JOINT LABOR-MANAGEMENT BENEFITS COMMITTEE www.myFlexLA.com

Joint Labor-Management Benefits Committee

COMMITTEE REPORT 16-02

JOINT LABOR-MANAGEMENT BENEFITS

COMMITTEE MEMBERS:

Management

Wendy G. Macy, Chairperson

June Gibson

Tony Royster

Matthew Rudnick

Miguel Santana

Employee Organizations

Cheryl Parisi, Vice-Chairperson

Paul Bechely

Chris Hannan

David Sanders

Gregory West

Date: January 11, 2016 To: Joint Labor Management Benefits Committee From: Staff Subject: Health & Dental Plan Procurements RECOMMENDATION: That the Joint Labor-Management Benefits Committee (JLMBC) (a) review and provide feedback on the attached preliminary draft Medical Services RFP and (b) receive and file this update regarding development and issuance of the Medical and Dental Plan procurements. DISCUSSION: At its meeting on September 3, 2015, the JLMBC approved moving forward with Requests for Proposal (RFPs) for health and dental service providers in 2015/2016 with a target implementation date for new service provider contracts to be in place by January 1, 2017. The JLMBC further approved staff’s proposed procurement development plan and calendar for RFP development, as well as a Pledge Form Regarding Conflict of Interest, Confidentiality and Proposer Communications and its execution by all JLMBC members/City staff involved in the development process for this procurement. At its meeting on October 8, 2015, the JLMBC reviewed and had discussion relative to a presentation from staff and the Plan’s consultant with respect to design of the RFPs. This discussion focused on review of benefit service mission, major service categories, current medical/dental trends, and RFP design best practices. At its meeting on November 12, 2015, the JLMBC adopted a member survey. The survey window was open to Flex members November 30-December 21 and addressed the following primary topics:

Awareness of current Flex Benefits services and features Medical/dental services utilization and value Medical/dental resources utilization and value Potential new services

The survey results are addressed in a Report 16-01. This report will address the draft Health RFP. The final proposed RFP as well as the Dental RFP will be presented for approval at the JLMBC’s February 5, 2016 meeting.

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A. Proposed Health Services RFP As stated at the JLMBC’s October 8th meeting, the mission of the health and dental procurements is to identify the service providers who can best support the Flex population in its health and wellness efforts by: Providing a broad range of quality choices for members in the delivery model and

benefit levels of how they receive care; Providing timely and broad geographic access to care; Communicating and assisting members in navigating benefit and service

complexity; Providing effective member self-service tools; Engaging members in wellness as well as the prevention, diagnosis, and

treatment of disease; and Producing and improving upon measurable member outcomes.

Staff’s and the JLMBC’s objective has been to frame these procurements from a “member-based” perspective focused first and foremost on addressing the support services, quality of care, access to care, and communications efficacy that Flex members are most concerned with and which directly impact their health and wellbeing. The importance of this focus is reinforced by the feedback obtained from members through the focus groups and survey, and is consistent with the mission and objectives of the developing Flex Wellness Program. Staff has developed this draft with the assistance of the JLMBC’s consultants (Keenan and Segal). Staff will be working closely with both firms to further refine this document prior to the JLMBC’s February 4th meeting date, and to incorporate any feedback from the JLMBC from the current meeting. The draft RFP for Health Services is provided as Attachment A.

(1) Plan Profile & Scope of Services As previously discussed with the JLMBC, it is to the benefit of the City and the Flex Program to be as transparent as possible with prospective RFP respondents as to the City’s values and its current benefit services and features. Towards that end, staff has developed a draft Plan Profile & Scope of Services as a key component of the RFP. This Section is intended to reflect the evolving and sharper focus the JLMBC and Personnel Department are developing around the Flex Program’s mission, how it measures success, and how to best meet the needs of Flex members.

(2) Health Overview The RFP provides opportunities for health insurance companies to submit proposals for any of the current core menu of offerings presently offered to the City’s Flex Benefits population. These include:

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National Provider Network Preferred Provider Organization (PPO);

Statewide Provider Network Staff Model Health HMO;

Statewide Provider Network Full Network Model HMO;

Statewide Provider Network Narrow Network HMO. In addition, the RFP also incorporates an option to consider proposals for alternative provider network and care models which may be offered as part of the core menu of offerings and could include:

More narrowly tailored regional local provider network HMOs;

Accountable Care Organizations (ACOs);

Patient Centered Medical Homes (PCMHs); and/or

Other alternative network or care models. Staff’s intent in drafting the RFP to provide for these non-core proposals was to address member feedback from the focus groups and participant survey, which indicated some degree of interest for more choice in the menu of medical plan options, particularly among Blue Shield HMO and PPO members. Alternative care models may provide other choices with respect to philosophy, flexibility, service care delivery, and communications. It is unknown whether such providers have products that would present meaningful alternatives or whether they would be willing to propose them in response to this RFP. It is also unknown whether, even if they did, incorporating them into the Flex Plan menu design would prove to be a desired outcome. Nevertheless, the RFP as presently constructed provides an opportunity to request and assess this information.

(3) RFP Evaluation Categories

Primary evaluation and item categories for the Health HMO and PPO plans were previously adopted by the JLMBC and are included in the RFP document. As noted previously, staff’s intent in designing the broad structure of the RFP has been to incorporate a greater member-based perspective focused on addressing the support services, quality of care, access to care, and communications efficacy that Flex members are most concerned with and which directly impact their health and wellbeing. In addition, within these categories it is staff’s intent to explore vendor capabilities and services relative to their commitment to support new initiatives such as the City’s Wellness Program; potential new services such as member advocacy resources (to help members navigate service, care and benefit complexity); and self-service and other emerging technology resources.

(4) RFP Questionnaires The JLMBC previously adopted the use of a written questionnaire, problem resolution essay questions, and performance exams as methods of inquiry to exchange information with RFP respondents. The written questionnaire requests information in

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various narrative and data-driven formats and represents the most substantial portion of the inquiries and means by which the City will compare and assess, qualitatively and quantitatively, each provider’s services and capabilities. Problem resolution essay questions ask providers how they would address or resolve specific problems or challenges that are situational in nature and written from the member perspective. Those questions are uniquely identified within the RFP questionnaire. Performance exams provide opportunities to assess a vendor’s resources, philosophy, and skills on specific topics. The specific topics and scheduling of the exams will be developed in the period between when the RFP is released and responses are due. Because the exams are tailored to specific topics, they provide for a “deeper dive” on a variety of subjects to a degree which is not available in standard narrative responses.

(5) Evaluation Panels and Process Evaluation of the proposals will involve a substantial amount of time and analysis. The review panels should include the necessary subject matter expertise and member-based orientation that will be necessary to fulfill the procurement mission. Staff recommends that the evaluation panels include teams of consultant/staff representatives who will review various primary segments of the RFP responses (Member Services, Access/Continuity of Care, Organizational Strength, and Fees). Both consultants (Keenan and Segal) would review all RFP responses. All panel members would participate in the performance exams and review the fee proposals. The proposed evaluation panels would be comprised as follows:

Medical & Dental RFPs Evaluation Panels Consultant B Consultant A Staff Panelist A Staff Panelist B

Member Services Keenan Segal Staff Panelist

Access & Continuity of

Care Keenan Segal

Staff Panelist

Organizational Strength Keenan Segal Staff Panelist

Performance Exams Keenan Segal Staff Panelist Staff Panelist

Fees Keenan Segal Staff Panelist Staff Panelist

The evaluation panels would be charged with evaluating, scoring and summarizing all of the vendor responses and performance exams. Upon completion of their review and analysis, the review panel would present a report to the JLMBC with its findings and recommendations for selection.

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At that point the JLMBC would have the option of conducting interviews of proposers. The RFP language has been drafted to provide discretion to the JLMBC as to which firms it would interview but also makes clear that the evaluation and scoring will be based strictly on the vendor responses to the RFP and the scoring of performance exams.

B. Updates & Next Steps Staff, working together with the JLMBC’s consultants from Keenan and Segal, will address feedback from the JLMBC on the Health services RFP and return with a proposed final document, along with a proposed Dental RFP, at the JLMBC’s meeting on February 4, 2016. At the JLMBC’s September 3, 2015 meeting, staff presented and the JLMBC adopted a project plan which included a timeline for executing the development, issuance, review and decision-making related to the medical/dental procurements. The deliverables and timeline have been updated to address several crucial deadlines, including the response due dates, evaluation due dates, JLMBC consideration of the responses, and submission of the report to City Council for adoption/approval of the Flex Plan for Plan Year 2017. To meet these ambitious deadlines, staff is contemplating a 30-day response evaluation period during the month of April. Staff would then schedule a series of special JLMBC meetings ( the regularly scheduled meeting of May 5, 2016 would be canceled) on May 12, 19 and 26 for the JLMBC to consider the initial scoring results, conduct any desired interviews, and take final action by no later than May 25, 2016. This will allow time for staff to generate a report/recommendation to City Council to adopt the Flex Plan for Plan Year 2017. This calendar contemplates delivery of the report to Council by June 1, 2016, which provides sufficient time for Council to review and act on the findings before June 30, 2016, a deadline which must be met in order to address the third-party-administrator programming and communications deadlines for October’s Open Enrollment cycle. The updated timeline and deliverables are outlined as follows:

Month(s) Action Status

Sep-15 Approve staff proposals related to moving forward with the health/dental procurement development

Completed

Oct-15

(1) Staff/consultant review/discussion of medical and dental plan RFP development

(2) Conduct focus groups of Flex Plan participants

(1) Completed 10/8/15 (2) Completed October 2015

Nov-15

(1) Discussion of focus group results and proposed evaluation methods/criteria

(2) Finalize membership survey (3) Issue membership survey

(1) (1) Completed 11/12/15 (2) (2) Completed 11/12/15 (3) (3) Completed: 11/30/15

Dec-15 (1) Close membership survey (1) Targeted 12/14/15, extended

to 12/21/15

Jan-16 (1) Review first draft medical RFPs (1) Scheduled for 01/14/16

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(2) Review survey results (2) Scheduled for 01/14/16

Feb-16 (1) Finalize Medical/Dental RFPs (2) Release RFPs

(1) Scheduled for 02/04/16 (2) No later than 02/15/16

Mar-16 Response Due Date No later than 03/31/16

Apr-16 Response Evaluation 04/01/16 : 04-30/16

May-16 JLMBC Meeting: Review of Findings 05/12/16

May-16 JLMBC Meeting: Interviews 05/19/16

May-16 JLMBC Meetings: Final Action 05/26/16

Jun-16 Submit Recommendation to Council for Adoption of Flex Plan 2017

06/01/16

Jun-16 Council Adoption of 2017 Flex Plan No later than 06/30/16

Dec-16 Execute contracts No later than 12/31/16

Submitted by: ______________________________ Steven Montagna

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REQUEST FOR PROPOSAL

FLEX BENEFITS HEALTH PLANS City of Los Angeles Flex Benefits Program

Personnel Department - Employee Benefits Division Joint Labor-Management Benefits Committee

Date Issued: February 12, 2016 TITLE: FLEX BENEFITS PROGRAM MEDICAL PLANS:

NATIONAL PROVIDER NETWORK: PREFERRED PROVIDER ORGANIZATION (PPO)

STATEWIDE PROVIDER NETWORK: STAFF MODEL HEALTH MAINTENANCE ORGANIZATION (HMO)

STATEWIDE PROVIDER NETWORK: FULL NETWORK MODEL HEALTH MAINTENANCE ORGANIZATION (HMO)

STATEWIDE PROVIDER NETWORK: NARROW NETWORK MODEL HEALTH MAINTENANCE ORGANIZATION (HMO)

ALTERNATIVE PROVIDER NETWORK AND CARE MODELS

- REGIONAL/LOCAL PROVIDER NETWORK HEALTH MAINTENANCE ORGANIZATION (HMO)

- ACCOUNTABLE CARE ORGANIZATIONS (ACO)

- PATIENT CENTERED MEDICAL HOME (PCMH)

- OTHER ALTERNATIVE NETWORK OR CARE MODELS CONTRACT TERM: A period of three years with a City option for up to two additional years from the contract effective date as provided for by the final contract. PRE-PROPOSAL CONFERENCE:

MARCH 2, 2016 City Hall 200 North Spring Street, Room 805 Los Angeles, CA 90012 9:00 a.m. – 10:00 a.m. PROPOSAL DELIVERY ADDRESSES:

City of Los Angeles Attention: Steven Montagna City Hall 200 North Spring Street, Room 867 Los Angeles, CA 90012

Attachment A

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DEADLINE FOR SUBMITTING PROPOSAL: MARCH 25, 2016 at 3:00 p.m. DEADLINE FOR OUTREACH TO SUBCONTRACTORS (pursuant to the City’s Business Inclusion Program outreach requirements): _______ 2016 at 5:00 p.m.

RFP ADMINISTRATOR:

Steven Montagna, Chief Personnel Analyst Phone (213) 978-1621 Email: steven.montagna@lacity.org

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PART A TABLE OF CONTENTS PAGE NUMBER

Section 1: Introduction/Background __

Section 2: Plan Profile & Scope of Services __

Section 3: Proposal Questionnaire __

Section 4: Submission Requirements __

Section 5: Evaluation of Proposals __

Section 6: General Terms and Conditions __

Section 7: Additional Plan Information __

PART B City of Los Angeles General Contracting Requirements

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SECTION 1 INTRODUCTION/BACKGROUND

1.0 INTRODUCTION

The City of Los Angeles is seeking proposals for fully insured health plan benefits for its Civilian Flex Benefits Program (Flex Program). The mission of this procurement is to identify the service provider(s) who can best support the Flex population in its health and wellness efforts by:

Providing a broad range of quality choices for members in the delivery model and benefit levels of how they receive care;

Providing access to services and care across the Los Angeles region and surrounding communities;

Communicating and assisting members in navigating benefit and service complexity; Providing effective member self-service tools; Effectively engaging members in the prevention, diagnosis, and treatment of disease; and Producing and improving upon measurable member outcomes.

It is the City’s intent to approach this procurement from a “member-based” perspective focused first and foremost on addressing the support services, quality of care, access to care, and communications efficacy that Flex members are most concerned with and which directly impact their health and wellbeing. The City presently currently contracts with service providers who provide Flex members with broad geographic access to care across the Los Angeles region and surrounding communities. These plans comprise a core menu of health service providers which includes Kaiser Permanente, which offers a Staff Model HMO plan; and Blue Shield, which offers a Network Model HMO Narrow/Full Network as well as a PPO plan. Pursuant to this RFP, the City is soliciting proposals for a National Provider Network Preferred Provider Organization (PPO); a Statewide Provider Network Staff Model Health HMO; a Statewide Provider Network Full Network Model HMO; and a Statewide Provider Network Narrow Network HMO. These plans comprise the core menu of offerings presently offered to the City’s Flex Benefits population. In addition, the City will also consider proposals for alternative provider network and care models which may be offered as part of the core menu of offerings and could include more narrowly tailored regional local provider network HMOs; Accountable Care Organizations (ACOs); Patient Centered Medical Homes (PCMHs); and/or other alternative network or care models. Further details regarding each model type included within this RFP are provided as follows:

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CORE MENU

Statewide Provider Network Staff Model Health HMO

Statewide Provider Network Full & Narrow Network Model

HMO

National Provider Network Preferred Provider Organization (PPO)

A Staff Model involves an insurance company providing a fully insured Health Maintenance Organization (HMO) whereby doctors, hospitals and other healthcare providers are combined within a fully integrated system. Participants must access covered services as directed by a Primary Care Physician (PCP). Benefits include physician, hospital, prescription drug, and vision services.

A Network Model involves an insurance company providing a fully insured Health Maintenance Organization (HMO) that provides care through a network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP). Benefits include physician, hospital, prescription drug, and vision services.

A Preferred Provider Organization model involves an insurance company providing a fully insured network of medical doctors, hospitals and other health care service providers offering medical care at reduced rates to the insurer's or administrator's clients. Benefits include physician, hospital, prescription drug, and vision services.

OPTIONAL SUPPLEMENTARY MODEL(S)

ALTERNATIVE PROVIDER

NETWORK AND CARE MODELS

Alternative Care Providers include alternative delivery models such Regional/Local Health Maintenance Organization (HMO), Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMH), and other models that may be more narrowly tailored by region, provider risk sharing structures, networks, or philosophy of care.

The City will be awarding contracting terms of three years with options for two additional years. The service agreements resulting from this RFP will at maximum length cover the period January 1, 2017 through December 31, 2021. Proposal Options: A vendor may submit a proposal or proposals for any of all of the service provider categories indicated above. Proposals for each plan type will be evaluated separately. The City reserves the right to contract with multiple vendors pursuant to this RFP and to select more than one vendor within any provider category. Fully insured premium proposals for each medical plan category must be separately provided.

