ November 14, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX must agree to update redacted. In accordance with redacted. This means that BCBSTX must make redacted. There cannot be a redacted. BCBSTX’s November 15, 2016 Clarified Response: Entire response is considered confidential and proprietary and is redacted.

8. RFP Section VII.H.6.g. ERS retains the right to have its data excluded from any type of data sharing arrangement. If Respondent sells or reports data from its clients to others, either specifically or in aggregate, provide the following information: BCBSTX’s August 11, 2016 Original Response: All confidential and proprietary information has been redacted and shown as “redacted” below. Table redacted.



ERS’ November 14, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX shall confirm that, unless specifically authorized in writing by ERS, it shall not share ERS data or include ERS data in any data sharing arrangement. BCBSTX’s November 15, 2016 Clarified Response: *Confirmed. ERS data will not be shared without ERS’ prior written approval. Paragraph redacted.

9. RFP Section VII.J.3.a.iii. If applicable, specify the name and address of any sponsoring or parent corporation or others who provide financial support to Respondent. Provide an indication of the type of such support, i.e., guarantees, letters of credit, etc. What are maximum limits of additional financial support? Provide a copy of the sponsoring organization's most recent audited financial statement if any such entity provides financial support to Respondent. The financial statements should include, but not limited to, Balance Sheet, Income Statement, Statement of Retained Earnings or Statement of Stockholders’ Equity, Statement of Cash Flows, and Notes to the Financial Statements. BCBSTX’s August 11, 2016 Original Response: Agreed. ERS’ November 14, 2016 Clarification Request: BCBSTX shall: (a) Provide the name and address of any sponsoring or parent corporation or others who

provide financial support to BCBSTX. (b) Provide an indication of the type of such support. BCBSTX’s November 15, 2016 Clarified Response: BCBSTX is clarifying that the correct answer to the original question regarding the “… sponsoring or parent corporation” of Respondent, should have been “Not Applicable”, instead of “Agreed”. We clarify that Blue Cross Blue Shield of Texas (“Respondent”) is an operating division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”), a mutual insurance company established and operating under Illinois law since 1982. As such, Respondent is neither a sponsored entity, nor a subsidiary or affiliate of HCSC. Rather, it is an operating division within HCSC. Accordingly, the Respondent and HCSC are, for all intents and purposes, a single entity, and the financial reserves and other resources of HCSC backstop in all respect the undertakings of Blue Cross Blue Shield of Texas.



We appreciate the opportunity to provide clarification and welcome additional questions that provide ERS clarity to any outstanding questions. Please do not hesitate to contact me at (512) 795-5908 or [email protected] with any further questions.

Sincerely,



Enclosures (All enclosures include confidential and proprietary information and are redacted.)


October 11, 2016 Ms. Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 East 18th Street Austin, Texas 78701

Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated October 4, 2016

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated October 4, 2016, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.


Article VII. Scope of Work 1. RFP Section VI.A.5. Performance Guarantees. The Contract will include Performance Guarantees (as

attached to the RFP as Appendix F) and other legal remedies to ensure proper administration of the Plans. Performance Guarantees may include, but are not limited to, provisions in Articles I through IX of the RFP. Respondent shall refer to Appendix F for a comprehensive listing of the Performance Guarantees. Respondent may submit deviations to the Performance Guarantees. If deviations are submitted, they must include specific language rather than vague suggestions that certain provisions require discussion. Such specific language should be shown as redlined changes. Any such deviations will be considered by ERS; however, ERS will not be obligated to accept or agree to any such deviations.

BCBSTX’s August 11, 2016 Original Response: Please see BCBSTX’s August 11, 2016 Proposal for complete response.


BCBSTX’s response requires further clarification. BCBSTX shall withdraw its deviations to the Performance Guarantees that are attached as Appendix F to the RFP.

Ms. Ginger Grissom October 11, 2016 Page 2

*Blue Cross and Blue Shield of Texas considers this information to be proprietary and confidential.


2. RFP Section VII.C.1.c. How does Respondent ensure that there are an adequate number of network

providers that will accept new patients?



BCBSTX’s response requires further clarification. How does BCBSTX ensure there are an adequate

number of network providers that will accept new patients?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX continuously reviews the adequacy of the network with and without the providers who

have reported closed panels. BCBSTX also redacted for a given service area. These standards are based on redacted.

3. RFP Section VII.C.1.g. Describe Respondent’s network management policies and procedures.



BCBSTX’s response requires further clarification. Please fully describe at a high level what BCBSTX's policies actually are for contracting, credentialing, delegation, fee schedules and reimbursements, referral patterns and non-compliance, provider terminations, and network adequacy guidelines (i.e., BCBSTX states that they have policies for these items but does not actually describe what the policies are).


4. RFP Section VII.D.2.d. Describe any risk sharing arrangements between Respondent’s organization

and providers relative to in-network referrals and use of out-of-network providers.





BCBSTX’s response requires further clarification. Does BCBSTX have the ability to penalize or terminate network providers for continuing to refer OON? How does BCBSTX view the impact/applicability of HB574 on discouragement of use of OON providers?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Sentence redacted. HB574 does provide a terminated provider another potential argument, but primarily adds requirements that were already addressed in the insurance code or not used by BCBSTX. A contractual requirement to use network providers is not prohibited by the bill.

5. RFP Section VII.D.2.m.vii. Does Respondent have contractual relationships of any kind with health

care providers other than those in Respondent’s managed care networks? If so, describe such relationships fully. ERS is particularly interested in relationships that provide discounted fees and no balance billing for Participants using non-network providers.



All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall provide additional information on the discounts passed to ERS and the number of claims processed in-network. How and when are the discounts received from negotiated rates with out-of-network, contracted providers? Sentence redacted.




6. RFP Sections VII.D.3.b. and VII.D.3.b.i. Does Respondent currently have an active tiered or high performance provider network in Texas? If yes, what is the basis for the establishment of those providers in Respondent’s highest ranking group?



BCBSTX’s response requires further clarification. Does BCBSTX have a tiered system that evaluates all network PCPs and specialists on several cost effective and quality criteria measurements? Does the tiering that currently exists only apply for physicians and facilities designated as ACOs/COEs or does BCBSTX already have a preferred provider tiering network for network physicians regardless of affiliation with PCMH or ACO, etc.?


7. RFP Section VII.D.4.b.i. Is utilization review performed by Respondent’s staff or through a contract

with a third party? If contracted to a third party, identify the name, address and telephone number of the third party.

BCBSTX’s August 11, 2016 Original Response: Please see BCBSTX’s August 11, 2016 Proposal for complete response. ERS’ October 4, 2016 Clarification Request:

BCBSTX’s response requires further clarification. How does this coordination with a third-party vendor work for both BCBSTX and the providers? How do network providers know which vendor to utilize for their UM and which services require UM? For services requiring UM, which are not described in this third-party vendor list, confirm that BCBSTX handles the UM functions.

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. As part of our education and transition plan, our redacted. Providers will either use the toll-free number or provider portal to verify benefits and during that exchange, will be advised if preauthorization is required. Information on how to contact BCBSTX will be on the back of the ID card directing all providers to the appropriate resource for authorization. Sentence redacted. This approach ensures an easy and seamless process for the requester. Sentence redacted.



8. RFP Section VII.D.4.b.ii. Describe the location and hours of operation of the facility or facilities from which utilization review activities will be conducted.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. If an urgent preauthorization is needed after hours (perhaps not directly related to the emergency admit, but maybe an emergency surgery or other radiological test), how are the preauthorizations handled? Sentence redacted.


9. RFP Section VII.D.4.j. Describe Respondent’s preauthorization process, if applicable.


BCBSTX’s response requires further clarification. What services fall under "physical health requests"? What services do BCBSTX typically require PA for both at the in-network provider level and out-of-network provider level (i.e., which standard services is a network physician required to obtain PA for vs. which services is a member required to obtain PA for)?


10. RFP Section VII.D.5.h. Respondent shall offer self-care initiatives to Participants such as health

education, nurse help line, health risk assessment, reminders, and motivation and wellness services to assist Participants with health care decisions.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. What is the redacted program that BCBSTX refers to? What does this program involve and what incentives does this include? Two sentences redacted.




11. RFP Section VII.D.5.i.i. What Disease/Condition Management Services does Respondent offer?



BCBSTX’s response requires further clarification. What is included with these disease management services? Does it include counseling and provider coordination?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. The Program is designed specifically for the delivery of individually customized, nationally recognized evidence-based interventions that focus on the specific needs of each participant with a chronic condition. BCBSTX sends educational mailings to redacted. Engagement includes redacted. Follow-up calls include redacted. The clinician educates the participant regarding redacted. Our targeted outreach design encompasses numerous strategies to remove barriers, which may hinder engagement, but more importantly, our design utilizes innovative modalities to enhance participants’ ease in activation. Our engagement model includes redacted. For engagement purposes, participants are considered redacted for condition management. Active engagement includes redacted.

Paragraph redacted. The frequency of the participant interactions with the clinician depends on redacted. Redacted is another strategy utilized in redacted.

Title Redacted

Another component of redacted.

Paragraph redacted.

Online Portal



We offer numerous other resources for participant activation, enhancing the participants’ adaptive health behaviors and motivation for self-care management, which often serves as redacted. Within our online portal, participants can access redacted.

Responses to redacted. Our shared-decision making library redacted. Participants access redacted. Completed questionnaires redacted for a more extensive telephonic assessment and engagement.

12. RFP Section VII.D.5.i.v. How is return on investment calculated for Respondent’s Disease/Condition

Management Services?



BCBSTX’s response requires further clarification. Does BCBSTX have the capability to report estimated ROI at the disease management/condition level?


13. RFP Section VII.D.5.l.i. What Wellness Services does Respondent offer?


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. What health trackers does BCBSTX offer and what types of information do they track? What incentives does BCBSTX provide? Is there wellness coaching for any additional topics other than weight management and tobacco cessation? Other than reduced redacted, what does BCBSTX's redacted program entail--is there an education or health coach aspect involved? Is weight tracking involved? With BCBSTX's wellness example, who redacted? Three sentences redacted.


What health trackers does BCBSTX offer and what types of information do they track? Entire response redacted. What incentives does BCBSTX provide? Entire response redacted.



Is there wellness coaching for any additional topics other than weight management and tobacco cessation? Entire response redacted. Other than reduced redacted, what does BCBSTX's redacted program entail--is there an education or health coach aspect involved? Entire response redacted. Is weight tracking involved? With BCBSTX's wellness example, redacted? Entire response redacted.

Clarification request redacted? BCBSTX response redacted. Clarification request redacted? BCBSTX response redacted.

14. RFP Section VII.D.5.l.iv. How does Respondent identify Participants, initiate the management, and encourage the participation in Respondent’s Wellness Services and then report on results?



