STATE OF FLORIDA DEPARTMENT OF … Scoring of Financial Replies ... The Florida Department of Management Services invites interested vendors to submit replies to ... b. Is a fully-insured

4050 Esplanade Way

Tallahassee, Florida 32399-0950

Tel: 850.488.2786 | Fax: 850. 922.6149

Chad Poppell, Secretary Rick Scott, Governor

STATE OF FLORIDA

DEPARTMENT OF MANAGEMENT SERVICES

DIVISION OF STATE GROUP INSURANCE

INVITATION TO NEGOTIATE

INSURED HEALTH MAINTENANCE ORGANIZATION BENEFITS

and SELF-INSURED HEALTH PLAN SERVICES

ITN NO.: DMS 15/16-005

Replies DUE:

October 23, 2015

Refer ALL Inquiries to:

Maureen Livings, Procurement Officer

Departmental Purchasing

Department of Management Services

4050 Esplanade Way, Suite 335.2Y

Tallahassee, FL 32399-0950

[email protected]

mailto:[email protected]

ITN No.: 15/16-005 Insured Health Maintenance Organization Benefits

and Self-Insured Health Plan Services

Page 2

Table of Contents

Section 1 Introduction .............................................................................................................. 5

1.1 Purpose ......................................................................................................................... 5

1.2 Overview of the Program .............................................................................................. 5

1.3 Questions Being Explored ............................................................................................. 8

1.4 Specific Goals of the ITN ............................................................................................... 8

1.5 Contact Person .............................................................................................................. 9

1.6 Anticipated Contract Term ........................................................................................... 9

1.7 Schedule of Events and Deadlines .............................................................................. 10

1.8 Notice of Intent to Submit a Reply and Non-Disclosure Agreement .......................... 11

Section 2 General Instructions to Vendors ............................................................................. 13

2.1 General Overview ....................................................................................................... 13

2.2 Contacting Department Personnel ............................................................................. 13

2.2.1 Contact Other than During the Negotiation Phase ................................................ 13

2.2.2 Violation of Contact Limitations ............................................................................. 14

2.3 Order of Precedence ................................................................................................... 14

2.4 Vendor Questions ....................................................................................................... 14

2.5 Florida Substitute Form W-9 Process ......................................................................... 15

2.6 MFMP Registration ..................................................................................................... 15

2.7 Special Accommodation ............................................................................................. 15

2.8 Receipt of Replies........................................................................................................ 15

2.8.1 Reply Deadline ........................................................................................................ 15

2.8.2 Changes to Replies after Submission Prohibited .................................................... 16

2.8.3 Receipt Statement .................................................................................................. 16

2.9 Cost of Preparation ..................................................................................................... 16

2.10 Electronic Posting of Department Decisions .............................................................. 16

2.11 Firm Reply ................................................................................................................... 16

2.12 Use of Reply Content .................................................................................................. 17



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2.13 Public Records and Vendor’s Confidential Information ............................................. 17

2.13.1 Public Records ......................................................................................................... 17

2.13.2 Replies are Public Records ...................................................................................... 17

2.13.3 Replies will be Subject to Public Inspection ............................................................ 17

2.13.4 How to Claim Trade Secret or Other Exemptions ................................................... 17

2.13.5 Public Records Request ........................................................................................... 18

2.13.6 Department Not Obligated to Defend Vendor’s Claims ......................................... 18

2.14 General Instructions to Vendors PUR 1001 Form and General Contract Conditions

PUR 1000 ..................................................................................................................... 18

2.15 Section 20.055(5), Florida Statutes ............................................................................. 19

2.16 Subcontracting ............................................................................................................ 19

2.17 Protests ....................................................................................................................... 20

2.17.1 Time Limits for Filing Protests ................................................................................. 20

2.17.2 Bond Must Accompany Protest .............................................................................. 20

2.17.3 Filing a Protest ........................................................................................................ 20

2.18 Department’s Reserved Rights ................................................................................... 21

2.18.1 Waiver of Minor Irregularities ................................................................................ 21

2.18.2 Right to Inspect, Investigate and Rely on Information ........................................... 21

2.18.3 Rejection of All Replies ........................................................................................... 21

2.18.4 Withdrawal of ITN ................................................................................................... 21

2.18.5 Reserved Rights after Notice of Award ................................................................... 22

2.18.6 No Contract until Execution .................................................................................... 22

Section 3 Responding to the ITN ............................................................................................ 23

3.1 Overview ..................................................................................................................... 23

3.2 Submittal of Replies .................................................................................................... 23

3.3 Format of Reply ........................................................................................................... 23

3.4 Draft Contract ............................................................................................................. 26

Section 4 Evaluation and Negotiation Methodology.............................................................. 27

4.1 Selection Criteria ......................................................................................................... 27

4.2 Evaluation and Negotiation Process ........................................................................... 27



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4.2.1 Phase One – Evaluation – General Overview ......................................................... 27

4.2.2 Phase Two – Negotiations – General Overview...................................................... 27

4.3 Evaluation Phase ......................................................................................................... 28

4.3.1 Scoring of Technical Information ............................................................................ 28

4.3.2 Scoring of Financial Replies ..................................................................................... 31

4.4 Negotiation Phase ....................................................................................................... 32

4.4.1 Determination of Vendors Advancing to Negotiations .......................................... 32

4.4.2 Goal of Negotiations ............................................................................................... 32

4.4.3 Vendor Attendance at Negotiations ....................................................................... 32

4.4.4 Revised Replies and Best and Final Offers .............................................................. 33

4.4.5 Other Department Rights during Negotiations ...................................................... 33

4.5 Negotiation Meetings Not Open to Public ................................................................. 34

4.6 Final Selection and Notice of Intent to Award Contract ............................................. 34

4.6.1 Award Selection ...................................................................................................... 34

4.6.2 Department’s Negotiation Team Recommendation .............................................. 34

4.6.3 Secretary of the Department’s Approval ................................................................ 35

4.7 Posting Notice of Intent to Award .............................................................................. 35

Section 5 Minimum Qualifications ......................................................................................... 36

Section 6 Minimum Service Requirements ............................................................................ 40

Section 7 Corporate Information ............................................................................................ 75

Section 8 Vendor and Subcontractor Information ................................................................. 78

Section 9 Technical Information ............................................................................................. 94

Section 10 Service and Program Information ........................................................................... 98

Section 11 Recommended Solutions and Alternatives .......................................................... 105

Section 12 Network Information ............................................................................................ 109

Section 13 Financial Reply ...................................................................................................... 110

Section 14 Purchasing Forms .................................................................................................. 111

Section 15 Attachments .......................................................................................................... 116



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Section 1 Introduction

1.1 Purpose

The Florida Department of Management Services invites interested vendors to submit replies to

this Invitation to Negotiate (“ITN”). The purpose of this ITN is to explore the various questions

identified in this ITN and to determine, through the negotiation process, the preferred set of

solutions to achieve the goals of the ITN.

1.2 Overview of the Program

Pursuant to section 110.123, Florida Statutes, the Department’s Division of State Group

Insurance (“Division”) administers the State Group Insurance Program (“Program”). The

Program is comprised of a package of insurance benefits, including health insurance options,

flexible spending and health savings accounts, life insurance, dental insurance, and other

supplemental insurance products for State of Florida employees and retirees, COBRA

participants, and covered spouses and/or children. Each employee, retiree or COBRA

participant that is the primary insured is an “Enrollee.” Covered spouses and/or children are

“Dependents.” Each individual covered under the Program is a “Member.”

Through the Program, the Department currently offers four (4) medical benefit plan designs

option. Two (2) of these are Preferred Provider Organization (“PPO”) plans, while the other two

(2) plans are either Health Maintenance Organizations (“HMO”) or HMO-style plans.

The PPO options, available statewide, are currently self-funded, with medical benefits

administered by a single third party administrator (“TPA”). The insured HMO and self-insured

HMO-style options are currently provided by six (6) separate HMOs and TPAs, with a mix of fully

insured and self-insured funding arrangements. A single pharmacy benefits manager, currently

CVS/Caremark, administers the pharmacy benefits for all plans with the exception of Medicare

Advantage HMO Enrollees, whose pharmacy benefits are administered by their respective

HMOs.

The PPO options are as follows:

The Standard PPO Plan

The Health Investor PPO Plan (high deductible with a health savings account (“HSA”))

The HMO and HMO-style options are as follows:

The Standard HMO Plan

The Health Investor HMO Plan (high deductible with an HSA)

The benefits to be provided by the successful vendor(s) are described in Attachment H: Covered

Benefits and Services.



Page 6

The “Plan Year” runs from January 1 to December 31 of each calendar year. The State provides

two (2) primary enrollment opportunities outside of qualifying status change events: 1) when a

person begins employment with the State, and 2) annually during an open enrollment period.

Open enrollment changes are effective January 1 of the following year. The State’s outsourced

human resource administrator, People First, handles all enrollment activity and its system is the

system of record for eligibility determinations.

Presently, Enrollees are eligible to enroll in any HMO or HMO-style plan with a service area that

includes their home or work address within the state of Florida. Currently a single HMO or TPA

in each county is available to Enrollees within the State, except for six (6) counties (Flagler,

Volusia, St. Lucie, Palm Beach, Broward and Miami-Dade) where two (2) are available to

Enrollees.

Health insurance premiums for active employees are funded primarily through employer

contributions and include a fixed employee payroll deduction. The Department collects

employer and employee contributions from which fully-insured premiums, self-insured claims

costs, and fees are paid. Enrollee and employer contributions are established annually through

the State’s General Appropriations Act. Currently, Enrollees pay a premium based on coverage

tier (i.e., single or family) and whether they enroll in a Standard Plan or Health Investor Plan.

The employee and employer contributions are the same for all standard plan options and for all

health investor plan options regardless of vendor or plan type (i.e., PPO or HMO). Non-

Medicare eligible retirees pay the full premium; COBRA enrollees pay the full premium plus a

two percent (2%) administrative fee. Contribution amounts and premiums for 2015 are

provided on the following page.



Page 7

Premium Rate Table

Subscriber Category /

Contribution Cycle Coverage

Type

PPO/HMO Standard PPO/HMO HIHP

Employer Enrollee Total Employer Enrollee Total

Active Employees

Single Single 591.52 50.00 641.52 591.52 15.00 606.52

Family Family 1,264.06 180.00 1,444.06 1,264.06 64.30 1,328.36

Spouse Spouse 1,429.08 30.00 1,459.08 1,298.36 30.00 1,328.36

COBRA

Single Single 0.00 654.35 654.35 0.00 576.16 576.16

Family Family 0.00 1,472.94 1,472.94 0.00 1,269.93 1,269.93

Early Retirees

Single Single 0.00 641.52 641.52 0.00 564.86 564.86

Family Family 0.00 1,444.06 1,444.06 0.00 1,245.03 1,245.03

Overage Dependents Single 0.00 641.52 641.52 0.00 564.86 564.86

Medicare Monthly Premium Rates

Plan Name Plan Type Medicare I Medicare II Medicare III

One Eligible One Under/Over

Both Eligible

Self-Insured PPO / HMO Standard 359.61 1,036.90 719.22

HIHP 271.07 849.19 542.15

Capital Health Plan

Standard 276.00 893.92 552.00

HIHP 251.20 814.71 502.40

Florida Health Care Plan

Standard 59.00 763.74 118.00

HIHP 59.00 640.26 118.00

To assist with this ITN process, the Department has engaged Foster & Foster as a technical and

actuarial subject matter expert. Foster & Foster shall not receive override commissions or any

other valuable consideration, in any form, from any issuer, insurance agent, insurance broker,

or any involved party when such fee proceeds from or may be attributable to the award of the

contract(s) with the Department. Fees earned by Foster & Foster relating to this procurement

will be limited exclusively to those fees paid under the purchase order for these services

between Foster & Foster and the Department.



Page 8

1.3 Questions Being Explored

Vendors are not to respond directly to these questions. The Department will use the

information obtained throughout this ITN process to assist it in developing opinions and

positions regarding the following questions:

a. How can the Department most efficiently provide health care benefits to Program

Members?

b. Is a fully-insured program, a self-insured program, or a combination of both in the best

interest of the State?

c. Is a single vendor or multiple vendor platform in the best interest of the State?

d. Should the Department establish a county-by-county program or are there other geographic

distributions that may be in the best interest of the State, and which approach provides the

best value?

e. What levels of network discount guarantees and risk corridor guarantees or medical loss

ratio reimbursements are available to provide the best value?

f. Can the State achieve greater value by carving out or including pharmacy benefits with the

insured HMO benefits provider?

g. Can the State achieve greater value by including an insured Medicare Advantage Plan with

prescription drug coverage with the insured HMO benefits provider?

h. How can the Department ensure pricing remains competitive throughout the entire term of

the contract?

i. How can the Department best ensure flexibility for future program changes (e.g., benefit

design, moving to a defined contribution structure, implementing employee or Member

wellness initiatives)?

j. Can greater value be attained by pricing certain programs separately on a per Member per

month utilization basis (e.g., disease management)?

k. What value propositions can vendors offer that are in the best interest of the State?

l. The remaining questions and issues being explored are provided in sections 6 – 13 .

1.4 Specific Goals of the ITN

a. To establish a contract(s) promoting the cost efficient and prudent administration of the

HMO and HMO-style benefit plans.



Page 9

b. To establish a flexible contract(s) that provides the ability to effectuate future policy and

program changes. Future changes may include, but are not limited to benefit design,

changing contribution structures, and implementing employee or Member wellness

initiatives.

c. To determine the combination of services, service areas, service levels, and pricing terms

preferred by the Department and that will provide the best overall value in executing

preferred solutions.

d. To ensure continued price competition throughout the initial term and any renewal years of

the contract.

e. To ensure the best value for the State.

1.5 Contact Person

All contact with the Department regarding the ITN shall be directed to the procurement officer

in writing by email only and must contain the ITN number in the subject line of the email. No

facsimiles or telephone calls will be accepted for any reason.

The exclusive point of contact for all communications regarding this ITN is:

Maureen Livings, Procurement Officer

Departmental Purchasing



Tallahassee, FL 32399-0950

Email: [email protected]

1.6 Anticipated Contract Term

The Department anticipates that the contract will be entered into by June 1, 2016, allowing the

successful vendor(s) up to seven (7) months to provide transition services before providing

services under the contract resulting from this ITN. The anticipated length of the initial term of

the contract is three (3) years; however, negotiations may lead to a shorter or longer period in

the resulting contract. The contract may be renewed for a period not to exceed three (3) years

or for the term of the original contract, whichever period is longer. Such renewal shall be made

at the Department’s sole discretion and shall be contingent upon satisfactory performance

evaluations as determined by the Department and shall be subject to the availability of funds.




Page 10

1.7 Schedule of Events and Deadlines

Anticipated

Date

Time

(Eastern)

Activity

9/22/15 Release of this ITN

9/25/15 3:00 p.m. Vendor deadline to submit the Confidentiality & Non-

Disclosure Agreement (Attachment E) and the Notice of Intent

to Submit a Reply (Attachment F) to the procurement officer

9/25/15 Census file (Attachment D) and claims utilization file

(Attachment G) shipped via overnight delivery on CD-ROM to

vendors who submitted the Notice of Intent to Submit a Reply

(Attachment F) along with the Confidentiality and Non-

Disclosure Agreement (Attachment E) in accordance with

subsection 1.8 of this ITN

10/2/15 3:00 p.m. Vendor deadline to submit questions via email to the

procurement officer

10/12/15 Department posts answers to vendor questions on Vendor Bid

System

10/23/15 3:00 p.m. Vendor replies due to Department:



Tallahassee, FL 32399

10/26/15 -

11/25/15

Phase one evaluation

11/30/15 -

4/21/16

Phase two negotiations

5/16/16 Department posts Notice of Intent to Award on Vendor Bid

System

6/1/16 Contract implementation date

1/1/17 Contract effective date

Dates are subject to change. All updates or revisions to any of the dates/times noted will be

accomplished by an addendum to the solicitation or other notice posted on the Vendor Bid

System. All times listed are local time in Tallahassee, Florida (Eastern Time, both E.S.T. and

E.D.T. when applicable).

http://www.myflorida.com/apps/vbs/vbs_www.main_menu

http://www.myflorida.com/apps/vbs/vbs_www.main_menu



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1.8 Notice of Intent to Submit a Reply and Non-Disclosure Agreement

To be eligible to reply to this ITN, vendors must obtain the claims utilization file (Attachment G)

and the census file (Attachment D) directly from the Department procurement officer. These

files contain certain confidential/HIPAA protected information and data.

To obtain these files and data, vendors must submit a fully completed copy of the

Confidentiality and Non-Disclosure Agreement (Attachment E) and the Notice of Intent to

Submit a Reply (Attachment F) to the procurement officer, by email at

[email protected], by the time and date indicated in subsection 1.7,

Schedule of Events and Deadlines.

Upon receipt of the forms, the Department will send the claims utilization file (Attachment G)

and the census file (Attachment D) on CD-ROM by Federal Express overnight delivery.

The census file (Attachment D) includes the following information for current HMO Enrollees:

Year of birth

Gender

Home ZIP code

Plan name (Standard or HDHP)

Plan coverage tier (Active Single, Active Family, Non-Medicare Single, Non-Medicare

Family, Medicare I, Medicare II or Medicare III)

Number of dependents

The claims utilization file (Attachment G) includes:

System-generated claim number

Patient home county

Total charge amount

DRG code

Primary diagnosis code

Diagnosis code 2

Diagnosis code 3

Diagnosis code 4

Diagnosis code 5

Procedure code

Procedure code modifier

Place of service

Provider Federal Tax ID




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Provider name

Provider specialty

Provider sub-code

Medicare eligibility indicator

Vendors who submitted a Notice of Intent to Submit a Reply (Attachment F) and the

Confidentiality and Non-Disclosure Agreement and received the data included in Attachments D

and G but failed to submit a reply to the ITN shall destroy the confidential information,

including any copies, by the time replies are due and shall provide a certification and complete

access list (page 3 of Attachment E: Confidentiality and Non-Disclosure Agreement) to the

procurement officer that vendor has complied with this requirement on or before the due date

of replies.



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Section 2 General Instructions to Vendors

2.1 General Overview

The ITN process is divided into two (2) phases. The evaluation phase involves the Department’s

initial evaluation of replies. During the evaluation phase, all responsive replies will be evaluated

to establish a competitive range of replies reasonably susceptible of award. The Department

will then select one (1) or more vendors within the competitive range with which to commence

negotiations.

The negotiation phase involves negotiations with the vendors. During the negotiation phase,

the Department may request revised replies and/or best and final offers based on the

negotiations. After negotiations, the Department intends to post a notice of intent to award a

contract(s), identifying the responsive and responsible vendor(s) that provides the best value.

Responsive vendors who are not selected for negotiations will not be formally eliminated from

the ITN process until the posting of the notice of intent to award. Final contract terms will be

established with the selected vendor(s) during the negotiation phase.

2.2 Contacting Department Personnel

2.2.1 Contact Other than During the Negotiation Phase

Prospective vendors or persons acting on their behalf may not contact, between the release of

this ITN and the end of the seventy-two (72) hour period (Saturdays, Sundays and State

holidays excluded) following the Department's posting of the notice of intent to award a

contract, any Department personnel or consultants, or any employee or officer of the executive

or legislative branch concerning any aspect of this solicitation, except in writing to the

procurement officer in accordance with subsection 1.5 above or as otherwise provided in this

solicitation. Any such contact by an affiliate, a person with a relevant business relationship with

a prospective vendor, or an existing or prospective subcontractor to a prospective vendor is

assumed to be on behalf of a prospective vendor unless otherwise shown.

During the negotiation phase of this ITN: (i) any contact and communication between the

members of the negotiation team for the prospective vendor(s) with whom the Department is

negotiating and the negotiation team for the Department is permissible, but only "on the

record" (as required by subsection 286.0113(2), Florida Statutes) during the negotiations

meetings; and (ii) communication between the lead negotiator for the prospective vendor with

whom the Department is negotiating and the procurement officer outside of the negotiation

meetings is permissible so long as it is by email only.



Page 14

2.2.2 Violation of Contact Limitations

Violation of the provisions of subsection 2.2.1 of this ITN may be grounds for rejecting a reply, if

determined by the Department to be material.

2.3 Order of Precedence

In the event of conflict in terms among the foregoing during this ITN, the following order of

precedence shall apply.

Addenda to the ITN, if any

This ITN

All attachments and exhibits to this ITN

The Department’s draft contract

2.4 Vendor Questions

Vendors will submit all questions during the question and answer period in writing to the

procurement officer by email. The deadlines for submission of questions are reflected in

subsection 1.7 of this ITN.