1.1 DEFINITIONS OF TERMS

The following terms used in the RFP documents shall be defined as follows:

“Agreement” will mean the contract to be entered between the City and proposer(s)

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“Alternative Provider Network or Care Model” will mean alternative delivery models such as Regional or Local Health Maintanance Organizations (HMOs), Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCMH), and other models that may be more narrowly tailored by region, provider risk sharing structures, networks, or philosophy of care.

“Bidder” or “Proposer” will mean the entity that responds to the Request for Proposal.

“City” will mean the City of Los Angeles.

“Contract” will mean the contract to be entered between the City and selected proposer(s).

“Contractor” will mean the individual, partnership, corporation or other entity to which a contract is awarded, and will be synonymous with the term “vendor”.

“Department” will be considered synonymous with the City’s Personnel Department.

“Flex Benefits Program” will mean the City’s benefits program for its Civilian and other eligible employees.

“JLMBC” will mean the City of Los Angeles Joint Labor Management Benefits Committee.

“MOU” will mean a Memorandum of Understanding, or collective bargaining agreement, to which an employee labor organization and the City of Los Angeles are both parties.

“Non-Represented” will mean an employee who is not represented by a City of Los Angeles employee bargaining unit.

“Network Model HMO” will mean a fully insured Health Maintenance Organization (HMO) that provides care through a network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP).

“PPO” will mean a fully insured network of medical doctors, hospitals and other health care service providers offering medical care at reduced rates to the insurer's or administrator's clients.

“Represented” will mean an employee who is represented by a City of Los Angeles employee bargaining unit.

“RFP” will mean a Request for Proposal for contracted services issued by the City of Los Angeles.

“Staff Model HMO” will mean a fully insured, fully integrated Health Maintenance Organization (HMO) that provides care through an integrated network of doctors, hospitals and other healthcare providers. Participants must access covered services as directed by a Primary Care Physician (PCP).

1.2 CONTRACT TERM

The term of any contract(s) awarded pursuant to this RFP shall be for a period of three years with a City option for renewal of up to two additional years from the contract effective date as provided for by the final contract. 1.3 RFP CONTENTS

The contents of this RFP are as follows: PART A – Request for Proposal, including the Plan Profile & Scope of Service, Proposal Questionnaire, Submission Requirements, Evaluation of Proposals, and General Terms and Conditions. PART B – General Contracting Requirements and Attachments, which includes the City of Los Angeles Standard Provisions for City Contracts (rev. 6/14) and other general contracting

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requirements that must be reviewed and completed by proposers as specified in order for a proposal to be deemed responsive.

1.4 RFP CONTACT INFORMATION

The Personnel Department and JLMBC are committed to ensuring that all Flex Benefits business transactions, including procurement processes, are based strictly on integrity, competence, merit and benefit to Flex members and their dependents. As a matter of policy, JLMBC members and staff will not communicate with current or prospective vendors or their representatives, or any other person or organization, for the purpose or intent of having a particular vendor secure or maintain a contract or business with the Flex Program, or otherwise realize financial gain from the Flex Program, whether during or outside of a procurement process. In support of this, and to ensure the transparency and objectivity of this procurement process, all communications and questions regarding or related to the services included in this RFP should be directed as follows:

PART A Contact Information All questions regarding this RFP PART A must be in writing and should be directed to the RFP Administrator as follows:

Personnel Department, Employee Benefits Division Steven Montagna steven.montagna@lacity.org (213) 978-1621

PART B Contact Information All questions regarding this RFP PART B must be in writing. Questions may be directed to the Personnel Department’s Administrative Services Division staff as follows:

Personnel Department, Administrative Services Division Roberta (Bobbi) Jacobsen bobbi.jacobsen@lacity.org (213) 473-9148

Questions regarding certain General Contracting Requirements may also more appropriately be directed to the City department responsible for the particular requirement, as specified within the Part B materials.

1.5 GENERAL INFORMATION AND PRE-PROPOSAL CONFERENCE

The City intends to award a contract, in a form approved by the City Attorney, to the selected proposer. Written proposals submitted to the City constitute a legally binding contract offer and shall remain open for twelve (12) months. It is requested that proposals be prepared simply and economically, avoiding the use of unnecessary promotional material. Proposal Timeline The following is the current timeline for the RFP process. The City reserves the right to adjust this schedule. Changes to the timeline, if any, will be posted online as an RFP Addendum.

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Proposal Timeline Dates Event

February 12, 2016 Request for Proposal Released

February 24, 2016 Deadline for receiving written questions for the Pre-

Proposal Conference is 4:00 p.m.

March 1, 2016 Deadline to register to participate in Pre-Proposal

Conference by telephone is 4:00 p.m.

March 2, 2016 Pre-Proposal Conference at 1:00 p.m. Pacific

Standard Time

March 9, 2016 General Contracting Requirements Preliminary

Submission Deadline

March 16, 2016 City Review of General Contracting Document Due to

Vendor by This Date

_______________

Deadline for vendors to issue written solicitations to

subcontractors via www.labavn.org website. This step

should be completed by ______________ Pacific

Standard Time to avoid risk of late submission.

March 18, 2016 Deadline for receiving written questions regarding the

RFP is 4:00 p.m.

March 25, 2016 RFP responses due by 3:00 p.m. Pacific Standard

Time

_______________ BIP Summary Sheet Submission on LABAVN – 4:30

p.m. Pacific Standard Time

March 25-April 30, 2016 RFP evaluations

May-June, 2016

City makes selection and begins contract negotiation

with successful proposer

December 31, 2016

Deadline for executing contract

January 1, 2017 Commencement of Services

Pre-Proposal Conference A Pre-Proposal Conference will be held to provide information regarding the RFP requirements and answer questions from prospective proposers regarding this RFP. The Pre-Proposal Conference will also give proposers and potential subcontractors the opportunity to network. City staff will not provide assistance regarding a proposer’s individual RFP response.

The conference has been scheduled pursuant to the schedule noted in the Proposal Timeline. Potential proposers may participate by physically attending or by calling in. Participants will be asked to identify themselves by name and firm.

If you intend to participate by telephone, please pre-register by contacting the RFP Administrator by the deadline noted in the Proposal Timeline. The City will provide a call-in number at that time for those interested in participating by telephone.

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It is to your benefit to bring your own copy of the RFP, particularly the City’s General Contracting requirements, to the conference. No copies will be provided at the conference.

Questions Regarding the RFP To maximize the effectiveness of the conference, to the extent possible, proposers should provide questions in writing prior to the conference in accordance with the deadline noted in the Proposal Timeline. This will enable the City to prepare responses in advance.

Specific questions concerning the RFP should be submitted in writing via e-mail to the RFP Administrator. Please identify the RFP title on the subject line of your message. All questions should identify the RFP section and page number, or the relevant General Contracting provision, for each question submitted. Additional questions may be accepted and addressed at the conference. However, certain responses may be deferred and posted online as addenda to the RFP at a later date. All questions regarding the RFP should be in writing and sent via e-mail to the RFP Administrator. The City will make every effort to respond to all written questions as soon as practical. All questions and responses to questions, or any other changes to or interpretation of the RFP, will be posted on the Plan’s website at www.labavn.org. Any such changes or interpretations shall become a part of said RFP and may be incorporated into any Contract awarded pursuant thereto.

1.6 GENERAL CONTRACTING REQUIREMENTS PRE-SUBMISSION OPTION AND

SUBMISSION DEADLINES The City’s General Contracting Requirements are included in Part B, which is attached hereto. Part B contains the Standard Provisions for City Contracts and a variety of documents and forms with which prospective City vendors must demonstrate compliance in order to be awarded a City contract. Within Part B is a list of requirements that must be fully met, including forms to be completed and submitted and details regarding certain processes which must be followed by prospective vendors as part of their RFP response. Failure to meet any of these requirements to the satisfaction of the City by the RFP Proposal Submission Deadline will result in disqualification of the vendor’s proposal as being non-responsive. The City will provide vendors an opportunity to demonstrate responsiveness to the City’s General Contracting Requirements at a date prior to the RFP due date. Vendors are not required to complete and submit their General Contracting Requirements forms/processes by the Preliminary Submission Deadline; however, it may be to their advantage to do so. If a vendor utilizes this option, City staff will identify whether the documents as submitted are or are not responsive to the City’s requirements. If deemed non-responsive, the vendor will have time to demonstrate responsiveness by no later than the RFP Proposal Submission Deadline. Following the Proposal Submission Deadline, there will be no further opportunity for demonstrating responsiveness to the City’s General Contracting Requirements. Failure to adequately demonstrate responsiveness to the City’s General Contracting Requirements, or a rejection by the vendor of those requirements or the Standard Provisions for City Contracts, will result in disqualification of the proposal. The relevant dates with respect to this process are included in the Proposal Timeline.

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1.7 PROPOSAL SUBMISSION DEADLINE Response to this RFP must be submitted on paper and electronic copy must be received by the RFP Administrator by the deadline noted in the Proposal Timeline. Electronic portions, as specified further in this RFP, must be received no later than this date/time as well. Late responses will not be considered. The City reserves the right to extend the Proposal Submission Deadline should this be in the interest of the City. 1.8 CONSULTANT RESPONSE INFORMATION Responses to this RFP must also be submitted on paper and electronic copy to the consultants used by the City in the evaluation of responses to this RFP. Delivery should be provided to:

Keenan Consultants Attention: Laurie Lofranco Vice President Municipalities 4204 Riverwalk Parkway, Suite 400 Riverside, CA 92505 llofranco@keenan.com

Segal Consultants Attention: Stephen E. Murphy Vice President, Benefits Consultant 330 N. Brand Blvd., Suite 1100 Glendale, CA 91203-2337 smurphy@segalco.com

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SECTION 2

MEDICAL PLANS PROFILE & SCOPE OF

SERVICES

A. FLEX BENEFITS PLAN OVERVIEW

The City of Los Angeles Flex Benefits Program is offered to eligible full-time and half-time employees of the City of Los Angeles Civilian employee population. The City offers its Civilian Flex Benefits Program (“Flex Benefits”) under Internal Revenue Code (IRC) Section 125. The Flex Benefits Program includes approximately 24,000 City employees and their 32,000 dependents. In 2016 the Flex Program will spend approximately $297 million in combined employer and employee contributions to health insurance premiums to its medical service providers, along with an additional $41 million on combined premiums for other Flex Benefits service providers (dental, life, disability, & AD&D).

B. FLEX PROGRAM GOVERNANCE & CONTRACTING AUTHORITY

The City’s Joint Labor-Management Benefits Committee (JLMBC) and the Personnel Department's Employee Benefits Division administer the Flex Benefits Program for active City civilian employees and their qualified dependents. The JLMBC is composed of five management and five labor representatives and makes recommendations to the General Manager Personnel Department for Flex Benefits service provider selections. The General Manager Personnel Department is the contracting authority for Flex Benefits service providers.

C. CORE MISSION

The core mission of the Flex Benefits Program is to promote employee health/wellness with competitive benefits at a reasonable level relative to the City's financial capacity. Promoting employee health/wellness involves delivering the support services, quality of care, access to care, and communications efficacy that directly impact the health and wellbeing of Flex members.

D. KEY SUCCESS METRICS The key metrics for evaluating the success of the City’s medical plans in meetings the Flex Program’s core mission include the following:

Member Satisfaction Quality of Care Access to Care Wellness, Prevention & Disease Management Cost & Affordability

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E. FLEX BENEFITS PROGRAM DESIGN

The Flex Benefits Program offers employees a menu of medical, prescription drug, vision, dental, life, disability, employee assistance and tax-advantaged savings programs, detailed with incumbent service providers as follows:

F. SUMMARY MEDICAL DATA Indicative statistical data regarding the City’s health plans is provided in Attachment A, and includes the following:

Current and historical enrollment information Current and historical premium information Access to the City’s most recently published Evidence of Coverage documents Access to historical plan experience Access to census data Benefit Summary Data

G. ELIGIBILITY

Full-Time Employees - The eligible population includes all Civilian full-time employees who are contributing members of the City’s Los Angeles City Employees’ Retirement System (LACERS) and who are working a minimum of 40 hours per pay period1. In addition, eligible employees must also meet at least one of the following requirements:

1 Or alternate number of hours specified in a Memorandum of Understanding

MEDICAL

Statewide Staff-Model HMO

Kaiser Permanente

Statewide Narrow Network HMO

Statewide Full Network HMO

National PPO

Blue Shield

All Medical plans include vision

DENTAL

Preventive Only

DHMO

PPO

Delta Dental

LIFE INSURANCE

Basic life

Supplemental life (1-5 times pay)

Dependent life

The Standard Insurance Company

DISABILITY INSURANCE

Basic disability

Supplemental disability

The Standard Insurance Company

ACCIDENTAL DIEATH & DISMEMBERMENT (AD&D) INSURANCE

Voluntary AD&D

Dependent AD&D

The Standard Insurance Company

TAX-ADVANTAGED SAVINGS ACCOUNTS

Flexible Spending

Dependent Care Reimbursement

Transportation Spending

Parking Spending

Wageworks

EMPLOYEE ASSISTANCE PROGRAM

Managed Health Network

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Eligible for membership within one of the employee representation units where the Flex

Program has been negotiated through a Memorandum of Understanding (MOU). A “Non-Represented” Civilian employee. A Port Police Officer (MOU 27 or MOU 38) and a member of Tiers 5 or 6 of the Fire & Police

Pension System. An elected official of the City of LA or a full-time member of the Board of Public Works.

Half-Time Employees – The eligible population includes all Civilian half-time employees who are contributing members of LACERS and who are working a minimum of 20 hours per pay period. Employees in part-time, temporary or seasonal positions who are not LACERS members are not generally eligible for Flex Benefits unless pursuant to requirements of the Affordable Care Act (ACA) and any negotiated provisions for ACA-compliant health care as provided for in the applicable MOU. Employee Family Member Eligibility – Flex members may also enroll eligible dependents including a spouse, domestic partner, biological or step child, child of a domestic partner, grandchildren for whom the member has legal custody, and grandchildren of children who are up to age 26, unmarried, and financially dependent on the member.

H. HEALTH INSURANCE COVERAGE TIERS Flex members may elect from one of the following four coverage tiers for health insurance:

Employee Employee + Spouse/Domestic Partner Employee + Child(ren) Employee + Family

I. PREMIUM COST-SHARING

Premium Cost-Sharing Models - The Flex Benefits program has three primary cost-structure arrangements which are determined by applicable MOU provisions:

Flex Plan - has no required percent of premium contribution from the member towards the member’s health insurance, but a member will pay the difference between the negotiated maximum subsidy and the full premium.

Flex Pay 1 - has a required 5% percent of premium contribution from the member towards the member’s health insurance, plus a member will pay the difference between the negotiated maximum subsidy and the full premium.

Flex Pay 2 - has a required 10% percent of premium contribution from the member towards the member’s health insurance, plus a member will pay the difference between the negotiated maximum subsidy and the full premium.

In addition, beginning January 1, 2017, certain current “Flex Plan” employees in certain bargaining units representing approximately 65% of the Flex member population will pay 1.5% of their base salary towards the aggregate cost of health care premiums for their members. These individuals will simultaneously receive a 1.5% salary bonus. On a per-member basis, the contributions of 1.5% of pay will not alter the fundamental structure of the “Flex Plan, Flex Pay 1, and Flex Pay 2” premium structure models.

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In 2016 the City will pay approximately 96.2% and members will pay approximately 3.8% of total health insurance premiums. 73% of members do not have a contribution towards their premiums, while 27% do have a contribution. Please refer to Attachment B (Census File) for details. Maximum Subsidy – For full-time employees, the maximum subsidy provided by the City for the Flex Plan for all medical plan models (excluding the HMO Full Network) is 100% of the Kaiser full family premium. The maximum subsidy provided by the City for Flex Pay 1 for all medical plan models (excluding the HMO Full Network) is 95% of the Kaiser full family premium. The maximum subsidy provided by the City for Flex Pay 2 for all medical plan models (excluding the HMO Full Network) is 90% of the Kaiser full family premium. With respect to the HMO Full Network, the City pays the subsidy up to the subsidy amount paid by the City for HMO Narrow Network coverage as applicable within Flex Plan, Flex Pay 1, and Flex Pay 2. Regular Half-Time Employees: The City’s maximum subsidy for those categorized as Regular Half-Time employees and hired after July 20, 1989 is the Kaiser single party premium less applicable cost sharing of 10% as provided for under Flex Pay 2. Regular Half-Time Employees hired prior to July 20, 1989, are eligible for 100% of the Kaiser full family premium.

J. THIRD-PARTY-ADMINISTRATION The City presently contracts with Mercer Benefits Administration to provide third-party-administrator (TPA) services for the Flex Benefits Program. The TPA is responsible for administering eligibility and benefit elections. Relative to health insurance, the TPA recordkeeps employee eligibility through a data exchange with the City’s payroll system, as well as employee elections of providers, coverage tiers, dependents, family status changes, etc., as a result of either Open Enrollment (held in October of each year) or family status or employment status changes which occur throughout the year. Data updates are provided to the health insurance carriers on a bi-weekly basis.