BCBSTX’s response requires further clarification. Does a participant have the ability to opt out of receiving targeted emails if requested?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX provides each participant the opportunity to opt out of targeted email messages at any time. Participants also have the option to redacted. In addition to managing email preferences, participants redacted. In some cases, we will have to distribute a communication via a prescribed channel regardless of participant preference. We will work with ERS in those instances to effectively coordinate distribution.

15. RFP Section VII.D.5.l.v. How is return on investment calculated for Respondent’s Wellness Services?





BCBSTX’s response requires further clarification. Does BCBSTX have the capability to break out reporting ROI for wellness services if requested?


16. RFP Section VII.D.5.m.iii. Describe Respondent’s customer satisfaction survey process. Your answer

should include, but not be limited to, how often they are conducted, how Participants are identified, and how member satisfaction is typically measured.



BCBSTX’s response requires further clarification. Does BCBSTX have the ability to send paper satisfaction surveys to participants rather than placing phone calls? Are the results from the enterprise survey, digital survey, participant experience survey, and market research survey aggregated to determine overall satisfaction or does BCBSTX only use one of these survey types to determine whether the Performance Guarantee for participant satisfaction has been met?


BCBSTX does have the ability to send paper satisfaction surveys to participants rather than placing phone calls. Four sentences redacted. Paragraph redacted. BCBSTX does conduct other surveys of participants, most often related to specific transactions redacted. Two sentences redacted.

17. RFP Section VII.D.5.m.v. Respondent shall provide an ongoing review of complaints received from

Participants and providers and respond as necessary and appropriate, monitor the denials of benefits made under the utilization management program to maintain the appropriateness of the program, and provide information about the utilization management program to ERS as requested.


\




BCBSTX’s response requires further clarification. BCBSTX mentions their diabetic disease management program. Does BCBSTX offer any diabetes prevention programs or something similar to specifically address and prevent pre-diabetics and other at-risk individuals from becoming diabetic? If so, what is included in this program and how does it work?


18. RFP Section VII.D.6.d. Respondent shall provide the following in-network professionals at one or

more onsite clinics pursuant to Chapter 671 of the Texas Government Code during normal business hours at no additional charge: either a licensed advance practice registered nurse or a licensed physician assistant and a supervising physician (not onsite). At the request of ERS, Respondent shall submit reports on information and data related to the onsite clinics at no additional expense to ERS, the GBP or the employers providing the locations for such clinics.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Would ARC submit member-specific claims and diagnosis and procedural data to BCBSTX? If so, would BCBSTX have the capability to report either cost savings or increase in cost to the plan regarding redacted?


Yes, ARC will submit member-specific claims, which include diagnosis and procedural data, to BCBSTX for reimbursement of services rendered. Two sentences redacted.

19. RFP Section VII.E.1.a. ERS is interested in increasing its participation in program(s) within the State

in which the GBP, in cooperation with provider groups, health plans, and other health systems, would work jointly to achieve greater program efficiencies and effectiveness through the refinement and customization of benefit programs offered to Participants in the following ways:

• Support integrated, efficient and effective systems of care, delivery and payment; • Promote a patient-centered approach to service delivery and payment; • Improve Participant outcomes; opportunities to develop, share and systemically sustain

best-practices; • Encourage and reward the prevention and management of disease; • Promote the value of care over the volume to measurably lower costs; • Support payment and processes that are transparent, easy to understand, and simple to

administer for Participants, providers, purchasers and other stakeholders;



• Balance the interests of Participants, payers and providers while pursuing necessary change thereby yielding shared savings;

• Provides greater efficiencies with opportunities to reduce or eliminate provider costs; and • Standardize business processes to facilitate improved technical data exchange.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX states redacted. How has this type of initiative been deployed and leveraged with other clients? What were the results? What were the lessons learned? Sentence redacted.


20. RFP Sections VII.E.2.a.-VII.E.2.d.ii. Through the current HealthSelect third party administrator, ERS has standing contracts with multiple Patient-Centered Medical Homes across Texas and intends to continue these arrangements regardless of chosen TPA. The large PCMHs are paid claims under a fee-for-service reimbursement strategy. This program is made up of integrated multi-specialty provider teams. The model generally focuses on wellness, advanced technology uses, evidence-based medicine, expanded hours, and awards shared savings to provider groups when quality standards and cost trends are met.

RFP Section E.2.b. Is Respondent capable of working with ERS in managing the medical home program for Participants? Yes No RFP Section E.2.c. What definition does Respondent currently use for a medical home (i.e., joint principles or something else)? RFP Section E.2.d. If Respondent currently offers additional medical home programs, provide the following information: RFP Section E.2.d.i. Describe the terms and how Respondent currently ensures that participants receive quality medical care in its medical home program. RFP Section E.2.d.ii. Discuss Respondent’s experience in managing a medical home program. BCBSTX’s August 11, 2016 Original Response: Please see BCBSTX’s August 11, 2016 Proposal for complete response.

ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX cited it will “. . . redacted.” How will BCBSTX accomplish this? What is BCBSTX’s proven methodology in redacted? What has been BCBSTX’s effect (cost savings, improved patient outcomes, quality of care results, etc.) from redacted?



BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX continues to work with physician and health care professionals across the state to drive innovations in our value based care models. These strategies, redacted, allow us to transform healthcare delivery in Texas, together. BCBSTX will leverage redacted. Additionally, BCBSTX’s close alliance redacted. Remaining response redacted.

21. RFP Section VII.E.2.d.xi. [With regard to medical home programs] How long would it take to get this

type of model in operation following onset of the Contract? BCBSTX’s August 11, 2016 Original Response:

Please see BCBSTX’s August 11, 2016 Proposal for complete response.


BCBSTX’s response requires further clarification. BCBSTX states that the parties will commit to work collaboratively to redacted. Does this mean redacted or does it mean at the redacted?


22. RFP Sections VII.E.3.a. and VII.E.3.b. Does Respondent offer a program to contract with an ACO? Yes No

RFP Section VII. E.3.b. If yes, discuss the advantages and disadvantages of offering an ACO for a group such as the GBP.



ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Has BCBSTX successfully leveraged redacted for other large clients? If so, what was the outcome? BCBSTX cited redacted. What is BCBSTX’s solution for this proposed redacted?




23. RFP Section VII.E.3.c. Please describe in detail any ACO or other demonstration projects that

Respondent has in Texas.



BCBSTX’s response requires further clarification. Who are BCBSTX's redacted and where are they located? What services are covered under the redacted model and how does BCBSTX determine the target cost that should be utilized?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has partnered with CMS in the deployment of redacted that aims to improve the quality, cost, and coordination of redacted. BCBSTX has agreed to participate in redacted along with redacted. BCBSTX’s redacted program includes redacted. Three sentences redacted.

24. RFP Section VII.E.4.a. Is Respondent capable of working with ERS in the establishment of a remote health program for Participants? Yes No



BCBSTX’s response requires further clarification. Is the MDLIVE telemedicine program available to participants in all 50 states? Are interactions telephonically or is a video component included as well? What types of conditions can MDLive treat and does the participant have the ability to send the provider a picture or video of their complaint/symptom to be used in their diagnosis? Are there any limitations regarding the types of illness/injuries that can be treated by this telemedicine visit?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Yes, the Virtual Visits offering is available to all participants across the United States dependent upon local state regulations including but not limited to the (a) availability and (b) communication



channels of virtual visits. We continue to monitor these regulations and ensure ongoing compliance and the best participant experience. Availability: All states except Arkansas currently allow telehealth. Please note: Legislation is close to being passed that would open up Arkansas for video access, which is being closely monitored. In the interim, participants living in Arkansas will have the benefit and can utilize it when they are physically located in a different state. Communication Channels: The communication channel is dependent upon the state regulations for where the participant is physically located at the time of the consult. For example, Texas typically has access to telephone consultations; Oklahoma, Idaho, and Montana have access to video consultations, and all other states (besides Arkansas) have access to both telephone and video consultations. Sentence redacted. It should be noted that we will work with ERS to determine communication channels appropriate for its participants. Virtual Visits includes acute non-emergency medical conditions such as redacted. Virtual visits are also available for redacted. Virtual Visits is meant to augment primary care, not replace it, nor is it meant to be used as a crisis hotline or a replacement for a true emergency such as a heart attack. Participants can also redacted to the physician during the virtual visit.

25. RFP Section VII.E.4.c.iii. How will Respondent initially engage Participants, provider groups, health

plans, and health systems in project initiatives, if such involvement is needed?



BCBSTX’s response requires further clarification. Does BCBSTX actually redacted? Other than MDLive, is BCBSTX proposing to offer other telemedicine services and, if so, what are they? BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. MDLive is responsible for redacted; BCBSTX conducts the redacted of these activities. Paragraph redacted.

26. RFP Section VII.E.4.c.iv. What incentives does Respondent use to encourage participation in its

remote health program?




ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. Is MDLive a contracted provider who provides virtual visits or merely the platform for actually accessing telemedicine visits? Since BCBSTX mentions that members redacted? Sentence redacted. If so, are there any limitations to this prescribing?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has contracted with MDLIVE to provide redacted. However, in Texas, redacted. For Texas providers redacted. Prescriptions are available to participants using virtual visits and can be sent electronically to a pharmacy of their choice. Controlled substances are not offered through virtual visits.

27. RFP Section VII.E.4.c.vi. Describe the skills, experience and expertise that indicate why you are better qualified to provide a remote health program than other Respondents.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. If BCBSTX's standard is to offer redacted, how does BCBSTX ensure they are meeting Texas state TMA guidelines? Has BCBSTX sought approval from TMA on this model?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX assumes the clarification request is regarding Texas Medical Board (TMB) guidelines regarding telemedicine. The TMB rules apply to and regulate physicians and it is physicians and physician organizations that must provide telemedicine services in accordance with TMB rules regarding delivery of telemedicine services. Our telemedicine provider, MDLive, has determined that their model redacted meets the current requirements of the TMB rules for telemedicine delivery and this is consistent with BCBSTX’s understanding of current TMB telemedicine rules and the pending litigation regarding same. As BCBSTX is not regulated by TMB, it has not sought approval from TMB for this model.



Please note that the landscape regarding telemedicine services in Texas is likely to change in the near future as a result of resolution of the pending litigation and the 2017 legislative session and this may necessitate modifications to the telemedicine delivery model to align with any new requirements or guidelines.

28. RFP Section VII.E.4.c.vii. How does Respondent propose to measure the extent to which the remote

health program has achieved its objectives and goals?



BCBSTX’s response requires further clarification. BCBSTX states RFP for these services was sought in 2016. How long has BCBSTX offered telemedicine visits as described to clients?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. We have provided telemedicine support for several clients for redacted years. Recognizing the needs of our clients for a standard platform, redacted..

29. RFP Sections VII.E.5.a. and VII.E.5.b. Describe in detail any products, services, ideas, or facilities

(including any discounts) which may enhance the health care services but are not essential in providing the required services. Respondent shall provide an accurate and detailed description of any additional enhancements to services offered by Respondent, including the implementation history for each service.