Each vendor’s submission of questions must be clearly labeled with the title of this ITN and the

ITN number.

Questions must be submitted in the following format to be considered:

Vendor

Question

#

Vendor

Name

ITN

Section

ITN Page # Question

Responses to all written questions, and any resulting revisions to the ITN, will be posted

through the Vendor Bid System.

Questions will not constitute formal protest of the specifications or of the ITN.



Page 15

2.5 Florida Substitute Form W-9 Process

State of Florida vendors must register and complete an electronic Florida Substitute Form W-9.

The Internal Revenue Service (IRS) receives and validates the information vendors provide on

the Form W-9. For instructions on how to complete the Florida Substitute Form W-9, please

visit: http://www.myfloridacfo.com/Division/AA/StateAgencies/W-9Instructions022212.pdf.

The awarded vendor(s) if any must have completed this process prior to contract execution.

This form is not required to be submitted with the reply to the ITN.

2.6 MFMP Registration

The awarded vendor(s) providing self-insured health plan services shall pay the required MFMP

transaction fee(s) as specified by statute, unless an exemption has been requested and

approved prior to the award of the contract pursuant to Rule 60A-1.032 of the Florida

Administrative Code.

The awarded vendor(s), if any, must have completed this process prior to contract execution.

For additional information, please visit: https://vendor.myfloridamarketplace.com/.

2.7 Special Accommodation

Any person requiring a special accommodation because of a disability should call Departmental

Purchasing at (850) 488-1308 at least five (5) business days prior to the scheduled event.

Persons with hearing or speech impairments should call Departmental Purchasing by using the

Florida Relay Service at (800) 955-8771 (TDD).

2.8 Receipt of Replies

2.8.1 Reply Deadline

Replies must be received by the Department no later than the date and time provided in

subsection 1.7 of this ITN and addressed to the procurement officer at:



Tallahassee, FL 32399

All methods of delivery or transmittal to the procurement officer are exclusively the

responsibility of vendors and the risk of non-receipt or delayed receipt shall be borne

exclusively by the vendors.

http://www.myfloridacfo.com/Division/AA/StateAgencies/W-9Instructions022212.pdf

https://vendor.myfloridamarketplace.com/



Page 16

2.8.2 Changes to Replies after Submission Prohibited

During the evaluation phase, no changes, modifications, or additions to the reply will be

allowed after the replies have been opened. However, the Department reserves the right to

seek clarifications or additional information.

2.8.3 Receipt Statement

Replies not received at the specified address by the deadline will be rejected, remain unopened

and retained for use in the event of a dispute. After the contract award, the Department will

return the originals to the vendor.

2.9 Cost of Preparation

Neither the Department nor the State is liable for any costs incurred by a vendor in responding

to this ITN.

2.10 Electronic Posting of Department Decisions

On the dates indicated on the Schedule of Events and Deadlines in subsection 1.7, as amended

or updated, the Department shall electronically post a notice of the Department’s decisions at

the following Vendor Bid System website: http://vbs.dms.state.fl.us/vbs/main_menu.

IT IS THE SOLE RESPONSIBILITY OF VENDORS TO CHECK THE VENDOR BID SYSTEM FOR

INFORMATION AND UPDATES.

2.11 Firm Reply

The Department may make an award within two-hundred-forty (240) calendar days after the

date the final replies are due. By submitting a reply, vendors acknowledge and agree that their

replies shall remain firm for (and shall not be withdrawn) for at least two-hundred-forty (240)

calendar days after the final replies have been submitted. If an award is not made within the

two-hundred-forty (240) day period, the final reply shall remain firm until either the

Department awards the contract or the Department receives from the vendor written notice

that the reply is withdrawn.

Vendors may request to withdraw replies within seventy-two (72) hours (excluding state

holidays, Saturdays and Sundays) after the due date for replies provided in the Schedule of

Events and Deadlines, subsection 1.7 of this ITN. Requests received in accordance with this

provision may be granted by the Department upon proof of the impossibility to perform based

upon an obvious error as determined solely by the Department.

http://vbs.dms.state.fl.us/vbs/main_menu



Page 17

2.12 Use of Reply Content

All materials produced to the Department through this ITN become the exclusive property of

the Department and may not be removed by vendors. Further, all replies become the property

of the Department and will not be returned to the vendor. The Department will have the right

to use any or all ideas or adaptations of the ideas presented in the reply. Selection or rejection

of a reply of award will not affect this right.

2.13 Public Records and Vendor’s Confidential Information

2.13.1 Public Records

All electronic and written communications pertaining to this ITN, whether sent from or received

by the Department, are subject to Florida’s public records law, chapter 119, Florida Statutes.

Subsection 2.13.4 below addresses the submission of trade secret and other information

exempted from public inspection.

2.13.2 Replies are Public Records

All materials submitted in reply to this ITN will be a public record subject to the provisions of

chapter 119, Florida Statutes. Selection or rejection of a reply does not affect the public record

status of the materials.

2.13.3 Replies will be Subject to Public Inspection

Unless exempted by law, all public records are subject to public inspection and copying under

Florida’s public records law, chapter 119, Florida Statutes. A time-limited exemption from

public inspection is provided for the contents of replies pursuant to subsection 119.071(1)(b),

Florida Statutes. Once that exemption expires, all contents of replies become subject to public

inspection unless another exemption applies. Any claim of trade secret exemption for any

information contained in vendor’s reply to this solicitation will be waived upon submission of

the reply to the Department, unless the claimed trade secret information is submitted in

accordance with subsection 2.13.4. This waiver includes any information included in the

vendor’s reply outside of the separately bound document described below.

2.13.4 How to Claim Trade Secret or Other Exemptions

If a vendor considers any portion of the documents, data, or records submitted in its reply to be

trade secret or otherwise exempt from public inspection or disclosure pursuant to Florida’s

Public Records Law, the vendor must submit all such information as a separately bound,

unredacted document clearly labeled “Attachment to Invitation to Negotiate, Number

DMS 15/16-005—Exempt Material,” together with a brief written description of the grounds for



Page 18

claiming exemption from the public records law, including the specific statutory citation for

such exemption.

Vendor must also simultaneously provide the Department with a separate, electronic redacted

copy of its reply. The file name of the electronic redacted copy shall contain the name of

vendor, the ITN number, and redacted copy (e.g., Vendor Name_DMS ITN 15/16-005_redacted

copy.pdf). The first page of the electronic redacted copy and each page on which information is

redacted shall prominently display the phrase “Redacted Copy.”

This submission must be made no later than the reply submittal deadline. Where such

information is part of material already required to be submitted as a separately bound or

enclosed portion of the reply, it shall be further segregated and separately bound or enclosed

and clearly labeled as set forth above in addition to any other labeling required for the material.

2.13.5 Public Records Request

If a vendor fails to mark any materials submitted to the Department as exempt and failed to

submit a redacted copy as provided in this section, the vendor waives the exemption, and the

Department will produce all of vendor’s documents, data or records to any person requesting a

copy under chapter 119, Florida Statutes. The vendor exclusively bears the burden of complying

with subsection 2.13.4 to ensure its exempt information is appropriately marked.

2.13.6 Department Not Obligated to Defend Vendor’s Claims

The Department is not obligated to agree with a vendor’s claim of exemption and, by

submitting a reply, the vendor agrees to defend its claim that each and every portion of the

redactions is exempt from inspection and copying under Florida’s Public Records Law. Further,

by submitting a reply, the vendor agrees to protect, defend, indemnify and hold harmless the

Department for any and all claims and litigation (including litigation initiated by the

Department), including attorney’s fees and costs, arising from or in any way relating to vendor’s

assertion that the redacted portions of its reply are trade secrets or otherwise exempt from

public disclosure under chapter 119, Florida Statutes.

2.14 General Instructions to Vendors PUR 1001 Form and General Contract Conditions PUR 1000

The Florida Administrative Code requires that the Department include the standard PUR 1001

Form “General Instructions to Vendors” and the PUR 1000 “General Contract Conditions” with

this solicitation. The PUR 1001 and the PUR 1000 forms can be found at:

http://www.dms.myflorida.com/business_operations/state_purchasing/documents_forms_ref

erences_resources/purchasing_forms.

http://www.dms.myflorida.com/business_operations/state_purchasing/documents_forms_references_resources/purchasing_forms





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The Department is permitted by the Florida Administrative Code, however, to override the

provisions of both forms. Accordingly, the terms and conditions of PUR 1001 FORM do not

apply to this solicitation and are instead modified and superseded by the instructions,

specifications, and other terms contained throughout this ITN. The terms and conditions of PUR

1000 do not apply to this solicitation and are instead modified and superseded by the draft

contract included as Attachment A to this ITN.

2.15 Section 20.055(5), Florida Statutes

Vendor and any subcontractor understand and will comply with subsection 20.055(5), Florida

Statutes, which places a legal duty on the vendor and any subcontractor to cooperate with the

inspector general in any investigation, audit, inspection, review, or hearing.

2.16 Subcontracting

The successful vendor(s) is fully responsible for all work performed under the resultant contract

of this solicitation. If vendor intends to use any subcontractors to perform the work, such

subcontractors shall be identified as required by ITN section 8. If a vendor should need to

replace a subcontractor prior to the Department’s notice of intent to award, the vendor shall

provide to the procurement officer a request to substitute the subcontractor, explaining why

the vendor seeks to substitute the subcontractor. The substitution will be subject to

Department approval.

The successful vendor(s) acknowledges that it will not be released of its contractual obligation

to the Department because of any subcontract. The Department may treat vendor’s use of a

subcontractor not disclosed during the ITN process or approved by the Department as a breach

of contract.

Health care providers are not considered subcontractors. Rented networks are also not

considered subcontractors and the successful vendor(s) using rented networks will not be

excused from performance should the rented network become unavailable to the vendor at any

time.

Any processes, services, and deliverables that are subcontracted or provided by a subsidiary or

third party (e.g., via a rental network), including but not limited to, the provider network,

clinical management, customer service, disease management vendors, printing services, and so

forth, shall be managed through vendor and be seamless and transparent to both the members

and the Department.



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2.17 Protests

Section 120.57, Florida Statutes, applies to this solicitation, as modified by subsection

110.123(3)(d)4, Florida Statutes.

2.17.1 Time Limits for Filing Protests

Any person whose substantial interests are adversely affected by the decision or intended

decision made by the Department pursuant to this solicitation shall file with the Department a

formal written protest petition in writing within seventy-two (72) hours after the posting of

the Department’s notice of decision or intended decision in accordance with subsection

110.123(3)(d)4, Florida Statutes.

2.17.2 Bond Must Accompany Protest

When protesting a decision or intended decision (including a protest of the terms, conditions,

and specifications of the solicitation), the protestor must post a bond equal to one percent (1%)

of the Department’s estimated contract amount. The estimated contract amount for any

protest of this procurement is $310,000,000.

The estimated contract amount is not subject to protest. The bond must be conditioned upon

the payment of all costs and charges that are adjudged against the protestor in the

administrative hearing in which action is brought and in any subsequent appellate court

proceeding. In lieu of a bond, the Department will accept a cashier’s check, official bank check,

or money order. An original cashier’s check, official bank check, or money order must be posted

in the same fashion as a protest bond.

FAILURE TO POST AN ORIGINAL BOND OR OTHER SECURITY REQUIRED BY LAW AT THE TIME

OF FILING THE FORMAL WRITTEN PROTEST WILL RESULT IN A REJECTION OF THE PROTEST.

2.17.3 Filing a Protest

A formal written protest is “filed” when actually received by the procurement officer listed in

subsection 1.5 or by the Department’s agency clerk. Filing of a formal written protest may be

achieved by hand-delivery, courier, mail, facsimile, or email. Actual delivery by the deadline

shall remain the sole responsibility of the protestor, and the risk of non-receipt or delayed

receipt shall be borne exclusively by the protestor.

A protest bond must be posted together with the formal written protest. A protest bond is

“posted” when the original bond is physically tendered to the procurement officer or agency

clerk. Bonds (and cashier’s checks, official bank checks, or money orders) cannot be posted by

facsimile, email, or other transmission that does not result in the original being physically



Page 21

tendered to the Department. Actual posting of a bond by the deadline shall remain the sole

responsibility of the protestor, and the risk of non-receipt or delayed receipt shall be borne

exclusively by the protestor.

FAILURE TO FILE A PROTEST WITHIN THE TIME PRESCRIBED IN SUBSECTION 120.57(3),

FLORIDA STATUTES (as altered by subsection 110.123(3)(d)4, OR FAILURE TO POST THE BOND

OR OTHER SECURITY REQUIRED BY LAW WITHIN THE TIME ALLOWED FOR FILING A BOND

SHALL CONSTITUTE A WAIVER OF PROCEEDINGS UNDER CHAPTER 120, FLORIDA STATUTES.

2.18 Department’s Reserved Rights

2.18.1 Waiver of Minor Irregularities

The Department reserves the right to waive minor irregularities when to do so would be in the

best interest of the State of Florida. A minor irregularity is a variation from the terms and

conditions of this ITN that does not affect the price of the reply or give the vendor a substantial

advantage over other vendors and thereby restrict or stifle competition and does not adversely

impact the interests of the Department. At its option, the Department may allow a vendor to

correct minor irregularities but is under no obligation to do so. In doing so, the Department

may request a vendor to provide clarifying information or additional materials to correct the

irregularity. However, the Department will not request and a vendor may not provide the

Department with additional materials that affect the price of the reply, or give the vendor an

advantage or benefit not enjoyed by other vendors.

2.18.2 Right to Inspect, Investigate and Rely on Information

The Department reserves the right to inspect vendor’s facilities and operations, to investigate

any vendor representations and to rely on information about a vendor in the Department’s

records or known to its personnel in making its best value determination.

2.18.3 Rejection of All Replies

The Department reserves the right to reject all replies at any time, including after an award is

made, when to do so would be in the best interest of the state of Florida, and by doing so the

Department will have no liability to any vendor.

2.18.4 Withdrawal of ITN

The Department reserves the right to withdraw the ITN at any time, including after an award is

made, when to do so would be in the best interest of the state of Florida, and by doing so the

Department will have no liability to any vendor.



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2.18.5 Reserved Rights after Notice of Award

The Department reserves the right, after posting notice thereof, to withdraw or amend its

notice of intent to award and re-open negotiations with any vendor at any time prior to

execution of a contract.

2.18.6 No Contract until Execution

A notice of intent to award under this ITN shall not constitute or form any contract between the

Department and a vendor. No contract shall be formed until such time as a vendor and the

Department formally execute a contract with requisite written signatures.



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Section 3 Responding to the ITN

3.1 Overview

Replies should provide a straightforward, concise description of the vendor’s ability to provide

the solution sought by the solicitation. Excessive information distracts readers from focusing on

essentials. Properly referenced replies may be in the form of informational materials and

brochures, but must be specific to the issue raised or question asked. When responding to

specific questions, vendors must reprint each question in its entirety in the reply.

The vendor’s reply may not apply any conditions or exceptions to any mandatory requirements

of the solicitation.

The reply text must be at least 11 pt Calibri, Arial or Times New Roman in legible font.

3.2 Submittal of Replies

Each vendor is responsible for ensuring that its reply is delivered at the proper time and to the

proper place. REPLIES MUST BE RECEIVED AT OR BEFORE THE TIME AND DATE reflected on the

schedule included in subsection 1.7 (“Schedule of Events and Deadlines”) of this ITN. The

Department will reject replies received after this deadline.

Each submission must be in a sealed box(es) and addressed to the attention of the

procurement officer and indicate the Departmental Purchasing address, the ITN number, and

date and time the reply is submitted. Any submitted documents claimed to be exempt from

Florida’s Public Records Law must comply with the provisions of subsection 2.13.4 (“How to

Claim Protection for Exempt Materials”) at the time of the reply submission.

The reply must be submitted in a properly marked, sealed box(es) containing the following:

a. One (1) original unredacted and 10 (ten) separate unredacted, bound paper copies;

b. Ten (10) electronic copies on ten (10) separate CD-ROMs or “thumb drives”; and

c. One (1) electronic redacted copy of entire reply on CD-ROM or “thumb drive” (if applicable,

as described in subsection 2.13.4 (“How to Claim Protection for Exempt Materials”) of this

ITN).

3.3 Format of Reply

THE VENDORS MUST SUBMIT REPLIES IN THE FOLLOWING FORMAT AND ORDER IN

ACCORDANCE WITH THE INSTRUCTIONS PROVIDED IN EACH CORRESPONDING SECTION OF

THIS ITN. EACH REPLY MUST BE TABBED AS FOLLOWS:



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TAB 1: Transmittal Letter

The purpose of this letter is to transmit the reply and acknowledge the receipt of any addenda.

The transmittal letter should be brief and signed by an individual who is authorized to commit

the vendor to the services and requirements as stated in this ITN. The transmittal letter must

also include the name and contact information for the vendor’s primary contact person for this

solicitation. The transmittal letter must not exceed one (1) page.

TAB 2: Title Page and Table of Contents

The title page should bear the name and address of vendor and the name and number of this

ITN. This should be followed by a table of contents for the entire reply.

TAB 3: Exempt Information

A listing of information that is declared proprietary, trade secret or confidential and claimed to

be exempt from public disclosure is to be provided immediately following the table of contents.

This listing must identify each section of the reply that has been marked as exempt and

excluded from the redacted copy provided with the reply as described in subsection 2.13

(“Public Records and Vendor’s Confidential Information”) of this ITN.

TAB 4: Executive Summary

Vendor must condense and highlight the contents of the reply to the ITN in a separate, section

titled “Executive Summary” including a general description of how the vendor intends to offer

the services sought by this ITN.

TAB 5: Minimum Qualifications (ITN Section 5)

Vendors must provide a response to each of the minimum qualifications identified in section 5

of this ITN. A response of “No” or failure to submit a response to any of the minimum

qualifications in section 5 of this ITN will disqualify the vendor from further consideration.

TAB 6: Minimum Service Requirements (ITN Section 6)

Vendors must provide a response acknowledging the ability and agreement to provide the

minimum service requirements as required in section 6 of this ITN. A response of “No” or

failure to submit a response to section 6 of this ITN will disqualify the vendor from further

consideration.



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TAB 7: Corporate Information (ITN Section 7)

Vendors must provide responses to the questions and requests for information in section 7

(“Corporate Information”) of this ITN. Failure to provide a response to any item in section 7

may disqualify the vendor from further consideration.

TAB 8: Vendor and Subcontractor Information (ITN Section 8)

Vendors must provide a response to each requested item in section 8 (“Vendor and

Subcontractor Information”) of this ITN. Additional tables may be added by the vendor as

needed for the response to any item in section 8.

TAB 9: Technical Information (ITN Section 9)

Vendors must respond to each question and request for information in section 9 of this ITN.

Vendors must restate each item and provide a response to the item in at least 11 pt Calibri,

Arial or Times New Roman, blue font. Vendors must respond to all parts of each question or

request for information. Failure to submit a response to a question or request for information

may disqualify the vendor from further consideration. See subsection 4.3.1 (“Scoring of

Technical Information”) of this ITN for scoring. Tab 9 must be limited to fifty (50) singled sided

or twenty-five (25) double sided pages in font indicated above.

TAB 10: Service and Program Information (ITN Section 10)

Vendors must provide a response to each requested item in section 10 of this ITN. Failure to

provide a response to any item in section 10 may disqualify the vendor from further

consideration.

TAB 11: Recommended Solutions and Alternatives (ITN Section 11)

Vendors must provide a response to each requested item in section 11 of this ITN.

TAB 12: Network Information (ITN Section 12)

Vendors must complete and submit Attachment B: Network Information as instructed in

section 12 of this ITN. Failure to provide a GeoAccess® and disruption analysis using an intact

workbook with complete information for any item in Attachment B may disqualify the vendor

from further consideration.



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TAB 13: Financial Reply (ITN Section 13)

Vendors must provide a financial reply by completing and submitting the Microsoft Excel

document labeled Attachment C: Financial Reply.

Vendors must complete the financial reply according to the instructions in Attachment C.

Vendors must submit the final electronic version (on CD-ROM or thumb drive) of the financial

reply in original file format (Excel .xls) with the Excel workbook intact (see subsection 4.3.2 for

scoring information). Vendors may not add additional tabs to the workbook or break apart the

tabs of the workbook and submit as separate attachments. Failure to provide a financial reply

using an intact workbook with complete pricing information for any item in Attachment C will

disqualify the vendor from further consideration.

TAB 14: Purchasing Forms (ITN Section 14).

Vendors must complete and submit the following forms listed below in the following order

displayed:

a. Form 1 – Vendor Certification

b. Form 2 – Notice of Conflict of Interest

c. Attachment E: Confidentiality and Non-Disclosure Agreement Page 3, “Vendor’s Employees

Who Will Be Given Access to the Confidential Information” Note: this form is required even

if there are no updates from the initial submittal.