ORGANIZATIONAL STRENGTH, RECORDKEEPING & PLAN SPONSOR

SERVICES

K. ORGANIZATIONAL QUALIFICATIONS AND RELIABILITY

(1) Organizational Background, Financial Strength, Experience The City will be evaluating each proposer’s organizational experience, stability, financial strength, experience in administering medical plans, staff qualifications and turnover, and other factors related to determining the degree to which an organization can be a long-term viable partner with the City in executing the Flex Program’s mission, goals and strategies.

(2) References

The City will be evaluating references provided by the proposer, including governmental plan sponsors who are currently utilizing the provider’s services as well as those who have terminated those services in the recent past.

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(3) Regulatory and Compliance Services The City relies on the medical provider’s regulatory and compliance services to ensure that administrative functions are conducted in accordance with Internal Revenue Code rules and guidelines. The City will be reviewing each proposer’s organizational resources for enforcing, monitoring and providing updates to plan sponsors regarding regulatory processes and changes.

(4) HIPAA Compliance The City will be evaluating each proposer’s Health Insurance Portability and Accountability Act (HIPAA) compliance plans and member communication processes to ensure that the Flex Benefits program meets all requirements.

(5) Rating Agency Financial Ratings The City will be evaluating each proposer’s rating agency financial ratings as a means of assessing organizational stability and reliability.

L. ADMINISTRATION SUPPORT & ACCOUNT MANAGEMENT

(1) Claims Processing The City values service provider attention to organizational efficacy with respect to the claim administration process. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to the timely and accurately processing of claims, and effectively communicating with members regarding their benefits and how to successfully navigate the claims process.

(2) Billing & Eligibility The City wishes to ensure that each proposer can work with the City’s TPA with respect to data file transfers, and will also evaluate each vendor’s billing and payment requirements.

(3) Plan Sponsor Services The City will be evaluating the plan sponsor services provided by each proposer, including its electronic and written reporting capabilities, new member processing requirements and timeframes, processing of ID cards, and other services in support of City membership.

(4) Imaging & Document Storage The City will evaluate the provider’s resources for imaging and storing member records, documents, and forms related to the administration of member accounts.

(5) Security Protocols, Disaster Recovery & Guarantees

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The successful bidder is responsible for maintaining the confidentiality and security of member records relative to its administration of services. “Confidential Information” includes participant data, records and personal information such as social security numbers, dates of birth, marital status, home addresses, and other information related to participation in the plan. The successful bidder will need to execute, as part of its contract, a Confidentiality Agreement providing that all confidential information provided to the vendor by or on behalf of City and/or City Personnel, or accessed or reviewed by the vendor during the performance of the Contract, is and will remain the confidential property of the City. The vendor will be required to further agree not to provide or divulge confidential information to any other person or entity except as authorized in writing by the City. The vendor will also be responsible for protecting the confidentiality and maintaining the security of all confidential information in its possession by implementing and maintaining adequate and necessary security systems, along with policies and protocols, to provide the highest reasonable level of safety and security of the confidential information. In the event of a security or data breach, the vendor must have in place an emergency response plan. The vendor must also agree that if there is a breach of its security system, as defined by Civil Code Section 1798.82, and confidential information is accessed or believed to have been accessed, then the vendor shall include the information set forth in Civil Code Section 1798.82(d)(3) in the required notification and provide a copy of such notification simultaneously to the City, and indemnify the City against any losses in connection with the data breach. In addition, the vendor will also be required to demonstrate its participant protection and remediation plan, including but not limited to the purchase of credit protection services for impacted participants. Finally, the vendor is responsible for establishing contingency plans for emergencies, disasters, and disaster recovery. These plans should include redundant processing centers and plans for activating the necessary participant support services in the event a primary processing center is, for emergency reasons, not available. These plans should also address backup systems and records in the event of damage or disaster impacting the storage and maintenance of the recordkeeping system and its records.

M. INNOVATIONS & ADVOCACY RESOURCES

(1) Advocacy Resources The City will consider vendor resources for member advocacy. Member advocates would act as resources for members to navigate the complexity of the provider’s benefits and services and applicable rules/regulations/policies. The City is interested in having its healthcare providers provide dedicated member advocates who would be available onsite at City facilities and/or via a local service center to address member questions and assist members with receiving services.

(2) Value Added Services Proposers are provided the opportunity, pursuant to this RFP, propose innovative programs, tools, plan design concepts, or other ideas that would improve quality, choice and efficiency for the City’s Flex Program health benefits.

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MEMBER SERVICES

N. DIRECT SERVICES The City values service provider attention to the quality and responsiveness of its member services team. The City will evaluate each provider’s member service support operation to include the staffing, resources, hours of operation, training, and tenure applicable to the team which would service the City’s account. The City will further evaluate the process and timelines for issuing eligibility ID cards, and whether medical/vision cards are bundled or separately issued. Finally, the City will evaluate each proposer’s resources, policies and practices for monitoring, assessing and improving upon the service quality of the member services team. Generally, the City expects that member service representatives be available to assist our members minimally between the hours of 7:00 a.m. and 5:00 p.m. Pacific Standard Time (PST) each business day; and that these calls will be recorded. If an automated line is used, the City will assess its responsiveness and ease of access for members who need to speak with a member service representative.

(1) Quality Control: Appointments, Wait Times, Consultations, etc. The City values service provider attention to interactions between physicians and other health service providers and Flex members. The City will evaluate each provider’s resources, policies and practices for monitoring and creating positive outcomes on essential service criteria such as setting appointments, appointment wait times, length of consultations with physicians, updating provider directories, etc. The City will also closely evaluate each provider’s resources, policies and practices with respect to measuring and creating goals around improving upon member satisfaction.

(2) Quality Control: Referrals The City values service provider attention to the referral process from a member’s perspective. The City will evaluate each provider’s resources, policies and practices for monitoring and creating positive outcomes with respect to timely specialist referrals.

(3) Quality Control: Appeals Process The City values service provider attention to the medical appeals process from a member’s perspective. The City will evaluate each provider’s medical appeals process as well as the resources, policies and practices for monitoring and creating positive outcomes with respect to member appeals.

(4) Vision Provider Benefits The City values service provider attention to the accessibility and ease of use of vision benefits offered as part of the services arrangement with the City from a member’s perspective. The City will evaluate the transparency, communications, and resources offered to members with respect to vision benefits. The City is reserving the option of unbundling vision benefits from any or all of its primary medical service provider relationships and offering a stand-alone and uniform vision benefit to Flex members.

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(O) PROVIDER QUALITY OF CARE

(1) PCP Continuity & Provider Turnover

The City values service provider attention to the continuity of medical personnel, including especially those primary care physicians with whom its members interact on an ongoing basis. The City will evaluate the resources devoted by your organization to promoting continuity and stability among primary care physicians and assessing your efforts to acquire feedback from your physicians to determine their satisfaction and assess what factors are impacting the stability of where they provide service and what kind of service they provide.

(2) Quality Control: PCP, Specialist and Other Providers The City values service provider attention to the quality of care provided by treating physicians and provider groups. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to providing quality care to its members.

(3) Quality Control: Prevention, Adherence, Follow-Up Care

The City values service provider attention to the efficacy of your organization and its treating physicians and provider groups with respect to prevention, adherence and follow-up care. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to preventive, adherence and follow-up care services.

(4) Prescription Options & Availability The City values service provider attention to the efficacy of your organization and its internal or contracted prescription drug providers with respect to availability and member-based engagement on the use of formulary/non-formulary and generic/brand-name drugs. The City will evaluate the resources devoted by your organization to promoting and providing the appropriate incentives around encouraging best practices, consistency, and accountability with respect to the use of prescription drugs.

(5) Health Plan External Agency Ratings The City will be evaluating the National Committee for Quality Assurance (NCQA) Accreditation and Health Plan Employer Data and Information Set (HEDIS) Rating. The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization founded in 1990. The NCQA develops quality standards and performance measures for a broad range of health care entities, and produces reports of performance against such measures measured in the form of statistics that track the quality of care delivered by the nation’s health plans. Accredited health plans are evaluated on more than 60 standards and must report on their performance in more than 40 areas in order to earn NCQA’s seal of approval. Health plans in every state, the District of Columbia and Puerto Rico are NCQA Accredited. These plans cover 109 million Americans or 70.5% of all Americans enrolled in health plans. In addition to its accreditation program, the NCQA has developed a Health Plan Employer Data and Information Set (HEDIS) Rating, which is a tool used by more than 90 percent of

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America's health plans to measure performance on important dimensions of care and service. Each provider’s accreditation and HEDIS ratings will be evaluated pursuant to this RFP.

(P) COMMUNICATIONS The Flex Program places the highest priority on member communications because they fundamentally represent the touch-points at which members engage with the resources provided by the medical provider to maintain their health and well-being. All of the communications resources provided by the health insurance provider are evaluated relative to their effectiveness in effectively communicating, translating and providing education regarding the services and resources available to members. In addition, the City contracts with a separate communications consulting firm to assist the City in designing its communications strategy and objectives, and to help develop and execute specific communications initiatives. In 2016 the City will initiate a project in which it will work with its consultant to conduct a communications audit and define a long-term, outcomes-based communications strategy that will align all member communications and communications metrics with the Flex Program’s core mission. An important value for the City is ensuring that its health insurance providers be able to communicate a high-level, accessible and coherent framework for participants to conceptualize the most fundamental objectives and aspects of their medical benefits. The City will look to ensure that communications/features/services “overload” does not come across as overwhelming to members or distract them from the most important and critical information they require to be successful in navigating their benefits.

(1) Website Facility and Content The vendor should administer a member website which will provide members with the ability to access contact information, provider directories, and other resources for managing their needs. The City will assess each proposer’s core website template and functions to evaluate their relative success in effectively organizing categories of information for members. The City will also evaluate each proposer’s website functionality for user-friendliness, opportunities for/limitations to customization, interactive features, planned enhancements, and speed/facility in generating and adapting messaging and content.

(2) Self-Service Tools The City will review the self-service tools that vendors make available to members such as verifying enrollment status, locating physicians, reviewing and processing claims, reviewing and managing pharmacy/prescription benefits, obtaining health advice, making payments, scheduling appointments, and other tools for members to efficiently access information and services.

(3) Electronic, Print, Video, & Other Media Technology The City is interested in reviewing other communications media technology that vendors may offer such as videos, mobile applications, social media tools, etc. The City is additionally interested in the vendor’s capabilities for communicating with its membership via email. Additional and alternative means of engaging participants is important as continued fragmentation occurs with respect to how participants prefer to or are willing to receive information.

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(Q) WELLNESS, PREVENTION & DISEASE MANAGEMENT

(1) Resource Support & Alignment w/Flex Wellness Program

A long-standing and important objective of the City has been the creation of a comprehensive and robust Wellness Program for the Flex Benefits population. On November 12, 2015, the JLMBC adopted a resource and implementation plan for a Flex Benefits Wellness Program. The mission of the Flex Wellness Program is to support our members in making progress on a continuum of improving health, with a particular focus on behaviors impacting the prevention, treatment and incidence of chronic disease. Progress in fulfilling this mission would be measured by outcomes in some or all of the following broad measurements:

Increasing utilization of personalized educational and support services

Increasing member awareness of personal health and biometric data

Improving outcomes in a variety of key health indicators related to metabolic syndrome, body

mass index, nutrition, tobacco use, stress impact, etc.

The City intends to proceed strategically with a focus on building the necessary infrastructure to establish, sustain and grow the Wellness Program over time. By creating and reinforcing a strong base of support, the Wellness Program can demonstrate to Flex members a clear mission, communications coherence and effectiveness, and the credibility of the City’s commitment to member health and well-being. This infrastructure can be thought of as a pyramid of resources (see visual). A crucial objective is to establish a service delivery resource model that can incorporate but “sit above” the City’s health plans, rather than being primarily structured around each health plan’s independent wellness resources. The City believes this is important in order to meet several critical objectives:

Establishing and aligning a universal mission, goals, strategies and tactics;

Ensuring consistency of communication content and messaging;

Providing a common platform for disseminating information and providing gateway access to multiple resources; and

Creating universal benchmarks and data management. This service delivery model will incorporate service providers into the program specializing in Wellness administrative or counseling services, as well as providers specializing in assisting with designing goals, benchmarking outcomes, and measuring success. Following is a brief discussion of each layer of the resource and implementation plan adopted by the JLMBC:

Organizational Commitment – Organizational commitment involves the commitment of the City’s elected officials, the JLMBC, the Personnel Department, and all City departments in

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supporting the objectives of the Wellness Program. This commitment manifests in the dedication of resources, modeling a culture of wellness, communicating the goals and resources of the program, and otherwise supporting Flex members on their unique health journeys.

Securing City Staffing – Dedicated City staffing is necessary to drive the program forward, interact with stakeholders and gatekeepers, and direct the use of contracted resources.

Strategic Planning – Under the direction of and in consultation with the Personnel Department and JLMBC, the JLMBC will work with its consultant to create a detailed strategic plan for developing, implementing and administering the Wellness Program. The strategic plan will cover multiple years and include defining the program’s mission, goals, objectives, strategies, and measurements of success, including objectives related to engagement (employee participation in various Wellness-related programs), awareness (employee knowledge of certain essential information that is a prerequisite for changing behavior), and outcomes (measurable health-related outcomes in areas such as chronic disease incidence, adherence to treatment protocols, etc.).

Communications Strategy/Branding – This will involve branding the program and developing a communications strategy at the Flex Program level (rather than by health plan provider), such that all Wellness-related communications are consistent, coherent, and aligned with the Flex Program’s and the Wellness Program’s mission and strategy.

Communications Distribution Channels/Content – This will involve development of common-platform distribution channels and content. This will likely include creation of a Flex-branded wellness portal and educational content designed to engage members and raise their awareness of information promoting behaviors conducive to positive health outcomes. This information must necessarily be provided through resources possessing the expertise and qualifications to communicate around complex and personalized topics such as nutrition, exercise, stress management, etc.

Wellness Education/Counseling – This will involve identifying and utilizing a contracted in-person educational/counseling services provider which would have the objective of engaging, educating, and raising awareness among the City’s population as part of creating a “culture of wellness” and helping members successfully access all of the Flex Program’s health and wellbeing resources.

Benchmarking/Data Management – This will involve identifying and utilizing a contracted resource for benchmarking and data management services, so that the Flex Plan can track and benchmark certain aggregate data related to a variety of data points including employee engagement, awareness, and health outcomes. As with the local counseling service, this would be done at the Flex Program level rather than the level of the individual medical plan providers, to assure data consistency.

Programs & Events – Under the direction of City staff, this would involve promotional event-based behavioral programs (such as walking programs, smoking cessation programs, HRA promotion, biometric screening, etc.) that are coordinated within the communications branding, long-term plan, and defined goals/objectives/strategies/metrics.

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Funding resources for these services in 2016 are available under the City’s current contract with one of its medical services providers. This provider allocates $900,000 annually for Wellness related services. Pursuant to this RFP, the City is requesting that each of its medical service providers commit specific and minimally restricted dollars for use by the City in funding its contracted Wellness-related service provider relationships, educational programs and events, and other expenses related to the City’s administration of the Wellness Program. In addition, the City will be evaluating proposers with respect to their ability to otherwise align their resources and organizational commitment to the City’s vision of Wellness for the Flex Benefits population.

(2) Disease Management Programs In connection with the focus of its Wellness Program on chronic conditions, the City will be looking to identify and evaluate each proposer’s Disease Management Programs insofar as they are designed to improve the health of persons with specific chronic conditions and to reduce health care service use and costs associated with avoidable complications, such as emergency room visits and hospitalizations. The City will evaluate the degree to which a provider is able to:

Identify specific populations with specific chronic conditions; Successfully enroll members in the program; Utilize evidence-based practice guidelines to assure consistency of service; Coordinate services among a multi-disciplinary team of providers including physicians, nurses,

pharmacists, dieticians, respiratory therapists, and psychologists; Provide educational services such as counseling, home visits, 24-hour call centers,

appointment reminder systems, etc.; and Measure outcomes.

(3) Coordination w/Utilization/Case/Disease/Rx Management

The City will also evaluate vendor capabilities with respect to the coordination of their Wellness and Disease Management Programs with overall utilization, case management, disease management and prescription drug management. The City values providers who are able to demonstrate a comprehensive and integrated approach to empowering patients to be proactive in not merely treating disease once it has manifested, but preventing disease and progressing across a continuum of improving health.

ACCESS/CONTINUITY OF CARE

(1) Provider Groups & Networks & Geographic Access The City will be evaluating accessibility and the potential for disruption of each proposer’s provider groups/networks relative to the provider groups/networks of the incumbent providers. The City’s objective is to minimize and mitigate disruption, such that 85-90% at maximum will be able to retain access to their current providers. The City will provide census data regarding its membership. Proposers will be required to submit a GeoAccess study for all proposed plans based on the City’s current plans/populations that would be served by the vendor’s proposed network. For example, incumbent PPO members should be separately compared to 1) each PPO proposed network(s) and

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2) each HMO proposed network(s). The same should be done for the current Blue Shield HMO and Kaiser HMO plans.