(VII.E.5.b.) Provide pricing on a per Member basis for any options specified above. ERS will not be obligated to select any of the options provided. If any option is selected by ERS, it will be specifically stated in writing which option(s) are selected.

BCBSTX’s August 11, 2016 Original Response: Entire response is considered confidential and proprietary and is redacted.


BCBSTX’s response requires further clarification. With regard to redacted? In addition, please provide additional information on the redacted coverage.




BCBSTX offers redacted clients for a total membership of redacted. Sentence redacted. Redacted is an innovative concept that redacted participants to optimal redacted design. If interested, we would work with ERS to design a redacted that drives participation and supports other redacted. Our redacted solution is based on redacted. Attached ERS will find a redacted. Below is a table representing an example of redacted available January 1, 2017.

Table redacted.


30. RFP Section VII.F.1.g. Communication material shall be available in both print and electronic forms.

Certain communication material, such as provider directories, may be made available electronically, only as long as printed materials can be provided upon request to Participants. Accommodations shall be made for individuals with visual and/or hearing impairments in the development, production, and deployment of all communication materials, including information disseminated via the Internet that complies with ADA and Section 508.



BCBSTX’s response requires further clarification. How is BCBSTX proposing to handle implementation of new ACA non-discrimination notice and tagline requirements? What materials is BCBSTX anticipating putting these notices/taglines on in order to meet the federal mandate?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. As with all member-facing materials, BCBSTX will work with ERS for the appropriate approvals and input before information is distributed to HealthSelect and Consumer Directed HealthSelect participants. We have internal checks and balances in place to ensure information is not distributed to participants without following the process outlined in VII.F. of the RFP. BCBSTX is working to support the requirements established through the ACA 1557 with the inclusion of redacted. The following materials represent some of the more frequent communications that will contain the non-discrimination notice and directions for access to language assistance resources for our book of business. Redacted. We will work with ERS to develop the appropriate language for your participants and assist ERS with compliance.



31. RFP Section VII.F.1.o. Media Inquiries. Respondent shall provide ERS with its process and protocols

for responding to general media inquiries. Respondent shall notify ERS when it anticipates media coverage that could raise questions among Participants and other constituencies before the coverage is expected to occur. When appropriate, Respondent will work with ERS to develop answers to potential questions from Participants and other constituents before coverage occurs.

Information about Participants in the GBP is considered confidential under Texas law. For media

inquiries specifically related to Participants, Respondent shall follow the process outlined below: • Respond to the media representative in a timely way, but only acknowledge receipt of the

inquiry and provide an expected timeframe to respond more fully. • Immediately provide a high-priority written notification to ERS’ Media Relations Officer and

AD of Benefit Contracts or designee, outlining all details related to the media’s inquiry and all known facts of the related circumstances.

• Wait for instructions or, as needed, work with ERS to determine how to respond. • Respond to the media as determined by ERS. (In many cases, ERS may respond to the

media directly and request that Respondent not respond at all.)



BCBSTX’s response requires further clarification. This does not meet ERS’ requirements. BCBSTX shall withdraw its deviations and confirm that it will follow all of ERS’ requirements related to Media Inquiries.


Agreed. BCBSTX will follow the process as outlined in VII.F.1.o.

32. RFP Section VII.F.4.k. Welcome Packets. Respondent’s packets shall be produced and mailed to

approximately 415,000 Plan Participants and 85,000 Medicare-eligible Participants at ERS’ direction. Respondent shall coordinate with other appropriate GBP vendors as appropriate to provide supplementary program information to be included in the Welcome Packets. New enrollment packets shall be mailed by Respondent throughout the year. A proposed sample of a Respondent packet shall be included in Respondent’s Proposal. This packet should contain, but not be limited to, the following materials:

• Welcome Letter; • Fact Sheet; • Benefits Summary; • Information on Disease/Condition Management Services, Wellness Services and cost

management features; • Information on value added benefits;



• Respondent’s customer service contact information; • HIPAA exemptions; and • Sample EOB.

ERS and Respondent will discuss appropriate timelines during implementation.



BCBSTX’s response requires further clarification. BCBSTX shall describe the process for identifying and applying the redacted to drive effective communications and engage participants. How will BCBSTX obtain data to determine redacted? Will this process impact the quality, timing and delivery of welcome packets?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has developed a redacted. This model redacted. We can then redacted. Starting redacted. For each communications campaign, for example the welcome packets, we can redacted. Upon the redacted, we would request redacted. Upon effective date, participants can redacted. On an ongoing basis, our redacted from BCBSTX. The approach for our communications strategy is to redacted. The redacted approach will not impact the quality, timing or delivery of welcome packets. Our intention is that participants will receive a message that resonates with them and drives them to take the appropriate action as it relates to their health and their health care.

33. RFP Section VII.F.5.i. Respondent Access Portal. Respondent shall provide an easy to use

Participant portal that provides access to a secure website that allows Participants to: • Search medical coverage information; • View and print EOB for claims; • Download forms; • Take a health risk assessment; • Acquire a temporary ID card; • Enroll in e-statements; • Compare treatment costs; • Provide information on any value-added products offered; and • Provide health and wellness information.





BCBSTX’s response requires further clarification. Does the portal offer any type of cost estimators? If so, please describe. If not, are there plans to add cost estimators? Are there any other value-added products or services offered by BCBSTX? If so, please describe and state, for each, if there are any additional costs associated with them or confirm that they will be included within the Administrative Fee quoted. If not, are there plans to add any other value-added products or services?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. The redacted offer a treatment cost estimator tied to network providers, plan benefits and, redacted. Sentence redacted. There are many other value-added products and services offered by BCBSTX via the member portal, including redacted. We are continually evaluating opportunities to add more value-added products and services to our offerings. As we seek to continually improve the participants’ end to end experience with us, we are focused on enhancing our participant facing digital and mobile capabilities to take advantage of technology advances and more widespread adoption of these technologies. This includes redacted. As technology advances and there are new redacted. Some of the areas we are looking at these capabilities for redacted. Through our redacted, we can partner with ERS to redacted.

34. RFP Section VII.H.1.a. ERS strongly believes that the account service relationship is the critical link

in developing and maintaining a strong working relationship dedicated toward the achievement of Plan objectives. As such, Respondent shall be committed to providing ERS with a service attention that is at the highest levels in the industry and fully consistent with ERS’ expectations. ERS shall define the criteria for measurement and evaluation of service performance.





BCBSTX’s response requires further clarification. When does BCBSTX expect to have redacted operational?


35. RFP Section VII.H.1.i. If Respondent contracts with a management company for some or all of its

administrative services, please specify:

Name of Company: Physical address: Mailing address: Email address: Telephone number: Facsimile number: Services provided: Reimbursement Method:



BCBSTX’s response requires further clarification. BCBSTX indicated that all administrative services are provided through internal resources. Are ID cards produced internally?


Table redacted.

36. RFP Section VII.H.2.a. Does Respondent propose to use subcontractors in the performance, delivery

and provision of any services and products requested hereunder? Yes No





BCBSTX’s response requires further clarification. BCBSTX's response to RFP Section VII.H.1.i. indicated that redacted. However, the answer to RFP Section VII.H.2.a. indicates that redacted. Which answer is correct?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. When responding to VII.H.1.i. it was our understanding that the intent of this question was determine if respondents use a third party administrator or management company to perform the proposed administrative services. Sentence redacted.

37. RFP Section VII.H.2.b. If applicable, provide the information below for each subcontractor and

specify what services may be performed by each subcontractor. Any planned or proposed use of subcontractors by Respondent shall be clearly disclosed and documented in Respondent’s Proposal, including specification of the services that may be performed by each subcontractor. Further, Respondent shall provide complete information, prior to and, if requested by ERS, after execution of the Contract, regarding each subcontractor used by Respondent to meet the requirements of the Contract. List each in the following format:

Name: Physical address Mailing address: Email address: Telephone number: Services performed: Length of time contracted with subcontractor:



BCBSTX’s response requires further clarification. Please describe how integration with redacted work. How would a physician know redacted to access if trying to complete redacted for an applicable service?


Paragraph redacted. Information on how to contact us will be on the back of the ID card which directs all providers to the appropriate resource redacted. Sentence redacted. This approach ensures an easy and seamless process for the requester. Sentence redacted.



38. RFP Section VII.H.3.h. Describe Respondent’s interactive web-based benefit “cost estimator tools” that allow cost comparison of GBP program choices (HealthSelect v. Consumer Directed HealthSelect v. HMO). Please also elaborate on any additional tools offered that are not specifically described in that section.


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. In BCBSTX's response, there was no clear indication of this tool other than it helps " redacted." What does this mean? Is there an input to prioritize cost, convenience or anything else? If so, describe. The response goes on to cite " redacted. . ." Is this available not only for plan selection but also for decisions like OOP costs for network vs. out-of-network care, etc.?


We will design and develop the plan selector tool in collaboration with ERS so that participants can compare GBP program choices along the most important characteristics, whether it is cost, ease of access, preferred provider, treatment cost, or other attribute. The plan selector concepts shared to date were developed based on the information available to us today. We anticipate building out a more robust experience with ERS so that participants can easily evaluate their plan choices.

39. RFP Section VII.H.4.n. How does Respondent ensure that its customer service representatives are

providing timely and accurate information?


ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX indicated that they audit redacted calls per CSR per week for redacted each month. Using redacted samples, does each CSR have a number of percentage of calls monitored weekly and monthly? Are there any call calibration sessions or meetings to discuss this with the CSR? How is feedback provided and/or discussed with each CSR and how frequently? Does BCBSTX require representatives to meet a specific call handling time? Will ERS have the ability to customize the post-call customer service survey?




Customer service supervisors currently evaluate soft skills through redacted. Two sentences redacted. Effective redacted, to include redacted for each audited inquiry. Criteria for evaluating the customer experience includes redacted. Paragraph redacted.

BCBSTX coaches representatives on their redacted. Our service philosophy is to provide exceptional service by identifying and resolving issues, anticipating needs, and helping educate customers. We strive to thoroughly resolve the customer’s inquiry the first time, and not give the customer a to-do list or put them in a position to have to call back. While we do train our representatives to recognize what issues might need to be pended for further review off line, we never want our customer representatives to feel they are rushed to get to the next call. We want 100% of their attention focused on the customer they are speaking with. The customer service metrics we believe translate to exceptional service, and for which we hold representatives accountable, are:

• Redacted

The Post Call Survey questions redacted.

40. RFP Section VII.H.4.t. Describe Respondent’s calculation methodology applicable to the proposed call center metrics requirements referenced in Appendix G.



BCBSTX’s response requires further clarification. BCBSTX shall include and describe the calculation methodology as requested.


Table redacted.