3.4 Draft Contract

Attachment A is the Department’s draft contract. Any attempts to red-line or modify the terms

of the Department’s draft contract will be disregarded and ignored by the Department during

the evaluation phase. Therefore, vendors should not make alterations or edits to the

Department’s draft contract. (The Department may negotiate and consider red-line edits or

modification during the negotiation phase.)

The draft contract contains the following documents as attachments. These attachments do not

need to be returned with the ITN reply.

a. Affidavit of Best Pricing

b. Affidavit of Warranty of Security

c. Affidavit of No Offshoring



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Section 4 Evaluation and Negotiation Methodology

The Department intends to award a contract(s) to the responsible and responsive vendor(s)

that presents the best value. The Department may award multiple contracts.

4.1 Selection Criteria

The following award selection criteria shall apply for this ITN:

Criteria

Vendor’s articulation of its approach and solution; and the ability of the

approach and solution to meet the Department’s needs, the requirements

of this ITN, and ITN sections 6 through 13.

The vendor’s approach and solution and any value enhancements at no

additional cost to the State.

Vendor references, track record implementing similar solutions to the one

specified in this ITN, and overall experience.

Vendor’s pricing, overall costs to the Department, and financial guarantees.

4.2 Evaluation and Negotiation Process

4.2.1 Phase One – Evaluation – General Overview

The Department will appoint an evaluation team for the initial evaluation and scoring of the

replies for the evaluation phase (phase one). Each evaluator will be provided a copy of each

vendor’s reply. Foster & Foster will independently review Attachment B: Network Information

and Attachment C: Financial Reply and will provide the Department with a summary of these

replies.

The Department will score replies consistent with subsection 4.3 below.

4.2.2 Phase Two – Negotiations – General Overview

The Department will establish a negotiation team to conduct the negotiations, assess the final

value proposition of each vendor, and make an award recommendation to the Department. The

negotiation team will not be bound by phase one scoring and has full authority to reassess any

of the phase one evaluation determinations and may consider any additional information that



Page 28

comes to its attention during the negotiations phase. The negotiation team will not engage in

any scoring.

Vendors may be provided an opportunity to recommend enhanced value alternatives, offer

alternative solutions and deliverables, provide additional information, and other options during

the negotiation phase that would present the best value to the State. The Department reserves

the right to negotiate different terms and related price adjustments if the Department

determines that such changes would provide the best value to the State. The negotiation team

may address proposed alternative terms or deliverables during negotiations but it is under no

obligation to accept proposed alternative terms or deliverables. If the negotiation team

determines that a proposed alternative is not acceptable and the vendor fails to offer another

alternative that is acceptable to the negotiation team, the vendor may be removed from

further consideration.

4.3 Evaluation Phase

The Department’s initial evaluation of replies will determine which vendors are considered to

fall within the competitive range of vendors reasonably susceptible of award and eligible for

inclusion in the negotiation phase (phase two). All replies that meet the pass/fail requirements

in section 5: Minimum Qualifications and are determined to be otherwise responsive will be

evaluated using the following process:

The evaluation phase (phase one) begins with the scoring of technical replies based on the

methodology described in subsection 4.3.1. Technical Information will be allocated a maximum

of 350 points. Financial Replies will be allocated a maximum of 650 points.

The maximum points any vendor can achieve is 1,000 points.

4.3.1 Scoring of Technical Information

The technical information sections count as thirty-five percent (35%) of the overall score and

are comprised of the following ITN sections: section 9: Technical Information and section 12:

Network Information. The scoring analysis will be conducted for each county for which a vendor

submits a reply.



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Scoring of Section 9 (Technical Information)

Evaluators will score section 9: Technical Information, worth a total of eighty (80) points. Each

vendor response to the eight (8) questions will be scored and may earn a maximum of five (5)

points. After the responses have been scored on the five (5) point scale, the scores will be

multiplied by two (2) for a maximum possible score of eighty (80) points. For example:

Vendor A receives a total score of thirty-five (35) points based on the five (5) point scale.

Vendor A will earn seventy (70) points for section 9.

The five point scale that will evaluators will use is below.

SCORING SCALE

5 = Superior. The response exhaustively addresses the question and demonstrates vendor has

extraordinary experience in performing the required services related to the question. The

response indicates vendor would provide exceptionally enhanced value to the State and/or to

Members. The response demonstrates the ability of the vendor to exceed the State’s

requirement, provide outstanding quality of service levels, provide cost savings or cost

avoidance to the State, and/or implement innovative ideas.

4 = Good. The response extensively addresses the question and demonstrates exceptional

experience in performing the required services related to the question. The response indicates

vendor would provide enhanced value to the State and/or to Members.

3 = Adequate. The response adequately addresses the question and demonstrates vendor has

sufficient experience in performing the required services related to the question.

2 = Poor. The response minimally addresses the question or demonstrates vendor has nominal

experience in performing the required services related to the question.

1 = Unsatisfactory. The response inadequately addresses the question or demonstrates vendor

has very limited experience in performing the required services related to the question.

0 = Inadequate. The response is blank, does not address the question, or demonstrates vendor

has no experience in performing the required services related to the question.



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Scoring of Section 12 (Network Information)

The GeoAccess® reports and provider disruption reports will be scored based on responses to

Attachments B-1 through B-7.

The four (4) provider categories of the GeoAccess® reports (Attachments B-1 through B-4) will

be scored separately from the disruption reports (Attachments B-5 through B-7). Attachments

B-1 through B-4 each are eligible for thirty-three and three-quarters (33.75) points.

For the GeoAccess® reports, in each county the vendor with the highest percentage of

employees meeting the access criteria in each of the four (4) provider categories will earn the

full thirty-three and three-quarters (33.75) points for that category. All other vendors in that

county will earn points in proportion to the ratio of their percentage of employees meeting the

access criteria to the highest percentage in the county. For example, if there are two (2)

vendors for a certain county:

Vendor A’s network Adult Primary Care Physician (PCP) access score is one hundred percent

(100%) of employees.

Vendor B’s network Adult PCP access score is ninety-two percent (92%) of employees.

Vendor A will earn thirty-three and three-quarters (33.75) points for the Adult PCP category

as the highest percentage of the vendors in that county.

Vendor B will earn thirty-one and five-hundredths (31.05) points for the Adult PCP category,

based on the following formula:

Similarly, for the provider disruption reports (Attachment B-5 through B-7), the vendor with the

highest percentage of utilized providers considered in-network in each of the three (3)

categories (Attachment B-5 through B-7) will earn the full forty-five (45) points for each county.

Each vendor’s provider disruption score below the highest scoring vendor’s score will earn

proportional points. For example, if there are only two (2) vendors for a certain county:

Vendor A’s network matches one-hundred percent (100%) of facilities.

Vendor B’s network matches ninety percent (90%) of facilities.

Vendor A will earn forty-five (45) points for the facilities category as the highest percentage

of the vendors in that county.

Vendor B will earn forty and one-half (40.5) points for the facilities category, based on the

following formula:



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The maximum possible points for a technical reply in each county is 350.

Scored Questions 80

GeoAccess® 135

Disruption 135

Total 350

4.3.2 Scoring of Financial Replies

The financial reply will count as sixty-five percent (65%) of the overall score and will be

evaluated based on responses for at least one of the two (2) funding scenarios in Attachments

C-5 and C-6, with a maximum score of six-hundred fifty (650) points for each county. The two

(2) funding scenarios are as follows:

a. Self-insured health plan services for medical benefits without prescription drug benefits.

b. Fully-insured medical benefits without prescription drug benefits.

For counties included in the vendor’s reply, vendors must submit a reply by county under a self-

insured funding scenario or a fully-insured funding scenario, or they may submit replies for both

scenarios.

Responses under the self-insured scenario will be evaluated based on the projected monthly

expense per Enrollee, utilizing the re-priced claims by county and the proposed monthly

administrative fee per Enrollee. If vendor provides a tiered administrative fee based on the

number of covered Enrollees, the fee used to determine the score for each county will be

determined using the number of non-PPO Enrollees in that county as of July 2015. The re-priced

medical claims will be projected to the proposed contract period utilizing trend rates of seven

percent (7%) per year for medical claims.

Responses under the fully-insured scenario will be evaluated based on the projected monthly

expense per Enrollee, utilizing the premium provided for each county.

The vendor with the lowest projected monthly expense per Enrollee for the proposed contract

period for each county, regardless of the funding scenario, will be awarded the full six-hundred

fifty (650) points for that county. The remaining vendors in that county will earn points in

proportion to the ratio of the lowest projected expense to their reply’s projected expense. For

example, if there are only two (2) vendors for a certain county:

Vendor A has a projected monthly expense per employee of $500



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Vendor B has a projected monthly expense per employee of $520

Vendor A will earn six-hundred fifty (650) points for that county as the lowest monthly cost

per employee

Vendor B will earn six-hundred twenty-five (625) points, based on the following formula:

4.4 Negotiation Phase

4.4.1 Determination of Vendors Advancing to Negotiations

The Department intends to select no fewer than two (2) vendors using the Phase One scoring

specified above with whom to conduct negotiations.

Although the Department intends to negotiate with at least two (2) vendors, it reserves the

right to select more or fewer vendors with whom to negotiate.

No presumption of preference or merit in the negotiation process or for contract award shall

arise from the scores awarded during the evaluation phase and such scores shall not carry over

to the negotiation phase.

The Department will establish a negotiation team to conduct negotiations and make award

recommendations. The negotiation team will use the Selection Criteria to determine best value;

however, the negotiation team is not bound by the phase one scoring and will have full

authority to reassess any evaluation phase determinations and may consider all information

that comes to its attention during the negotiations.

The Department may negotiate sequentially or concurrently (or a combination of both) and

may at any time during the negotiation phase eliminate a vendor from further consideration.

Additionally, the Department reserves the right to conclude negotiations at any time and

proceed to contract award.

4.4.2 Goal of Negotiations

The negotiation process is intended to enable the Department to determine which vendor(s)

presents the best value and to establish the principle terms and conditions of such contract.

4.4.3 Vendor Attendance at Negotiations

The Department reserves the right to require attendance at negotiation sessions by particular

representatives of the vendor. At a minimum, the Department expects that the following

representatives will be in attendance: the account manager, the implementation manager, the



Page 33

executive sponsor and any other individuals who will perform a critical role in the day-to-day

management of the contract. The vendor should limit its negotiation team to six (6) individuals.

Any written summary of presentations or demonstrations provided by vendors during negotiations

shall include a list of attendees, a copy of the agenda, and copies of any visuals or handouts, all of

which shall become part of the vendor(s) reply. Failure to provide any information requested by the

Department during the Negotiation Phase may result in termination of negotiations with the

vendor.

4.4.4 Revised Replies and Best and Final Offers

During the negotiation phase, the Department will request clarification and revisions to replies

(including best and final offers) until it is satisfied that it has achieved the best value for the

State.

4.4.5 Other Department Rights during Negotiations

The Department reserves the right at any time during the negotiation process to:

a. Schedule additional negotiating sessions with any or all vendors.

b. Require any or all vendors to provide additional, revised, or final written replies addressing

specified topics.

c. Require any or all vendors to provide written best and final offer(s).

d. Require any or all responsive vendors to address services, prices, or conditions offered by

any other vendor.

e. Pursue a contract with one (1) or more responsive vendors for the services encompassed by

this ITN, any addenda thereto, and any request for additional, revised, or final written

replies or request for best and final offers.

f. Award contracts to responsive vendors by type of service or geographic area, or both.

Geographic areas may be county-by-county, any combination of two (2) or more counties,

statewide, or as otherwise determined by the negotiation team to be in the best interests of

the State in providing best value.

g. Arrive at an agreement with any responsive vendors(s), finalize principal contract terms

with such vendor and terminate negotiations with any or all other vendors, regardless of

the status of or scheduled negotiations with such other vendors.

h. Decline to conduct further negotiations with any vendor.



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i. Re-open negotiations with any vendor.

j. Take any additional administrative steps deemed necessary in determining the contract

award, including additional fact-finding, evaluation, or negotiation where necessary and

consistent with the terms of this solicitation.

k. Review and rely on relevant information contained in the replies or other information

gathered by the Department regardless of source.

The Department has sole discretion in deciding whether and when to take any of the foregoing

actions, the scope and manner of such actions, the vendor(s) affected, and whether to provide

concurrent public notice of such decision.

4.5 Negotiation Meetings Not Open to Public

Negotiations between the Department and vendors are temporarily exempted from chapter

286, Florida Statutes.

Negotiation team strategy meetings are exempted by subsection 286.0113(2)(a), Florida

Statutes.

The Department will record all meetings of the negotiation team, as required by law, and such

recordings will eventually become public record pursuant to chapter 286, Florida Statutes.

During negotiations, vendors must inform the Department if any portion of the meetings

should be considered exempt because of discussions of trade secrets so that the Department

can make appropriate arrangements for the segregation of the recording.

4.6 Final Selection and Notice of Intent to Award Contract

4.6.1 Award Selection

The Department will select for award the responsive and responsible vendor(s) that provides

the best value to the State based on the Selection Criteria in subsection 4.1.

The Department reserves the right to make a single or multiple awards or to make no awards

at all.

4.6.2 Department’s Negotiation Team Recommendation

The Department’s negotiation team will develop a recommendation as to the award that will

provide the best value. In so doing, the negotiation team will not engage in scoring, but will

arrive at its recommendation by majority vote.



Page 35

The scores from the evaluation phase will not carry over into the negotiation phase, and the

negotiation team will not be bound by those scores. The negotiation team will forward its

recommendation to the Secretary of the Department or his designee for review.

4.6.3 Secretary of the Department’s Approval

The Secretary of the Department or his designee will make the final decision to approve or

reject the recommendations of the negotiation team.

4.7 Posting Notice of Intent to Award

If the Department decides to award a contract(s), it will post a notice of intent to award

contract, stating its intent to enter into one or more contracts with vendor(s) identified therein,

on the Vendor Bid System website: http://vbs.dms.state.fl.us/vbs/main_menu. If the

Department decides to reject all replies, it will post its notice at the same Vendor Bid System

website.

Vendor shall destroy the confidential information, including any copies, remaining in its

possession within the later of five (5) business days of the State’s notice of intent to award in

connection with this ITN or the conclusion of any legal proceedings or protest regarding the

procurement and shall provide a certification and a final access list to the procurement officer

as defined in the ITN that it has complied with this requirement.

http://vbs.dms.state.fl.us/vbs/main_menu



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Section 5 Minimum Qualifications

Instructions: Vendors must respond to each of the following minimum qualifications. Vendors

must meet the minimum qualifications identified below. Failure to submit a response, or

selection of the response “No” will disqualify the vendor from further consideration.

Vendors must copy and paste without modification both the statements and boxes for each

of the numbers in this section into their replies and then select either “Yes” or “No.”

1. Vendor confirms that it will be able to provide all required services to Members

beginning January 1, 2017.

☐ Yes ☐ No

2. Vendor agrees that its reply is not contingent upon being the only plan offered in a

service area and does not include any minimum participation or employee contribution

requirements.

☐ Yes ☐ No

3. Vendor is authorized and registered by the Florida Department of State to do business

in Florida.

☐ Yes ☐ No

Submit proof of such registration as Reply Attachment 5.3

4. Vendor possesses a current accreditation from Accreditation Association for Ambulatory

Health Care, National Committee for Quality Assurance, Joint Commission of the

Accreditation of Healthcare Organizations, or Utilization Review Accreditation

Commission.

☐ Yes ☐ No

Submit proof of such accreditation for the corporate entity submitting the reply as Reply

Attachment 5.4

5. Vendor confirms that it is not in receivership under the Florida Division of Rehabilitation

and Liquidation or under regulatory action per the Florida Office of Insurance

Regulation.



Page 37

☐ Yes ☐ No

6. Vendor is able to and agrees to administer the Plan in accordance with the plan design

as specified in Attachment H: Covered Benefits and Services.

☐ Yes ☐ No

7. Vendor is registered or certified as required by the Florida Office of Insurance

Regulation.

☐ Yes ☐ No

Submit proof of such registration/certification as Reply Attachment 5.7

For vendors submitting pricing replies for any county under the fully-insured scenario, the

vendor must also respond to each of the following pass/fail requirements. A selection of the

response “No” will disqualify the vendor from further consideration. If a vendor is not bidding

any county under the fully-insured scenario, the vendor should check “Not Applicable”

indicating it is not bidding any fully-insured scenario.

8. Vendor has at least five (5) years of experience in providing HMO services with $90

million in annual earned premium in its commercial group business.

☐ Yes ☐ No ☐Not Applicable

Describe such experience and identify the top five (5) clients as Reply Attachment 5.8.

9. Vendor has at least five (5) years of experience in providing HMO Services for more than

15,000 covered lives in the state of Florida in its commercial business.


Describe such experience and identify the top five (5) clients by number of covered lives

as Reply Attachment 5.9.

10. Vendor has had at least one (1) government client with at least $10 million in annual

earned premium in the State of Florida in its commercial group business.



Page 38


Provide the name, contact person, address, telephone number, and email address for

such client(s) as Reply Attachment 5.10.

11. Vendor is presently registered or certified as required by Florida law as a Commercial

Health Care Provider by the Agency for Health Care Administration for each county in

the vendor’s proposed service area.


Submit proof of such registration/certification for the corporate entity submitting the

reply as Reply Attachment 5.11.

For vendors submitting pricing replies for any county under the self-insured scenario, the

vendor must also respond to each of the following pass/fail requirements. A selection of the

response “No” will disqualify the vendor from further consideration. If a vendor is not bidding

any county under the self-funded scenario, the vendor should check “Not Applicable”

indicating it is not bidding any self-funded scenario.

12. Vendor administers self-insured benefits for at least one (1) government client with at

least $10 million in annual medical claims in the State of Florida in its commercial group

business.




13. Vendor has at least five (5) years of experience in administering self-insured benefits

with $90 million in annual medical claims in its commercial group business.






Page 39

14. Vendor has at least five (5) years of experience in administering self-insured benefits for

more than 15,000 covered lives in the state of Florida in its commercial business.






Page 40

Section 6 Minimum Service Requirements

Instructions: Vendors must be able to provide all minimum service requirements below. Failure

to submit a response or selection of the response “No” will disqualify the vendor from further

consideration.

Vendors must copy and paste without modification both the statement and box below into

their replies.

Vendor confirms that it can and will provide, at a minimum, all minimum service requirements

as described in this ITN section 6.

☐ Yes ☐ No

1. Implementation Plan

Vendor shall submit the final implementation plan to the Department for approval not later

than ten (10) business days following execution of the contract. If the Department deems

the implementation plan to be insufficient, vendor shall work diligently to deliver an

updated, final implementation plan satisfactory to the Department, recognizing that time is

of the essence. Implementation plan shall be based on the proposed implementation plan

submitted by vendor during the procurement process.

Implementation plan shall fully detail all steps necessary to begin full performance of the

contract on January 1, 2017, 12:00:00 a.m., EST, and specifically identify due dates of all

steps with a person assigned responsibility for each. Implementation plan shall include the

following action items:

a. Establish an interactive Enrollee website with value add features (see MSR-23 below),

mobile app, dedicated toll-free phone line, interactive voice response system, and

Department approved communications at least two weeks in advance of the fall 2016

open enrollment period for the 2017 plan year.

b. Participate in fall 2016 open enrollment for the 2017 plan year benefit fairs and

meetings coordinated by the Department.

c. Schedule regular implementation status meetings and/or conference calls with contract

manager. Vendor shall appoint one of their team members to be responsible for

recording detailed meeting minutes and follow up action items on behalf of all team

members, including assignment of tasks and due dates. Minutes of decisions made and

list of action items shall be sent to contract manager within twenty-four (24) hours of

the end of the meeting/call.