Proposers will need to identify the number of participants that meet the network access standard by utilizing the zip code information provided in the census file, including all valid zip codes in which participants reside, including those not in the proposer’s service area, and the total number of provider practices available to each zip code, as well as the number of open practices (i.e., those providers accepting new patients). However, the access studies should be based on open practices only. If, after award of the contract, the actual disruption proves to be greater than that identified in the proposal, the successful bidder must be prepared to provide accommodations to address the deviation.

(2) Extended Hours, Emergency and Urgent Care Access The City will review the extended hours, emergency and urgent care resources available from each provider, and the resources provided by the health plan to assist and effectively communicate to members where and how to access care when and where it is needed.

(R) FINANCIAL COST

(1) Provider Reimbursements For the PPO plan, the City will evaluate the non-network equivalent Reasonable & Customary Percentile used for non-network reimbursement and source of non-network Reasonable & Customary Allowances.

(2) Hospital and Outpatient Facility Charges The City will evaluate how network hospitals are reimbursed for each plan that you are proposing. The City will further evaluate how network outpatient facilities such as surgicenters, imaging centers and laboratories are reimbursed, as well as any special arrangements that may exist with “Cultures of Excellence.”

(3) Underwriting Terms & Conditions

The City will be evaluating all aspects of the underwriting terms and conditions of your proposal, including the rate development to support the proposed rates. The rate development includes the claims cost, trend, pooling point and charges, reserves, and ACA fees. The City will also evaluate how the vendor will calculate subsequent renewals and any underwriting provisions that you will impose on the City.

(4) Retention Levels

The City will be evaluating the retention levels included in developing the rates. The City will review the way in which the retention is developed each year and the reasonableness of the retention charges.

(5) Rate Guarantees & Risk Sharing

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The City values proposals that include multiple year rate guarantees or rate caps for future renewals. The City is requesting fully insured, non-participating rates at this time. At the City’s discretion, they may request alternative funding arrangements at a later time.

(6) Premium Rates and Rate Adequacy for Plan Design Options

The City values proposals that include cost effective premiums based on plan design options that match closely to the current plans offered by the City. The City will be evaluating the proposed rates and benefits and the impact any changes will have on the participants.

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SECTION 3

PROPOSAL QUESTIONNAIRE

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QUESTIONNAIRE INTRODUCTION AND INSTRUCTIONS i. Introduction The RFP questions included in this RFP are intended to solicit important background information about your firm and fully disclose the data points upon which proposers will be evaluated. The City is not evaluating firms using any information other than what is outlined within this RFP. Responses to this section along with documents required to be submitted pursuant to Part B of this RFP are necessary for the proposal to be considered responsive. ii. Instructions

Provider answers to the questions in hard copy and Adobe PDF and Microsoft Word format on a USB flash drive, CD or DVD (original and redacted). Do not protect the CD or DVD copy of the proposal.

Do not alter the questions or question numbering. Complete all appropriate sections of the questionnaire. Provide answers to the questionnaires in Word format. Provide an answer to each question even if the answer is “not applicable” or “unknown.” Answer the question as directly as possible.

o If the questions asks “How many…” provide a number o If the question asks, “Do you…” indicate Yes or No followed by any additional brief

narrative explanation to clarify. Be concise in your response. Use bullet points as appropriate. Reconsider how to word any

response that exceeds 200 words in length so that the response contains the most important points you want displayed.

Referring the reader to attachments for further information should be avoided or used on a limited basis. Any response that does not directly address the question, but only contains marketing information, will be considered non-responsive.

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A. ORGANIZATION BACKGROUND Items 1-9 are required in order for your proposal to be considered responsive but will not be rated.

1. Cover Letter and Proposal Declaration - Provide a cover letter and Proposal Declaration to include the

following:

Title “City of Los Angeles Flex Benefits Health Plans RFP” and submission date

Contact name of person authorized to bind the proposer to the proposal

Contact Name/Title:

Mailing Address:

Location of Business (if different from mailing address):

Type of legal entity (corporation, limited liability company, joint venture, partnership, etc.)

A short description of your organization, the businesses in which it engages and the services it provides.

Telephone Numbers (Office, Cell, and 24-hour lines):

Fax Number:

E-mail Address:

Date entity was established and location of entity when established

Location of headquarters (full address) and, if your firm has more than one office location, which of your firm’s offices will service this account.

Annual revenues

Total number of employees

Total number of employees in the City of Los Angeles

Total number of employees in the County of Los Angeles

Number of employees reported in whose exclusive, primary work location is in the County of Los Angeles

Number of employees providing services for this contract

The following statement:

“The undersigned hereby offers and agrees to furnish the goods and/or routine services in compliance with all the service level requirements, instructions, specifications, and any amendments contained in this RFP document and any written exceptions in the offer accepted by the City. This proposal is genuine, and not sham or collusive, nor made in the interest or in behalf of any person not herein named; the proposer has not directly or indirectly induced or solicited any other proposer to put in a sham proposal, or any other person, firm or corporation to refrain from submitting a proposal; and the proposer has not in any manner sought by collusion to secure for itself an advantage over any other proposer.”

A signature submitted on behalf of the proposer by an officer authorized to bind the proposer to the proposal, acknowledging:

i. Receipt of and agreeing the submitted Proposal is based on the RFP and any identified addenda.

ii. Failure to indicate receipt of addenda may result in the proposal being rejected as non-responsive

iii. To constitute a responsive proposal all pages of the proposal questionnaire and required forms must be submitted.

iv. Under penalty of perjury under the laws of the State of California that the proposal is true and correct and the proposer agrees to the terms and conditions in the proposal.

2. City Business License Number or Vendor Registration Number - Indicate your City Business License Number or Vendor Registration Number if available. A license or registration number is not required for your proposal but will be required prior to execution of a contract. To obtain a Business Tax Registration Certificate (BTRC) or Vendor Registration Number call the Office of Finance at (213) 473-5901 and pay the respective business taxes. The address is as follows: City of Los Angeles, City Hall, Room 101, Office of Finance, 201 North Main Street, Los Angeles, CA 90012 – http://www.lacity.org/finance/).

3. State of California Board of Equalization Permit - Indicate your company’s State of California Board of Equalization permit number. If you do not have this permit, please make a statement to this effect.

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4. California Revenue and Taxation Code - Fill out and submit the appropriate California Revenue and Taxation Code form, if applicable (for out of state vendors).

5. Compliance with Standard Provisions - Provide a statement indicating that your firm will comply with the City of Los Angeles General Contracting Provisions attached to this RFP in Part B, including the Standard Provisions for City Contracts (Rev. 6/14). Please note that your statement does not relieve you from providing all of the documents required pursuant to the “Proposal Response Checklist.”

6. Insurance - The City is estimating that the following insurance coverage types will apply to this contract: Workers Compensation ($ ____________) General Liability ($ __________) Automobile Liability ($ _________) Professional Liability ($ _________) Please verify that you will be able to meet the required coverage levels and that you will submit proof of such pursuant to Part B, “General Contracting Requirements - Insurance Requirements,” as a condition of execution of any final contract (see Part B, “Standard Provisions – Insurance Requirements” for further details). Note that if the proposer is a sole owner company with no employees, the proposer can sign the City’s waiver of workers compensation. General Liability can also be obtained through the City’s SPARTA program for small contractors. Links to the City’s waiver form and SPARTA program from the City’s Risk Management website are provided as follows: http://www.2sparta.com/ http://cao.lacity.org/risk/waivewc.pdf

7. Lobbyist Disclosure – Disclose any (1) arrangements your company has with any lobbyists and/or agents representing your company, and (2) any arrangements your company has with an unrelated individual or entity with respect to the sharing of any compensation, fees, or profit received from or in relation to the proposing company being awarded a Contract with the City. If any such arrangements exist, describe the nature of the relationship and the manner in which compensation or fees would be shared.

8. Endorsement Disclosure – Disclose any financial relationship your company has with any union, organization or association in conjunction with an endorsement. Provide details regarding the relationship, including any benefit that will be recognized by the union, organization or association in the event your company is awarded a Contract with the City.

9. Subcontracting - If any portion of the Contract is to be subcontracted, it must be clearly set forth as to the part(s) to be subcontracted, the reasons for the subcontracting and a listing of subcontractors. For each subcontractor proposed, provide the following information:

i. The specific service being subcontracted ii. Name of Subcontractor iii. Subcontractor’s Contact Name iv. Contact Title v. Contact Phone Number vi. Mailing Address vii. Location of Business (if different from mailing address) viii. Business Telephone Number ix. Subcontractor’s registration # and/or license #, if applicable x. Description of Work to be Subcontracted xi. Reason for Subcontracting xii. Percent of Total Contract to be Subcontracted & Dollar Amount xiii. Relevant work experience in years and level of responsibility xiv. Experience in number of years that your firm has worked with the Subcontractor providing

these services xv. If subcontractor is a MBE, WBE, LBE, SBE, EBE, or OBE xvi. If subcontractors will not be utilized, so indicate here.

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QUALIFICATIONS The questions in the following sections will be rated.

QUESTIONNAIRE # Question Response

ORGANIZATIONAL STRENGTH & PLAN SPONSOR SERVICES

Organizational Qualifications and Reliability

Organizational Background, Financial Strength, Experience

1

Please provide an overview of your organization and organizational structure, to include the name of your parent company (if you have one), the nature of its business, the name of your company, the length of time your firm has been providing the broad range of services included within this procurement, headquarters, number of clients and covered lives, and geographic service area.

2

Please provide your organization’s revenues and net profits for 2013, 2014, and 2015.

3 Is your company a subsidiary or affiliate of another company? If yes, describe the nature of the business of the parent firm. Provide full disclosure of all direct or indirect ownership.

4

Describe any pending agreements to merge or sell your company or any portion thereof, or your parent company; or any pending or anticipated plans to reorganize your company within itself or as part of the larger organization of which your company is a part.

5

Describe any change in senior management (including CEO, CFO, CIO, or other executive management) in the last five years. Indicate the average tenure (in years) of senior management.

6

For the work unit(s) that you would propose servicing the City's Plan, what was total staff turnover for 2012, 2013, & 2014?

Number of full-time employees

Percent

7 Please provide an overview of the proposed health plan model (e.g. Staff model HMO, Network Model HMO, PPO, ACO, PCMH, Unbundled Vision) that you are proposing pursuant to this RFP.

8

Please indicated by checking the box if, in the last 12 months, your firm has:

Closed any network services areas (if yes, please list the centers).

Combined/consolidated member service or claims service centers. If yes, please list the centers.

Closed/consolidated or relocated any claims offices. If yes, please list the offices.

9

Please complete the following applicable membership profile/client base information for calendar years 2014 and 2015:

Annual PPO Membership - National

Annual PPO Membership - California. Please break down the percentages for Commercial, Medicare, Covered California, Medi-Cal, and other membership categories.

Annual HMO Membership - National

30

Annual HMO Membership - California. Please break down the percentages for Commercial, Medicare, Covered California, Medi-Cal, and other membership categories.

Annual Alternate Care Model Membership - National

Annual Alternate Care Model Membership - California. Please break down the percentages for Commercial, Medicare, Covered California, Medi-Cal, and other membership categories.

10

Please complete the following client retention rate information for group accounts only for calendar years 2013, 2014, and 2015.

Client Retention Rates

PPO

HMO

Alternative Provider Network or Care Model

Client Termination Rates

PPO

HMO

Alternative Provider Network or Care Model

References

11

Provide three current public sector client references in the following format:

Client Name

Contact Name

Phone, Email and Location

Number of Employees Covered

Contract Start Date

12

Provide three terminated (within the past five years) public sector client references in the following format:

Client Name

Contact Name

Phone, Email and Location

Number of Employees Covered

Contract Start Date

Regulatory Compliance

13

Has your company been the subject of any complaint filed with any state or federal regulatory agency or office In the past five years? Has your company ever had a license to do business, an agent/broker license or any other insurance license revoked or suspended? Has your company ever been reprimanded or otherwise cited by a licensing agency? If any of these apply, please describe fully.

14

Are there any outstanding legal actions pending against your organization? If so, please explain the nature and current status of the action(s). What guarantees can you provide that these actions will not disrupt your business operations or impact the City’s account if you were awarded a contract?

31

15

Identify and describe any past, pending or threatened judicial or administrative litigation (including lawsuits or protests) in which you have litigated against a client or prospective client, within the past five years, related to the type of services you are proposing. Indicate the reasons for the lawsuit/protest and the outcome. Provide contact information for the entity sued or challenged.

16

Describe any incident within the past ten years in which your business has had a contract terminated for default. Termination for default is defined as notice to stop performance due to your organization's non-performance or poor performance and the issue was either not litigated, or litigated and such litigation determined your organization to be in default. Submit full details of all termination for default experienced by your firm during the past five years including the other party’s name, address, telephone number and your firm’s position on the matter. The City will evaluate the facts and may, at its sole discretion, reject your firm’s proposal if the facts discovered indicate that completion of a contract resulting from this RFP may be jeopardized by selection of your firm. If your firm has experienced no termination for default in the past ten years, so indicate.

17

Has your company or its subsidiaries ever filed or been petitioned into bankruptcy or insolvency or has your company ever made any assignment for the benefit of your creditors? If so, provide complete details.

18

Describe what procedures and policies you have in place to protect against, and provide disclosure of, any potential or perceived conflict of interest involving relationships your firm may have with the City’s current or prospective service providers, governing authorities, advisors, or other interested parties.

HIPAA Compliance

19 Do you have a formal Health Insurance Portability and Accountability Act (HIPAA) compliance plan in place? If yes, attach a copy to your proposal.

20

Do you have a website that details information about your policies and procedures for accepting and sending Electronic Data Interchange (EDI) transactions? If so, please indicate the website.

21

Where does the copy of your Companion Guide for HIPAA EDI transactions reside?

22

Will your organization be issuing Notices of Privacy Practices as required by HIPAA to each new plan enrollee? At what cost?

Rating Agency Financial Ratings

23

Please provide the most recent ratings for your company by the following:

- Standard and Poor's

- Duff and Phelps

- A.M. Best

- Moody’s

If your firm is not rated, submit documentation of a similar nature, which attests to your firm’s financial stability.

32

24 Indicate if there have been any downgrades in your ratings in the last 2 years, and if so indicate to what they are attributable.

Administration Support & Account Management

Claims Processing

25

With regard to the claim offices that will be used, provide the following:

a) Location:

b) Average Claims / Processor / Day:

c) Annual Claim Volume:

d) Staffing: (Complete the following):

Processors (# of staff, avg. years claims administration experience, annual turnover %)

Supervisors (# of staff, avg. years claims administration experience, annual turnover %)

Managers (# of staff, avg. years claims administration experience, annual turnover %)

26

For each of the products that you are proposing, describe the claims payment process from date of receipt to full adjudication of checks to providers or patients. If the process is different for network and non-network claims please discuss separately. For example, do you batch process checks to network providers? If so, explain.

27

Based upon the latest 24 month period , please indicate the following:

2014 2015

Average number of business days to process a claim from date received to date check / EOB issued.

Percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check / EOB issued) within 10 business days.

Percent of all claims submitted (regardless of information provided on claim) are processed (from date received to date check / EOB issued) within 30 business days.

28

Have you been penalized by any state for failing to meet state average claim turnaround requirements? If yes, list states where you were sanctioned in the last 12 months.

29

For the claim office proposed, please indicate the following percentages over the past 12 months:

Financial accuracy as a percent of total claims dollars paid (include over / underpayments)

Coding accuracy (claims without error) as a percent of total claims submitted

30

What are your procedures for recovery of the overpayments or duplicate payments?

31

Explain your Coverage of Benefit (COB) procedures. Indicate if you pursue COB prospectively or retrospectively to payments, and how often records are updated for new information on other coverage.

32

Please provide the following regarding your fraud detection programs:

(a) Describe your ineligible claimant program, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives.

33

(b) Describe how you assure that services billed are actually rendered, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives.

(c) Describe your overbillings program, including whether you have a formal written program and, if you do, the total number of events per 1,000 covered lives.

33

Do you retain medical consultants for the review of any unusual claims or charges? If yes, explain the method in which such consultants are used and describe their qualifications and any affiliations.

34

How do you reimburse multiple surgical procedures being performed during one operation? Is a reduced scale used for the 1st and subsequent procedures?

35

Please outline the frequency and duration of any formal training programs for claim processors and claim managers. Describe initial and ongoing training separately.

36

Please indicate your willingness to allow and pay for the cost of an outside auditor to conduct an on-site, random, annual claims processing audit. Indicate the cost in dollars that you would allocate for this audit.

Billing & Eligibility

37

Indicate whether the City's payment options include electronic fund transfer, manual invoicing, or both.