41. RFP Section VII.H.4.v. With regard to written inquiries received by Respondent, provide the

following:

Describe Respondent’s procedure for managing written inquiries.



What is Respondent’s current response time standard with respect to questions requiring written communication?



BCBSTX’s response requires further clarification. BCBSTX shall fully describe the process for managing written inquiries: what is BCBSTX’s standard time for response and resolution to written inquiries? Will a dedicated ERS team member handle the written inquiries? How are written inquiries routed to the appropriate review area?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Written, faxed, and emailed inquiries are scanned into our electronic image system and redacted for research and resolution. At the same time the image is scanned, redacted. Two sentences redacted. For example, the inquiry might involve action items such as a request for a claim review, a COB update, and an ID card. Two sentences redacted. Sentence redacted. Only when all activities within the service request have been completed can the service request be closed. BCBSTX standards for responding to written inquiries varies by type of inquiry: Remaining response redacted.

42. RFP Section VII.H.4.x. Describe the types of access (automated, interactive, etc.) Respondent

provides to Participants in order that Participants can obtain the necessary information regarding health care services, coverages, benefits, equipment, supplies, products and providers.


BCBSTX’s response requires further clarification. BCBSTX indicated that web chat is available. Is web chat available to all participants? How will BCBSTX ensure that GBP participants will receive accurate program information? Which representatives participate in web chat? Is chat a feature that requires the participant to log in first? BCBSTX indicated that a mobile app is available. Is the mobile app configurable/customizable? Is it available to all participants? Is the information behind



a log-in screen? With regard to the mobile app, BCBSTX states that eligible participants will have access. Please define who is eligible or if the GBP has a population who is considered ineligible.

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Webchat is available to all HealthSelect and Consumer Directed HealthSelect participants. The representatives who manage webchat inquiries will be part of the dedicated customer service unit. As with all our dedicated teams, these representatives will receive specialized training on both plans to ensure responses are accurate whether through phone, webchat, or secured email messaging. Webchat and secured email interactions are audited for quality and held to the same standard as all interactions with customer service. Webchat is accessible through the secure member portal, Blue Access for Members. It can also be accessed through our mobile app, which will be available to all participants with either HealthSelect or Consumer Directed HealthSelect. Paragraph redacted.

43. RFP Section VII.H.4.aa. How does Respondent’s customer service system support Participants with

disabilities?



BCBSTX’s response requires further clarification. Does BCBSTX offer any additional support for the visually impaired? BCBSTX shall confirm that it has visual and auxiliary aids available to adhere to ACA non-discrimination laws as required.

BCBSTX’s October 11, 2016 Clarified Response*: BCBSTX offers additional support for the visually impaired. As an example, visually impaired participants can request printed materials in Braille. Our approach for supporting ERS participants extends across phone, print and digital communications. Our intent with every communication is to make sure that participants understand the content and what action they need to take next (even if in some cases they do not need to take any action). This includes participants with hearing, visual or other impairments.

44. RFP Section VII.H.4.bb. Language Accessibility. Respondent’s Call Center shall have staff available

to provide language translation services to meet the service level objectives defined in Appendix G, Call Center Metrics, and Appendix F, Performance Guarantees. This may be provided by using a language translation organization.





BCBSTX’s response requires further clarification. BCBSTX shall confirm that it has the capability to translate written "significant benefit materials" to members in any of the top fifteen (15) languages within Texas if requested in adherence with ACA non-discrimination requirements.

BCBSTX’s October 11, 2016 Clarified Response*: Confirmed. BCBSTX has relationships with translation vendors that will be able to translate "significant benefit materials", if requested, and in accordance with ACA non-discrimination requirements.

45. RFP Section VII.H.4.gg. Describe Respondent’s ability to make immediate/emergency enrollment

updates upon phone or email request from ERS.



BCBSTX’s response requires further clarification. Does BCBSTX have an employer/client portal that would permit ERS' representatives to update emergency coverage on request?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Yes. We have a secure online portal, Blue Access for Employers, that many of our clients use to conduct initial enrollment and maintenance eligibility transactions. Sentence redacted. Blue Access for Employers also features redacted. As part of the redacted this portal. Sentence redacted. The following include examples of redacted transactions:

• Redacted

46. RFP Section VII.H.4.hh. Are the updates real-time and how quickly can a provider view the

enrollment update?





ERS’ October 4, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX’s response requires further clarification. BCBSTX shall confirm that if redacted, BCBSTX will proactively redacted. BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Paragraph redacted. This applies to situations redacted. Additionally, our redacted.

47. RFP Section VII.H.4.ii. Describe the hours that Respondent’s staff is available to handle immediate/emergency updates.



BCBSTX’s response requires further clarification. Does BCBSTX offer an option for ERS staff to update the BCBSTX enrollment system when BCBSTX staff is unavailable? If not, is this an option that may be provided in the future? If so, when?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Yes. We have a secure online portal, Blue Access for Employers, redacted. Blue Access for Member is available 24 hours a day and 7 days a week. As part of the implementation and transition plan, BCBSTX will provide ERS representatives the necessary training and support to access this portal and together, we will determine the most appropriate timeline for when the portal is available. For example, ERS may determine it does not want to use this portal for summer or fall enrollment and only use for emergency updates.

48. RFP Section VII.H.5.a. Audits. ERS may contract with one or more auditing firms to conduct

periodic audits of Respondent. Respondent shall cooperate with and support the efforts of the auditors. Neither ERS nor the auditors will be required to indemnify Respondent for any costs



incurred in connection with these audits. Article 15 of the Contractual Agreement has additional requirements regarding audits.





49. RFP Section VII.H.5.b. Administrative Audit. As Plan administrator for the GBP, ERS may access,

request, and audit documents related to the Plans and Participant records as required for purposes of administering the GBP.





50. RFP Section VII.H.5.c.ii. Respondent’s support shall include maintaining readily available data that

is accessible electronically as well as through hard copy. Neither ERS nor the auditor shall reimburse or indemnify Respondent for any cost incurred or any claim that may arise in connection with or relating to these audits.







51. RFP Section VII.H.7.j. Are customer service representatives separated from the claim processing

unit, or do claim processors have customer service responsibilities?



BCBSTX’s response requires further clarification. How does this coordination between the claims processors and customer service representatives occur while the member is on the phone if there's a billing concern?

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. Coordination between the claims processors and customer service representatives is not required to resolve billing concerns or claim issues. Both redacted, have access to redacted and redacted. Most claim inquiries can be resolved independently by the customer service representative, but when additional help is needed, they rely on redacted for assistance with complex issues, including complex claims issues. Two sentences redacted. Paragraph redacted.

52. RFP Section VII.I.4.m. Briefly describe Respondent’s data back-up and recovery procedures for the

system(s) to be used in the services proposed to ERS.



BCBSTX’s response requires further clarification. Is BCBSTX referring to live real-time data replication in this response with regards to their predetermined critical apps?




53. RFP Sections VII.8.l. and VII.8.l.i. Describe the reports to be provided by Respondent on a regular

basis at no charge to its customers by including the following information:

Title of Report Detailed description of the information provided in the report

Frequency provided (monthly, quarterly, annually)

RFP Section VII.H.8.l.i. Provide copies of the reports listed above.



BCBSTX’s response requires further clarification. The submitted reports only show the redacted, but none of the others described. BCBSTX shall provide the other reports described.

BCBSTX’s October 11, 2016 Clarified Response*: All confidential and proprietary information has been redacted and shown as “redacted” below. The following sample reports are attached:

• Redacted

54. RFP Section VII.J.1.d. Before 8:00 a.m. CT on each business day, Respondent shall notify ERS

electronically of the balance of the DDA that is pending for reimbursement. ERS will instruct its custodian bank to transfer the funds via Fedwire to the DDA to settle the claim reimbursement on the same day if it is a business day on which ERS is fully open for business and if it is at all reasonably practicable to do so. Although Respondent shall be responsible for maintaining sufficient funds to provide for the cost incurred, Respondent shall not be responsible for the sufficiency or collection of Plan contributions. Due to the timing of the claims reimbursements, Respondent may be required to advance up to three (3) days (or more, depending on the applicable State holiday schedule) of its own resources for claims payments. Three (3) days of claims payments is projected to average around $20 million.





BCBSTX’s response requires further clarification. BCBSTX shall confirm that filing claim reimbursements from ERS is based on check presentment, not on check issuance. For example, a provider filed a claim from BCBSTX and BCBSTX issued a check to BCBSTX for settlement of the claim on October 1, 2015. The provider cashed the check on October 15, 2015. BCBSTX would file the claim reimbursement from ERS on October 15, 2015, not on October 1, 2015.



Sincerely,





Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated November 7, 2016

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated November 7, 2016, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.



1. The Contractual Agreement will include additional language (under separate cover to counsel) under which the TPA is required to credit to the Plan any and all rebates and other revenue it receives from a pharmaceutical manufacturer in connection with a covered pharmaceutical product that is submitted to and paid by the TPA as an eligible claim under HealthSelect. ERS’ November 7, 2016 Clarification Request:


BCBSTX’s November 9, 2016 Clarified Response: * Entire response is considered confidential and proprietary and is redacted.



2. Based on the discussions between ERS and BCBSTX on October 31, 2016, it is ERS’ understanding that HealthSelect participants may obtain Network benefits through: All confidential and proprietary information has been redacted and shown as “redacted” below. (a) A Primary Care Physician (PCP) who is redacted. (b) A hospital-based physician who is a member of redacted has been mutually agreed upon by

ERS and BCBSTX. (c) A specialist who is a member of redacted has been mutually agreed upon by ERS and

BCBSTX. (d) A hospital that is a member of the redacted has been mutually agreed upon by ERS and

BCBSTX in order to meet access standards as required under Article VII.D.2.l and VII.D.2.l.i of the RFP.

ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX shall confirm the following: (a) These provisions will eliminate redacted. (b) These provisions will redacted.


(a) *If there are areas redacted exist as required in the RFP, BCBSTX will redacted. Sentence

redacted. Paragraph redacted. Upon contract award, we ask that ERS provide a membership listing of all participants and their PCP designation. This information will redacted. Currently, our redacted. Paragraph redacted. Paragraph redacted.

We recognize the importance of minimizing disruption to your participants, redacted. Upon contract award, redacted. To help with this transition, redacted.



(b) * Paragraph redacted. Paragraph redacted

3. Based on the discussions between ERS and BCBSTX on October 31, 2016, it is ERS’ understanding that: All confidential and proprietary information has been redacted and shown as “redacted” below. (a) Paragraph redacted.

(b) The September 26, 2016 BCBSTX Clarified Response includes the following statement on

page 24:

“Statement redacted.”

ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. Paragraph redacted


Paragraph redacted

Paragraph redacted

4. Currently under HealthSelect, emergency services provided at a free-standing emergency facility are reimbursed based on billed charges, provided the medical condition for which the emergency services are provided meets the standards established by the Plan Document. ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.