Page 41

d. Conduct background checks in accordance with the contract’s section 3, Contract

Administration, including subcontractors.

e. Apply the provisions of Attachment H: Covered Benefits and Services and successfully

implement all necessary system edits, controls, and/or other policy/procedural

functions to ensure accurate administration and provision of Plan coverage for

Enrollees.

f. Test enrollment files, review key procedures and program process controls (i.e.

approval, design, testing, acceptance, user involvement, segregation of duties, and

documentation). Department must render functional acceptance approval prior to go-

live.

g. Submit to a pre-implementation audit of approximately 200-300 test claims and a

service delivery readiness assessment.

h. Finalize and validate billing procedures, invoice design, banking, reconciliation and other

financial processes, all subject to Department’s prior approval.

i. Design and present to the Department for approval all communication materials to be

used for Plan Enrollees. Communication materials include ID cards, brochures,

explanation of benefit statement forms, paper claim (reimbursement) forms, Summary

Plan Description (SPDs), Summaries of Benefits and Coverage (SBCs), standard letters,

system generated letters, templates, envelopes, clinical program notices and letters,

appeal denial letters, posters and, if applicable, mail order and other pharmacy forms

and flyers.

j. Ensure that ID cards and Plan education materials are mailed to Enrollees no later than

December 20, 2016 for coverage effective January 1, 2017.

k. Create an education plan for medical providers/prior authorization staff at physician’s

offices so they know the Plan benefits, including providing a regularly updated online

reference guide for doctor's office staff regarding pre-authorization processes for

medical services, supplies, prescriptions, utilization management, surgeries, and other

Plan access/pre-authorization requirements.

l. Finalize a process for tracking and responding to Member inquiries and complaints,

which includes measuring and reporting turn-around time.

m. Vendor shall be one-hundred percent (100%) operational prior to the effective date of

January 1, 2017, 12:00:00 a.m., EST. Vendor pays the liquidated damages listed in the

contract (Implementation Delays) for failure to meet this milestone.



Page 42

n. Vendor shall mail ID Cards (without Social Security Numbers) to all Enrollees the earliest

of December 20, 2016 or ten (10) business days after receipt of a clean and accurate

enrollment file.

2. Account Manager

a. Vendor shall assign a dedicated, but not necessarily exclusive, account manager as the

primary contact for the Department, unless the Department determines an exclusive

account manager is in the State's best interest.

b. The account manager shall participate on the implementation team and coordinate,

troubleshoot, advance and track the State’s interests and requests throughout the

organization.

c. If requested by the Department, the account manager shall be replaced. If in the State’s

best interest, replacement may be interviewed and approved by the Department.

3. Account Management Team

a. Vendor shall assign a dedicated, but not necessarily exclusive, account management

team which may include an executive sponsor, an account manager, a data/fiscal

analyst, enrollment/eligibility manager, claims manager, customer service manager,

medical director, and, if applicable, a pharmacist.

b. Vendor agrees that replacement of personnel to the account management team

assigned to this contract shall be subject to the Department's prior written approval,

should the Department request it at the time.

c. The account management team shall act on behalf of the State in advancing the

interests of the State through vendor's corporate structure.

d. The account management team shall be able to devote the time and resources needed

to successfully manage the account including being available for frequent telephonic,

email, and on-site consultations.

e. The account management team shall be thoroughly familiar with vendor's functions and

operations that relate directly or indirectly to the Department and the Plan including but

not limited to provider networks, claims and enrollment systems, systems reporting

capabilities, claims adjudication policies and procedures, standard and non-standard

banking arrangements, and relationships with third parties. Account management team

shall be on the forefront of healthcare industry trends, medical technology

developments, and best-in-class practices and share this knowledge with the State.



Page 43

f. Vendor shall maintain a current account management team organizational chart.

Vendor shall promptly notify the Department of any changes and provide detailed

information regarding new personnel including name, professional background, mailing

and physical address, email address, work and cell phone numbers along with an

updated organizational chart.

g. Department may give a plan performance review to the account management team or

separately to each team member. An action plan, as determined by the Department,

must be implemented based on measurement criteria listed in the Performance

Guarantees section.

4. Background Checks

Vendor shall comply with employee and Subcontractor Security Requirements, including

performing background checks described in section 3.2.5, Background Screening, of the

contract.

5. Dedicated Teams

a. Vendor shall assign a dedicated, but not necessarily exclusive, customer service team for

the Department, unless the Department determines an exclusive team is in the State's

best interest.

b. Vendor shall assign a dedicated, but not necessarily exclusive, enrollment and eligibility

manager for the Department.

c. Vendor shall assign a dedicated, but not necessarily exclusive, billing manager for the

Department.

d. Vendor shall assign a dedicated, but not necessarily exclusive, claims supervisor for the

Department, unless the Department determines an exclusive claims supervisor is in the

best interest of the State.

e. Vendor shall assign dedicated, but not necessarily exclusive, claims processors for the

Department, unless the Department determines exclusive claims processors is in the

State's best interest.

f. Vendor shall assign a dedicated, but not necessarily exclusive, claims processing facility

for the Department.

g. The Department reserves the right to accept or decline vendor's designated claims

supervisor, claims processor(s), and/or claims facility for any reason at any time.



Page 44

6. Meetings/Conference Calls

a. Quarterly Meetings: vendor shall attend all quarterly meetings at the State offices in

Tallahassee, Florida, or by telephone conference call as directed by the Department.

Vendor shall not be entitled to additional compensation for meeting preparation or

attendance. Quarterly reports are due within forty-five (45) calendar days following

quarter end and meetings/calls are to be held within sixty (60) calendar days following

quarter end. The fourth quarter meeting shall include both quarterly and annual

calendar year reports and deliverables. Requirement also includes quarterly reports and

meetings as required by the Department through the sixteen (16) month period or

following termination of the contract resulting from this ITN.

i. Agenda: At the Department's request, vendor shall provide for the Department's

approval a draft agenda five (5) business days in advance of a meeting allowing

changes to the agenda and a reasonable opportunity to prepare for the meeting.

At a minimum, vendor and Department will discuss medical goals (pharmacy

goals, if applicable), set expectations and priorities, review vendor's quarterly

reports (e.g., thoroughly explain based on data the reasons for increases and

decreases in utilization and cost), and other issues such as performance

guarantees, quality assurance, operations, network status and access (including

pharmacy, if applicable), benefit and program changes or enhancements,

legislative matters, audits, cost trends, utilization patterns, program outcomes,

customer service issues, future goals and planning, and other issues reasonably

related to the contract. Vendor shall address past performance, anticipated

future performance, and compare the Plan's experience to 1) national trends, 2)

vendor's total book of business, 3) other governmental clients, and 4) vendor's

"best in class."

ii. Minutes: Within five (5) business days after any meeting, vendor shall provide the

Department detailed draft meeting minutes. Department will review and revise

the draft minutes as appropriate and return to vendor. Vendor shall provide the

Department with final minutes within three (3) business days after revised

minutes. Minutes shall include a list and description of follow up Deliverables,

with assigned person and due date.

b. Other Meetings: progress meetings, issue meetings, and emergency meetings shall be

held as necessary. Either party may call such a meeting, subject to reasonable notice.

Any meeting held in person shall be at the State's offices in Tallahassee, Florida. Vendor

shall not be entitled to additional compensation for meeting preparation or attendance.



Page 45

7. Benefit Fairs

a. Vendor shall participate in all locations as applicable to vendor's service area of the

annual open enrollment benefit fairs that are sponsored by the Department or its

designee. Number of fairs and locations may vary each year, but approximately twenty-

four (24) fairs statewide are held in the fall. Vendor's representatives attending the

benefit fairs shall be employees of vendor (not subcontractors or temporary personnel)

and adequately trained and knowledgeable about the Plan. Vendors shall educate

Members on Plan benefits, services and other tips to ensure a positive Member

experience.

b. Vendor shall be responsible for all costs associated with participating in benefit fairs

including travel and a proportionate share of facility fees. For illustrative purposes, in

2014 the share of fees was one-hundred-fifty dollars ($150) per vendor per fair.

c. Vendor shall not solicit State Employees at the work place or during work hours in

person, by email or other means, except during Department-sponsored benefit fairs or

meetings hosted by a State agency or university for its employees.

d. Vendor shall not discuss with Enrollees or prospective Enrollees or in any manner allude

to coverage, products, or materials other than those explicitly related to the Plan

without the permission of the Department. Such prohibition shall also apply to vendor’s

state-specific website.

8. Advertisements and Marketing Materials

a. Vendor shall submit copies of all promotional and Enrollee educational materials to the

Department for prior written approval, if distributed to or accessed by Enrollees for

marketing the Plan. All such materials shall be approved in writing by the Department

prior to use.

b. As applicable, vendor shall pay for the expenses for printing and mailing the State of

Florida Summary Plan Description, Certificate of Coverage, and any associated forms.

c. Vendor shall assist the Department (i.e., review, clarify, edit, and confirm accuracy) as

requested in developing Department communications on the Plan including but not

limited to the Summary Plan Description and the Department's benefit website:

www.mybenefits.myflorida.com.

9. Plan Materials

a. No promotional or Enrollee educational materials related to the Plan may be distributed

or otherwise communicated without the prior review and written approval of the

Department.

http://www.mybenefits.myflorida.com/



Page 46

b. Subject to the Department's customization and written approval, on a Plan Year basis,

vendor shall be responsible for the development of Plan benefit information including

but not limited to 1) open enrollment brochures and promotional pieces, and 2) other

Plan-related printed materials (e.g., Summary Plan Description, ID cards, benefit

brochures, claim forms, clinical program access tips and notices along with letters,

notices, preformatted letters, templates, system generated letters and notifications,

correspondence forms, Explanation of Benefits (EOBs), and other written materials and

forms).

c. In addition, vendor shall provide ongoing via secure website and/or annually by mail a

summary of covered health care expenses along with Member responsibility amounts

for the purpose of helping Enrollees make better informed health decisions. Therefore,

two (2) weeks prior to the first day of each annual open enrollment, vendor shall either

1) mail this health care summary to the Enrollee and each adult Member, or 2) send

Enrollees and each adult Member a notice advising them how to register themselves to

access this summary information online.

d. Vendor shall be responsible for writing, printing, distributing, and mailing all such

Department-approved information.

e. Vendor shall provide, upon request of the Member, printed materials in a medium

widely accepted for the visually impaired.

f. All printed material shall be provided in electronic format with final versions submitted

to the Department in PDF file format.

10. Provider Directory (e-version)

a. Vendor shall provide an online directory of network providers, which shall be updated

and made available to Members in real time (i.e., same day when provider notifies

vendor or, if provider suddenly stops seeing patients, when vendor learns of it through

Member calls, other providers, other means and media). Directory shall state the list will

change as needed, as well as displaying the actual date of most recent update (e.g.,

noted by “Last Update”).

b. In addition to online, vendor shall provide and support mobile applications of the online

provider directory for cell phones, tablets and other mobile devices.

c. Vendor shall mail provider directories to Members upon request.



Page 47

11. Membership Materials

Vendor shall mail the following materials to new Enrollees within four (4) business days

after receipt of the enrollment data file or notice from the Department or its designated

agent:

a. Flyer, letter or other mailer advising on where to locate the Summary Plan Description,

how to select a PCP, and other information applicable the plan and enrollment; and

b. Member Identification Cards.

Membership mailing may include a customized greeting and form letter to new Enrollees,

subject to the Department's prior approval. Letter may include a summary of information

already contained in the Summary Plan Description and/or highlight important information

(e.g. how to obtain a referral to a specialist or access urgent or after-hours care).

Vendor may supply new Enrollee information kits to local state agency personnel offices

throughout their respective service areas. Department must pre-approve these enrollment

kits.

12. Summary Plan Description (SPD) (distribution)

Vendor shall use and make available online and by print upon request the Department-

approved Summary Plan Description with certain edits allowed to provide contact

information, vendor-unique processes, and other limited information, all pre-approved by

the State.

Vendor shall provide the Summary Plan Description in Spanish and other language versions where mandated by law based on census demographics.

13. ID Cards

a. Vendor shall provide ID cards to new Enrollees.

b. Vendor shall mail one (1) ID card for each individual contract and at least one (1)

additional ID card for each family contract.

c. Vendor shall provide additional ID cards as requested by the Enrollee.

d. Vendor shall display on the ID cards unique Enrollee-identifying numbers (not SSNs).

Although never displayed, SSN shall be the number of record and maintained in

vendor's information system. ID cards shall be compliant with State standards. ID cards

shall display information for both medical and, if applicable, pharmacy benefits.



Page 48

14. Mail

Vendor shall hold returned mail for thirty (30) calendar days during which time vendor shall

search for an updated address with each subsequent file coming from People First. After

thirty (30) calendar days, vendor shall store copies on its document imaging system and

destroy the returned mail.

Special post office boxes: vendor shall maintain dedicated post office boxes (e.g., one box

each for claims, appeals, general correspondence, returned mail) which shall be used

exclusively for State-specific correspondence and Plan Enrollees.

15. Department Inquiries, Account Service, and Dispute Support

Vendor shall upon request of the Department or its attorneys and at no additional cost

assist the Department in responding to inquiries received by the Department from

Members, providers, or other persons related to any aspect of Services delivered under the

contract. Such requests shall be a) given a priority status, b) subject to a method of tracking,

c) result in the delivery of all requested information, documentation, etc., and d) handled or

overseen by a lead customer service person.

Vendor shall immediately assist the Department in preparing its reply when the Department

requires an instant reply, including providing data and documentation within the time

frames prescribed by the Department given at that time.

16. Public Records Requests and Subpoenas

Vendor shall upon request and at no additional cost provide the Department with any

necessary data, documents, and so forth, to enable the Department to respond in a timely

manner to public records requests and subpoenas related to any aspect of Services

delivered under the contract.

17. Requests for Legislative Initiatives

Vendor shall make available, at no additional cost to the Department, all necessary

resources to assist the Department in responding to bill analyses, legislative inquiries and

requests including but not limited to the account management team, analytics and

outcomes, research and development, actuarial support, and government relations

department related to any aspect of Services delivered under the contract. Vendor shall

respond within the timeframe set by the Department, which shall be determined at the

time of the inquiry depending upon the scope and complexity of the request.



Page 49

18. Underwriting and Actuarial Services

Vendor shall provide the Department with underwriting and/or actuarial services related to

any aspect of Services delivered under the contract at no additional cost to the Department.

For actuarial certification and required signature activities by a Fellow of the Society of

Actuaries, up to fifty (50) hours per calendar year shall be designated for these services with

unused hours rolled over to the following year.

19. Consulting Services

Vendor shall, upon request, provide consulting services at no additional cost to the

Department related to the Services (e.g. to verify improved pricing, review consolidated

claims platforms, and other situations).

20. Medicare Secondary Payer

Vendor shall coordinate benefits with Medicare's third party administrators without

involving the Member (see MSR 52 below). Vendor shall respond to all Medicare Secondary

Payer notices to avoid offsets to the State.

21. Customer Service Unit

a. Vendor shall maintain a customer service unit dedicated, but not necessarily exclusive,

to performing all aspects of Member-related customer service and shall include a state-

of-the-art call center. Calls to this unit shall be accepted and answered promptly by a

live customer service representative during the hours of 8:00 a.m. to 6:00 p.m. Eastern

Time, Monday through Friday, excluding State holidays set forth in section 110.117,

Florida Statutes.

b. Vendor shall maintain an exclusive toll-free customer service number, which will permit access anywhere in the United States. Customer service unit is subject to pertinent requirements in the Performance Guarantees section.

22. Customer Service Operations

The customer service operation shall include, at a minimum, the following:

a. Integrated member support for all plan services;

b. Plan specific training and knowledge to assist Members, prospective Enrollees,

physicians, pharmacists, etc. regarding Plan;

c. Assist Members who contact vendor's customer service unit with only their name

and/or Social Security number;



Page 50

d. Maintain an enrollment file that identifies eligible Members and other pertinent

information regarding Members;

e. Processes for triaging emergency requests (i.e. out-of-network provider coordination,

early fills, if appropriate);

f. Adequate and appropriate access to the customer service system for Members with

disabilities (e.g. TTY and online access);

g. Sufficient personnel available to provide multi-lingual (Spanish, at a minimum) service

and the ability to provide service to the hearing and vision impaired;

h. Information systems capable of electronically transmitting, receiving, and updating

Enrollee profile information from People First as required in contract Attachment 3:

Enrollment File Interface Layout. Maintain a service disruption plan or procedure to

continue customer service activities when temporarily unavailable due to either

scheduled or unforeseen events (e.g., relocating offices, repairing/restoring utility or

power supply, upgrading phone systems, and other events). The Department shall be

notified as soon as possible for scheduled disruptions and other events; and

i. Provide services on a reciprocal basis throughout its authorized service areas to

Members enrolling in its plan. An eligible dependent of an Enrollee living in a different

service area is entitled to receive the same Services in that Dependent’s remote service

area if such county is part of the vendor's commercial book of business.

23. Member Website Tools

Vendor shall provide and maintain a State of Florida-specific Member website with 24/7

access for medical, general health and, if applicable, prescription drug information, if

applicable. This website shall include links to the Department's website and other state,

federal, and condition-specific websites as appropriate to make available a variety of

information to Members. Such web-and/or cloud-based access shall include the ability to, at

a minimum:

a. Access forms and brochures;

b. Order ID cards and/or otherwise display ID cards on a mobile application;

c. Access preventive educational information;

d. Access general health and chronic disease information;

e. Track medical out-of-pocket Plan limit (medical only);

f. Track federal out-of-pocket limit (medical and pharmacy combined);



Page 51

g. Track Health Investor Health Plan accumulator information including separate tracking for both individual and family member out-of-pocket costs;

h. Complete online health risk assessments;

i. Communicate with a customer service representative;

j. Offer other valuable tools;

k. Locate participating network physicians and hours of operation when hours are known;

l. Locate participating network facilities and hours of operation when hours are known; and

m. For fully insured plans providing prescription drug benefits, track prescription drug history.

24. Cost Estimator

The online system shall offer a cost estimator that shows the maximum Member cost share

and the plan cost share for a specific procedure prior to rendering of the service.

25. Member Satisfaction Surveys

Vendor shall conduct an annual Member satisfaction to measure overall satisfaction subject

to contract Attachment 2: Performance Guarantees. Survey instrument, methodology,

timing, and distribution are subject to the Department’s approval. In addition to the

vendor’s annual Member survey, Department may conduct its own Member satisfaction

survey. The Department may select the survey instrument and may either conduct or have

it conducted by an independent third party. Survey results shall be used, in part, to

determine satisfactory performance of the contract. If the survey shows unsatisfactory

performance, vendor shall implement a corrective action plan approved by the Department.

26. Protected Health Information

Vendor agrees to adhere to leading industry practices in the development, implementation,

and application of administrative, physical and technical safeguards that reasonably and

appropriately protect the confidentiality, integrity, and availability of the protected health

information that vendor creates, receives, maintains, or transmits in vendor's

administration of the Plan, as required by the HIPAA security standards and all applicable

HIPAA administrative simplification rules.

27. The Department Determines Eligibility

Vendor shall permit all eligible Enrollees as determined by the Department or its designee

to obtain health insurance benefits for themselves and their eligible dependents. The



Page 52

Department retains final authority in determining eligibility and this determination may

result in rare instances when the effective date goes back more than sixty (60) calendar

days.

28. Selection of a Primary Care Physician (PCP)

a. Vendor shall offer Enrollees a choice of PCPs and either require or strongly encourage

each family member to select one.

b. Vendor shall not use a State agency personnel office or the Department as an

intermediary for the PCP selection process.

c. If applicable, vendor shall make it clear to Members that the Plan requires each Member

to select a PCP. Absent that selection, vendor may assign one to each family member

with the Member’s option to change via vendor’s website or member services.

d. Vendor must encourage and make available internet or computerized telephone

response systems to facilitate PCP selection. If available, such internet or mobile

application means shall be advertised by vendor in Enrollee communications.

e. Do Not Delay Enrollment due to No PCP Selected: vendor shall not delay an Enrollee's

effective date of coverage because of failure to select and register with a PCP. Further, if

vendor requires a PCP selection, then vendor shall send member a letter within ten (10)

business days of coverage effective date asking them to choose a PCP with steps on how

to register such selection with the vendor.

29. Verification of Persons with Disabilities

Vendor agrees to maintain and verify documentation of permanent and total disability

status for eligible dependents of Enrollees. Vendor must verify permanent disability status

at least every five (5) years using a process approved by the Department.

30. Notify the Department

a. Vendor shall, within twenty-four (24) hours of announcement, notify the State if vendor

or provider network loses any accreditation, service area approval, licenses, or liability

insurance coverage.

b. Vendor shall, within twenty-four (24) hours of announcement, notify the Department

with a statement of justification in the event of a major loss of network health care

providers or disruption to the network (i.e. loss of a hospital, facility, provider group,

and so forth). The statement shall include the following:



Page 53

i. Member Impact Report: a description of how the contract action impacts the

interests of the State including number of impacted Members; and

ii. Confirmation that vendor shall continue to maintain minimum access standards

through other providers.

31. Continuity of Care

Vendor shall continue coverage under certain circumstances when provider contract is

terminated.

a. Unexpected: vendor shall notify impacted Members as soon as administratively possible

but no later than five (5) business days of vendor receiving formal notice when a

provider’s contract unexpectedly terminates (e.g., death or loss/suspension of a license

to practice medicine and so forth).