38

What are your premium billing frequency options (monthly, quarterly, etc.)? What are your specific due dates for receipt of premiums? Do penalties apply for late payments and if so on what schedule and if so how are the penalties calculated?

39

Do you agree to receive and timely and accurately process as indicated in this RFP all of the enrollment and eligibility information in the format as provided by the City's third party administrator?

Plan Sponsor Services

40 By checking each box, verify that you will provide the following. If there are exceptions, do not check the box and explain the deviations.

Monthly Enrollment Reports by Plan Type and Membership Segment

Monthly Claims Reports by Plan Type and Membership Segment

Monthly Large Claimant Reports by Plan Type and Membership Segment

Quarterly Utilization Reports by Plan Type and Membership Segment

Annual Utilization Reports by Plan Type and Membership Segment

Notify the City immediately if the network loses any accreditation, licenses, or liability insurance coverage or if there is a change in hospital network contracts.

Provide any required health insurer B-series ACA-related tax reporting

Plan sponsor on-line claims summary

Plan sponsor on-line billing history

Plan sponsor on-line premium rates

34

Plan sponsor on-line provider directory

Plan sponsor on-line eligibility summary

Plan sponsor on-line enrollment counts

Plan sponsor on-line plan details

Plan sponsor health topics/medical information

Plan sponsor address changes

Forms w/cost included in premium: SPDs and SBC

Forms w/cost included in premium: Claims Forms

Forms w/cost included in premium: EOBs

Forms w/cost included in premium: Network Directory

41

Please describe your account team that will be assigned to the City of LA to include:

a) Day to day contact

b) Underwriting

c) Billing

d) Local Overall account management

e) Location of your local telephone service office, number of staff, and hours of operation

42

Assuming a contract award of 07/01/16 and beginning service date of 01/01/17, provide a proposed implementation plan and timetable, beginning with the aware of business to effective date of coverage, including the following:

a) Steps required to implement the program

b) Role played by the plan sponsor/vendor

c) Eligibility feed

d) Production and distribution of ID cards, directories, and enrollment materials

e) Contacts and personnel assigned to each step of the implementation process

f) Establishment of on-line plan information

43

What is the process and requirements from the City for distributing ID cards as part of annual open enrollment or other enrollment during the plan year? Please indicate whether the participants would receive one ID card or separate ID cards for medical and vision benefits. What is the timeframe for issuing ID cards?

44

Describe your online plan sponsor reporting services which would enable the City to review its aggregate membership data.

45

Provide your plan sponsor website and dummy account access information.

46

Do customer service representatives have on-line access to real-time claim status information?

47

From the date you receive eligibility information from the City, describe the length of time involved to add and activate benefit access for a new member.

48

Verify that you will agree to work with the City's Flex Benefits Third Party Administrator to exchange eligibility information.

49

Verify that you will agree to accept eligibility rules as established by the City and in accordance with applicable law/regulation.

35

50

Verify that if a participant has a family status change pursuant to Internal Revenue Code Section 125, the member will be able to change plan elections outside of open enrollment without having to provide evidence of good health.

51

Describe the ACA tax and other reporting services provided by your firm, and if any of those reporting services involve additional fees to the City. Please provide copies of sample reports.

Imaging & Document Storage

52 Describe your imaging and document storage capabilities.

53

Will you transfer enrollment cards, claim information, and other administrative records to any carrier that would replace you in the event of termination of this contract? If so, will you do so without charge to the City?

Recordkeeping, Security Protocols, Disaster Recovery & Guarantees

52

Describe your recordkeeping software system including: --When your recordkeeping system was first put into place --Whether the software was developed internally, leased, or purchased from another provider and if the system is leased or subcontracted --Who has the ultimate responsibility/authority to make sure the software remains current with respect to laws, regulations, and client needs

53

When was the last major system enhancement and what was the nature of the enhancement?

54

Do you foresee any specific problems incorporating the City’s population and plan features into your system? If so, describe in detail.

55

Describe your response plan in the event of a data security breach.

56

Describe what credit protection and other services you provide to participants who may be impacted by a data security breach.

57

Describe your disaster planning/prevention resources and plans, including the frequency with which your data is backed up and redundant processing centers.

58

Describe your disaster recovery resources and plans; indicate how often you test your recovery system.

59

With regard to your recordkeeping systems, please describe your record retention and destruction policy, including how long records are retained.

Innovations and Miscellaneous Services

Advocates and Onsite Services

60 Have you utilized member advocates or other onsite services with other clients? If so, describe the services offered and the client outcomes.

61 Will you provide dedicated advocates to assist plan participants in resolving administrative, clinical, and claim issues associated with your organization and affiliated providers? If yes:

(a) Provide the number of proposed advocates, titles, responsibilities, and the aggregate number of annual hours they will be dedicated to the City;

36

(b) Confirm whether the advocates will be available to plan participants at City facilities; and,

(c) Confirm whether these resources are included in your proposed fully insured premium rates.

Value Added Services

62

Do you have the ability to do population risk profiling? If so, what forms of risk scores do you use?

63

Provide any innovative ideas, programs, tools, and/or coverage that would improve quality and cost for the health care program. Describe what they are, how they work, how much they cost, what is the expected savings, and how savings estimates are derived. Are you willing to guarantee the savings through funds at risk and/or performance guarantees?

64

Can your company undertake a Performance Improvement Project (PIP) with providers that are to achieve, through ongoing measurements and interventions, significant improvement, sustained over time, in clinical care and non-clinical care areas that are expected to have a favorable effect on health outcomes and member satisfaction. The PIPs shall include the following:

• The use of objective, measurable, and clearly defined quality indicators to measure performance;

• Valid sampling techniques;

• Accurate and complete data collection;

• The implementation of appropriate planned system interventions to achieve improvement in quality;

• An evaluation of the effectiveness of the intervention, including sufficient data and barrier analysis;

• An achievement of real improvement that is sustained; and

• A plan and activities that shall increase or sustain improvement.

Are all of the services included in your base quote? If not, indicate the changes on a per capita basis.

MEMBER SERVICES

Direct Service

Customer Service Staffing/Availability

65

Describe the call center resources you will provide, including the following:

Hours (Pacific Time Zone)

Total Customer Service Representatives (CSRs) employed on a year-round basis

Hours of availability (Pacific Time Zone)

Location of primary and backup centers

Total staffing

Member services call center phone number

Staffing as a percentage of total covered members covered by that support operation

Hours of operation (Pacific Time Zone)

Proposed staffing with description of the types of personnel to be involved

Roles and responsibilities of staff

37

66 Describe the training provided to your CSRs and indicate the average tenure of those member services representatives that would service the City's members.

67

Describe what resources, policies and practices you have in place to monitor, assess and improve upon the service quality of your CSR team/staff.

68

Please indicate your Call Center's average response speed, average member telephone wait time to speak to a live CSR (not just an operator), in seconds based on the past 12 month period by product type (i.e.. HMO, PPO, etc). Also, please provide your percent abandonment rate in the past 12 months by product type.

69

Can your plan provide Interactive Voice Response (IVR) and Live Call reason statistics specific to the City's population? If yes, please provide a sample report of your call statistics report indicating major categories of call reasons and the frequency of the availability for this report.

70

Will a dedicated CSR team serve the City’s covered members? If yes, how many CSRs will be assigned to the City?

71

In staffing CSRs, how many participants do you assume a single CSR can cover? How many calls per day is a CSR expected to cover and what is the average length per call?

72

Describe the policies and procedures in place to ensure CSRs safeguard member’s personal information.

73

What language services other than English are available? Confirm your ability to provide Spanish language services, vision, and hearing-impaired access services during all hours of telephone customer service availability. Please indicate the total number of your CSR staff that are bilingual that speak 1) Spanish and 2) a language other than Spanish.

74

Do you offer a 24 hour telephone Nurse Triage (nurse advice / demand management) telephone program for enrollees? If so, indicate whether it is staffed by live health professionals and whether additional costs are charged for this service. Please indicate whether Nurseline call statistics and call reasons for your Nurseline can be shared with the City on a regular basis; provide a sample report and indicate frequency of the availability for this report.

75

Please provide a sample member handbook, evidence of coverage, summary plan description, and sample member I.D. card (please provide actual card and not a picture).

76

Please indicate your willingness to allow and pay for the cost of an outside auditor to audit your plan operations, specifically in conducting an on-site audit of your member services, customer call center department and processes, complaints/grievance/appeals process, and claims processing results and procedures. Indicate the cost in dollars you would allocate for this audit.

Quality Control: Appointments, Wait Times, Consultation Length, etc.

75

Please complete the following table on types of calls / complaints received by your member services department in the last 12 months (or latest calendar year available) by product (i.e.. HMO, PPO).

Types of Complaints

# Per 1,000

Members

38

Benefit Program Coverage & Administration (regarding Covered Benefits, Exclusions, Limitations, Claim Processing Issues, Member Services Issues, and Communication Materials)

Provider Access & Services Issues (i.e.. Appointment Wait Time, Physician/Hospital Customer Service Issues, and Language/Cultural/Interpretive Issues)

Physician Network Choices

Balance Billing Issues

Referral Process

Pre-Authorization

Claim Resolution

Total Member Complaints

76

What is your response time goal for which to respond to claims, complaints and other questions?

77

Describe what resources, policies and practices you have in place to monitor and create positive outcomes on essential service criteria such as setting appointments, appointment wait times, and length of consultations with physicians.

78

What is the average wait time (days) for members to schedule a routine appointment with their PCP? Describe what resources, policies and practices you have in place to monitor PCP accessibility and wait times?

79

Please disclose any and all policies, practices or incentives / disincentives related to the length of physician consultations with patients.

80

Describe how frequently you update your provider directories, both the online and print versions. Please indicate what resources, if any, you devote to monitoring the accuracy of directory content.

81

Please provide a copy of your latest health plan members' Annual Satisfaction Survey and results.

82

Please indicate your willingness to include in your scope of services the cost for designing, distribution, compilation, and analysis of a customized annual member health plan satisfaction survey (by product: HMO, PPO) approved by the City for its specific membership population. If so, please indicate the dollar amount you are willing to allocate annually for this project.

83

Problem Resolution Essay Question: As described in the Scope of Services, the City values improving member satisfaction with regards to setting appointments, appointment wait times, length of consultations with physicians, updating provider directories, etc. If you measure member satisfaction, what have your member satisfaction rates been for the last two years? What mechanisms are provided to members to provide feedback? If surveys are conducted, how often is this done and are they administered internally or externally? How are the survey results used and what is done to improve member satisfaction?

Quality Control: Referrals

84 What is the average wait time (days) for members to obtain a referral appointment with their specialist? Describe what resources, policies and practices you have in place to monitor

39

specialist referral accessibility and wait times.

Quality Control: Grievance & Appeals Process

85 Describe your process and requirements for members to submit complaints, grievances, and appeals for medical services including pharmacy.

86

What was your average response time to the following medical service appeal categories during 2014 and 2015:

Urgent care cases

Prior authorization for treatment

Services already received

87 What is your process for monitoring member satisfaction regarding member complaints, grievances, and appeals?

88 Do you provide client-specific HMO or PPO member complaints, grievances, and appeals reports? If so, please include a sample report and indicate frequency of availability for this report.

Vision Provider Benefits & Transparency

89

Please describe the vision benefits you're offering to the City. If bundled with a medical services proposal, indicate whether you manage your own vision program or if it's outsourced, and if the latter to whom it's outsourced and whether any additional fees apply related to the benefit.

90

Describe the composition of your vision provider network (e.g., number of optometrists, total number of locations, percentage of independent optometrist offices compared to retail establishments) and your top 10 providers in Los Angeles County during the last 12 months based on individual members served.

Provider

# Members Served

1) 1)

2) 2)

3) 3)

4) 4)

5) 5)

6) 6)

7) 7)

8) 8)

9) 9)

10) 10)

91 Describe the vision billing process from the member's perspective, including if it is different from other medical services.

Provider Quality of Care

PCP Continuity & Provider Turnover

40

92

For plans with gatekeepers, describe the different ways in which participants can select PCPs. What is the average wait time (in days) for a participant to schedule a routine appointment with their PCP? Describe the process you have in place to monitor PCP accessibility and wait times.

93

Do you notify members if a network physician terminates their contract during the plan year, at no additional cost? Explain what happens to patients receiving on-going treatment from a terminated network physician.

94

Describe what resources, policies and practices you have in place to monitor and create positive outcomes with respect to the continuity of primary care physicians within or contracted with by your organization.

95

Please indicate if your health plan conducts an annual provider (physician or medical group) survey. If so, what are the results of the latest survey?

96

For the Los Angeles county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

PPO

Hospital

Physicians

97 For the Orange county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

PPO

Hospital

Physicians

98 For the Riverside county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

41

PPO

Hospital

Physicians

99 For the San Bernardino county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

PPO

Hospital

Physicians

100 For the Ventura county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

PPO

Hospital

Physicians

101 For the San Diego county service area provide the number of Network Providers that have terminated their contract:

Provider Type Unknown Total # Terms in past 12 mos.

Terms = to what % of

your contracted providers?

% of Terms that are

Voluntary

Most common reasons

for terms

HMO

Hospital

Physicians

PPO

Hospital

Physicians

102 Network Hospital and Outpatient Facility Profile - Complete the following table(s) for the network within the geographic areas requested.

List Number by County Los Angeles Orange Riverside

San Bernardino

Ventura

Acute Hospitals

Urgent Care Facilities

42

Urgent Care Facilities – with extended hours

Emergency Rooms

Outpatient Surgical Centers

Clinics

General / Family Practice Physicians

General / Family Practice Physicians – Accepting new patients

General / Family Practice Physicians – with extended hours

OB/GYN Specialists

Other Specialists

Optometrists

Ophthalmologists

103

Based upon the counties listed above, provide the percentages of physicians that are board certified for:

- PCP

- Specialist

104

Problem Resolution Essay Question: Continuity of and stability of provider care is a primary concern of Flex members. A variety of factors may influence the stability and continuity of individual physicians and group practices. What policies, practices, and metrics does your organization use to promote stability/continuity within your physician provider network? What efforts, if any, do you make to obtain feedback from your physicians or provider groups to determine their satisfaction and assess what factors are impacting the stability of where they provide service and what kind of service they provide. (PPO proposals should specifically address this question from the perspective of maintaining continuity of your in-network providers).

Quality control: PCP and Specialist Options and Availability

105

PPO only - Please indicate which states your PPO network does NOT extend to.

106

Please provide a description of how your narrow and/or tiered networks are structured.

107

Please provide a response for each type of network proposed.

─ Is the selection based upon Specialist, Hospitals, and/or Primary Care Physicians?

─ Is the selection criteria quality or cost based?

─ How do you make the assessments of cost and quality?

─ How often are the providers profiled?

108 Do your alternative networks have the same underlying cost trend increases? What kind of guarantees are you willing to provide around cost and / or trend increases?

109

The City currently provides Out-of-Area (OOA) coverage to employees who reside outside of California (e.g. certain employees who live in Washington D.C. and utilize the PPO option. Please describe your proposed out-of-area coverage(s). Are you able to administer similar benefit options for the different out-of-state employee groups? If not, please describe the differences.

110 How will you handle the following situations:

─ Eligible dependent students residing out-of-area

43

─ Eligible spouse/domestic partner and/or children of employees residing out-of-area

─ Eligible employees on a temporary assignment out-of-area (including extended assignments out of the country)

─ Eligible employees/dependents while on vacation in the continental U.S.

─ Eligible employees/dependents injured while on vacation outside the continental U.S.

Quality control: Prevention, Adherence, Follow-up

111 Indicate if you have a mechanism for routinely investigating if a contracted provider has any disciplinary actions imposed by their State licensure medical board.

112

Do you compare individual network provider practice patterns against Best practices or averages on any of the following: (Check all that apply)

Referral rates to specialists

Frequency and quality of prescription drug dispensing

Rates of Diagnostic Procedures ordered (Lab/Imaging)

Rates of surgical procedure relative to peers

Repeat Procedures within given timeframes

Hospital Readmission Rates

Unknown/do not track

113

Other than provider directories and access to providers via your website, what quality or practice pattern data about your contracted providers do you make available to plan participants?

114

Please provide an electronic copy or link to your provider and/or hospital profiling information that will be available to members. If this is different for your Full HMO, Narrow Network, or Tiered network, then provide a copy or link for each.

Rx Options and Availability

115

Do you manage your own prescription drug program or is it outsourced? If outsourced, to which organization?

116

Describe your process and requirements for members to submit complaints, grievances, and appeals for prescription drug services, including requests for exceptions for to generic and forumlary prescriptions.

Describe your criteria/process for patients to obtain brand name/non-formulary prescriptions if a medical necessity for such is identified.

117 What was your average response time to the following prescription drug service appeal categories during 2014 and 2015:

(a) Urgent care cases

(b) Prior authorization for treatment

(c) Services already received

118 Please describe any formulary requirements of your proposed plan, and include a copy of your formulary.

119

Describe your pre-authorization process and the list of drugs to which it applies.