Please confirm that BCBSTX intends to administer such services redacted.


* Paragraph redacted



5. As discussed on October 31, 2016, the Member Rewards program proposed includes a cash reward to be paid to the eligible HealthSelect participant. Because ERS is an employer-sponsored, self-funded health plan, such payments require provision of a W-2 to the participant. Since ERS is not the employer, it is unable to provide the required W-2. As a result, ERS is unable to administer the proposed Member Rewards program. ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.

What impact does redacted have on the following: (a) Paragraph redacted.

(b) The proposed In-Area Target Claim Cost guarantees. (c) Other financial terms of BCBSTX’s Proposal.


(a) *If ERS determines redacted.


6. ERS’ November 7, 2016 Clarification Request:


BCBSTX shall provide the following: (a) Please specify the cost to the health plan and to the participant of redacted

(b) Please provide further information regarding the cost of redacted. BCBSTX’s November 9, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

(a) *Paragraph redacted..

The redacted below outlines the redacted.

Table redacted.

(b) *MDLive also redacted. In the event a redacted.

Below ERS will find the average reimbursement rates redacted.

Table redacted.



7. ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below. Please describe the legal relationship between BCBSTX and/or HCSC and the Texas Medical Association related to TMA Practice Edge. BCBSTX’s November 9, 2016 Clarified Response: TMA PracticeEdge, L.L.C. is a Texas limited liability company whose members (owners) are the Texas Medical Association (TMA) and Blue Cross and Blue Shield of Texas (BCBSTX). TMA hold the majority membership interest in TMA PracticeEdge. Management and control of PracticeEdge is vested in a Board of Managers who are appointed by TMA and BCBSTX.

8. As discussed on October 31, 2016, ERS is confused by the following chart provided on page 46 of the September 26, 2016 BCBSTX Clarified Response.

Table redact.

ERS interprets the data provided in the column captioned redacted. Based on other information provided re: redacted. ERS’ November 7, 2016 Clarification Request:

Please confirm or correct the information provided in the chart above. BCBSTX’s November 9, 2016 Clarified Response:

*Paragraph redacted. Table redacted. For example, using a standard distribution of services, the average redacted

9. The September 26, 2016 BCBSTX Clarified Response includes the following statement on page 10:

“We are actively deploying contracting strategies to support the HealthSelect network and the network continues to grow. For example, since our proposal submission we have added the integrated health system University of Texas Medical Branch in Galveston to the HealthSelect network at a 10% reduction off our existing network.” ERS’ November 7, 2016 Clarification Request: All confidential and proprietary information has been redacted and shown as “redacted” below.



(a) Please confirm that this addition was not reflected in the original response to RFP Article VII.C.3 and Article IX.C.

(b) If there are changes from your original RFP response, please provide the redacted data requested in RFP Article VII.C.3. and Form 1-4 in RFP Article IX.C.


(a) *The addition of redacted.

(b) *Under separate cover, BCBSTX will be sending an updated redacted. There are no changes to

Forms 1-4 of Article IX.C as submitted in our original RFP response.

We appreciate the opportunity to provide clarification and welcome additional questions that provide ERS clarity to any outstanding questions. Under separate cover, I will be sending the redacted referenced in question 9(b). Please do not hesitate to contact me at (512) 795-5908 or [email protected] with any further questions.

Sincerely,




September 6, 2016

Ms. Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 East 18th Street Austin, Texas 78701

Re: RFP No. 327-94807-160623; Request for Proposal to Provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – Clarification Request Dated August 30, 2016; Price Proposal/Network Access Clarification Questions

Dear Ms. Grissom,

We are pleased to submit a response to ERS’ request for clarification, dated August 30, 2016, related to our price proposal and network access from our proposal to provide Third-Party Administrative services for HealthSelect, including Consumer Directed HealthSelect.

Price Proposal/Network Access Clarification Questions 1. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting

Ms. Ginger Grissom September6, 2016 Page 2

status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.


Acknowledged.


BCBSTX’s response requires further clarification. Please confirm that the repricing claim file in Form 5 of the Price Proposal was done by BCBSTX and not Milliman. In addition, please describe the methodology used to reprice the claim files.

BCBSTX’s September 6, 2016 Clarified Response:

*The repriced claims file in Form 5 was conducted by BCBSTX. The Milliman analysis submitted as part of our proposal was third-party analysis of the value of our network. Milliman’s analysis was separate and distinct from the repricing performed by BCBSTX and similarity of the results from both parties serves as a confirmation of the accuracy of the analysis from both parties.

Methodology for Repricing Form 5:

Response redacted. This information is confidential and proprietary.

2. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a


detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.


Acknowledged.


BCBSTX’s response requires further clarification. Please describe the contents of the three repricing files provided, Reg_CLMs.txt, Magellan_KR_CLMs.txt, and TX_NO_PFIN_CLMS.txt. Provide explanations for when allowed amounts were not provided.



*The following provides explanation on the contents of the three repricing files.

Reg_CLMs.txt

• Claims that were repriced.

Magellan_KR_CLMs.txt

• Redacted. • It is important to note that these claims are only those where the servicing provider was

redacted. It does not include all redacted services as we do not have primary care physician designations to truly capture all redacted claims.

TX_NO_PFIN_CLMs.txt

• Claims where BCBSTX was unable to match the provider information included in the RFP (NPI, and Tax ID) to any provider record in our files.

Allowable amounts were not provided in the following situations:

o Claims with deleted or invalid HCPCS/CPT codes that could not be mapped to an appropriate code.

o Claims with invalid diagnosis or procedure codes that prevented proper grouping/assignment of the claim.

o Claims with "0" charges. o Claims for which we have a contract for capitation (identified separately in

Magellan_KR_CLMs.txt).


o Claims for providers that could not be identified based on the information provided in the RFP (identified separately as TX_NO_PFIN_CLMS.txt).


3. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.


Acknowledged.


BCBSTX’s response requires further clarification. Please describe the capitation arrangements listed in the repricing files. Please provide capitation amounts for each group and how to attribute ERS’s members to the group.



*BCBSTX currently has redacted.

Magellan Behavioral Health is redacted behavioral health services. Redacted. Additionally, attached ERS will find redacted.


• Inpatient precertification and concurrent review • Ambulatory follow-up/discharge planning; hospital transition • Intensive outpatient precertification/concurrent review • Outpatient solutions program (in-network only) • Quality improvement/reporting • Appeals/Complaints • Care Coordination • Behavioral health provider network (facility and professional) • Claims processing and payment • Co-located case management • Autism connections (case management, claims processing, network access) • Computerized cognitive behavioral therapy (CCBT)

(Note that emergency room claims that do not result in an inpatient stay, and other Non-ER (e.g. lab) claims are not included.)

Kelsey-Seybold Clinic and Renaissance Physician Organization redacted as their primary care physician. A detailed summary of redacted for these groups are included in the enclosed risk matrices; “redacted”.

Check marks under the column redacted. When a check is seen under “HealthSelect” it means the services redacted.

.


4. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a


detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.


Acknowledged.


BCBSTX’s response requires further clarification. Providers generally have a single contracting status with a TPA. The attached file "NPI BCBS.xlsx" presents the re-price allowed amount by billing NPI and provider contracting status. The BCBSTX reprice claim file has multiple provider contracting status for every billing NPI. Please review and confirm the accuracy of the provider contracting status field. If necessary re-submit the re-price claim file in Form 5 of the RFP.



*Our objective was to map the Tax ID’s and NPI’s, provided by ERS, in a manner that allowed for the selection of the most granular and appropriate provider numbers and reprice these claims based on provider network status and the rates contained in our provider contracts effective 6/1/2016. Redacted. We have corrected this issue and the refined mapping now assigns the right provider network in all cases. Enclosed ERS will find a resubmitted Form 5. Two copies have been provided.

Note that there can be occurrences whereby a provider is in one network for most of their services and then in another network, or out of Network, for an isolated set of services. And Physicians can participate under multiple tax ID numbers, with different network participation. These are the exception, rather than the rule, and our revised repricing file submission illustrates that.

Additionally, as discussed in our meeting on August 25, 2016 our network continues to aggressively contract with providers and our discounts will continue to improve.


5. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status


should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.


Acknowledged.


BCBSTX’s response requires further clarification. On the August 25, 2016 clarification conference call, BCBSTX stated that a couple of providers have been incorrectly coded as non-contracted. Please resubmit the reprice claim file in Form 5 of the RFP.


*Attached is a resubmitted Form 5 of the RFP. Two copies have been provided.


6. RFP Section IX.C.1.e. Form 5 is to be completed with Respondent’s allowable charge for each of the claims included in the file claims.zip, which is described in Appendix J of this RFP. Instructions for reading the file and a file record description are included in Exhibit R of Appendix J. For each claim, Respondent is to provide (a) the unique record number, (b) provider contracting status as of June 1, 2016, and (c) the charge amount that Respondent would have allowed under its reimbursement arrangement with that provider as of June 1, 2016. Provider contracting status should indicate whether the provider is (1) a contracted network provider, (2) a non-network provider with some alternative contracting status, either directly or indirectly with Respondent, which allows for discounted reimbursement and/or relief from balance billing to Participants (referred to herein as a contracted non-network provider). or (3) a provider with no contracting status with Respondent. The information provided in the claims file should be adequate to determine the allowable charge. Respondent is not to provide payment amounts, only allowable charges. Provide a description of the methodology used to reprice these claims along with a detailed example of repricing an individual claim. If Respondent uses capitation in its reimbursement methodology for certain facilities, so indicate.



Acknowledged.


BCBSTX’s response requires further clarification. BCBSTX shall provide a control report for the repricing file. This file should summarize the billed, eligible, and allowed amounts by Provider Contracting Status.


*A control total summary has been submitted with Form 5. It is labeled as the fourth file “Control_Totals.txt”.


7. RFP Section VII.C.1.l. Provider Accessibility and Availability. Respondent must provide documentation on CD or DVD using ERS-required format to describe its existing provider network. Separate documentation must be provided for each of the following: (i) hospitals, (ii) PCPs, (iii) specialty care physicians, and (iv) behavioral health providers. The current HealthSelect provider directory is included in Appendix L.


Agreed. Please find BCBSTX CD/DVD documentation in TAB B-1.


BCBSTX’s response requires further clarification. The In-Network provider listing file “20 Tab VIb - Requested Materials - B-1 - BCBSTX HealthSelect Provider Listing.xlsx” has multiple records for each provider. BCBSTX shall provide a new file that only contains one record for each provider using the primary address.



*BCBSTX has updated the HealthSelect Network Provider Listing to be limited to a single NPI for purposes of identifying an aggregate provider count. This updated HealthSelect Network Provider Listing is attached; “HealthSelect Network Provider Listing - Single NPI_08312016.xlsx.”.