For terminating PCPs, vendor shall assist Members in selecting another PCP. New

selection shall be effective the day immediately following the provider’s termination

effective date or sooner if requested. If the provider does not properly notify vendor of

intent to terminate, then vendor shall pursue disputes with the provider’s contract

without interruption of patient care.

b. Expected: vendor shall notify impacted Members at least thirty (30) calendar days prior

to the expected termination date of provider's contract when failure to renew,

unsuccessful negotiations, and so forth.

c. As provided for in subsection 110.123(3)(h)6, Florida Statutes, when vendor terminates

a provider without cause, vendor shall allow Members to continue coverage when

medically necessary the longer of: through completion of a condition for which the

Member was receiving care at the time of termination, until the Member selects

another treating provider, or until the next open enrollment period offered, but no

longer than six (6) months after the termination of the contract. Vendor shall allow

pregnant Members to continue care with a terminated treating provider until

completion of post-partum care.

d. These requirements shall not apply to treating providers who have been terminated

from the vendor for cause. Vendor shall develop and maintain policies and procedures

for the provision of continued care as prescribed above.

e. Vendor's physician and hospital contracts shall have a "continuation of care" clause

consistent with the requirements of subsection 110.123(3)(h)6, Florida Statutes.



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32. Nominating Providers

Vendor shall have a procedure in place to allow plan Members and/or the State to

nominate providers to be considered for inclusion in vendor’s network and/or vendor’s sub-

contracted provider’s network (e.g., Applied Behavior Analysis (ABA) therapists, mental

health providers, urgent care centers, primary care physicians, and others).

33. Annual Visits

Vendor shall perform annual visits to network physician offices, both general practitioners

and specialists, to educate the physician's or facility's business office manager on Plan

benefits, billing, and resolving claim issues.

34. Access Standards

Vendor shall establish and maintain a comprehensive network of participating physicians,

hospitals and other providers and facilities to sufficiently provide all services under the Plan.

In addition, vendor shall provide access to the doctor types and hospitals listed in the

Performance Guarantees section.

35. Balance Billing Prohibited

Vendor confirms that, for insured HMO benefits, procedures are in place for ensuring that a

network provider does not bill State of Florida Enrollees and/or the State any amount in

excess of the contracted network rate, network allowance or allowed amount in accordance

with chapter 641, Florida Statutes.

36. Onsite Clinic

a. Vendor may be required to assist the Department in examining the feasibility of

implementing, staffing, and maintaining an on-site clinic.

b. In the event the Department establishes an on-site clinic, vendor shall enter a network

contract allowing Enrollees in-network utilization of the clinic.

37. Enrollment File Transfers from the Department

a. Vendor shall maintain an information system capable of electronically receiving and

updating Enrollee information on weekly, monthly and/or ad hoc basis (e.g. eligibility,

change of address, coverage information, and so forth). Vendor shall accurately convert

and load the Department's enrollment files in a secure point-to-point connection

format.

b. Vendor shall maintain enrollment records for all Enrollees based on the Department's

weekly and monthly enrollment files.



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c. Vendor agrees that the Department's enrollment file shall be the official system of

record. Vendor shall not overwrite, update or in any way change the enrollment

information without the express written direction from the Department or People First.

d. Vendor shall accept the enrollment files in a format and according to the schedule

required by the Department in contract Attachment 3: Enrollment File Interface Layout

and Attachment 4: Enrollment File Transfer Schedule.

e. In addition to the file schedule above, vendor shall accept enrollment file typically

provided at the end of November following open enrollment for the purpose of

generating ID cards for distribution prior to the new Plan Year.

f. The enrollment files shall be processed as required by contract Attachment 2:

Performance Guarantees.

g. Vendor shall conduct and maintain enrollment reconciliation between vendor's system

information/files and the Department's enrollment files.

h. Enrollment file transfers and subsequent discrepancy reports between vendor and the

Department shall be exchanged using a method required by the Department.

i. Enrollment updates including manual reinstatements and terminations from People

First shall be processed as required by contract Attachment 2: Performance Guarantees

at no additional cost to the Department.

38. Paid Claims File to the Department and/or Department’s Designee

Vendor shall provide a secured file including all claim data related to the Plan in the data file

layout and timeframe specified by the Department. Data shall be provided in a secured

method to the Department and/or a third party designated by the Department and shall

include, but not be limited to, trade secret, proprietary or confidential claim related

financial information: total charged amount, allowed amount, discount amount, deductibles

and copayments, and plan payment amount provider information ,including, but not limited

to, name, location and National Provider Identifier or Tax Identification Number; and all

fields, whether received electronically or via paper, from CMS 1500 (837-P) and UB-05 (837-

I) medical claims forms including all patient demographic information (including dependent

social security number), diagnosis codes, procedure codes, surgical procedure codes,

modifiers, and all other data elements associated with each claim. All claims processed

during the reporting period, including paid, denied and adjusted claims, shall be included.

The Department reserves the right to utilize the monthly paid claims files in any manner

deemed necessary, including but not limited to, source data for audit purposes. Failure to



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timely submit complete, properly formatted data shall be considered a material breach of

the contract and shall be subject to the breach requirements in the contract.

39. Use of Plan Data

a. Vendor shall not sell or share the Plan's data without the prior written authorization of

the Department.

b. Vendor agrees that the only compensation to be received by or on behalf of its

organization in connection with this Plan shall be that which is paid directly by the State.

40. System Upgrades, Enhancements and Problems

a. Vendor shall provide at least six (6) months prior notice of any significant planned

system upgrades or changes, including but not limited to claims, customer service,

enrollment, operating systems and any other changes that may materially affect the

administration of the Plan. Changes shall be subject to the Department's prior written

approval.

b. Vendor shall immediately notify the Department upon the discovery of problems or

issues impacting claims processing related to the Plan. Failure to timely notify the

Department shall be considered a material breach of contract resulting from this ITN.

c. Vendor shall not take corrective action related to systemic problems or issues impacting

claims processing related to the Plan without the written approval of the Department.

41. Out-of-Pocket Accumulators

On a daily basis or more frequently as mutually agreed vendor shall:

a. Provide the file of all Member accumulator information to the Department’s pharmacy

benefits manager and/or other required third parties. This file shall be formatted as

agreed upon by the parties and approved by the Department, subject to the

Performance Guarantees section and/or contract.

b. In addition, vendor shall be the record keeper of Member medical and drug spend

accumulator information and update applicable Member cost shares (i.e., remaining

deductible, medical out-of-pocket maximum, and global out-of-pocket maximum) using

all pertinent information as appropriate and consistent with the Plan design.

42. Paid Claims Exchange with PBM

On a monthly basis or more frequently as mutually agreed vendor shall:

a. Provide a file of all paid claim activity to the Department’s pharmacy benefits manager

and/or other required third parties.



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b. Accept a paid claim file from the Department’s pharmacy benefits manager and/or

other required third parties.

This file shall be formatted as agreed upon by the parties and approved by the Department,

subject to the Performance Guarantees section and/or contract.

43. Other Data Transfers as Required

a. File transfers between vendor and Department and/or authorized third parties shall be

exchanged using a method, format and frequency required by the Department.

b. Vendor shall provide all medical and pharmacy data related to the plan to the

Department and/or to a third party designated by the Department, in the time frame

and in the format specified by the Department. Failure to timely submit complete,

properly formatted data shall be considered a material breach of the contract.

44. Records Retention

Vendor shall retain records as required by the contract, or longer, if required by state

and/or federal laws or regulations.

45. Claims Processing and Adjudication

a. Vendor shall establish and perform all aspects of claims processing, coordination of

benefits, claims reimbursement, point-of-sale transactions, adjudication, and payment

in accordance with the Summary Plan Description. Vendor shall verify benefits and

eligibility before authorizing services.

b. Vendor’s claims processing guidelines are subject to the claims standards in the

Performance Guarantees section including, but not limited to, for timeliness, financial

accuracy, payment accuracy, and overpayment recovery, and so forth.

46. Standard Claims Administration Practices

a. Vendor shall receive, process, and adjudicate claims in accordance with best industry

practices using nationally recognized standards, as determined by the Department. At

the Department’s direction, vendor shall implement best industry practices.

b. Vendor certifies its ability to administer the Plan in compliance with all State and federal

mandated benefits.

c. Vendor shall maintain a system for statistically profiling charges and allowances by

procedure code and by ZIP code. Regarding claims edits within the claims adjudication

process, vendor shall use, in accordance with the CMS National Correct Coding Initiative



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(NCCI), Procedure-to-Procedure (PTP) edits, Outpatient Code Editor (OCE) and Medically

Unlikely Edits (MUE).

d. Vendor agrees that illnesses, conditions and services associated with its preferred

medical facilities and/or centers of excellence programs shall be bundled with regard to

reimbursement. Vendor also agrees that the facility shall be at risk for costs incurred in

excess of the negotiated (bundled) charge.

e. Vendor shall accept and load historical data from any carrier that severs ties with the

Department for tracking and accurate payment of benefits (i.e., service limits,

deductible accumulator, and medical and global member out-of-pocket max amounts).

47. Must Offer Standard and Health Investor Health Plan (HIHP) Plan Options

Vendor shall accommodate both a standard plan and a health savings account qualified high

deductible health plan design (e.g. HIHP), as described in the Department’s Summary Plan

Description.

48. Summary Plan Description (Strict Adherence)

The Florida Legislature, through the annual General Appropriations Act, establishes the

desired set of benefits. Vendor shall strictly adhere to the coverage provisions of the

Summary Plan Description, including but not limited to providing payment of non-network

services except in the case of verified emergencies.

49. Conversion Policy

Vendor agrees to provide a post-COBRA fully insured conversion policy to terminated

Enrollees, pursuant to sections 627.651(1), 627.6675, 641.3921 and 641.3922, Florida

Statutes.

50. Other Coverage Liability

Vendor shall conduct other coverage liability (OCL) verification annually through the most

appropriate channel, which may involve the Member.

51. Coordination of Benefits

a. Vendor shall use applicable State laws for determining order of liability for Coordination

of Benefits (COB) including but not limited to other insurance, workers’ compensation

insurance, and Medicare. In addition to order of liability, vendor shall interface with the

State’s workers’ compensation vendor, Centers for Medicare and Medicaid (CMS)

through voluntary data exchange, and other payers and methods as the Department

determines.



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b. Vendor shall coordinate benefits on a pay-and-pursue basis for active Enrollees and

Dependents and, conversely, a pursue-and-pay basis for all other Members.

c. As a secondary payer, vendor shall reimburse as specified in the Coordination of

Benefits section of the Summary Plan Description.

d. As secondary payer, vendor shall coordinate with Medicare and benefits shall be paid up

to the lessor of 1) the covered expenses Medicare does not pay, up to Medicare

allowance, or 2) the amount this Plan would have paid if Member had no other

coverage. Plan benefits for Members who are eligible for Medicare Parts A and B but

have not enrolled will be paid as if Medicare had paid first as the primary plan.

52. Coordination with Medicare’s Third Party Administrators

a. Vendor shall coordinate with Medicare’s third party administrators and shall ensure that

claims are processed with primary and secondary payers without involving the Enrollee.

Vendor shall be responsible for timely responding and resolving all Medicare Secondary

Payer (MSP) notices to avoid offsets to the State of Florida. Vendor shall be financially

responsible for its failure to accurately and timely resolve such MSP notices resulting in

the offset of State funds.

b. Plan benefits for Enrollees who are eligible for Medicare Parts A and B, but failed to

enroll, will be paid as if Medicare had paid first as the primary plan.

c. As secondary payer to Medicare, vendor shall allow for, and establish, automatic

crossover from Medicare.

d. Vendor shall appropriately process electronic (real time) and paper claim submissions

for Coordination of Benefits (COB) as secondary payer for Medicare Part D enrollees.

53. Subrogation

Vendor shall identify, to the extent possible, any claim payments for which the plan has, or

may have, a right of subrogation. Vendor shall make a reasonable and diligent effort to

enforce, in accordance with section 768.76, Florida Statutes, and the Summary Plan

Description, any subrogation claim belonging to the Plan. Vendor shall develop and

implement a subrogation process subject to the Department's approval for reporting

subrogation claims belonging to the Plan. Vendor shall pursue, settle and collect all

subrogation rights allowed in the Summary Plan Description. Department must approve any

recommended settlement if less than the State’s full lien amount minus any cost sharing or

reduction allowed by section 768.76, Florida Statutes. Additionally, vendor shall develop a

monthly subrogation report, subject to the Department's approval, for reporting the

identification, status, and resolution of all pertinent subrogation cases.



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Recovery amounts from subrogated claims shall not be reduced or otherwise offset by contingency fees or other fees charged by an auditor or other recovery service.

54. Explanation of Benefits (EOB) Statement

Monthly: Vendor shall furnish an Explanation of Benefits (EOB) Statement for all claims

processed within a month timeframe via regular mail to last known address. In lieu of hard

copy EOB, vendor may provide a per-claim electronic EOB, subject to authorization of the

Enrollee. Department must approve and may customize the design of the EOB.

The EOB shall include all claim details, including accumulation balances for each medical

and global out-of-pocket maximum amounts (i.e., medical only claims and, separately,

medical and prescription drugs, respectively). Vendor shall be the keeper of

record/accumulator of medical and prescription drug claims and shall be responsible for

accurately storing, calculating and displaying (hard copy and online) both accumulation

amounts in real-time (online).

In addition, vendor shall provide two (2) member Benefit Statements each year: one near

the start of the open enrollment period showing year-to-date claims; the other just after

the start of the new year showing previous calendar year claims. The fall Benefit Statement

provides members the value of their plan by showing how much the plan paid versus the

Member paid; annual Benefits Statement provides the same plus information that the

Member uses for tax filing purposes.

55. Inaccurate Payments

a. Upon discovery, notification, or recoveries as part of audits (i.e., vendor self-audit,

Department/contract required audit, eligibility audit, hospital audits, and/or provider

audits) or other claim review activities, the vendor shall fully rectify the inaccurate

payment, including but not limited reprocessing incorrect claims and reimbursing the

Department, whenever payment is made that is not in accordance with the terms of the

contract. The vendor shall reimburse one hundred percent (100%) of all identified

overpayments to the Department. Such overpayments shall not be reduced by

contingency fees or other fees charged by an auditor or other recovery service.

b. Vendor shall reimburse the Enrollee in the event a recovery impacts the Enrollee's cost

share. In certain situations, vendor may repay health care provider with instructions for

them to repay member. Simultaneously, vendor shall notify Enrollee of any applicable

refund.

c. Under a self-funded arrangement, vendor shall reimburse the Department first and then

pursue reimbursement from the provider. Vendor shall send payment of these



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recoveries to the State via an electronic fund transfer. Daily claims funding will not be

reduced or otherwise offset by these overpayment recovery amounts.

56. Recovery Procedures

a. Vendor shall have procedures in place for recovery of capitation fee and claims

processing financial errors identified in all audits (i.e., vendor self-audit, Department or

contract required audit, eligibility audit, hospital, and provider audits). Vendor shall

recover and send payment of these recoveries to the State, not reduce the daily claims

funding amounts or otherwise offset amounts, subject to the standards in the

Performance Guarantees section.

b. Under a fully insured arrangement, recoveries shall be credited to the Plan's financial

experience.

c. The vendor shall reimburse the Department for any and all overpayments regardless of

whether the overpayment is recovered from the Plan member or provider, and

regardless of how the error was discovered. Reimbursement shall be made to the

Department via an electronic fund transfer or to the Plan member, as applicable, within

sixty (60) days of identifying the overpayment.

57. Accounting System

Vendor shall maintain an accounting system and employ accounting procedures and

practices conforming to generally accepted accounting principles and standards. Vendor’s

accounting records and procedures for medical and pharmacy, if applicable, shall be open

to inspection by the Department, or its authorized representatives, at any time during the

contract period and for so long thereafter, as Department requires. However, that any such

inspections shall be subject to confidentiality protocol requirements. All charges, costs,

expenses, etc. applicable to the contract shall be readily ascertainable from such records. As

applicable, supporting documentation for all charges, fees, guaranteed savings and rebate

payments including reimbursement invoices for prescription drug payment shall be readily

ascertainable from such records.

58. Appeal Services

a. At no additional cost to the Department, vendor shall administer appeals in accordance

with the appeals process described in the Summary Plan Description and as otherwise

required by the Department, state and federal law. Such appeals include Level I appeals,

medical review/assistance to the Department for Level II appeals, administrative

hearings and, for fully insured arrangements, external reviews by vendor's Independent

Review Organization (IRO). Department shall approve and may customize any and all



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correspondence, letters, communications and so forth related to any part of the appeals

process. Vendor shall adhere to the standards in Performance Guarantees section.

Vendor shall maintain a record of all grievances/appeals from Members and shall

provide a summary of grievances/appeals to the Department quarterly, or more

frequently upon request. Upon request, vendor shall provide a narrative summary of

the reasons for the grievances/appeals, the disposition thereof, and any corrective

action plans implemented as the result of the grievance/appeal.

b. Appeal-related Documentation and Testimony: Upon Department's request or its

attorneys and within specified timeframes by the Department, vendor shall provide all

documentation related to a Plan Member's appeal/administrative hearings(s). This

documentation shall include but not be limited to clinical/medical policy guidelines, any

notes, medical review notes or statements of medical providers and/or vendor's medical

reviewers or consulting medical providers. Vendor shall make available the

documentation and testimony of vendor's employees, physicians, nurses, consultants,

associates and other personnel necessary for the Department's presentation of the

review or appeal/administrative hearings via telephone or in-person if required by the

Department, at no cost to the Department.

59. Notify Enrollee if Not Paid within 45 Days

Pursuant to subsection 110.123(5)(g), Florida Statutes, vendor shall provide written notice

to Enrollees if any payment to any provider remains unpaid forty-five (45) Calendar Days

after receipt of the Claim.

60. Medical Necessity Determination and Review

a. Prior to any denial of an appeal as not medically necessary, experimental, and/or

investigational, the claim being appealed shall be reviewed by an appropriate medical

professional. Vendor shall apply the definition of "Medically Necessary" as defined in

the Summary Plan Description and in accordance with vendor's medical policy or

coverage guidelines in effect at the time the claims is incurred. Vendor shall create,

maintain, and annually update medical guidelines, which shall be thoroughly researched

using published medical literature. Except for appeals on eligibility, the Department may

request and vendor shall provide a medical review in any other instance.

b. In accordance with the Summary Plan Description and Florida Law, the Department shall

have full and final decision making authority concerning eligibility, coverage, benefits,

claims and interpretation of the Summary Plan Description.

c. Vendor shall provide copies of medical policy guidelines upon the Department's request.



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61. Prescription Drug Rebates

Vendor shall provide to the State one hundred percent (100%) of all prescription drug

rebates, discounts, dispensing fees and other pharmaceutical manufacturer revenue

collected and related to claims as part of this Plan. Such rebates and other revenue shall be

separately identified and included in the quarterly report as described in Quarterly Reports

section within these Requirements.

62. Fraud and Abuse Investigations

Vendor shall develop and/or maintain protocols, procedures, and/or system edits, subject

to the Department’s approval and customization upon request, to aggressively monitor for

fraud, abuse and waste. Vendor shall provide the Department with a quarterly report of all

fraud and fraud-prevention activities and discoveries relating to this contract subject to the

accuracy and timeliness provisions in the Performance Guarantees.

Vendor shall investigate any fraudulent, suspected fraud or suspicious activity relating the

Plan which it believes to be fraudulent or abusive whenever detected or brought to

vendor's attention by the Department or other persons. Vendor shall timely notify the

Department of any fraudulent or abusive Claims or other activities relating to the Plan

which it uncovers and shall fully cooperate with and assist the Department, law

enforcement, and State agencies in their investigations or inquiries regarding any such

matters and in any related recovery efforts.

63. Audit Trail

Vendor shall establish and maintain an effective audit trail for each Claim received for

medical and, if applicable, pharmacy services.

64. Unusual Charges Review

At no additional cost to the State, vendor shall obtain the advice and consultation of

qualified experts (internal or external, as needed) to review unusual charges or Claims for

medical and, if applicable, pharmacy benefits to ensure strict adherence to all Plan

provisions.

65. Care Management and Utilization Management

Vendor shall maintain policies and procedures in its care management and utilization

review processes for the Plan:

a. Pre-certification;

b. Prior authorization;



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c. Concurrent review and discharge planning for inpatient admissions;

d. Retrospective clinical review;

e. Second surgical opinions;

f. Other care management programs currently offered or implemented in the future;

g. Use of an automated system for medical and pharmacy benefits with the ability to

provide utilization statistics and savings reports, including utilization trends, care

management interventions, and clinical and financial outcomes ;

h. Use of an automated system for identification, tracking, and management of care

management activities. The system shall be fully integrated to include medical and

pharmacy claims processing, benefits and enrollment systems, if separately maintained.