44

120

In cases where members have chronic conditions (diabetes, CAD, COPD, etc.) that are treated by prescriptions, the City is considering having copays reduced or eliminated in order to increase compliance with maintenance drugs. The pairing of a diagnosis with the prescription is required to avoid reducing copays for prescriptions when the diagnosis is not a chronic condition. Please describe your Rx/Dx pairing for maintenance prescriptions. Include diagnosis and maintenance medications that qualify for Rx/Dx pairing. How are members identified? What is the outreach?

121

Describe your drug utilization review features, capabilities, and/or processes.

122

What is the name of the Specialty Pharmacy? Describe your management of Specialty Drugs and the programs offered to members to encourage appropriate utilization. How do you identify and introduce members to these programs?

123 Describe your process for communicating formulary changes.

124

Provide any innovative ideas, tools, and or coverage that would improve the quality and cost of the Rx benefit. Describe what they are, how they work, how much they cost, what the expected savings are, and how savings estimates are derived. Are you willing to guarantee the savings through funds at risk and/or performance guarantees?

125

Describe your pre-authorization protocols available to the City. Include information on step therapies and other clinical management programs along with any additional costs for such services and credentials of the staff performing pre-authorization. What drugs or class of drugs do you recommend be pre-authorized?

126 What programs do you offer to address potential drug abuse?

127

What programs, tools, and / or coverage do you have available to improve the quality of the Rx benefits or lower Rx costs? What is the expected savings of these programs? Are you willing to guarantee the savings or provide performance guarantees for these programs?

128

Problem Resolution Essay Question: When taking prescription medications, members often experience frustration when either a brand-name prescription is changed to generic or when a change in Rx providers results in elimination of a prescription from the formulary. What steps would you take to assist members in being better informed of the consequences of such changes and what steps, if any, might you propose to mitigate these types of situations from occurring?

National Committee for Quality Assurance (NCQA) Accreditation

129 Provide your organization’s current accreditation status and duration of continuous accreditation (in years) for the National Committee for Quality Assurance (NCQA).

130

Provide your organization’s current NCQA ratings (from 1.0 to 5.0) for the following:

Consumer Satisfaction

Prevention

Treatment

Overall Rating

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Health Plan Employer Data and Information Set (HEDIS) Results

131 Provide your latest National Committee for Quality Assurance (NCQA) Health Plan Employer Data and Information Set (HEDIS) results for California plans.

132

Please indicate your willingness to provide a City of LA-specific Health Plan Employer Data and Information Set (HEDIS) study. If so, indicate how frequently you would recommend conducting such a study and at what volume of membership.

133

Please share and summarize your latest Consumer Assessment of Healthcare Provider Survey (CAHPS/HEDIS) results in the following categories for a commercial and adult population: Claims Processing Composite Score; Customer Service Composite Score; Getting Care Quickly Composite Score; Getting Needed Care Composite Score; and How Well Doctors Communicate Composite Score. Indicate the year of your survey, overall response rate, and product type (i.e.. HMO, PPO, etc).

Communications

Website Facility and Content

134 By checking each box, verify that you will provide the following. If there are exceptions, do not check the box and explain the deviations.

Provider directory including physician office address and phone number, specialty designation, office hours, languages spoken in office, and list of hospitals with admitting privileges

Provider profiles

Plan details

Health information

Claim status

Lab results

Submission of referrals

Request for prior authorization

Submission of RX

Availability of Complaints, Grievances, and Appeals forms

How often do you review and update the member and provider information on your website? Is there a 24 hour 1-800 number to call if there are technical issues related to your website functionality?

Can you share the analytics and statistics collected by your health plan regarding areas and links frequently accessed by members? If so, please provide a sample report.

Self-Service Tools

135

Do you have any decision support tools (e.g. provider/facility selection, cost comparison, provider quality, email access, lab results, Rx refills, telemedicine, etc.) available to members? Is it your tool or a third party’s? Describe the kind of information available to members and how they would access it? Provide a link to these tools.

136

Would you offer a dedicated toll-free number for Flex Plan members?

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137 Describe other communication tools available for members such as after hour contact capability, chat feature and email.

138

Please provide your latest reports or statistics indicating the frequency of usage of your decision support tools and the demographics that are likely to use them.

Electronic/Print/Video

139

Do you have any tools for members and/or providers to create and maintain a electronic patient record? Is it your tool or a third party’s? How is the information populated? How do members access their information? How do your medical providers use the electronic patient records to ensure quality healthcare is delivered? What are your policies about making this available to other treating providers in the event of an emergency?

Mobile Apps/Education

140

Indicate if you have a mobile application or mobile optimized website, what features it includes or may be limited to as compared to the regular member website, and what information (if any) can be customized by the plan sponsor. If you offer one, provide information regarding how to access your mobile application. Indicate whether and how you maintain consistency between your mobile application and website.

141

Can you share the analytics and statistics collected by your health plan regarding members that access your website or information through mobile apps? If so, please provide a sample report.

142

Describe your organization's video educational and marketing content and what specific video content you make available and whether this material requires or does not require customization for the City. Indicate whether you charge your clients for the use of this material in their plans or for customization.

143

If you have produced them, provide five samples videos that could be used by a client for marketing or educational purposes.

Would you be able to offer/host webinars for employees during or outside of Open Enrollment?

Wellness, Prevention and Disease Management

Resource Support for & Alignment w/City Wellness Program

144 Please indicate if you would be willing to provide dedicated funding for the City's use in administering its Wellness program, and if so at what annual value.

145

For any dedicated funding resources you would provide to the City for its Wellness program, please verify that the City is able to use those resources to fund its contracted, communication, promotional, incentive, and administrative expenses, whether or not any of those services are provided by your firm, and identify any restrictions in the use of those funds.

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146

Indicate if you will provide dedicated or partially dedicated staff to implement and support the City's wellness program, including administrative staff, consulting, and counseling (including onsite) staff. Please provide name, title, responsibility, and number of annual hours or ongoing percent of a full-time position for the key staff that would be assigned to service the City's account.

147

Indicate if you provide wellness coaching resources for members, and if so what services are included, the qualifications of the individuals delivering those services, the coaching process, whether those services are restricted in any way to only certain members, and whether those resources are offered face-to-face or telephone only or both.

148

Indicate if you will support the City's wellness program benchmarking efforts by fulfilling available aggregate (non-member identifying) data requests supplied to an external benchmarking/data management firm.

149

In support of the City's Wellness Program, confirm your ability to transfer medical and pharmacy utilization data on a scheduled basis to an independent data warehouse at no additional cost.

150 Provide an overview of the Wellness resources that your firm has developed and your organization's philosophy with respect to Wellness programs generally.

151

Which of your programs focus on helping patients identify and lessen the following risk factors:

a. Overweight/obesity

b. Tobacco use

c. High cholesterol/triglycerides

d. High blood glucose

e. High blood pressure

f. Lack of physical activity/exercise

e. Stress management

152 Explain how your organization's wellness program resources could be coordinated with those provided by other providers and describe your experience with this coordination.

153

Explain how your organization's wellness program services (e.g.,biometric screenings, health risk assessments, wellness challenges, health education classes, etc.) could be offered to members of various health plans, and describe your experience this provision of cross-member services.

154 What wellness programs/resources are included within your premium pricing and which are available at an additional cost? Explain in detail and include additional cost.

155

Explain your organization's philosophy and beliefs regarding how best to measure the success of Wellness efforts, programs and resources, and the metrics that you believe would serve as the best indicators of success.

156

Explain your organization's philosophy/practice and experiences with respect to the use of incentives to facilitate participation in the wellness programs and for achieving health enhancement goals.

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157

Based on your experience, what wellness-related programs and strategies have the greatest impact on the following:

a. Member engagement, participation and utilization of wellness resources

b. Improved health outcomes

c. Long-term cost reduction

158

Problem Resolution Essay Question: As described in the Scope of Services, the City is in the process of creating its own plan sponsor directed Wellness program. The City has articulated a unique vision and will be constructing and implementing a highly customized program offered at the broad level of the Flex Benefits program as a whole. Please discuss how your existing wellness resources and services can be administered to align with and support the City's vision and implementation plan.

Disease Management Programs

159 Do you perform Disease Management (DM) services? If yes, describe the DM services in detail that are included in the fully insured premium.

160

Do you have a minimum of three (3) years experience in performing disease management services?

161

Are you currently providing DM services to a group of at least 10,000 covered employees (not counting dependents)?

162

Do you have the ability and are you willing to customize your DM services to meet the needs / desires of the City?

163

How are members identified and stratified for the DM programs?

164 Describe your DM delivery model, including who delivers the DM coaching, their qualifications, the average DM patient load per coach, and the coaching process.

165 Do you agree to provide reports of DM activity at least quarterly and the annual Return on Investment (ROI) within 3 months of the close of the prior year?

166

If the claims data is available, do you agree (that after the award of this contract and during the implementation phase of your services) you will mine the client’s medical claims and prescription drug data and identify those individuals appropriate for your DM services AND provide the City (prior to the start date of the contract) with a short summary report/memo that outlines what you found in their data, including but not limited to the following elements:

(a) The total number of patients identified with chronic diseases you will manage in the initial data analysis

(b) The number of patients you identified in each of your risk classes/level

(c) The metrics you will use to track the patients' condition management engagement and progress

(d) The percent of clinical goals/objectives the population is NOT adhering to in the baseline data search

167

Which of the following DM programs do you offer for those patients identified as qualifying for DM services?

a. Obesity

b. Diabetes

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c. Hypertension

d. Coronary Artery Disease

e. Congestive Heart Failure

f. Chronic Obsructive Pulmonary Disease (COPD)

g. Asthma

h. Hyperlipidemia

i. Back/neck pain

j. Depression

k. Other:

168

Are your DM services available to be used by participants who live in any of the 50 states?

169

How do you recommend that a client communicate and encourage the use of DM services?

170

Indicate the most effective service you believe your DM staff provides to patients with chronic diseases?

171

Explain how your DM staff introduces themselves to patients for the first time (e.g. phone call, letter)?

172 What DM programs are available at an additional cost? Explain in detail and include the additional cost.

Coordination of Care

173 Describe how your programs provide for coordination of a member's care through utilization review, case management, disease management, Rx management, and wellness programs.

ACCESS / CONTINUITY OF CARE

Provider Groups/Networks & Geographic Access

174 Please provide a description of how your narrow and/or tiered networks are structured.

175

Are your proposed networks licensed in the State of California? Please indicate the initial/original year and type of license (for HMO and PPO, as applicable).

176

Please provide a response for each type of network proposed. ─ Is the selection based upon Specialist, Hospitals, and/or Primary Care Physicians? ─ Is the selection criteria quality or cost based? ─ How do you make the assessments of cost and quality? ─ How often are the providers profiled?

177

Do your alternative networks have the same underlying cost trend increases? What kind of guarantees are you willing to provide around cost and or trend increases?

178

Please provide an electronic copy or link to your provider and/or hospital profiling information that will be available to members. If this is different for your Full HMO, Narrow Network, or Tiered network, then provide a copy or link for each.

179

Provide separate GeoAccess results for each product that is included in your proposal. Please make sure that the GeoAccess reports match the total of participant counts based on current census data provided. Standard for Definition of Access to Network Provider: - PCPs: 2 in 8 miles for urban/suburban areas, 2 in 15 miles for rural areas - Specialists: 2 in 8 miles for urban/suburban areas, 2 in 15

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miles for rural areas - Hospitals: 1 in 10 miles for urban/suburban areas, 1 in 15 miles for rural areas

180 Please complete the disruption analysis tables as accessed through information contained in Attachment B.

181

Explain how the member disruption will impact plan members (employees and dependents). Please identify significant areas of concern in your plan disruption results. Explain how you plan to address member disruption and how your plan will ensure continuity of care.

182

Describe your proposed transition of care plan. At a minimum, the transition plan must address: − Individuals who are in the course of medical treatment − Transition of prescriptions − Communication to all plan members and stakeholders

183

Do you agree to cover all eligible expenses incurred by a covered participant who is hospitalized on the date of termination until that person is discharged from the hospital?

184

How would the following situations be handled in which eligible employees/dependents are receiving treatment on the plan’s effective date? ─ Member is hospitalized ─ Member is receiving major ongoing treatment (not hospitalized) for an acute condition ─ Member is receiving ongoing chronic care (e.g., asthma, COPD, diabetes) requiring specialized management ─ Member is receiving non-acute ongoing care ─ Member is pregnant ─ Member is receiving ongoing treatment for outpatient mental health or substance abuse

185

Are you willing to fund a Pre-Implementation Review/Audit by an auditor of the City's choosing? This would involve running test claims in a test environment utilizing the City's actual plan parameters.

186

Does your plan have the experience and capability to work with onsite or shared wellness clinics in California? If yes, please describe your experience and capabilities.

187

Problem Resolution Essay Question: When a provider group or groups within a network is eliminated there can be changes in what is included within the definition of reasonable and customary for certain services, members may not realize the impact of those changes until after the services are incurred. What steps would you take to assist members in being better informed of the consequences of such changes and what steps, if any, might you propose to mitigate these types of situations from occurring?

Extended Hours, Emergency and Urgent Care Access

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188

Describe the extended hours, emergency, and urgent care access resources available to your members, and what resources, policies or practices you have developed to ensure that these resources are member responsive and effectively communicated.

FINANCIAL COST

Provider Reimbursement and Discounts

186

For the PPO plan, indicate non-network equivalent Reasonable & Customary Percentile used for non-network reimbursement.

187

For the PPO plan, indicate source of non-network Reasonable & Customary Allowances (Ingenix, Medicare, ADP, Other).

188

For the PPO plan, please indicate if your plan partners have the ability to access other organizations' PPO networks for claims incurred outside of California.

189

When you are the secondary payor in a Coordination of Benefits (COB) situation, do you use your Usual, Customary & Reasonable (UCR) profiles, reduced network fees, or those of the primary carrier in determining your level of reimbursement?

Hospital and Outpatient Facility Charges

190

Describe how network hospitals are reimbursed for each plan that you are proposing. Your answer should be consistent with the fees provided on the proposal sheets provided. If reimbursement varies by geographic location, identify reimbursement arrangements by area for those relevant to the plan sponsor.

191

For each of the products that you are proposing, how are network outpatient facilities such as surgicenters, imaging centers and laboratories reimbursed (on a discounted fee arrangement, percent of Medicare APCs, pre-paid capitated arrangement)?

192

If a scheduled fee arrangement is the basis for reimbursement, describe how the scheduled fees are derived.

193

Do you have special arrangements with “Centers of Excellence” facilities?

a) Describe the illnesses / conditions and services associated with your Centers of Excellence programs.

b) Are services bundled with regard to reimbursement?

c) Is the facility at risk for cost incurred in excess of the negotiated charge?

d) Include the actual bundled charge for each condition, AND list the facilities by name and region.

Underwriting Terms and Conditions

194

Please provide the detailed rate development to support the rates in the proposal including claims cost, trend, pooling point and charges, retention, reserves, ACA fees, and all other components including the calculation of tiered rates.

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195

Explain the methodology and data to be used for the renewal process. How will projected incurred claims and expenses be estimated for these plans? Please include a sample rate renewal development worksheet.

196 What experience period(s) will be used for the first renewal?

197 What credibility will be given to each period of experience used? Provide a copy of the rate development formula to be used during the first and subsequent annual renewal periods.

198

Explain your methodology for establishing Incurred but not reported reserve.

199

Indicate the factors used to set rates for the proposal, to include Annual Trend Factor % of expected claims Reserve Factor % of expected claims, and Margin % of expected claims.

200

Explain any other required reserves other than for Incurred But Not Reported (IBNR). Indicate amounts, reason for reserve, is interest credited and whether reserves are refunded to the client upon policy termination.

201

Detail any underwriting provisions if any (rules) you will impose on the City. Please explain in detail any conditions or requirements, if any, that may cause your organization to increase the rates presented to the City.

202

Please indicate if you can provide a refunding or participating fully-insured HMO or PPO contract. If so, please provide the estimated percentage change in rates and sample contract.

Retention Levels

203 Are retention charges set based on a percent of premium, percent of claims, a per employee amount, or some other methodology?

Multi-year Rate Guarantees or Rate Caps

204

All insured rates, contract terms, and provisions must be guaranteed for twelve months and renewable for a minimum of 12 months for subsequent periods. Will you guarantee initial rates for a longer period of time or provide caps on rate increases? If so, please specify all caveats attached to the rate guarantee(s) offered.

Performance Guarantees

205 Please describe any proposed performance guarantee for the

first year, second year, and third year.

206 Please include a sample Performance Guarantee Contract.

Premium Rates and Rate Adequacy for Plan Design Options

207

All insured rates, contract terms, and provisions must be guaranteed for twelve months and renewable for a minimum of 12 months for subsequent periods. Please confirm your agreement to this requirement.

208

Do you agree that changes in the premium rate may only occur on the anniversary date unless required by mandatory benefit changes or other legislative action?