BCBSTX does not require a primary location be specified redacted. This updated listing should not be used to represent network adequacy or participant disruption as many providers have multiple office locations to service participants.







BCBSTX’s response requires further clarification. Some billing NPIs are listed in both the In-Network provider listing file “20 Tab VIb - Requested Materials - B-1 - BCBSTX HealthSelect Provider Listing.xlsx” and the Contracted Non-Network provider listing file “44 Tab VIb - Requested Materials - B-3- Contracted Non-Network Providers....xlsx”. For example, redacted. BCBSTX shall explain why they appear in both files.



*BCBSTX utilizes more than just a provider NPI to determine contracting status of a provider. This allows for flexibility when considering exclusive or preferred listings within our provider directories.


For example, for facility based providers, it is the combination of Tax ID number, NPI, provider specialty, or location that correlates with a BCBSTX provider number and assigned to network. For professional providers it is the combination of Tax ID number and NPI. A professional provider may practice under multiple tax id numbers, and we may have a contract with one tax id number but not another. In response to the supplied examples:

Redacted – NPI is being used by two different hospitals that are part of the same system but at different locations. One location is in network; the other is not.

Redacted – This NPI maps to two distinct BCBSTX provider records, a medical and behavioral health record. The provider type that is contracted non-network is Psychiatric Residential Treatment Center.


9. RFP Section IX.B.1.a. GBP Self-Funded Benefit Coverage Program Administrative Fee is $_______per Member per month. Member is defined as a Participant who is an employee, retiree or other person eligible to participate in the GBP as provided under the Act and who is not a dependent.


All confidential and proprietary information and has been redacted.


BCBSTX’s response requires further clarification. Confirm that the administrative fee provided in response to RFP Section IX B.1.a includes production and distribution of 1095-Bs.



*Confirmed. Our offered administrative fee of redacted.




Sincerely,

Cyrus Walker Sales Strategy Executive cc: Keith Barnes, Vice President, Enterprise National Accounts Enclosures (All enclosures include confidential and proprietary information and are redacted.)

Response to Clarification Request

August 23, 2016

Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 E. 18th Street Austin, Texas 78701

RE: RFP No. 327-94807-160623 RFP No. 327-94807-160623; Request for Proposal to Provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – Clarification Request

Dear Ms. Grissom,

We are pleased to submit a response to ERS’ request for clarification to our proposal to provide Third-Party Administrative services for HealthSelect, including Consumer Directed HealthSelect.

Article II. General Instructions

1. RFP Section II.E.4. Signature Requirements. Respondent’s Authorized Representative (as reflected on the Incumbency Certificate) shall execute, in blue ink, the Signature Pages attached herein within Appendix A which is a part of this RFP. The signatures of Respondent’s Authorized Representative on the Proposal’s signature pages and all other related documents submitted by Respondent reflect Respondent’s agreement with the truth and accuracy of all statements, warranties and representations contained in the Proposal and other documents submitted by Respondent. The


signatures further reflect Respondent’s authorization for ERS to rely on same for all purposes in connection with the RFP/Proposal process.


Acknowledged.


BCBSTX’s response requires further clarification. The notary statement on the following signature pages states that Blue Cross and Blue Shield of Texas is a Texas corporation: Statement of Officer Regarding RFP, Proposal and Financial Standing; Statement of Officer Regarding Conflicts of Interest Contractual Provisions; Statement of Officer Regarding Confidential and/or Proprietary Information; and Statement of Officer Regarding Information Security and Confidentiality Requirements. In its due diligence check, ERS has been unable to confirm that Blue Cross and Blue Shield of Texas is a Texas corporation. In addition, in its response to RFP Section VI.D.3.b., BCBSTX states that it was incorporated in Illinois. Please respond as follows:

a) BCBSTX shall state where it was incorporated. b) If the signature pages referenced above were incorrect, BCBSTX shall provide corrected

signature pages.

BCBSTX’s August 25, 2016 Clarified Response:


a) An inadvertent clerical error was made when completing the notary acknowledgment. Blue Cross and Blue Shield of Texas, a division of Health Care Service Corporation, a Mutual Legal Reserve Company, an independent licensee of the Blue Cross and Blue Shield Association. HCSC was incorporated in Illinois in 1936 and authorized to do business in Texas in 1939.

b) An inadvertent clerical error was made when completing the notary acknowledgment. Corrected signature pages are provided.



2. RFP Section VI.D.3.a. Provide Respondent’s Texas Franchise Tax Account Status report and, if not incorporated or formed in Texas, evidence of good standing in its jurisdiction of incorporation or formation.


Acknowledged. Please refer to TAB B-6 Texas Franchise Tax Account Status.


BCBSTX’s response requires further clarification. BCBSTX’s Texas Franchise Tax Report indicates “Franchise Tax Ended.” BCBSTX shall explain why the franchise tax has ended.

BCBSTX’s August 25, 2016 Clarified Response:

As described below, pursuant to Section 171.052, Subchapter B. Exemptions, Blue Cross and Blue Shield of Texas, a division of Health Care Service Corporation, a Mutual Legal Reserve Company, is exempted from paying Franchise Tax.

TAX CODE TITLE 2. STATE TAXATION

SUBTITLE F. FRANCHISE TAX CHAPTER 171. FRANCHISE TAX

SUBCHAPTER B. EXEMPTIONS

Sec. 171.052. CERTAIN CORPORATIONS.


a) Except as provided by Subsection (c), an insurance organization, title insurance company, or title insurance agent authorized to engage in insurance business in this state that is required to pay an annual tax measured by its gross premium receipts is exempted from the franchise tax.



Sincerely,

Cyrus Walker, Sales Strategy Executive (512) 795-5908 [email protected]


Enclosure (1)


September 26, 2016 Ms. Ginger Grissom, CTCM, CTPM Procurement Manager, Office of Procurement and Contract Oversight Employees Retirement System of Texas 200 East 18th Street Austin, Texas 78701

Re: RFP No. 327-94807-160623; Request for Proposal to provide health care administration (claims processing, network management and utilization review), benefits and services for the HealthSelectSM of Texas plan under the Texas Employees Group Benefits Program – ERS Clarification Request Dated September 16, 2016

Dear Ms. Grissom,

Blue Cross and Blue Shield of Texas (BCBSTX) is pleased to submit a response to Employees Retirement System of Texas’ (ERS) request for clarification, dated September 16, 2016, related to our proposal to provide Third-Party Administrative services for HealthSelect of TexasSM (HealthSelect), including Consumer Directed HealthSelect.


Article IV. Organizational Information

1. RFP Section IV.C.4. Client Due Diligence. Provide the name of every entity that has terminated a contract with Respondent for any reason in the past five (5) years by providing the information below:

Company Name: Address: Account Primary Contact: Title: Email Address: Telephone Number: Services Performed for Client: Date contract terminated: Reason contract terminated:

Ms. Ginger Grissom September 26, 2016 Page 2



The following represents Administrative Services Only (ASO) accounts with membership representing 5,000+ who have terminated their contract with HCSC in the past 5 years. For purposes of this response we define termination as a cancelation of the contract prior to original contract end date, not to include cedes to other Blue Plans. In general, reasons for termination are confidential, but examples of “reason contract terminated” include; unable to pay administrative fees, plan no longer can fund the claims, or breach of contract by either party.

Table redacted. This information is confidential and proprietary.


BCBSTX’s response requires further clarification. BCBSTX shall remove its qualification that it is providing a response with respect to only certain contracts and provide ERS with the most recent five (5) Contract terminations that involved third-party health administration services with memberships of at least 10,000 participants.


The following includes former clients of BCBSTX who have terminated their contract within the most recent five (5) years that involved third-party health administration services and held membership of at least 10,000 participants.*

Table redacted. This information is confidential and proprietary.


2. RFP Section VI.A.5.b. Respondent shall state the amount placed at risk for the GBP Self-Funded Basic Coverage Program Performance Guarantees, which shall be at a minimum 10% of total annual Administrative Fees or an amount larger highlighting the Respondent’s commitment to the GBP.

$__________________

RFP Section VIII.A.3. Health Care Management Incentive. Under the Contract, Respondent will have an incentive for the efficient and cost-effective management of health care provided to in-area Participants. Generally, the incentive will be a potential charge to Respondent based on actual in-area claims (actual claims) as compared to target claims agreed upon in advance by Respondent and ERS as described more fully below. Respondent understands and acknowledges that if actual claims are more than 102% of target claims then it shall be charged and assessed all sums that Respondent states in its Proposal it will pay for failing to meet the HCMI. This incentive is not an insurance or reinsurance arrangement. The Contract will not include either specific or aggregate stop loss coverage.



BCBSTX’s August 11, 2016 Original Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

RFP Section VI.A.5.b.: Redacted

Note: At ERS’ discretion, Performance Guarantees will be allocated to the various severity levels based on the total amount at risk. Assessments for any single Fiscal Year will not exceed the total amount at risk.

Acknowledged. BCBSTX is redacted.

RFP Section VIII.A.3. Agreed.


BCBSTX’s response requires further clarification. In the worksheet “Ranking” of the file 17a Tab Vb – Requested Materials – B-5 -Deviations to Performance Guarantees V1.xlsx, included in the BCBSTX Response is the following note: “*redacted.”

The note seems to indicate redacted.

Provide two separate amounts as requested in the RFP.

a) State the amount placed at risk for the GBP Self-Funded Basic Coverage Program Performance Guarantees, which shall be at a minimum 10% of total annual Administrative Fees or an amount larger highlighting the Respondent’s commitment to the GBP.

b) State the amount the Respondent will pay for failing to meet the HCMI. Note that Exhibit 1 on page 85 of the RFP presents the required Health Care Management Incentive Arrangement. The arrangement includes a maximum amount at risk of 2% of Target Claims (as defined in the RFP). Therefore, it is necessary to state an amount only if the Respondent intends to establish a limit that is different from 2% of the Target Claims.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. a) Redacted. b) Redacted.



Article VII. Scope of Work

3. RFP Section VII.B.8.o. Respondent shall describe its COB process as it relates to the requirements described in the RFP and MBPDs. Respondent shall collect other health insurance information for the purposes of COB. Respondent is required to coordinate benefits with any group plan (other than a GBP-sponsored plan) under which a Participant has coverage. Respondent is not relieved of the duty to provide covered services as a result of such COB. If a Participant is eligible to receive benefits under another group plan for services, Respondent shall be responsible to coordinate benefits.


Agreed.


BCBSTX’s response requires further clarification. BCBSTX’s response was incomplete. BCBSTX shall describe its COB process as it relates to the requirements described in the RFP and MBPDs.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX uses a highly automated, online COB system that interfaces with the claims system in a real-time environment. This COB system stores all history for each active participant, complete with coverage dates and benefit descriptions of other coverage. Each claim submitted is processed against this history. Other automated features of the COB system include: • Redacted.