Medical necessity and length of stay criteria shall be integrated within the system.

Vendor's utilization review staff shall have access to online diagnostic and procedure

codes ;

i. DRG validation;

j. Responses on all urgent and/or emergency utilization review prior authorization/pre-

certification requests for medical and, if applicable, pharmacy benefits, shall be made to

the attending physician, hospital, patient, and claim administrator within twenty-four

(24) hours of initial request;

k. Responses on all routine utilization review prior authorization/pre-certification requests

for medical and, if applicable, pharmacy benefits shall be made to the attending

physician, hospital, patient, and claim administrator within fourteen (14) Calendar Days

of initial request; and

l. The licensed care management staff shall have an average of five (5) years of clinical

experience. A licensed physician shall provide oversight to all non-clinical support staff

participating in care management activities. Only a licensed physician may issue clinical

denials.

66. Required Format and Timeliness

Vendor shall electronically deliver all reports listed in contract Attachment 5: Reporting

and Deliverables in the format, frequency, timeframe and to the intended recipient noted

in the list of reports or as otherwise required by the Department. The Department shall not

be required to produce such reports in a self-service manner by accessing vendor’s online

reporting tool.



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Vendor shall provide all required reports and/or deliverables to the Department and/or its

authorized third party in a format specified by the Department showing utilization, claims

reporting, and administrative services, fees and other activities, (i.e., administrative

services only, or fees for optional clinical management programs) data by both plan

options (Standard and Health Investor), benefit type (medical and, if applicable, pharmacy

and aggregated medical-pharmacy), and by subgroup. The subgroups at a minimum are:

active employee, including variable hour (hourly) employees, COBRA, retirees not eligible

for Medicare, and retirees eligible for Medicare. Administrative activities include claims

adjudication, customer service, medical management and so forth.

67. Vendor's One-Day Acknowledgement of Report Requests

Vendor shall acknowledge report requests within one (1) business day and shall provide an

expected timeline for completion and delivery date. Such reports may include Plan-specific

financial and statistical files, claims processing, Enrollee services, network adequacy, patient

management, and medical and drug utilization reports, as applicable.

68. Revenue Estimating Conference Report

Vendor shall provide the required data and forecasts in support of the Department's

Revenue Estimating Conference Report. Such data shall be provided in the timeframes and

layout specified by the Department.

69. Redacted Copies

Reports containing proprietary, trade secret and/or confidential information shall be

delivered in a redacted format at the same time as any non-redacted report, with redacted

report delivered electronically. Complete and detailed supporting documentation must be

provided with the submission of each report. Supporting documentation must identify the

source of the material.

70. Evidence Based Medicine

If the Department chooses to implement evidence based medicine or disease management

programs at any point during the contract, vendor shall cooperate fully with the

Department’s vendor, including coordination of care management activities and

transmission of data to and from the vendor in a mutually acceptable format and at no

additional cost.

71. Clinician Staffed Toll-Free Line

Vendor shall make available to all Members a 24/7/365 clinician staffed toll-free line.



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Clinical staff shall, at a minimum, address immediate and every day health issues and

concerns, and distribute educational materials

72. Prenatal Education and Early Intervention Program

Vendor shall make available to pregnant Members a prenatal education and early

intervention program to screen for potential risk factors and assist in development of

personalized education and monitoring program, including monitoring of high-risk

pregnancies.

73. Direct Deposit EFT

Vendor shall accept payments from the Department processed through the Department’s

standard transmittal process (i.e. EFT transfer to the vendor) and by Department

determined due dates. The vendor must complete a direct deposit authorization form

(currently form number DFS-A1-26E rev.6/2014).

The vendor shall provide any payments due to the Department through the normal

transmittal process (i.e. EFT transfer from the vendor) and by Department determined due

dates.

74. Net of Funds and/or Offset Prohibited

All payments to the Department shall be made separately by electronic funds transfer from

any payment balances due from the Department. The netting of payments related to the

Plan is prohibited.

75. Overpayments Must Reconcile

Vendor shall remit overpayments to the Department monthly by electronic funds transfer.

Such overpayments shall reconcile with monthly reports in a form required by the

Department.

76. Premium Payments – Fully Insured Arrangement

Under a fully insured arrangement, vendor shall conform to the following procedures for

the invoicing of contracted premiums.

a. After the close of the month, vendor shall accept monthly fully insured premium

payments processed on or about the twentieth (20th) day of each following month

based on the Department’s enrollment report data as calculated by the Department.

Retro adjustments for enrollment in prior months may also be included in the payment.

b. Vendor agrees that the only compensation to be received by or on behalf of its

organization for this contract shall be the premiums paid directly by the Department for

fully insured plans.



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77. ASO Fee Payments – Self-Funded Arrangement

a. Vendor shall provide the Department a detailed (itemized) invoice for administrative

fees and charges no later than the tenth (10th) Calendar Day of each month following

the month services were rendered. Required detail and documentation for such invoices

shall be as specified by the Department and shall provide sufficient detail for pre and

post audit. Invoices and supporting documentation shall be provided in paper and

electronically.

b. Upon determination by the Department that the invoices are complete and accurate

and that payment is due, the Department shall process each invoice in accordance with

the provisions of section 215.422, Florida Statutes. The Department shall forward

payment through electronic funds transfer to the vendor for the invoiced amount.

c. If the Department contests the invoice charges as submitted, vendor may be required to

provide additional documentation.

d. Vendor agrees that the only compensation to be received by or on behalf of its

organization for this contract shall be administrative fees.

78. Banking Requirements

Vendor shall establish and maintain a medical claims reimbursement demand deposit

account at no cost to the Department to assign, report, and provide audit controls for

Department's claim liability for medical claims benefit payments made solely under the

contract resulting from this ITN.

a. This account shall only be used by vendor to:

i. Request funding;

ii. Provide online detailed reconciliation data, which shall be provided within 24

hours of liability assignment;

iii. Detail monthly issued/cashed reporting on medical claim payments to or on

behalf of those Members under the Plan; and

iv. Issue benefit payments using either tamper resistant drafts or secured electronic

funds transfer (EFT).

b. Vendor shall cover day one claims liability prior to invoicing the Department on day two.

Vendor shall provide daily invoice notices via email to the Department covering all

checks presented (cleared), excluding outstanding issued checks, and EFT payments

settled for the prior day and the Department will wire payment to vendor's designated

demand deposit bank account previously agreed to by the Department.



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c. Vendor shall provide at least ninety 90 days’ notice to the Department if vendor changes

the bank account. Vendor shall suspend issuance of drafts or electronic fund transfers in

payment of medical claims upon receipt of written notice of contract termination to the

designated representative of the vendor by the Department.

d. The Department shall only reimburse vendor's daily invoices for EFT transaction and

cleared checks that have been presented to vendor's bank account. Issued and

outstanding checks will not be included in the reimbursement.

e. The banking contract shall include but not be limited to a record of electronic funds

transfers and/or transmission of daily written drafts register by vendor to the bank for

positive confirmation procedures. The transmission must include draft number, draft

amount, payee's name and date of draft. The method of transmission shall be

determined by mutual agreement between vendor and the Department's bank with

approval by vendor's bank.

f. The Department shall identify the necessary documentation and the related reporting

requirements for the reconciliation. Vendor shall submit to the Department

recommended processes and internal controls developed by vendor to identify

payments due to overbilling and other errors that may occur as part of the payment

process. Reconciliation activities shall include but are not limited to:

i. Daily notification of amount of request

ii. Listing of daily charged claim activity report (claim charge activity by check/item

and Member)

iii. Daily detail report for transfer evaluation (all claim charge items at Enrollee

level)

iv. Monthly bank account statement

v. Monthly summary of daily bank activity for each calendar year

vi. Monthly Outstanding Report #1 (checks less than 90 days old that have not

cashed)

vii. Monthly Outstanding Report #2 (checks that are more than 90 days old that

have not been cashed)

viii. Monthly aged outstanding report with stop payment placed (details the in-house

stop payments placed on items that remain uncashed 12 months from issuance)



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ix. Monthly issue/cashed reconciliation report (issued vs. cashed items in policy

month).

79. Daily Funding for Medical Claims Paid

a. Vendor shall provide the Department with an itemized invoice for reimbursement of

processed Claims on a daily basis, with Claims broken out by Enrollee subgroup (active,

including variable hour (hourly) employees), COBRA, retirees eligible for Medicare, and

retirees not eligible for Medicare).

b. Weekly invoices shall be sent to the State by 4:00 p.m. Eastern Time each Monday (next

day if State holiday) for Claims processed during the prior week. Weekly invoices shall

be specific to a given month with the last invoice possibly having less than a full seven

(7) Calendar Days to capture the period from the ending date of the previous invoice to

the end of the specific month.

c. All invoices shall set forth details specified by the Department to ensure a proper pre-

audit and post-audit. Details shall include, but not be limited to, an invoice statement

provided on vendor letterhead, an invoice number, the employer or client number, the

billing period, an invoice date, and addressed to the Department.

80. Readiness Assessment

The Department and/or its authorized third party auditor may conduct a readiness

assessment of specific claims or other areas of the vendor as determined by the

Department prior to the Effective Date. Such assessment may include, but shall not be

limited to, procedures, computer systems, claims files, customer service records, accounting

records, internal audits, and quality control assessments.

81. Quarterly Self Audits

Vendor shall perform at least quarterly internal audits on a statistically valid sampling of

claims with results reported to the Department quarterly. Results shall be used to validate

self-reported quarterly performance metrics for claims timeliness, processing accuracy,

payment accuracy and financial accuracy.

82. Audit of Host Plans/Reciprocal Agreements with Other Plans

Vendor shall provide one hundred percent (100%) transparency and audit ability for any

and all financial transactions related to claims incurred by our plan Members in or out-of-

network, and submitted by a provider, Member, or third party.



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83. Quality Assurance Reviews for the Auditors

On a regularly scheduled basis, vendor shall review its procedures and processes for

medical and pharmacy to assess quality performance on Claims, suspense, adjustments, as

well as customer service inquiries by phone, mail, e-mail, etc. At the time of the audit,

vendor shall advise the Department on how the following areas are handled to ensure

quality:

a. Technical

b. Claim turnaround times

c. Financials

d. Call center and customer service

e. Mailroom operations

f. Imaging/record retention

g. Claims processing

h. Invoices/invoice generation

i. Write-offs

j. Recovery of overpayments

k. Paper claims payments and reimbursements

84. SSAE 16 External Audit

The vendor shall, at its expense, undergo an annual audit in accordance with the AICPA

Statement of Auditing Standards, A.U. section 324-Reports on the Processing of

Transactions by Service Organizations, specifically reporting on the Policies and Procedures

Placed in Operation and Tests of Operating Effectiveness.

The report shall cover the twelve (12) month time period of July 1 through June 30 of each

year. Reports are due to the Department by October 1 each year following the twelve (12)

month time period of July 1 through June 30. The audit shall be performed by an

independent accounting/auditing firm. The vendor is required to provide prior timely notice

to the Department of the independent accounting/audit firm conducting the audit with the

Department being permitted to review and comment on the audit period and the

associated scope of the audit. The SSAE 16 Report shall be subject to the provisions in

Performance Guarantees.



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85. Audits

a. The vendor shall provide the Department and the Department's third party auditor at

least the following audit access, in addition to any other audit rights specified in the ITN,

the network information, the contract and the financial reply:

i. To audit any data necessary to ensure the vendor is complying with all contract

terms; such audit rights include but not are not limited to: 100% of claims data,

approved and denied utilization management reviews, clinical program outcomes,

appeals, and information related to the reporting and measurement of

performance guarantees.

ii. To perform ongoing post claims audits as allowed in subsection 110.12301(1),

Florida Statutes.

iii. To audit post termination;

iv. To audit more than once per year if the audits are different in scope or for

different services;

v. To perform additional audits during the year of similar scope if requested as a

follow-up to ensure significant or material errors found in an audit have been

corrected and are not recurring, or if additional information becomes available to

warrant further investigation; and

b. The vendor shall submit to ongoing real-time post-payment claims audits and an annual

audit of contractual compliance as deemed appropriate by the Department. The vendor

shall cooperate with requests for information, which includes, but is not limited to, the

timing of the audit, deliverables, data/information requests and the time to respond to

questions during and after the audit process. The vendor shall provide a response to all

audit findings within 15 days of delivery to the vendor, or at a later date if mutually

determined to be more reasonable based on the number and type of findings.

86. Audit Findings

a. Upon the discovery of any overpayment(s) that result in financial harm to the

Department, the vendor shall immediately reimburse the Department one hundred

(100%) of the total overpayment amount upon finalization of the audit. Overpayments

arising from audit findings are not to be offset from claims or administration experience

and must be paid separately.

b. If an audit finding determines that there are systematic issues affecting the adjudication

of claims related to the Plan, the vendor shall coordinate with the Department to



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develop and immediately implement a corrective action plan subject to the

customization and approval of the Department.

87. Hospital Audits

a. The vendor agrees to perform hospital records audits (including clinical and billing

issues) on each hospital admission exceeding $50,000 in paid claims. In the event that

the number of claims exceeding $50,000 in paid claims represents less than 2% of all

hospital admissions, the vendor shall perform additional hospital records audits on

those claims less than $50,000 beginning with the highest paid amount and continuing

in decreasing order until at least 2% of all hospital admissions have been audited.

b. Vendor shall report such audit results and recoveries to the Department in accordance

with the Performance Guarantees section.

88. Data Remains Property of the Department

All claim records and eligibility data used by vendor relating to this contract shall remain the

property of the Department.

89. Fiduciary Responsibility

Vendor shall agree to assume Claim fiduciary responsibility, including appeals, for Claim

adjudication and defense of utilization review decisions.

90. Legal Defense

a. Vendor shall provide necessary legal defense and assistance as required in the event of

litigation for goods and services related to the performance of this ITN and/or contract.

b. Vendor shall cover all costs associated with legal defense in the event of Plan-related

litigation or any other litigation.

c. Vendor shall prepare and file all legal documents with Florida Office of Insurance

Regulation, Florida Agency for Health Care Administration, and other agencies as

necessary to implement and maintain the plan, including policies, amendments,

contracts, required state filings, and development of Summary Plan Description formats.

91. Disaster Recovery Plan

a. Vendor shall develop, implement, and maintain a disaster recovery plan and shall

submit a copy of such for review by the Department on or before the effective date of

this contract. At a minimum, the disaster recovery plan shall include daily backup of

Plan-related files/data, a contingency provision so that critical services are provided

within twenty-four (24) hours, and a fully operational provision so that all services are

provided within 48 hours of activating the disaster recovery plan at the same or better



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level of service as before the disaster recovery plan was activated. Any changes to the

plan throughout the term of the contract must be sent to the Department.

b. Vendor shall conduct annual mock disaster recovery exercises to perform an annual test

of its recovery/backup systems. Vendor shall report the results of such exercises to the

Department by December 31 of each year.

92. Contract Termination

Vendor agrees that, upon contract termination or expiration, vendor pays the cost of all

work required by a new administrator to bring its data and records in unsatisfactory

condition up to date and such expenses shall be reimbursed by vendor within three (3)

months of the end of the contract term. Department shall make final determination

regarding the condition of data and vendor's obligation under this provision.

Vendor shall continue to process and adjudicate run-out claims in accordance with the

terms of this contract and perform any related necessary claim services including medical

review and adjustments, customer service activities, Department and Auditor General audit

and support services, banking activities, including the continued transmission of related

data files to the Department and its third-party vendors, and any other mutually agreed

upon activities through the end of the 16-months following the effective date of

termination of the contract.

93. Services after Contract Termination

As mutually agreed upon by the Department and the vendor, vendor shall continue to

provide the following services to ensure that the contractually required services resulting

from this ITN are maintained at the required level of proficiency for up to sixteen (16)

months following the effective date of termination of the contract.

a. Mailroom services

b. Appeals services

c. System/technical services

d. Claim entry, adjudication and adjustments based on Summary Plan Description

e. Coordination of benefits

f. Subrogation tasks

g. Customer service and call center operations

h. Medical review as necessary



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i. Issue payments/checks and Explanation of Benefits Statements

j. Collection of overpayments

k. Banking activities

l. Reports

m. The Department and Plan Members shall continue to have the same current online

system access to information

n. Other tasks as required by the Department.

All claim records including all data elements of such electronic claim records and eligibility data used by relating to this contract shall remain the property of the Department and shall be provided to the Department immediately upon contract termination and at the end of the 16-month period following termination of the contract.

94. Compliance with Law

Vendor shall monitor federal and state legislation affecting the delivery of medical and

prescription drug benefits under the Plan and promptly report to the Department on those

issues prior to the effective date of any mandated Plan changes. In addition, vendor shall

provide the Department with interpretation as to the impact of such laws or regulations on

the Plan. Vendor shall absorb the cost of programming all benefit design changes.

95. Online Reporting and Management Tools

a. Vendor shall provide for unlimited users of the Department, at no additional cost, online

user access to its reporting and management services, systems, programs, current and

historical other covered liability, customer service call and correspondence notes and

logs

b. Vendor shall provide corresponding manuals and any other printed or digital material or

CIDs used in connection with the systems. This online tool shall have data accumulation,

claims specific and ad hoc reporting capabilities.

c. Vendor shall, upon request of the Department, provide Department staff with training

at the Department’s facilities for the online reporting and management tools.



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Section 7 Corporate Information

Instructions: Please provide a response to the following questions. The vendor’s response to

this section will not be scored. However, this section will be reviewed to determine if the

vendor’s reply conforms in all material respects to this solicitation and to determine the

vendor’s responsibility.

Vendors must copy and paste without modification both the statement and box below into

their replies. Describe vendor’s current accreditation status.

1. Provide an organizational chart identifying the names, area of expertise, functions, and

reporting relationships of key people directly responsible for implementing the State of

Florida account.

2. Provide the name of the person with primary responsibility for planning, supervising, and

implementing the program for the State.

a. What other duties, if any, will this person have during implementation? Please include

the number and size of other accounts for which this person will be responsible for

during the same time period.

b. What percentage of this person's time will be devoted to the State during the

implementation process?

4. Provide an organizational chart identifying the names, functions and reporting relationships

of key people directly responsible for account support services to the State.

5. Provide the name of the person with primary responsibility for planning, supervising, and

performing account services for the State.

a. What other duties, if any, does this person have? Please include the number and size of

other accounts for which this person is responsible.

b. What percentage of this person's time will be devoted to the State?

c. Describe the role and support by the account manager for the annual open enrollment

process (i.e. meetings, communications, implementation of plan design changes,

modification and updating of files, etc.)

6. Describe how many account executives and group services representatives will work full-

time on the State's account, and how many will work part-time on the State's account.



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7. Provide a copy of vendor's most recent financial ratings and complete the following table,

as applicable:

A.M. Best

Standard & Poor’s

Dunn and Bradstreet

Fitch Weiss Moody

Current Financial Rating

Date of Rating

Prior Financial Rating

Date of Rating

If such ratings are not available for the vendor, vendor must submit its two most recent audited

financial statements.

8. Provide a profile of vendor's HMO business for each of the latest three calendar years

(2012, 2013 and 2014).

Calendar Year 2012

Calendar Year 2013

Calendar Year 2014

Total premium volume

Total number of clients

Total number of Enrollees covered

Number of public sector clients

Average size of public sector clients

Number of public sector Enrollees

Number of claims handled

Number of plans terminated

Average size of terminated plans

9. Disclose all interests of key personnel, including officers, medical directors, board members

or significant shareholders who have any ownership or management interest in any

network affiliate.

10. Describe, to the best of vendor's knowledge, any acquisitions or mergers in which vendor is

expected to be involved within the next twelve (12) months.

11. Describe any and all acquisitions or mergers in which vendor was involved within the last

five (5) years.



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12. For the performance of services similar to those required in this ITN, has vendor ever been

notified of or been declared in breach or default of a contract; received written notice that

it was considered to be in breach or default; or been defaulted on a contract with any other

business entity?

If so, provide the particulars, including when, where, which parties were involved, what

occurred, and the ultimate outcome.

13. Has vendor ever been issued a letter of non-compliance on a contract involving services

similar to those required in this ITN?

If so, advise when, where and the ultimate outcome of such actions.

14. Has vendor ever terminated or given notice of termination of any contract for which it

performed services similar to those required in this ITN?



15. Has vendor ever received notice of termination or have had a contract terminated by the

other party for which it performed services similar to those required in this ITN?



16. Has vendor ever been assessed or paid liquidated damages/performance credits or any

other type of penalty for failure to meet performance metrics regarding the performance of

services similar to those required in this ITN?

If so, advise when, where, the amount(s) paid and the outcome of such actions.