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209 Do you agree to provide written notice of rate changes no later than April 1st of each year (9 months notice), including supporting experience and underwriting rate development?

210 Please complete the following rate tables. Quote rates on a 4-tier basis for active employees using the current rate tier structure and step ratios.

Enrollment Assumption

Proposed Monthly Premium

Rates 1/1/2017 -

12/31/2017

211 Option #1 - Fully Insured, Non-participating (including vision)

Step Ratios

PPO Plan

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 1.9

Family 2.5

Narrow Network Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Full Network Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Staff Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.6

Alternative Provider Network or Care Model

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Rate reduction if awarded multiple plans? If yes, provide percentage reduction.

Enrollment Assumption

Proposed Monthly Premium

Rates 1/1/2017 -

12/31/2017

b. Option #2 - Fully Insured, Non-participating (excluding vision)

Step Ratios

PPO Plan

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 1.9

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Family 2.5

Narrow Network Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Full Network Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Staff Model HMO

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.6

Alternative Provider Network or Care Model

Employee Only 1.0

Employee + Spouse / DP 2.2

Employee + Child(ren) 2.0

Family 2.7

Rate reduction if awarded multiple plans? If yes, provide percentage reduction.

c. Rate Development Worksheet - including claims cost, trend, pooling point and charges, retention, reserves, ACA fees, and all other components including the calculation of tiered rates.

212

Please provide confirmation of the following stipulations regarding the proposed rates:

a. Confirm that your proposed premiums do not include commissions.

b. All proposals must include fees and taxes mandated under ACA.

c. Confirm that your proposal does not include minimum contributions and / or enrollment levels.

d. Confirm that there will be no adjustments to the proposed fees and/or rates based on actual enrollment or subsequent shifts in enrollment.

e. Other than the quoted premium rates, there should not be any other charges or fees of any kind that will or could apply to the City such as start-up costs, any required ACA fees, booklets or printing. The rates quoted shall include all services, fees, and supplies that could reasonably be expected to be provided to the City during the course of your administration of the plan. Confirm your agreement to this requirement.

213

Please complete the "Benefit Summary" table included as Attachment B to this RFP

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SECTION 4

PROPOSAL FORMAT AND SUBMISSION

REQUIREMENTS Proposals must be based only on the material contained in the RFP, Pre-Proposal Conference responses, amendments, addenda and other material published by the City relating to the RFP. The proposer must disregard any previous RFP draft material. Proposals must be submitted in accordance with the requirements set forth in this RFP.

4.0 Addendum(a) The City reserves the right to issue addendum(a) to this RFP, which may add additional requirements which must be met in order for a proposal to be considered responsive. All proposers must acknowledge any addendum(a) issued as a result of any change in this RFP on the Proposer Signature Declaration Page. Failure to indicate receipt of addendum(a) may result in a proposal being rejected as non-responsive. 4.1 In Writing All proposals must be submitted in writing and proposers shall complete and return any and all applicable documents including but not limited to written responses, questionnaires, forms, appendices, spreadsheets, and any electronic files. The City may deem a proposer non-responsive if the proposer fails to provide all required documentation, copies or electronic files. 4.2 Cover Letter Each proposal must include a cover letter limited to two pages. The cover letter must include the title, address, email address, and telephone number of the person or persons who will be authorized to represent the proposer. 4.3 Best Offer The proposal shall include the proposer’s best terms and conditions. Submission of the proposal shall constitute a firm and fixed offer to the City that will remain open and valid for a minimum of 12 months from the submission deadline. 4.4 Authorized Signatures Proposals must be signed by a duly authorized officer eligible to sign contract documents and authorized to bind the company to all commitments made in the proposal. A non-officer individual, with the authority to bind the proposer to a contract, is sufficient to sign all applicable documents for the purpose of this RFP. Consortiums, joint ventures, or teams submitting proposals will not be considered responsive unless it is established that all contractual responsibility rests solely with one proposer or one legal entity. The proposal must identify the responsible entity. 4.5 Number of Copies Required Proposers are required to submit:

56

One (1) original written proposal sent to the City of Los Angeles RFP Administrator proposal delivery address which includes all required responses to Part A (see specific instructions in Section 3) and Part B, with all documents signed in ink.

Two (2) copies of the written proposal sent to the City of Los Angeles RFP Administrator proposal delivery address which includes all required responses to Part A only.

One (1) copy of the written proposal sent to the City of Los Angeles consultant proposal delivery address(es) which includes all required responses to Part A only.

Five (5) electronic (USB drive) copies of your Part A response only: three to the City of Los Angeles RFP Administrator, and one each to the City of Los Angeles consultants for this RFP.

Original and copies should be identified as such. If any proposal contains any trade secrets or other proprietary information that the proposer claims is exempt from disclosure under the California Public Records Act (see Section 6.0 of this RFP), then one (1) redacted copy of the proposal must also be submitted in addition to the original version. Written proposals must be presented in a sealed envelope or box. Proposer must enter the title and proposer’s name on the outside of the envelope or box. Sealed proposals are to be delivered to the address listed in this RFP no later than the stated proposal submission deadline. Certain efficiencies in how proposals are prepared and submitted are requested in order to facilitate the review, storage and recycling processes for proposal materials. Economy in presentation and packaging is preferred over materials which are not easily reproduced, create unnecessary waste, or are awkward to store. Please do not submit materials in plastic binders. Each response should have the bulk of its contents prepared on standard 8½ x 11 paper. Non-essential promotional materials and over-sized materials should be avoided wherever possible except as otherwise requested within the RFP. 4.6 Electronic (USB Drive) Submission In addition to the written copies of the proposal, proposers are required to provide a copy of the proposal in Adobe PDF, Microsoft Word, and (questionnaire only) Microsoft Excel format on a USB flash drive. Redacted versions should be sent separately and identified as such. The USB flash drive containing the proposal versions should be labeled with the firm name and title of this RFP and placed in a sealed envelope with the firm’s name written across the front of the envelope and attached or affixed inside the front cover of the original RFP response.

4.7 Information Requested and Not Furnished The information requested and the manner of submission are essential to permit prompt evaluation of all proposals. Accordingly, the City reserves the right to declare as non-responsive and reject any proposals in which information is requested and is not furnished or when a direct or complete answer is not provided. 4.8 Alternatives The proposer shall not change any wording in the RFP or associated documents. Any explanation or alternatives offered shall be submitted in a letter attached to the front of the proposal documents. Alternatives that do not substantially meet the City’s requirements cannot be considered. Proposals offered subject to conditions and/or limitations may be rejected as non-responsive. 4.9 Proposal Errors

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Proposer is responsible for all errors or omissions incurred by proposer in preparing the proposal. Proposer will not be allowed to alter proposal documents after the Proposal Submission Deadline, except as allowed by the City. The City reserves the right to allow proposers to make corrections. The City reserves the right to make corrections or amendments due to errors identified in the proposal by the City or the proposer. This type of correction or amendment will only be allowed for typographical errors, transposition, or other obvious error. Any changes will be dated and time stamped, and attached to the proposal. All changes must be coordinated in writing with, authorized by, and made by the Contract Administrator. 4.10 Proposal Clarification The City reserves the right to request proposers at any phase of the evaluation process to clarify information provided in RFP responses including clarification of assumptions used in the RFP response. All clarifications must be coordinated in writing with, authorized by, and made by the Contract Administrator. Clarifications must be submitted in writing by the requested deadline, otherwise the RFP response will be deemed non-responsive or evaluated without the benefit of the clarification requested.

If the City determines that all proposers failed to submit requested information or adequately responded to the same RFP question or request for data, the City may, at its discretion, issue an RFP Addendum and provide all proposers with an opportunity to provide a response to the RFP question. Responses to RFP Addendum questions must be submitted in writing by the stated deadline otherwise the RFP response will be deemed non-responsive or evaluated without the benefit of the clarification requested. 4.11 Waiver of Minor Administrative Irregularities The City reserves the right, as its sole discretion, to waive minor administrative irregularities contained in any proposal. 4.12 Interpretation and Clarifications of RFP Requirements The City will consider prospective recommendations or suggestions regarding any requirements before the Pre-Proposal Conference. All recommendations or suggestions must be in writing and submitted to the Contract Administrator (see page 1 of the RFP). The City reserves the right to modify or amend any and all requirements of the RFP. 4.13 Proposal Submission Deadline Timely submission of proposals is the sole responsibility of the proposer. The City reserves the right to determine the timeliness of all submissions. The proposals, including all hard copies, redacted copies and electronic copies of the final proposals and proposal questionnaire must be received by the RFP Administrator at the published location and by the published due date included with this RFP. It should be noted that all persons and materials entering the Employee Benefits Division’s City Hall location must go through a security check. Proposers should allow ample time to clear security in order to meet the deadline listed above. All proposals will be date and time stamped upon receipt. 4.14 Late Proposals Proposals submitted after the Proposal Submission Deadline shall be considered late. Late proposals will not be considered. 4.15 Cost of RFP

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The City is not responsible for any costs incurred by proposer while submitting proposals. All proposers who respond to the RFP do so solely at their own expense. 4.16 Withdrawal of Proposals Proposer may withdraw a submitted proposal in writing at any time prior to the Proposal Submission Deadline. A written request, signed by an authorized representative of the proposer, must be submitted to the RFP Administrator. After withdrawing a previously submitted proposal, the proposer may submit another proposal at any time up to the Proposal Submission Deadline. 4.17 Selection of Vendor The proposer with the highest score based on the RFP criteria and that satisfies all City contracting requirements. Selection is not restricted to the lowest offer or bid. Should contract negotiations not be successful with the selected proposer, the City may, based on its exclusive discretion, negotiate with the proposer having the next highest total score or cancel the RFP selection process. 4.18 Rejection of Proposals The City reserves the right to reject any or all proposals; to waive any minor informality in proposals received; to reject any unapproved alternate proposal(s); and reserves the right to reject the proposal of any proposer who has previously failed to perform competently in any prior business relationship with the City. The rejection of any or all proposals will not render the City liable for costs or damages. 4.19 RFP Withdrawal, Cancellation, Other Options The City reserves the right to withdraw or cancel the RFP at any time, if it deems such action necessary. If such action is taken, the City may re-issue the RFP. The City also reserves the right to contract with more than one respondent to this RFP. Furthermore, the City may exercise its right to not select any proposer from this RFP, if it determines that there was no responsive proposer. If an inadequate number of proposals is received or the proposals received are deemed non-responsive, not qualified, or not cost effective, the City may, at its sole discretion, reissue the RFP or award a sole-source contract with a vendor. The award of the contract is subject to the successful negotiation of the terms and conditions of an agreement.

The City reserves the right to verify all information in the proposal. If the information cannot be verified, the City reserves the right to reduce the rating points awarded. The City reserves the right to require a pre-award interview and/or site inspection. 4.20 Contract Evaluation Program When the term of the contract pursuant to this RFP has concluded, the City will conduct an evaluation of the Contractor’s performance. The City may also conduct evaluations of the Contractor’s performance during the term of the contract. As required by Section 10.39.2 of the Los Angeles Administrative Code, evaluations will be based on specified criteria, including the quality of the work product or service performed, the timeliness of performance, financial issues, and the expertise of personnel that the Contractor assigns to the Contract. A Contractor who receives a “Marginal” or “Unsatisfactory” rating will be provided with a copy of the final City evaluation and allowed fourteen (14) calendar days to respond. The City will use the final City evaluation and any response from the Contractor to evaluate Proposals and to conduct reference checks when awarding future service contracts. 4.21 Campaign Contributions

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a) Proposers are subject to Charter Section 470(c)(12) and related ordinances. As a result, proposers may not make campaign contributions to and or engage in fundraising for certain elected City officials or candidates for elected City office from the time they submit the Proposal until either the contract is approved or, for successful proposers, twelve months after the contract is signed. The proposer’s principals and subcontractors performing $100,000 or more in work on the contract, as well as the principals of those subcontractors, are also subject to the same limitations on campaign contributions and fundraising.

b) Proposers must submit CEC Form 55, provided as Attachment 11 in Part B, to the

awarding authority at the same time the Proposal is submitted. The Form requires proposers to identify their principals, their subcontractors performing $100,000 or more in work on the contract, and the principals of those subcontractors. Proposers must also notify their principals and subcontractors in writing of the restrictions and include such notice in contracts with subcontractors. Proposals submitted without a completed CEC Form 55 shall be deemed non-responsive. Proposers who fail to comply with City law may be subject to penalties, termination of Contract and debarment. Additional information regarding these restrictions and requirements may be obtained from the City Ethics Commission at (213) 978-1960 or http://ethics.lacity.org/

4.22 Business Inclusion Program Requirements (BIP) It is the policy of the City to provide Minority Business Enterprise (MBE), Women Business Enterprise (WBE), Small Business Enterprise (SBE), Emerging Business Enterprise (EBE), Disabled Veteran Business Enterprise (DVBE), and all Other Business Enterprise (OBE) concerns an equal opportunity to participate in the performance of all City contracts. Proposers will assist the City in implementing this policy by taking all reasonable steps to ensure that all available business enterprises, including MBEs, WBEs, SBEs, EBEs DVBEs and OBEs, have an equal opportunity to compete for, and participate in, City contracts. Equal opportunity will be determined by the proposer’s BIP outreach documentation, as described in Part B, Attachment 13, the Business Inclusion Program for this RFP. Participation by MBEs, WBEs, SBEs, EBEs, DVBEs and OBEs may be in the form of subcontracting. Proposers must refer to Attachment 13 Business Inclusion Program to this RFP for additional information and instructions. BIP outreach must be performed using the Business Assistance Virtual Network (www.labavn.org). A proposer’s failure to utilize and complete their BIP Outreach as described in Attachment 13 may result in their proposal being deemed non-responsive. Please note this RFP’s published deadline for submitting the BIP Summary Sheet on www.labavn.org. 4.23 Local Business Preference Program Ordinance Proposers are advised that any proposal submitted and or contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.47, Local Business Preference Program (LBPP) Ordinance. The City is committed to maximizing opportunities for local businesses, as well as encouraging local businesses to locate and operate in Los Angeles County. The LBPP Ordinance allows the Department to apply additional points to the Proposal’s final score under certain conditions.

Proposers shall refer to Part B, Attachment 12, “Local Business Preference Program” for further information regarding the requirements and application of the Ordinance. If applicable, proposers may choose to complete and upload the Local Business Certification Affidavit of Eligibility available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to the Proposal Submission Deadline. The City may request supporting documentation to verify qualification for designation as a Local Business. Only those

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proposers who apply and qualify for a Local Business designation (or otherwise qualify by using a qualified Local Subcontractor) by the RFP due date will be made eligible for additional points that can be awarded under the ordinance. Proposers seeking additional information regarding the requirements of the Local Business Preference Program Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org. 4.24 Confidentiality All documents, records and information provided by the City to the Contractor, or accessed or reviewed by the Contractor, during performance of the services will remain the property of the City. All documents, records, and information provided by the City to the Contractor, or accessed or reviewed by the Contractor and any if its employees during performance of services, are confidential (hereinafter collectively referred to as “Confidential Information”). The Contractor agrees not to provide Confidential Information, nor disclose their content or any information contained in them, either orally or in writing, to any other person or entity. The Contractor agrees that all Confidential Information used or reviewed in connection with the Contractor's work for the City will be used only for the purpose of carrying out City business and cannot be used for any other purpose. The Contractor will be responsible for protecting the confidentiality and maintaining the security of City documents and records in its possession.

Any Confidential Information provided by the City to the Contractor, or accessed or reviewed by Contractor, during performance of services, will be made available to its employees, agents, and subcontractors only on a need to know basis. Further, the Contractor will provide written instructions to all of its employees, agents and subcontractors, with access to the Confidential Information about the penalties for its unauthorized use or disclosure. The Contractor must not remove Confidential Information or any other documents or information used or reviewed in connection with the Contractor's work for the City from City facilities without prior approval from the City. At no cost to the City the Contractor will, at the conclusion of services, or at the request of the City, promptly return in an organized manner that preserves and protects the documentation, any and all Confidential Information and all other written materials, notes, documents, or other information obtained by the Contractor during the course of work under the contract. The Contractor will not make or retain copies of any such information, materials or documents. The Contractor and its employees, agents, and subcontractors may have access to confidential medical records information, which access is controlled by statute. Misuse of such information may adversely affect the subject individual’s civil rights and violates the law. The Contractor will implement reasonable and prudent measures to keep secure private medical history information accessed by its employees, agents, and subcontractors during the performance of services. The Contractor will advise its employees, agents, and subcontractors of this confidentiality requirement. The Contractor shall disclose the intent to use any service provider outside the continental United States of America to handle any aspect of the work within the scope of services, and shall describe to the City’s satisfaction the methods, which will be utilized to protect the City’s interests and confidentiality of City records and information in doing so. The City reserves the right to approve any such service provider throughout the term of the contract at its sole and absolute discretion. Any breach of security that occurs through Contractor’s website, offices or network shall require Contractor to be responsible for notifying City and all applicants affected by such breach. Contractor shall also be responsible for all costs associated with such notification.