Payment Procedures The COB system accommodates our pay and pursue provision: • Prior to payment, all claims are checked against the COB history file for duplicate coverage. • If BCBSTX has no indication of other insurance coverage, claims will be adjudicated assuming

BCBSTX has primary liability, even if the participant has not returned a completed coordination of benefits questionnaire.

• If BCBSTX receives information that there is other insurance coverage through a claim, a returned check or a questionnaire, the participant’s COB history files will be updated to reflect this information. All claims subject to the other insurance coverage based on the effective date of that coverage will be adjusted accordingly.

• A coordination of benefits questionnaire will be systematically generated on an annual basis (dependent on claim submission) for participants who could have other coverage and for whom there is neither indication of other insurance nor any COB update in the past year.



Checks for Other Coverage The claims processing system checks each claim for other coverage using data provided by the participant or provider on the claim form as well as information stored in the participant’s file. Other coverage may include: • Health coverage available under another group benefit contract that would require

coordination of benefit. This information is obtained from the participant, provider, prior claim or inquiry, and questionnaires.

• Workers’ Compensation. This information is indicated by providers when filing claim but may also be determined based on participant’s diagnoses.

• Medicare. Eligibility can be determined by age, indication of permanent disability (regardless of age), employer, or information already stored in BCBSTX’s data files.

• Other third-party liability. In the event of third-party liability, BCBSTX may recover dollars previously paid through subrogation. *

4. RFP Section VII.C.1.e. Describe the service area(s) covered by Respondent’s managed care network as of the date of submission of the Proposal.


The BCBSTX service area is the entire state of Texas, which includes each of the 254 Texas counties.

To minimize any provider disruption, we have developed redacted. This redacted ensuring ERS participants have access to a broad provider network, and have flexibility and choice when selecting providers. ERS will have the redacted.

HealthSelect participants will also benefit from discounts on services from contracted non-network providers -- a cost protection feature not available with any other carrier! When participants choose out-of-network care, redacted.. It has the following advantages:

redacted

Extended Service Area – Nationwide

Participants living or traveling outside of our Texas service area will have access to the national Blue Cross Blue Shield (BCBS) network. The program expands the service area by providing access to providers in every state and zip code in the United States. Redacted. The program links providers through a single network for claims processing and reimbursement.

Through the national program, nearly redacted on out-of-network claims because of their scale, longstanding relationships with providers, and skillful network management.





• Is the following a correct interpretation of the statistics provided above?

Table redacted


• Describe how the redacted differs from redacted. Do the redacted? If not, how do they differ? • Are the provider reimbursement provisions redacted? If not, how do they differ? • Does the redacted include redacted?

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below.

• Is the following a correct interpretation of the statistics provided above? ERS is accurate in its interpretation. *


Statistics provided on the redacted based on actual claims data on the redacted.

• Describe how the redacted differs from redacted. Do the redacted? If not, how do they differ?


• Are the provider reimbursement provisions redacted? If not, how do they differ?


• Does the redacted include redacted? Yes, redacted.

5. RFP Section VII.C.1.k. Are Respondent’s out-of-State networks leased or proprietary? Is Respondent approved by TDI for reciprocity arrangements? If “yes,” where? Describe such arrangements, if any.




ERS participants residing or traveling outside of Texas will enjoy the stability of redacted.

The Texas Department of Insurance has approved BCBSTX policy filings that include access to redacted.


BCBSTX’s response requires further clarification. Describe the redacted. Are these redacted.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. The redacted for participants residing or traveling outside of Texas is redacted.





BCBSTX’s response requires further clarification. The In-Network provider listing file “20 Tab VIb - Requested Materials - B-1 - BCBSTX HealthSelect Provider Listing.xlsx” has multiple records for each provider. BCBSTX shall provide a new file that only contains one record for each provider using the primary address.


*BCBSTX has updated the redacted Listing to be limited to a single NPI for purposes of identifying an aggregate provider count. This updated redacted Listing is attached; “redacted”

BCBSTX does not require a primary location be specified within the provider application supplied during credentialing. This updated listing should not be used to represent network adequacy or participant disruption as many providers have multiple office locations to service participants.





BCBSTX’s response requires further clarification. Confirm that the provider file that BCBSTX sent originally contains all practice locations for each provider.

Additionally, BCBSTX shall provide two additional provider files for contracted In Network providers for the following specialties: Radiologists, Anesthesiologists, Pathologists, and Emergency Medicine specialists. One file shall contain only the primary address for each provider; the other shall contain all practice locations for each provider. Use the following codes to denote each specialty.

Two-Digit Code Specialty AN Anesthesiology EM Emergency Medicine RAD Radiology PTH Pathology

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. Enclosed ERS will find two files listing redacted for the following specialty types: Radiologists, Anesthesiologists, Pathologists, and Emergency Medicine specialists.

Report 1 Includes all Radiologists, Anesthesiologists, Pathologists, and Emergency

Medicine providers and the first/primary address. Report 2 Includes all Radiologists, Anesthesiologists, Pathologists, and Emergency

Medicine providers and all remaining addresses for the providers found in Report 1. *

7. RFP Section VII.D.2.h. Describe Respondent’s ability to implement a capitated payment structure.


BCBSTX is highly proficient redacted.

Redacted in Texas

Redacted are among the various redacted we currently administer. Within the redacted. Additionally, we have entered into redacted. Over the past 10 years, redacted.

BCBSTX and its redacted, and more. By incorporating redacted.




BCBSTX’s response requires further clarification. Under the redacted services? Under your redacted, what percentage of total FY2018 HealthSelect medical expenditures do you anticipate will redacted.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. No redacted. It is estimated that redacted. If ERS is willing to provide BCBSTX with redacted can be provided. *

8. RFP Section VII.E.1.d. If Respondent is proposing to offer additional services other than those outlined in this RFP including, but not limited to, any products, services, ideas, or facilities (including any discounts) it shall provide them in response to this Article.


ERS can expect complementary and integrated products, services, and facilities, as well as unique industry ideas developed into proven practices that reduce cost and provide ERS participants with the best experience. Whether saving money, avoiding surgery, or managing difficult health issues, participants will work with BCBSTX redacted.

Additional services include a redacted. With each of these offerings, BCBSTX provides additional services to improve a participant’s experience and reduces costs for both ERS and participants.

Paragraph Redacted

BCBSTX has offered a redacted since 2012. Since then it has grown steadily in scope and adoption. At inception, the product provided comparative cost information for approximately redacted services. Redacted.

Avoiding Surgery with Redacted

BCBSTX has developed a partnership redacted.

Paragraph Redacted

BCBSTX’s strategic partner has redacted.



Image redacted

Redacted Wellness Offerings

BCBSTX’s strategic partnership also includes cost wellness and engagement programs available to participants that offers redacted. ERS will receive quarterly participant outcome and experience reporting and pre/post engagement claim analytics.

Redacted for ERS Participants

BCBSTX’s redacted and empower ERS participants with knowledge about the greatest opportunities for redacted. The redacted offers savings opportunities for ERS.

Through our strategic partner, redacted. The redacted program provides ERS an opportunity for savings by redacted.

Paragraph redacted.

Paragraph redacted.

Comprehensive Redacted Management

We follow a multifaceted approach to redacted of the most critical components. BCBSTX redacted cover a significant portion of the ERS membership throughout the state. Sentence Redacted.

Paragraph redacted.


BCBSTX’s response requires further clarification. Please describe the development of the target price used in the redacted program.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. The target price will be inclusive of the redacted, to include;

• redacted For all commercial business, we analyze redacted of claims data. The data are placed into an analytical tool/dashboard to help us determine redacted. This will help us determine the redacted. *



9. RFP Section VII.E.4.c.v. What are the health and risk factor metrics that Respondent suggests to be included in a remote health program?


Telehealth is appropriate for the treatment and diagnosis of common acute conditions such as acne, allergies, bronchitis, cold and flu, fever, gout, headache, infections, joint aches and pains, nausea and vomiting, pink eye, rashes, sinus infection, sore throat, sunburn, and urinary tract infection. We also offer programs for e-therapy, behavioral health, tele-dermatology, and second opinion.


BCBSTX’s response requires further clarification. How does e-therapy, behavioral health, and tele-dermatology work use this platform? Is a member able to stick with the same provider for the treatment of a skin condition or mental health problem, or is this platform only to be used for an urgent type of visit? For plans with a gatekeeper model, does the vendor require a referral from a PCP to see a tele-dermatologist? What is the cost for these types of visits; are they redacted?

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. E-therapy/behavioral health – Licensed behavioral health clinicians, psychologist, and psychiatrist’s provider can treat conditions such as depression and anxiety, and help participants manage material problems, child behavioral and learning issues, financial hardship, and stresses and challenges of everyday life. Behavioral health consultations are conducted by video and by appointment. These services are managed by Breakthrough Behavioral, owned and operated by MDLIVE, which is an integrated platform with other medical consultations. The chart below outlines the behavioral health CPT codes and claim cost; however, please note that the redacted.

Chart Redacted. Tele-dermatology – Today the current network of board certified physicians treats a variety of skin conditions, including skin infections, acne, rashes, moles/warts and insect bites. These services are part of the non-emergency medical consultations and are all contained within the existing platform, including the capturing and uploading of images for physician review. Physicians can prescribe a range of medication, including anti-bacterial creams and lotions as medically appropriate. The participant may choose to redacted. Sentence redacted

The chart below outlines the medical CPT codes and claim cost; as with behavioral health providers, the redacted.

Chart Redacted



Physician Selection - As part of Blue Access for Members, the secure participant portal, participants will redacted. *

10. RFP Section VII.E.4.c.x. What is the reimbursement structure for Respondent’s remote health program?


Sentence redacted.


BCBSTX’s response requires further clarification. Does MDLive or the specific virtual visit provider submit a claim to BCBSTX for payment? And do the claim costs ever vary or are they always redacted per visit?


Our vendor partner, MDLive, submits a claim to BCBSTX. Costs for a virtual visit are redacted.

Statement redacted.*

11. RFP Section VII.F.1.d.iv. Describe Respondent’s ability to produce Participant-specific communications.


BCBSTX recognizes ERS’ desire to convey its message and benefits to participants. Program success of managing costs is based in part on a fully engaged population. We understand the importance of a well-informed population and how the power of appealing and compelling communications invoke individuals to action. Sentence redacted.

ERS Dedicated Customer Experience/Communications Team

BCBSTX is providing ERS redacted. This includes the redacted they can gain the most out of their benefits and become better health care consumers.



Our team will redacted. Samples of participant-specific communication can be found in TAB B-5, B-7, and B-8.

As an example of the level of video quality we will provide in ERS specific video shorts, ERS can find an example of videos used to educate participants online. Sentence redacted.

High quality and informative, BCBSTX videos are redacted. Most popular topics include, “Understanding Health Insurance,” “The Importance of Following Your Prescription,” “Pre & Post Op Questions to Ask Your Doctor,” and “What to do with your EOB”.