17. Describe any discipline, fines, litigation and/or government action taken, threatened or

pending against vendor or any entities of vendor during the last five (5) years regarding the

performance of services similar to those required in this ITN. This information must include

whether the vendor has had any registrations, licenses, and/or certifications suspended or

revoked in any jurisdiction within the last five years, along with an explanation of

circumstances.

18. Identify and describe all data security incidents related to unauthorized access of client or

member data or unauthorized physical access to the data center experienced within the last

five years. Explain how the organization handled such incidents.



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Section 8 Vendor and Subcontractor Information

The vendor’s response to this section will not be scored. However, this section will be reviewed

to determine if the vendor’s reply conforms in all material respects to this solicitation and to

determine the vendor’s responsibility.

Instructions: Provide a response to each requested item below

A. Vendor General Information

Company Information Response

Vendor’s legal name

Address

City

State

ZIP Code

Web address

Corporate tax status

Federal Employer

Identification Number

(FEIN)



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B. Contact Information

Identify the primary contact person responsible for the overall development of the vendor’s

reply.

Primary Contact Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address



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C. Executive Sponsor

Provide the following information regarding the Executive Sponsor that will be assigned to

the State’s account. This individual is the highest ranking officer with direct involvement in

the State’s account. In addition, submit a resume or curriculum vitae as Reply Attachment

8C for the Executive Sponsor below.

Executive Sponsor Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address

Years of HMO and/or TPA

industry experience

Years with the organization

Years in the current

position

Proposed percent of time

dedicated to the

Department

Number of HMO and/or

TPA clients, and size of

accounts



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D. Account Manager

Provide the following information regarding the Account Manager that will be assigned to

the State’s account. This individual provides oversight of account services for the State. In

addition, submit a resume or curriculum vitae as Reply Attachment 8D for the Account

Manager below.

Account Manager Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address

Years of HMO and/or TPA

industry experience



position


dedicated the Department

Number of HMO and/or

TPA clients, and size of

accounts



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E. Account Management Team Members

Provide the following information regarding the account management team that will be

assigned to the State’s account (add additional tables as needed for this response). In

addition, submit a resume or curriculum vitae as Reply Attachment 8E for each account

management team member below.

Account Management

Team Member Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address

Years of industry

experience

Years with the

organization


position

Proposed percent of

time dedicated to State

of Florida Plan

Number and size of

other accounts



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F. Implementation Manager

Provide the following information regarding the implementation manager that will be

assigned to the State’s account. In addition, submit a resume or curriculum vitae as Reply

Attachment 8F for the implementation manager below.

Implementation Manager Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address

Years of industry experience


Years in the current position


dedicated to the State of

Florida Plan

Number and size of other

accounts



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G. Customer Service Manager

Provide the following information regarding the customer service manager that will be assigned

to the State’s account. In addition, submit a resume or curriculum vitae as Reply Attachment

8G for the customer service manager below.

Customer Service Manager Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address





dedicated to State of Florida

Plan


accounts



Page 85

H. Analyst

Provide the following information regarding the financial analyst that will be assigned to the

State’s account. In addition, submit a resume or curriculum vitae as Reply Attachment 8H

for the analyst below.

Analyst Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address






Plan


accounts



Page 86

I. Medical Director

Provide the following information regarding the medical director that will be assigned to the

State’s account. In addition, submit a resume or curriculum vitae as Reply Attachment 8I

for the medical director below.

Medical Director Response

Name

Title

Address

City

State

ZIP Code

Telephone number

Email address






Plan


accounts



Page 87

J. Subcontractors

Provide responses below for each Subcontractor that the vendor proposes to perform any

of the required Services under the contract. Copy and insert additional tables as needed.

Information Subcontractor #1

Subcontractor Name

Corporate address, telephone

number and website

Office address, telephone

number and website of the

proposed Subcontractor that

will be performing any of the

required services under the

contract

Federal Employer

Identification Number

(Employer ID or Federal Tax

ID, FEID)

Occupational license number

(if applicable)

W-9 Verification

Primary contact person name,

address, email address and

telephone number

Brief summary of the history

of the Subcontractor's

company and information

about the growth of the

organization on a national

level and within the State of

Florida

Describe any significant



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government action or

litigation taken or pending

against the Subcontractor's

company or any entities of

the Subcontractor's company

during the most recent five

years

List and describe the Services

the Subcontractor will be

responsible for in the

performance of the contract

Explain the process for

monitoring the performance

of the Subcontractor and

measuring the quality of its

results.

What procedures does

vendor have in place to

ensure Subcontractor

compliance with HIPAA

requirements?

Describe the process that

vendor will implement during

the contract term to ensure

that background checks (as

described in the contract) will

be completed on the

Subcontractor.



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K. References

Provide at least four (4 ) references as follows:

The two largest public sector clients for whom the vendor currently provides similar

services to those sought in this ITN.

The two largest former clients (public or private sector) for whom the vendor provided

similar services to those sought in this ITN.

The Department will contact each reference. The vendor does not need to send the

reference form to its references.

References will not be accepted from:

Current employees of DMS.

Former employees of DMS within the past three (3) years.

Persons currently or formerly employed by the vendor’s organization.

Board members of the vendor’s organization.

Relatives.

Corporations based solely in a foreign country.

A member of the vendor’s organization, who has written, completed and submitted the form on behalf of the reference.

Vendors should complete the each following table in its entirety.



Page 90

Information Reference #1

Company Name

Contact Person

Title

Address

City

State

Telephone Number

Email Address

Size of Account/

Covered Lives

Contract Period

Brief Summary of

Services



Page 91


Company Name

Contact Person

Title

Address

City

State

Telephone Number

Email Address

Size of Account/

Covered Lives

Contract Period

Brief Summary of

Services



Page 92


Company Name

Contact Person

Title

Address

City

State

Telephone Number

Email Address

Size of Account/

Covered Lives

Contract Period

Brief Summary of

Services



Page 93


Company Name

Contact Person

Title

Address

City

State

Telephone Number

Email Address

Size of Account/

Covered Lives

Contract Period

Brief Summary of

Services



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Section 9 Technical Information

Instructions: Provide a response to each of the following Technical reply questions and

requests for information by restating the item and providing vendor’s response below the item

in at least 11 pt Calibri, Arial or Times New Roman blue font. Failure to submit a response to a

question or request for information may disqualify the vendor from further consideration.

This section will be scored pursuant to subsection 4.3.1 (“Scoring of Technical Information”) of

this ITN.

1. Describe the characteristics of vendor’s business model, health management, network

management and any other operational functions that set vendor apart from other

vendors. Topics may include, but are not limited to:

a. The approaches and value enhancements vendor offers that could mean best value for

the State;

b. Centers of excellence, transplant networks and other health care arrangements that

focus on quality of care and cost avoidance;

c. How vendor maximizes the use of State of Florida residents, state products (produced

and/or purchased within the State of Florida) and other Florida-based businesses in

delivering the Services; and

d. Expectations for the future direction of the organization.

2. Describe vendor's experience in providing health plan benefits. Topics may include, but are

not limited to:

a. Type of health plan administered and complexity/customization of the health plan;

b. Governance model;

c. Number of lives covered;

d. Types of clinical, disease, and utilization management programs; how candidates are

determined; level of participation in such programs and their impact on health risk and

cost containment;

e. After hours care (e.g., nurse line, urgent care centers)

f. How administering a self-insured plan differs from administering vendor’s insured

blocks; and



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g. Options for members outside of the network.

3. Describe vendor's network development model and contracting strategy in Florida. Topics

may include, but are not limited to:

a. Impact to the vendor’s network by taking on the State’s covered population;

b. Discounts and average reimbursement rates;

c. Impact of geography on network discounts;

d. Stability of the network (e.g., annual physician turnover – gross, not net of additions);

e. The provider credentialing process;

f. Provider quality measures and controls;

g. How provider satisfaction is measured;

h. Reasons for member dissatisfaction with the network or providers, steps taken to

improve or correct such reasons and how the level of member satisfaction prompts

changes in the network contracting strategy; and

i. If reply includes rental networks: how, where and how long rental networks have been

used; “a” through “h” of this question for rental networks; and cost containment

monitoring and strategies for rental networks.

4. Describe the protocols in place that ensure personal health information remains secure.

Topics may include, but are not limited to:

a. Monitoring of all electronic systems and personnel;

b. Established processes and fail safes to mitigate breaches;

c. Resolution, notification and reparation protocols when a breach is discovered;

d. Protocols that ensure no offshoring of or offshore access to any protected data; and

e. Security protocols for call center employees, correspondence tracking system and

process, and electronic systems that access or store protected data.

5. Describe the customer service call center. Topics may include, but are not limited to:

a. Location of call center, hours of operation, and number of representatives assigned to

State’s account;



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b. Training, minimum qualifications, experience and turnover of representatives;

c. Languages customer service unit can support (other than English) and how that support

is provided (i.e., language line or vendor call center representatives);

d. Year-to-date call targets and actual statistics (e.g., abandonment rate, speed to answer);

e. Call recording system; documentation of calls; and timeframe and manner to furnish call

recordings or notes to the department;

f. Online chatting, email capabilities, and other electronic access capabilities;

g. Customer satisfaction survey methodology and recent survey with results from a group

similar in size and composition to the State;

h. Any quality improvement activities initiated as a result of Enrollee satisfaction surveys;

i. Explain whether customer service representatives will be dedicated and exclusive. If not,

explain the ratio of representatives to Members.

j. Describe the services Members can access via the web, smartphone applications or

other electronic devices?

6. Describe claims processing. Topics may include, but are not limited to:

a. Training, minimum qualifications, experience and turnover of medical claims processors;

b. Location of claims administration office, and number of processors assigned to this

account and if these claims processors can be an exclusively dedicated unit;

c. Year-to-date targets and actual statistics for clean claims processing turnaround time

and accuracy;

d. Threshold under which claims processors can approve a claim for payment;

e. Coordination of benefits process, including with Medicare and worker’s compensation;

f. Methodology for reimbursing a non-participating hospital-based provider (radiologists,

pathologists, anesthesiologists, emergency room physicians, neo-natal physicians, etc.);

g. Protocols and/or tools to ensure claims are processed accurately and timely;

h. Ability to recognize fraudulent claims, abuse and other fraudulent actions and vendor’s

process for addressing:



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i. The procedure for handling emergency admission requests;

j. Describe vendor's procedures for handling and resolving claim inquiries from Members;

k. Describe vendor's procedures for handling and resolving claim inquiries from the

Department;

7. Describe clinical services. Topics may include, but are not limited to:

a. Training, minimum qualifications, experience and turnover of the case management

staff assigned to the this account;

b. Case management model and processes;

c. How the case management program integrates with other care management programs

such as utilization review and quality management; and

d. Accreditations vendor’s care management program currently holds, or is in the process

of pursuing.

8. Provide a detailed Implementation Plan that clearly demonstrates the vendor's ability to

meet the Department's requirements to have a fully functioning program in place and

operable on January 1, 2017.

a. Include a list of specific implementation tasks/transition protocols and a time table for

initiation and completion of such tasks, beginning with the contract award and

continuing through the effective date of operation (January 1, 2017). The

Implementation Plan should be specific about requirements for information transfer as

well as any services or assistance required from the State during implementation.

b. Indicate the critical dates that must be met to keep the Implementation Plan on

schedule. Include the processes that shall be reviewed, including system testing,

information required from the incumbent, historical claims data and format, and plan

documents.

c. Describe any anticipated major transition issues during implementation.

d. Describe vendor's procedures and processes for handling transition of care during the

transition period for the new contract.



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Section 10 Service and Program Information

Instructions: Provide a response to the following questions and requests for information.

Failure to provide response to any request below may result in rejection of the vendor’s reply.

The vendor’s response to this section will not be scored.

SUPPORT SERVICES

1. Provide a sample of a new Enrollee communications package in section 10 of the reply,

including how to locate providers, how to use network services and how to access

member services.

2. How many written complaints/grievances were received by vendor per 1,000 Enrollees

during 2014, what were the top five, and how were they resolved?

3. Provide a complete description (including a flowchart) of vendor's proposed 2017

member appeals process for medical services including external reviews.

NETWORK ACCESS MANAGEMENT

4. Provide vendor's average historical discount rates for the following provider types, for

the proposed HMO network:

Calendar Year 2013

Calendar Year 2014 Calendar Year 2015

through July 31

Primary Care

Physicians

Obstetricians and

Gynecologists

Pediatricians

Other Specialists

Acute Care Facilities

Urgent Care Facilities

Hospitals



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5. Provide a profile of vendor's business in Florida for the last three (3) calendar years:

Calendar Year 2012 Calendar Year 2013 Calendar Year 2014

Number of Primary

Care Physicians

Number of

Obstetricians and

Gynecologists

Number of

Pediatricians

Number of Other

Specialists

Number of Acute

Care Facilities

Number of Urgent

Care Facilities

6. For vendor's proposed network for the State, what percent of participating primary care

physicians and specialists are currently closed to new patients?

7. For vendor's proposed network for the State of Florida, what percent of participating

PCPs and specialists were closed to new patients for Calendar Year 2014?

8. Explain how a provider can be nominated to be considered for inclusion in the network.

9. What percentage of network PCPs are board certified?

10. What percentage of network specialists are board certified?

11. Describe any ongoing or upcoming provider and facility contract negotiations that may

result in a network change over the next 12 months.

12. Describe how vendor monitors waiting times for patients seeking appointments,

including the average number of working days between the date an appointment is

made and the date of the actual visit for both non-emergency care and urgent care.



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13. Describe the vendor's specialist referral process.

14. Do network physicians (or their staff) assist in arranging for services such as home

health care, hospice, skilled nursing, durable medical equipment and mental

health/chemical dependency? If yes, describe the process and their roles including how

often vendor meets to educate physician staff on pre-certification/pre-authorization

requirements and other Plan-specific benefits and processes.

15. Describe the procedures to be used to ensure that hospital-based physicians (radiology,

anesthesiology, emergency, pathology, etc.) are paid at the negotiated hospital based

network pricing.

16. Describe, if applicable, any financial incentives or disincentives to network providers

that are tied to utilization goals, specialty referrals, quality of care outcomes, or other

performance results and include risk sharing arrangements. Explain how financial

incentives are paid, if applicable.

17. Describe any penalties to which providers will be subject for failure to pre-certify non-

emergency admissions.

18. Describe any other penalties to which providers will be subject for failure to adhere to

utilization management policies.

19. How much notice are providers contractually required to give if they elect to terminate

a contract with vendor?

20. What happens to Members receiving ongoing treatment from a network provider who

elects to terminate a contract with vendor?

21. Describe what actions are taken to recruit individual providers or another group practice

for the network in place of terminated providers, including how often vendor initiates a

needs assessment.

22. Explain if vendor anticipates changes in 2017 reimbursement policies for out-patient,

free-standing facilities; inpatient hospital; or laboratory services.

23. What utilization controls are in place with vendor’s network providers to reduce the

number of unnecessary services being performed?

24. What happens in the self-funded scenario when a hospital based non-participating

provider administers services?



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25. Describe the procedure in place for covering emergency care services performed by

non-network facilities.

26. Describe vendor's process to perform provider profiling or other quality measures to

identify providers with patterns of over/under treatment to Enrollees and the actions

taken to address such patterns.

27. Explain if vendor has any ownership interest in or if vendor is involved in the operations

of any network outpatient facilities.

28. Explain if vendor partially owns, or subcontracts any part of vendor's network (i.e.

chiropractic, behavioral health, etc.). If yes, describe.

MENTAL HEALTH/SUBSTANCE ABUSE

29. Does the vendor subcontract for mental health/substance abuse care? If yes, identify

the organization and provide a detailed description of their program and vendor's

relationship to the Subcontractor.

30. Provide a detailed description of the mental health/substance abuse access and triage

process.

31. Describe vendor's mental health/substance abuse case management service from

structural and functional perspectives and how these lend to long-term stability of an

Enrollee.

TRANSPLANT NETWORK

32. Describe how vendor handles transplants (i.e., through a transplant network or vendor's

network).

33. Describe how Members access the transplant network (i.e., physician referral, utilization

or medical management review, direct access).

34. Provide a list of transplant procedures available within the network.

35. Describe how transplant costs are monitored and mitigated.

CENTERS OF EXCELLENCE

36. Describe all high-risk and/or high-technology services coordinated with the Centers of

Excellence. Provide the names and locations for vendor's top five (5) Centers of

Excellence by volume.



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37. How are patients utilizing Centers of Excellence case managed? (i.e. Are they

coordinated separately from other catastrophic cases?)

38. What are the financial arrangements for the Centers of Excellence?

39. Specify if the vendor is aware of any changes in the coming year to vendor's current

Centers of Excellence arrangements.

DATA PROCESSING / INTERFACE

40. Describe vendor's system update process.

41. Describe any electronic system changes planned for the contract term.

42. How often are the systems backup and disaster recovery procedures tested?

43. When were the systems last tested and what were the results?

42. Describe how claims, customer service, case management, and utilization review

systems are linked.

43. Describe how vendor's claims system automatically matches claims with utilization

management information.

44. Describe vendor's online reporting tool ad hoc reporting capabilities.

45. Explain the vendor’s process for routine maintenance of all systems to be used for this

contract.

CLINICAL SERVICES

46. Provide (as attachments) biographies of the medical management staff to be assigned

to this account.

47. What is the nurse/patient ratio for the utilization and case management programs?

48. Describe the access Members have to a nurse-line for counseling/support.

WELLNESS PROGRAM

49. Describe any program offerings vendor's organization has for health/fitness promotions

that can be provided at no additional cost to the State and comply with current plan

design and Florida law.



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50. Describe any program offerings vendor's organization has for health

assessment/screening, which can be provided at no additional cost to the State and

comply with current plan design.

51. Describe any program offerings vendor's organization has for wellness, which can be

provided at no additional cost to the State and comply with current plan design.

DISEASE MANAGEMENT

52. Describe each disease management program, how Members are identified and

contacted for participation, and Member access to support services.

53. Describe how reminders are sent to patients and/or physicians to encourage

appropriate health actions.

54. Describe how vendor will transition Enrollees who are undergoing treatment for chronic

and/or catastrophic conditions to vendor's plan.

QUALITY OF CARE

55. Describe how vendor measures the quality of care received by its Enrollees.

56. Describe any quality improvement initiatives undertaken in the last twelve (12) months.

57. Describe vendor's approach to assessing the effectiveness of its Quality Management

programs for both clinical services within the network and administrative operations of

the health plan.

58. Describe the role and content of quality management training programs for health plan

staff, providers and their administrative staffs.

AUDITS

59. Describe vendor's policy and procedures for auditing hospital bills/claims.

60. Describe vendor's internal audit staff duties, how frequently internal are audits

performed, and the frequency for which claims processing function audits are

performed by an external auditing firm.

61. Overall, what percent of claims are subject to internal audit?

62. What is the typical audit size?



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63. Describe in detail how are claims selected for audit (e.g., random by the system, fixed

percent per day, fixed number per day per week, diagnosis, dollar amount).

64. Describe vendor's method of selecting claims for internal quality review.

65. Describe any processor actions and/or claim characteristics that automatically trigger a

review.

66. What percentage of claims is reviewed on a daily basis for accuracy of payment?

SUBROGATION

67. Describe in detail vendor’s subrogation processes and procedures.



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Section 11 Recommended Solutions and Alternatives

Instructions: Provide a response to the following questions and requests for information.

Failure to provide response to any request below may result in rejection of the vendor’s reply.

The vendor’s response to this section will not be scored. This ideas and items submitted by

vendors in response to this section may be used during negotiations.

1. Provide any proposed service alternatives or recommendations to improve the delivery

of services to Members, for example, telemedicine, accountable care organizations,

centers of excellence, etc.

2. As allowed under current law, propose innovative approaches the Department could

consider to manage member health risk and mitigate rising health care costs. Discuss

cost, return on investment based on actual experience in vendor’s book of business and

impacts on member health based on vendor’s book of business medical claims

experience trend.

3. Provide a discussion of vendor's willingness and experience in implementing, staffing,

and maintaining an on-site clinic.

4. If replying for a fully-insured arrangement, describe vendor’s pharmacy benefits

management program. Briefly discuss the following topics

a. Name of vendor’s contracted pharmacy benefits manager (PBM), if applicable;

b. Which pharmacy management services are performed in-house, if any, and those

out-sourced to the PBM;

c. The type of preferred drug list (open, partially restricted or closed), and explain the

medical necessity approval process;

d. Types and impacts of pharmacy management protocols (e.g., step therapy and prior

authorization) on prescription drug costs and medical costs;

e. How prescription drug information is integrated into a managed care approach,

including how data is stored, what outcomes can be tracked, how results can be

reported (with respect to each medical condition;

f. How physician prescribing is managed; and

g. How insuring the pharmacy benefits would provide best value to the State and to

Members.