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4.25 Government Taxation Forms Proposers must submit the following three forms found in Part B, Attachment 3 to the awarding authority at the same time the Proposal is submitted:

IRS Request for Taxpayer Identification and Certificate (Form W-9)

Evidence of having obtained a tax registration account number (City of L.A. Tax Registration Certificate number and/or Vender Registration number)

State of California Withholding Exemption Certificate (Form 590) or Non-resident Withholding Certification (Form 587), if the proposer is located outside of California.

4.26 On-Line Submission of Required Documents

a) Nondiscrimination, Equal Employment Practices and Affirmative Action Program (Non-Construction) Proposers are advised that any contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.8.2., Non-discrimination Clause. Contractors that provide non-construction services to or for the City for which the consideration is $1,000 or more shall comply with the provisions of Los Angeles Administrative Code Sections 10.8.3., Equal Employment Practices Provisions. All proposers shall complete and upload the Non-Discrimination/Equal Employment Practices Affidavit (two (2) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract valued at $1,000 or more. Contractors that provide non-construction services to or for the City for which the consideration is $100,000 or more shall comply with the provisions of Los Angeles Administrative Code Sections 10.8.4., Affirmative Action Program Provisions. All proposers shall complete and upload the City of Los Angeles Affirmative Action Plan (four (4) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract valued at $100,000 or more. Proposers opting to submit their own Affirmative Action Plan may do so by uploading their Affirmative Action Plan onto the City’s BAVN. Both the Non-Discrimination/Equal Employment Practices Affidavit and the City of Los Angeles Affirmative Action Plan Affidavit shall be effective for a period of twelve months from the date they are first uploaded onto the City’s BAVN. Proposers seeking additional information regarding the requirements of the City’s Non-Discrimination Clause, Equal Employment Practices and Affirmative Action Program may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org.

b) Equal Benefits Ordinance

Proposers are advised that any contract awarded pursuant to this procurement process shall be subject to the applicable provisions of Los Angeles Administrative Code Section 10.8.2.1, Equal Benefits Ordinance (EBO). All proposers shall complete and upload the Equal Benefits Ordinance Affidavit (two (2) pages) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract, the value of which exceeds

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$5,000. The Equal Benefits Ordinance Affidavit shall be effective for a period of twelve months from the date it is first uploaded onto the City’s BAVN. Proposers do not need to submit supporting documentation with their bids or proposals. However, the City may request supporting documentation to verify that the benefits are provided equally as specified on the Equal Benefits Ordinance Affidavit. Proposers seeking additional information regarding the requirements of the Equal Benefits Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org.

c) Slavery Disclosure Ordinance

Unless otherwise exempt, in accordance with the provisions of the Slavery Disclosure Ordinance, any contract awarded pursuant to this RFP will be subject to the Slavery Disclosure Ordinance, Section 10.41 of the Los Angeles Administrative Code. All proposers shall complete and upload the Slavery Disclosure Ordinance Affidavit (one (1) page) available on the City of Los Angeles’ Business Assistance Virtual Network (BAVN) residing at www.labavn.org prior to award of a City contract. Proposers seeking additional information regarding the requirements of the Slavery Disclosure Ordinance may visit the Bureau of Contract Administration’s web site at http://bca.lacity.org.

d) First Source Hiring Ordinance Unless approved for an exemption, contractors under contracts used primarily for the furnishing of services to or for the City and that involve an expenditure in excess of $25,000 and a contract term of at least three (3) months, and certain recipients of City Loans or Grants, shall comply with the provisions of Los Angeles Administrative Sections 10.44, et seq., First Source Hiring Ordinance (FSHO). Proposers shall refer to Standard Provisions for City Contracts (Revised 06/12), Attachment 7, “First Source Hiring Ordinance”, for further information regarding the requirements of the Ordinance. The First Source Hiring Ordinance Compliance Affidavit shall only be required of the proposer that is selected for award of a contract.

4.27 Bond Assistance Program For those contractors wishing to bid on City projects but are experiencing difficulty obtaining the required bid, performance and payment bonds, the City of Los Angeles provides bonding assistance thru the Los Angeles Bond Assistance Program (BAP LA). For more information regarding the BAP LA please go to the City’s Risk Management website at http://cao.lacity.org/risk.

4.28 Americans with Disabilities Act As covered under Title II of the Americans with Disabilities Act, the City of Los Angeles does not discriminate on the basis of disability and, upon request, will provide reasonable accommodation to ensure equal access to its proposals, programs, services and activities. If an individual with a disability requires accommodations to attend the Pre-Proposal Conference, please contact the Contract Administrator at least five working days prior to the scheduled event. 4.29 Iran Contracting Act of 2010 In accordance with California Public Contract Code Sections 2200-2208, all bidders submitting proposals for, entering into, or renewing contracts with the City of Los Angeles for goods and services

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estimated at $1,000,000 or more are required to complete, sign, and submit the “Iran Contracting Act of 2010 Compliance Affidavit.”

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SECTION 5

EVALUATION OF PROPOSALS 1. Review Process

Proposals received by the Proposal Submission Deadline as specified in this RFP will be evaluated as outlined below. Preliminary Review – Level One Proposals will be reviewed to determine completeness of required documentation and compliance with the City’s administrative and General Contracting Requirements. Proposers that fail to submit or complete required documentation and/or satisfactorily comply with the City’s requirements will be deemed as non-responsive, eliminated from further consideration and will not proceed to the Level Two review process. Proposers will be notified in writing or email regarding the results of the Level One review. Proposal Evaluation - Level Two A Review Committee will be designated by the City to evaluate/score the proposals and generate recommendations for selection to the City. Following the City’s selection, the award of the contract is subject to successful negotiation of the terms and conditions of an agreement. 1) Written Responses – All written responses to the RFP questionnaire will be considered and

evaluated. Proposers are not required to submit responses to questions in service model categories for which they are not offering services.

2) Performance Examinations - Proposers will be required to participate in a series of performance examinations. The performance examinations will be narrowly focused on specific topics and will be approximately one hour each in length. The examinations will occur on a date to be determined by the City. The performance examinations will address in more substantive detail certain topics included within the Scope of Services of this RFP. Proposers will receive advance notice of the topics. Proposers will not be permitted at the performance examinations to discuss the qualifications of their firm; clarify or enhance written responses to the written portion of the RFP; or otherwise discuss any other component of their RFP response or interest in securing business with the City. The performance test is a separately scored component of the RFP and its evaluation will not affect the evaluation of any other portion of the RFP response. The City reserves the right to exclude from the performance examinations those firms whose scores on the non-performance examination components of the RFP have rendered them unviable for selection.

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2. Review Criteria Evaluation of submitted proposals will be based on the following factors and the weights associated with each factor.

ORGANIZATIONAL STRENGTH & PLAN SPONSOR SERVICES

Organizational Qualifications and Reliability

Organizational Background, Financial Strength, Experience

References

Regulatory Compliance

HIPAA Compliance

Rating Agency Financial Ratings

Administration Support & Account Management

Claims Processing

Billing & Eligibility

Plan Sponsor Services

Imaging & Document Storage

Recordkeeping, Security Protocols, Disaster Recovery & Guarantees

Innovations and Miscellaneous Services

Advocates and Onsite Services

Value Added Services

15%

MEMBER SERVICES

Direct Service

Quality Control: Appointments, Wait Times, Consultation Length, etc.

Quality Control: Referrals

Quality Control: Appeals Process

Vision Provider Benefits & Transparency

Provider Quality of Care

PCP Continuity & Provider Turnover

Quality control: PCP and Specialist Options and Availability

Quality control: Prevention, Adherence, Follow-up

Rx Options and Availability

National Committee for Quality Assurance (NCQA) Accreditation

Health Plan Employer Data and Information Set (HEDIS) Results

Communications

Website Facility and Content

Self-Service Tools

Electronic/Print/Video

Mobile apps/Education

Wellness, Prevention and Disease Management

Resource Support for & Alignment w/City Wellness Program

Disease Management Programs

Coordination with Utilization/Case/Disease/Rx Management

35%

ACCESS / CONTINUITY OF CARE

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Provider Groups/Networks & Geographic Access

Extended Hours, Emergency and Urgent Care Access

20%

FINANCIAL COST

Provider Reimbursement and Discounts

Hospital and Outpatient Facility Charges

Underwriting Terms and Conditions

Retention Levels

Multi-year Rate Guarantees or Rate Caps

Performance Guarantees

Premium Rates and Rate Adequacy for Plan Design Options

30%

5.2 Proposal Protest

Level One - Preliminary Review

Proposer may file a protest regarding disqualification at the Level One review. (see Section 5.0, “Preliminary Review – Level One”.) A Notice of Protest must be filed in writing and submitted to the Contract Administrator within five (5) calendar days of the notification of disqualification date. The Notice of Protest must clearly state the grounds for the protest and the facts on which they are based. The Personnel Department will respond to a protest within 15 calendar days of receiving it, and the Department, at its election, may set up a conference call with the proposer to discuss the protest concerns. The decision of the Personnel Department General Manager will be final. Level Two - Award of Contract Recommendation

Proposers may file a protest regarding the award of the contract recommendation submitted to the Board. A Notice of Protest must be filed in writing and submitted to the Contract Administrator within seven (7) calendar days of the date the City makes its final vendor selections pursuant to this RFP. The Notice of Protest must clearly state the grounds for the protest and the facts on which they are based. A protest based on non-selection alone or disagreement with award of the contract recommendation is not sufficient grounds for a protest. Personnel Department staff will respond to a protest, in writing, within 20 calendar days of receiving it, and the Personnel Department, at its election, may set up a conference call or meeting with the proposer to discuss the protest concerns. Findings and/or recommendations will be submitted to the General Manager Personnel Department and the decision of the General Manager will be final.

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SECTION 6

GENERAL TERMS & CONDITIONS

6.0 Property of City/Proprietary Material All proposals submitted in response to this RFP will become the property of the City of Los Angeles and subject to the California Public Records Act (California Government Code Section 6250 et seq). Proposers must identify all trade secrets or other proprietary information that the proposers claim are exempt from the Public Records Act. The City Attorney will make an independent determination regarding whether the identified information is disclosable. In the event a proposer claims such an exemption, the proposer is required to state in the proposal the following: “The Proposer will indemnify the City and its officers, employees and agents, and hold them harmless from any claim or liability and defend any action brought against them for their refusal to disclose trade secrets or other proprietary information to any person making a request therefore.” Failure to include such a statement will constitute a waiver of a proposer’s right to exemption from this disclosure. 6.1 Pre-Award Negotiations Prior to award of the contract, the successful proposer(s) may be required to attend negotiation meetings that will be scheduled at a later date. The intent of the meeting(s) will be to discuss and negotiate contract requirements, prices/premiums, service level agreements, detailed scope of work specifications, ordering, invoicing, delivery, receiving and payment procedures, etc. in order to insure successful administration of the contract. 6.2 Execution of Contract Unless otherwise stated, proposals submitted will be irrevocable for a period of one-year following the proposal due date. A contract will be developed following action by the Board.

Any contract made pursuant to this RFP must be accepted in writing by the Proposer. If for any reason Proposer should fail to accept the contract in writing, then the Proposer may be deemed non-responsive and the City may commence contract negotiations with another proposer.

Please note that the City takes a legal approach whereby all contracts contain an order of precedence. In the event of a discrepancy between the provisions of the Contractor’s documents and the City’s documents, the City’s documents take precedence with respect to resolution of the discrepancy. 6.3 Amendments/Modifications/Change Orders Any amendments, adjustments, alterations, additions, deletions, or modifications in the terms and/or conditions of the resultant agreement must be made by written amendment/change order approved by the Contracting Authority, the Contractor, and signed by the City Attorney. If Contractor performs any modification without a written amendment/change order, the City will neither pay for nor be obligated to accept said modification.

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6.4 Prime Contractor The Proposer awarded the contract must be the prime Contractor performing the primary functions of the contract. If any portion of the contract is to be subcontracted, it must be clearly set forth in the proposal document as to what part(s) are to be subcontracted, the reasons for the subcontracting and a listing of subcontractors. The City reserves the right to reject any proposal wherein use of subcontractors significantly affects the ability of the Proposer to function as the prime Contractor on the awarded contract. The prime Contractor will at all times be responsible for the acts and errors or omissions of its Subcontractors or joint participants and persons directly or indirectly employed by them. 6.5 Subcontractors/Joint Ventures Acceptance or rejection of a Proposer’s request to use subcontractors is at the sole discretion of the City. With approval of the City, the Contractor may enter into subcontracts and joint participation agreements with others for the performance of portions of resultant agreement. The provisions of the resultant agreement will apply to all subcontractors in the same manner as to the Contractor. In particular, the City will not pay, even indirectly, the fees and expenses of subcontractors that do not conform to the limitations and documentation requirements of the resultant agreement.

6.5.1 Copies of Subcontractor Agreements Upon written request from the City, the Contractor will supply the City with all subcontractor agreements at no cost.

6.6 Supplier Performance Feedback Meetings The Proposer awarded the resulting agreement is required to attend periodic performance feedback meetings facilitated by the Contracting Authority. The meetings will focus on the Contractor’s and the City’s performance in fulfilling the service level requirements contained in the contract. The meetings will provide a forum to informally discuss opportunities for improving contract terms and conditions, service level requirements, and cost reductions for both parties. 6.7 Replacement of Contractor’s Staff The City reserves the right to have the Contractor replace any contract personnel with equally or better qualified staff upon providing written notice to Contractor. In addition, the City reserves the right to approve in advance any changes in project personnel or levels of commitment by the Contractor to the project. 6.8 Contractor’s Address The address given in the proposal response will be considered the legal address of the Contractor and will be changed only by written notice to the City. The Contractor will supply an address to which certified mail can be delivered. The delivery of any communication to the Contractor personally, or to such address, or the depositing in the United States Mail, registered or certified with postage prepaid, addressed to the Contractor at such address, will constitute a legal service thereof. Also, telephone numbers, fax numbers and e-mail addresses (if applicable) must be provided.

6.09 Term & Option to Renew The term of any contract(s) established pursuant to this RFP shall be for the period identified in the RFP Introduction. The City reserves the right in its sole discretion to seek an extension of the term of the contract.

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6.10 Standard Contract Provision Requirements Please carefully review the information contained in the City of Los Angeles Requirements and Checklist (Part B), including the Standard Provisions for City Contracts. Compliance with these requirements and submission of necessary forms is mandatory at the time of submission of a proposal, prior to award of contract, or both. These requirements will be discussed in detail at the Pre-Proposal Conference. Failure to comply with the requirements and accept the contract provisions will render proposals non-responsive and eliminate them from consideration. 6.11 Governing Law All matters relating to the formation, validity, construction, interpretation, performance and enforcement of the RFP and the resultant agreement/contract, must comply with all applicable laws of the United States of America, the State of California and the City. 6.12 California State Sales Tax Do not include California State sales tax in prices quoted unless otherwise requested. If requested, sales tax must be identified as being included in the pricing. 6.13 California State Board of Equalization Permit Proposer must enter the company’s State of California Board of Equalization permit number on the proposal form. If the company does not have this permit, the proposer must sign the proposal form declaring that the company has no California sales tax permit. 6.14 Federal Excise Taxes The City of Los Angeles is exempt from the payment of excise taxes imposed by the Federal Government. Such taxes must not be included in the proposed prices. The Department of General Services, upon request, will furnish Federal excise exemption certificates. 6.15 Periodic Independent Audit The City reserves the right to assign an independent auditor to assess the quality of services being provided and the extent to which the vendor and its subcontractors are conducting City business within generally accepted industry standard practices. Each Contractor will be required to cooperate fully with any external audit. 6.16 Financial Audit Firms providing services to the City will be responsible for the verification of the legitimacy of payments made to service providers and their subcontractors. The City therefore reserves the right for staff of its Office of the Controller or their designee to conduct audits of financial accountability procedures. 6.17 Proposer Background Information Proposers must submit contact information as requested in the Proposal Questionnaire. 6.18 Verification of Prior City Contracts The City Council adopted a resolution requiring vendors to provide a list of all City contracts held within the past 10 years to be included in the response package for all bids and proposals. Performance on past contracts with the City of Los Angeles will be part of the evaluation criteria. Failure to disclose this information will deem the proposal non-responsive.

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6.19 History of Terminated Contracts You must describe any incident within the past ten years in which your business has had a contract terminated for default as requested in Proposal Questionnaire. 6.20 Business Organization Proposer shall provide an overview of the entity submitting this RFP as requested in Proposal Questionnaire. 6.21 Proposed Subcontractor Information If applicable to proposal, information must be provided for each proposed subcontractor as requested in the Proposal Questionnaire. 6.22 Proposer Signature Declaration Proposer shall provide a Signature Declaration as requested in the Proposal Questionnaire.