Redacted Communication

We believe it is important to communicate with ERS participants in the manner and modality they choose and best fits into their lifestyle. Sentence redacted.

Not every participant redacted. Sentence redacted. We also have the ability to redacted.


BCBSTX’s response requires further clarification. BCBSTX mentions ability to redacted. BCBSTX shall confirm they can redacted?


Entire response redacted as its considered confidential and proprietary.


12. The Executive Summary of BCBSTX’s August 11, 2016 Original Response includes the following statements. All confidential and proprietary information has been redacted and shown as “redacted” below.

The health care industry has changed significantly over the last five years and the challenges we face have never been more demanding. As such, Blue Cross and Blue Shield of Texas (BCBSTX) is doing things differently. Two sentences redacted. (Executive Summary, page 1, paragraph 2.)

ERS financial Two sentences redacted. (Executive Summary, page 2, paragraph 2.)

ERS needs a partner that stands behind their commitment. We are confident in our ability to redacted and we are offering the following guarantees to ERS:



1. Entire statement redacted. 2. Entire statement redacted.

In summary, our offering redacted. Sentence redacted. (Executive Summary, page 9, last paragraph.)



a) Provide documentation for the redacted. b) We redacted on an annual basis. Please confirm. c) We interpret the redacted to mean that redacted. Please confirm.


All confidential and proprietary information has been redacted and shown as “redacted” below. a) Provide documentation for the redacted.

In the original proposal response BCBSTX redacted. Two sentences redacted. *

Below is the redacted as reflected in the Executive Summary*:

Table Redacted

Below is an redacted over the 6 year contract*:

Table Redacted

b) We redacted on an annual basis. Please confirm.

Entire response redacted. *

d) We interpret the redacted to mean that redacted. Please confirm.

Entire response redacted. *

13. Tab B-5 of BCBSTX’s August 11, 2016 Original Response provides a description of the Discount Guarantee.

Entire response has been redacted as it is confidential and proprietary.




BCBSTX’s response requires further clarification. Please provide additional information regarding the following.

a) Regarding No. 6 above: Entire statement redacted. b) Regarding No. 7 above: Entire statement redacted. c) Regarding No. 8 above: Entire statement redacted.

BCBSTX’s September 26, 2016 Clarified Response: (a) Regarding No. 6 above: Entire statement redacted.

Entire response redacted *

(b) Regarding No. 7 above: Entire statement redacted. ?

Entire response redacted * (c) Regarding No. 8 above: Entire statement redacted.

Entire response redacted *

14. Tab B-5 of BCBSTX’s August 11, 2016 Original Response provides a brief description of the Innovation Center and your proposed Innovation Credit.



BCBSTX’s response requires further clarification. Please provide additional information regarding the Innovation Center.

(a) What products and services will the center provide?

(b) How will these products and services be funded?

(c) How will the redacted?

(d) Elaborate on the method through redacted.




The Innovation Center is where ideas come to life. It is where ERS and BCBSTX will redacted. This can include traditional concerns such as redacted.

The following is an example of how redacted can work. (Illustrative Only.)

Objective Reduce cost of care by redacted.

Traditional Recommendations Increase redacted copayment. Eliminate participant copayment/out-of-pocket expense for redacted.

Potential Idea Entire statement redacted.

ERS needs a partner who goes beyond traditional recommendations when solving complex problems – that partner is BCBSTX. Three sentences redacted. *

Image Redacted

(a) What products and services will the center provide?

The possibilities are limitless. Two sentences redacted. *

(b) How will these products and services be funded? Entire response redacted. *

(c) How will the redacted? It will be a joint decision redacted. *

(d) Elaborate on the method through redacted.

Entire response redacted. * 15. RFP Section IX.A.1. Respondent shall specify the formula it will use to develop the final FY 2018 TCC on or before February 1, 2018. The formula shall comply with the requirements and guidelines stated in Article VIII, Section A.3. and A.4. of the RFP. Enumerate the variables included in Respondent’s formula. Variables are limited to actual FY 2017 claims and the composition of FY 2018 in-area enrollment as discussed herein. All other factors including trend, network usage assumptions, plan design adjustments, network utilization/price adjustments and factors used to adjust for demographic and geographic changes



must be guaranteed for FY 2018 and will be negotiated in good faith in subsequent years. Note: the Projected FY 2018 TCC requested below should be based on the current HealthSelect benefits. If benefits are revised for FY 2018 or a subsequent year, the adjustment factors for the benefit change will be subject to good faith negotiation.





(a) Entire clarification request redacted as it contains information that is confidential and proprietary.

(b) Entire clarification request redacted as it contains information that is confidential and proprietary.

(c) Entire clarification request redacted as it contains information that is confidential and proprietary.

(d) Entire clarification request redacted as it contains information that is confidential and proprietary.

(e) Entire clarification request redacted as it contains information that is confidential and proprietary.

BCBSTX’s September 26, 2016 Clarified Response: Entire response has been redacted as it is confidential and proprietary.

16. RFP Section IX.A.1.b. Respondent shall specify the formula it will use to develop the FY 2019, FY 2020, FY 2121, FY 2022 and FY 2023 TCC. Enumerate the variables included in the formula. Maximum in-area trend factors must be guaranteed as indicated in Section IX.A.1.d. below. The formula shall comply with the requirements stated in Article VIII, Sections A.3. and A.4. of the RFP.

BCBSTX’s August 11, 2016 Original Response: Entire response has been redacted as it is confidential and proprietary.

ERS’ September 16, 2016 Clarification Request: Entire clarification request redacted as it contains information that is confidential and proprietary.




17. RFP Section IX.A.1.d. FY 2019, FY 2020, FY 2021, Maximum Guaranteed Trends. Respondent shall specify the maximum guaranteed trends to be used in projecting the TCC for FY 2019, FY 2020 and FY 2021. These are the maximum rates that shall be used for FY 2019 – FY 2021. The actual rates shall be subject to good faith negotiation between ERS and Respondent. FY 2022 and FY 2023 maximum trend factors shall be subject to good faith negotiations between ERS and Respondent.




18. RFP Section IX.C.1.c. Form 3 contains selected CPT codes for certain areas of Texas. Provide Respondent’s average network allowable charge as of June 1, 2016 for each procedure in each service area. Provide a global, unmodified fee for all procedures other than lab and radiology. For lab and radiology procedures (other than chest x-ray), provide a modifier 26 (professional only) fee. For chest x-ray, provide a global, unmodified fee. If Respondent uses multiple fee schedules in an area, provide the average fee weighted by the percentage of current membership. If Respondent uses capitation in its professional reimbursement methodology for certain physicians, so indicate.


BCBSTX’s Appendix J included Form 3 response.


BCBSTX’s response requires further clarification. Appendix J of your proposal includes Form 3 which presents the average network allowable charge for various CPT codes by region.

a) Are the allowable charge amounts included in your Form 3 redacted?

b) Provide the average redacted?


a) Are the allowable charge amounts included in your Form 3 redacted? The allowable amounts included in Form 3 are redacted *



b) Provide the average redacted?

Table redacted.

19. RFP Section IX.D.1. Based on your Texas book of business using the network proposed herein provide the average percentage discount from billed charges to allowed amount (amount due from the Plans and Participants) for the various provider types and in total. The only items that should be excluded from this calculation are ineligible charges (e.g., duplicate charges, non-covered charges), claims in which Medicare is the primary payor, other COB claims and all claims paid to non-network providers (including those paid as in-network benefits).



BCBSTX’s response requires further clarification. Please explain the difference between the discounts provided in Section IX.D.1 of the Proposal and Tab B-2 Exhibit 1A of the redacted. Sentence redacted. Please provide Exhibit 1A of redacted separately by redacted.

Table redacted.


20. RFP Section IX.D.3. Have your provider discounts for the network proposed herein been evaluated and compared against those of other vendors by an independent third party within the last 2 (two) years? If so, provide a copy of the most recent evaluation along with supporting documentation. A summary prepared by Respondent will not be considered adequate.


Yes. Please refer to TAB B-2


BCBSTX’s response requires further clarification. Sentence redacted. Please provide such a comparison.


Entire response has been redacted as it is confidential and proprietary. *



21. RFP Section IX.D.3.a. Provide the following information for arrangements with contracted non-network providers. In providing this information clearly distinguish between non-network providers with whom you contract directly and those with whom you contract indirectly through another vendor.

RFP Section IX.D.3.a.i. Summarize the key provisions of those contracts related to participant access.


BCBSTX incorporates redacted provisions that allow for members to access contracted out of network providers without being balance billed. The provisions are as follows:

Paragraph redacted.

Paragraph redacted.


BCBSTX’s response requires further clarification. Please explain the relevance of the redacted. Is there a similar redacted for Professional Providers? If so, please provide.

BCBSTX’s September 26, 2016 Clarified Response: All confidential and proprietary information has been redacted and shown as “redacted” below. BCBSTX has provided the redacted in its provider contracts to display the key provision that allows participants to redacted have protections from balance billing. There is also similar provisions outlined in the redacted as listed below. Remaining response redacted. *

22. RFP Section IX.D.3.a.ii. Describe the reimbursement arrangements applicable to contracted non-network providers. Quantify the difference in reimbursement between (i) the level provided under these arrangements, and (ii) the network reimbursement for similar specialties in the same geographic region.


BCBSTX employs redacted, fee schedules.




BCBSTX’s response requires further clarification. The information provided is insufficiently responsive to the request to “quantify redacted

BCBSTX’s September 26, 2016 Clarified Response: Table redacted.

23. RFP Section IX.D.3.a.vi. Provide a detailed explanation of the methodology used to determine reimbursement to non-network, noncontracted providers.


The Allowable Amount for non-contracted Providers for Covered Services will be redacted. The non-contracting Allowable Amount is developed from redacted. Such factor shall be not less than redacted.

Notwithstanding the preceding sentence, the non-contracting Allowable Amount for Home Health Covered redacted.

When a redacted, the Allowable Amount for non-contracting Providers will represent redacted. Such factor shall be not less than redacted.

Remainder of response redacted.


BCBSTX’s September 26, 2016 Clarified Response: Entire response redacted as it contains information that is confidential and proprietary. *

Miscellaneous Pricing Questions

24. (a) The re-price claim file “Reg_CLMs_UPDATED.txt” has a significant number of claims where i) the re-price allowable amount exceeds the eligible amount and ii) the re-price allowable amount is $0 for eligible amount greater than $0. The table below presents a summary of these two issues. Please provide an explanation of this. All confidential and proprietary information has been redacted and shown as “redacted” below.

Table redacted



(b) Please provide an estimate of the redacted for the calendar year 2015 period based on the ERS membership for redacted separately.

BCBSTX’s September 26, 2016 Clarified Response: Entire response redacted as it contains information that is confidential and proprietary.


Sincerely,



Documents

Article VII. Scope of Work