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5. If replying for a fully-insured arrangement, describe vendor’s experience providing

Medicare Advantage Prescription Drug (MAPD) plans in Florida. Briefly discuss the

following topics:

a. Vendor’s ability to offer the State’s Plan;

b. Counties in which the MAPD is available; and

c. The most recent CMS plan quality and performance ratings.

6. If replying for a fully insured arrangement, based on the targeted loss ratios provided in

Attachment C-5, briefly describe the vendor’s policy on reimbursing the State for a Plan

Year, if any, in which the actual loss ratio is less than the targeted loss ratio proposed.

Describe how the timing and amount of reimbursement are determined.

7. If replying for a self-insured arrangement, provide a discussion of vendor's experience in

establishing contract terms based off of vendor-calculated claims target guarantee and

risk corridor. By way of example from the current PPO TPA contract:

a. Projected and Target Claims Cost Vendor’s Projected and Target Claims Cost is based on the following Enrollee

types: (i) Active Employees, (ii) Early Retirees, (iii) Medicare eligible Retirees, and

(iv) COBRA. The Projected and Target Claims Cost includes in-network and out-

of-network claims, and excludes prescription drugs (except for those drugs

included in medical claims).

For each Plan Year after 2017, the Projected and Target Claims Cost will be

based on the actual total paid claims incurred in the prior Plan Year for all

Members by Enrollee type plus the Paid Claims Expected Trend.

Projected and Target Claims Costs (aggregate dollars) = Active + Pre-Medicare +

Medicare + COBRA.

b. Allowable Adjustment Factors Allowable Adjustment Factors will be used to develop mutually agreed upon

annual adjustments to the Paid Claims Expected Trend for each subsequent

Plan Year based on changes in enrollment, demographics and plan changes

which may impact total paid claims.

c. Paid Claims Expected Trend The amount of trend used to determine the claims target will be based, in part,

on the trend letter provided by the vendor to the Department for the Estimating



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Conference held in either January or February of the respective Plan Year. The

trend letter will be based on claims paid in the previous Plan Year. The Parties

will use the Allowable Adjustment Factors and the trend letter to develop a

mutually agreed upon “Paid Claims Expected Trend.”

d. Claims Target Guarantee No later than March 31 of the respective Plan Year, the vendor shall provide a

Claims Target Guarantee for the respective Plan Year (using the Projected and

Target Claims Cost and mutually agreed upon Paid Claims Expected Trend) on a

total aggregate basis. Medicare Subscribers shall not be included in the Claims

Target Guarantee.

The Claims Target Guarantee will be assessed annually based on the receipt of

the Annual Claims Target Guarantee Report. The PEPM basis guarantee

amount will be calculated by dividing the aggregate Claims Target Guarantee

by the average actual enrollment for the preceding Plan Year. The Department

will compute (excluding Medicare as noted above) the actual paid claims and

divide by the average actual enrollment for the preceding Plan Year to

establish the “Realized PEPM Claims.” The risk corridor established by the

Claims Target Guarantee will be compared to the Realized PEPM Claims. If the

Realized PEPM Claims exceed the risk corridor of the Claims Target Guarantee,

the vendor shall remit the appropriate amount to the Department no more

than 15 Calendar Days after the receipt of the annual report.

i. Vendor Calculations

Claims Target Guarantee = Projected and Target Claims

Cost (Active + Early Retiree + COBRA Only) + Paid Claims

Expected Trend (Delivered in January or February)

Risk Corridor = Claims Target Guarantee * Risk Corridor (Delivered to

Department by March 31 of Plan Year)

Risk Corridor (PEPM) = Risk Corridor / Actual Average

Enrollment (Enrollees) (Computed after end of Plan Year)

ii. DSGI Calculations

“Realized PEPM Claims” = (Actual Spend for Plan Year –

Claims amounts over $750,000)/ Actual Average Enrollment

(Enrollees) (computed after end of Plan Year)

If “Realized PEPM Claims” > Risk Corridor (PEPM); Multiply the amount



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in excess of the risk corridor (PEPM) by Average Actual Enrollment and

vendor is responsible to remit entire amount above the risk corridor to

Department, limited to a maximum of percentage of the

Administrative Fees paid in the respective Plan Year.

8. If replying for a self-insured arrangement, provide a discussion of vendor's experience in

establishing contract terms for average network discounts for each of the primary

categories: inpatient facility, outpatient facility, specialist, primary care, and ancillary

services.



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Section 12 Network Information

Instructions: Provide the information required in Attachment B-1 through B-7. Failure to

provide the information requested below may result in rejection of the vendor’s reply. The

vendor’s response to this section will be scored.

Vendors are required to submit fully completed Attachment Forms B-1 through B-7 in native

file format on a CD-ROM or “thumb drive.” Please follow the instructions in Attachment B.



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Section 13 Financial Reply

Instructions: Provide the information required in Attachment C. Failure to provide the

information requested will result in rejection of the vendor’s reply. The vendor’s response to

this section will be scored.

Vendors are required to submit fully completed Attachment Forms C-1 through C-7 in native

file format on a CD-ROM or “thumb drive.” Please follow the instructions in Attachment C.



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Section 14 Purchasing Forms

The following forms (Form 1 and Form 2) included in this section must be completed and

attached in their entirety with the signature of the vendor’s authorized agent and included in

Tab 14. Failure to complete, sign, and/or return these documents with replies by the

submission deadline may result in rejection of the reply.



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Form 1: Vendor Certification

As the person authorized to sign on behalf of ___________________________________

[vendor name], I certify the following.

1. The above-named vendor understands that all information provided by and

representations made by the vendor are material and will be relied on by the

Department in awarding the contract. The Department reserves the right to investigate

all representations and any other information the Department deems pertinent. Any

misstatement will be treated as fraudulent concealment from the Department of true

facts relating to the submission of the reply. A misrepresentation will be punishable by

law, including but not limited to chapter 817, Florida Statutes. Accordingly, all

information and representations contained in this reply are true and accurate to the

best of my knowledge, and no modifications have been made to this ITN section 14

forms submitted with the vendor’s reply.

2. The above-named vendor has not been placed within the last thirty-six (36) months on

the Department’s Convicted vendor List or on a similar list maintained by any other

governmental entity.

3. The above-named vendor is not currently under suspension of debarment by the State

of Florida or any other governmental entity.

4. The above-named vendor and its affiliates, subsidiaries, directors, officers, and

employees are not currently under any known investigation by any governmental

authority and have not in the last ten (10) years been convicted or found liable for any

act prohibited by law in any jurisdiction involving conspiracy or collusion with respect to

bidding on any public contract.

5. The above-named vendor has not been defaulted by the State of Florida under any

contract.

6. The above-named vendor has fully informed the Department in writing of all convictions

of the vendor; its affiliates (as defined in subsection 287.133(1)(a), Florida Statutes); and

all directors, officers, and employees of the firm and its affiliates for violation of state or

federal antitrust laws with respect to a public contract for violation of any state or

federal law involving fraud, bribery, collusion, conspiracy, or material misrepresentation

with respect to a public contract. This includes disclosure of the names of current



Page 113

employees who were convicted of contract crimes while in the employ of another

company.

7. Neither vendor nor any person associated with it in the capacity of owner, partner,

director, officer, principal, investigator, project director, manager, auditor or position

involving the administration of federal funds:

a. Has within the preceding three (3) years been convicted of or had a civil judgment

rendered against them or is presently indicated for or otherwise criminally or civilly

charged for commission of fraud or a criminal offense in connection with obtaining,

attempting to obtain or performing a federal, state or local government transaction

or public contract; violation of federal or state falsification or destruction of records,

making false statements or receiving stolen property; or

b. Has within a three-year (3) period preceding this certification had one or more

federal, state or local government contracts terminated for cause or default.

8. The submission is made in good faith and not pursuant to any agreement or discussion

with, or inducement from, any firm or person to submit a complementary or

noncompetitive reply.

9. Vendor has made a diligent inquiry of its employees and agents responsible for

preparing, approving or submitting the reply and has been advised by each of them that

he or she has not participated in any communication, consultation, discussion,

agreement, collusion, act or other conduct inconsistent with any of the statements and

representations made in the reply.

10. The prices and amounts have been arrived at independently and without consultation,

communication or agreement with any other vendor or potential vendor; neither the

prices nor the amounts, actual or approximate, have been disclosed to any vendor or

potential vendor and they will not be disclosed before the ITN opening.

11. No attempt has been made or will be made to induce any firm or persons to refrain

from submitting a reply for the contract, or to submit a price(s) higher that the prices in

this reply, or to submit any intentionally high or noncompetitive price(s) or other form

of complementary reply.



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_________________ , its affiliates, subsidiaries, officers, director, and employees

(Name of Firm)

are not currently under investigation, by any governmental agency and have not in the

last three years been convicted or found liable for any act prohibited by state or federal

law in any jurisdiction, involving conspiracy or collusion with respect to the reply, on any

public contract, except as follows:

Signature of Authorized Representative:

Name:

Title:

Date: , 2015

Mailing Address:

Email Address:

Telephone:



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Form 2: Notice of Conflict of Interest

Company or Entity Name

For the purpose of participating in the solicitation process and complying with the provisions of

chapter 112 of the Florida Statutes, the undersigned corporate officer states as follows:

The persons listed below are corporate officers, directors or agents and are currently

employees of the State of Florida or one of its agencies:

The persons listed below are current State employees who own an interest of ten percent or

more in the company/entity named above:

Dated this day of 2015.

Name of Organization:

Signed by:

Print Name

being duly sworn deposes and says that the information herein is true and sufficiently

complete so as not to be misleading.

Subscribed and sworn before me this day of 2015.

Notary Public:

My Commission

Expires:



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Section 15 Attachments

Following are the attachments to this ITN:

Attachment A: Draft Contract – provided as a separate document

Attachment B: Network Information – provided as a separate spreadsheet

Attachment C: Financial Reply – provided as a separate spreadsheet

Attachment D: Census File – see subsection 1.8 of the ITN regarding how to obtain this

file

Attachment E: Confidentiality and Non-Disclosure Agreement – included in this section

Attachment F: Notice of Intent to Submit a Reply – included in this section

Attachment G: Claims Utilization – see subsection 1.8 of the ITN regarding how to obtain

this file

Attachment H: Covered Benefits and Services – included in this section



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Attachment E: Confidentiality and Non-Disclosure Agreement

This Confidential and Non-Disclosure Agreement (the “Agreement”) is made this ____ day of ______

2015, by and between ____________________________________ hereinafter referred to as “the

vendor” and the State of Florida Department of Management Services, hereinafter referred to as “the

State.”

The vendor warrants and represents that it intends to submit a Reply in response to the State

solicitation entitled ITN No. DMS 15/16-005 HMO Services (ITN). The State must provide the Vendor

with access to certain confidential information (Confidential Information) including, but not limited to,

demographic and identifying information on the State’s eligible member population and plan utilization

data related to this procurement. This information includes data that is considered Protected Health

Information as defined in 45 C.F.R. § 160.103, Health Insurance Portability and Accountability Act of

1996 (HIPAA), as amended. All such information provided by the State during this procurement process

shall be considered Confidential Information regardless of the form, format, or media upon which or in

which such information is contained or provided, regardless of whether it is oral, written, electronic, or

any other form, and regardless of whether the information is marked as Confidential Information. As a

condition for its receipt and further access to the Confidential Information, Vendor agrees as follows:

1. Vendor will not copy, disclose, publish, release, transfer, disseminate or use for any purpose in

any form any Confidential Information received under this ITN, except in connection with the

preparation of its Reply to this ITN.

2. Vendor shall be liable for any violations by any of its employees who are provided or given

access to Confidential Information or any incidental access obtained by unauthorized persons

while in its control.

3. Vendor shall abide by the following procedures in handling the States’ Confidential Information:

a. Upon receipt of the data, the Vendor will password protect the Confidential

Information.

b. Vendor’s employees needing access to the State’s Confidential Information will be

informed that:

i. They are not to share the password or the State’s Confidential Information with

any unauthorized person;

ii. At the end of the solicitation process they will delete the State’s Confidential

Information from any laptop, desktop or any other electronic shared system

under their control and destroy any paper copies of such Confidential

Information; and

iii. They must confirm to the Vendor that they have so deleted or destroyed the

Confidential Information.

c. Files and passwords will be provided separately to appropriate users.



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d. Vendor will maintain the list of persons granted access (Access List) to the State’s

Confidential Information. Employees expected to have access to the State’s Confidential

Information are to be listed in the chart on page 3 of this attachment. Vendor will

update the list at the time it submits its Reply.

4. Vendor shall destroy the Confidential Information, including any copies, remaining in its

possession within the later of five business days of the State’s notice of an intended award in

connection with this solicitation or the conclusion of any legal proceeding or protest regarding

the procurement and shall provide a certification and a final Access List to the procurement

officer as defined in the ITN that it has complied with this requirement. If the Vendor does not

submit a Reply, the Vendor shall destroy the Confidential Information including any copies by

the time Replies are due and shall provide a certification and Access List to the procurement

officer that it has complied with this requirement on or before the due date for Replies. Vendor

acknowledges that the disclosure of the Confidential Information may cause irreparable harm to

the State and agrees that the State may obtain an injunction to prevent the disclosure, copying,

or other impermissible use of the Confidential Information. The State’s rights and remedies

hereunder are cumulative and the State expressly reserves any and all rights, remedies, claims

and actions that it may have now or in the future to protect the Confidential Information and/or

to seek damages for the Vendor’s failure to comply with the requirements of this Agreement.

5. In the event the State suffers any losses, damages, liabilities, expenses or costs (including by way

of example only, attorney’s fees and disbursements) that are attributable, in whole or in part to

any failure by the Vendor or any employee of the Vendor to comply with the requirements of

this Agreement, Vendor shall hold harmless and indemnify the State and the State of Florida

from and against any such losses, damages, liabilities, expenses and/or costs.

6. This Agreement shall be governed by the laws of the State of Florida. The Vendor consents to

personal jurisdiction in Florida state court, and exclusive venue shall be Leon County, Florida.

7. The individual signing below warrants and represents that they are fully authorized to bind the

Vendor to the terms and conditions specified in this Agreement.

Vendor: _____________________________________________________________

By: _____________________________________________________________________

Print Name: ______________________________________________________________

Title: ___________________________________________________________________

Address: ________________________________________________________________



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VENDOR’S EMPLOYEES WHO WILL BE GIVEN ACCESS TO THE

CONFIDENTIAL INFORMATION

Printed Name,

Address of Individual

Signature of

Individual

Date



Page 120

Attachment F: Notice of Intent to Submit a Reply

__________________________ informs the Florida Department of Management Services of its Enter Legal Name of Vendor

intent to respond to the solicitation titled ITN No. DMS 15/16-005 for Insured Health

Maintenance Organization Benefits and Self-Insured Health Plan Services.

Complete ALL Information Below

Name of Authorized Representative: ________________________________

Title of Authorized Representative: _________________________________

Signature of Authorized Representative: _____________________________

Date: __________________________ Date of Signature

Address: _____________________________________ Enter Street or PO Address for Delivery of Attachments D and G

_____________________________________ Enter City, State and ZIP Code for Delivery of Attachments D and G

Telephone No: (____) _____- ______

E-mail Address: __________________________



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Attachment H: Covered Benefits and Services

SCHEDULE OF MEMBER COST SHARE

Benefit Description Cost to Member

Standard Plan Health Investor Plan

Deductible (Per Calendar Year)

None $1,300 Single

$2,600 Family (not to exceed $1,300

per covered person)

Medical Out-of-Pocket Maximum (Per Calendar Year)

Includes covered medical expenses only.

$1,500 Single

$3,000 Family (not to exceed

$1,500 per Member)

See below Global Out-of-Pocket Max

Global Out-of-Pocket Maximum including Rx (Per Calendar Year)

Includes covered expenses for both medical and prescription drugs or Rx only.

$6,850 Single

$13,700 Family (not to exceed

$6,850 per Member)

$3,000 Single

$6,000 Family (not to exceed $3,000

Member)

Preventive Care

Preventive health care (including screening mammograms) and immunization benefits for all covered members shall be age and gender based in accordance with the current grade A and B recommendations of the U.S. Preventive Services Task Force as provided by the Patient Protection and Affordable Care Act and medical policy guidelines established by [vendor] for preventive services.

No Charge No Charge

Not Subject to Deductible

Primary Care Physician

Services at participating doctor’s offices include, but are not limited to:

Routine office visits

Minor surgical procedures

Medical hearing examinations

$20 per visit

20% of the contracted rate

after you pay Deductible

Specialty Care Physician Services

Office visits, consultation, diagnosis and treatment

$40 per visit 20% of the contracted rate


Hospital Pre-authorization is required for inpatient care, which at participating Hospitals includes:

$250 per admission; 100%

coverage


after you pay



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Room and board – unlimited days (semi-private)

Physician’s, specialist’s and surgeon’s services

Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication

Intensive care unit and other special units, general and special duty nursing

Laboratory and diagnostic imaging

Required special diets

Radiation and inhalation therapies

thereafter Deductible

Surgery Outpatient

Inpatient Treating physician must obtain authorization from the Health Plan prior to surgery including preparation services and treatment.

No Charge

$250 per admission; 100%

coverage thereafter



Vision Benefits Annual eye exam

Primary Care Physician

Specialist Services (office visits, refractions) o Participating optometrist and

ophthalmologist

$20 Copayment $40 Copayment



Outpatient Laboratory and X-ray

Diagnostic Tests

CAT scan, PET scan, MRI

Outpatient Laboratory Tests

Mammograms

No Charge 20% of the contracted rate

after you pay Deductible. No

Charge for mammograms or

preventive diagnostic tests

and services

Emergency Services Copayment waived if admitted. Emergency room at participating Hospitals, facilities and/or Physicians Hospital and/or referring or admitting physician must call the Health Plan as soon as possible and within 24 hours of

$100 Copayment 20% of the contracted rate




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emergency admission or as soon as reasonably possible.

Urgent/Immediate Care

Medical Services at a participating Urgent/Immediate Care facility or services rendered after hours in your Primary Care Physician’s office

Medical services at a participating retail clinic

Medical services at a Non-participating Urgent/ Immediate Care facility or non-Participating retail clinic outside the Health Plan’s Service Area. Within the Service Area, use the Health Plan’s participating Urgent Care Centers.

$25 Copayment 20% of the contracted rate


Mental Health Inpatient

Outpatient

$250 per admission, 100%

coverage thereafter

$20 per visit



Alcohol/Drug Treatment

Inpatient

Outpatient


coverage thereafter

$20 per visit



Family Planning Family planning services

Primary Care Physician Services

Specialist Services

Contraceptives, supplies and related services

Sterilization Except for contraceptives and sterilization where no Copayment applies, Copayment amount depends on type of service as noted within this chart for Preventive Adult Care, Physician office visits, other Physician services, Durable Medical Equipment and prescription drugs.

$20 per visit $40 per visit





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Maternity Care

Outpatient

Inpatient

$40 per visit. If

billed as a global fee, then first

visit only.


coverage thereafter

Allergy Treatments Injections


Specialist Services Skin Testing


Specialist Services





Ambulance When pre-authorized or in the case of an emergency

No Charge



Autism Spectrum Disorder, Diagnosis and Treatment of

Applied Behavior Analysis Services

Physical, speech or occupational therapy



Home Health Care

Per Occurrence No Charge 20% of the contracted rate


Durable Medical Equipment

Per Device No Charge 20% of the contracted rate


Rehabilitative Services

Outpatient Services limited to 60 visits per injury


after you pay



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Deductible

Skilled Nursing Facilities

Pre-authorization required

Up to 60 days maximum per calendar year

No Charge 20% of the contracted rate


Prosthetic or Orthotic Devices

Per Device No Charge 20% of the contracted rate


Prescription Drugs CVS/caremark

Participating Retail Pharmacy (up to a 30-day supply)

Generic

Brand Name, Preferred

Brand Name, Non-Preferred Participating Retail Pharmacy (up to a 90-day supply)

Generic


Brand Name, Non-Preferred Mail Order Pharmacy (up to a 90-day supply)

Generic


Brand Name, Non-Preferred

$7 $30 $50

$14 $60

$100

$14 $60

$100

After you pay Deductible:

30% 30% 50%

If a generic is available and you, rather than your Physician, request the brand name drug, your cost is the brand Copayment (or Coinsurance if HIHP) plus the difference in the Plan’s cost between brand name and the generic. For oral cancer treatment medications, your cost is the lesser of the appropriate Copay (or Coinsurance if HIHP) or $50.



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COVERED BENEFITS AND SERVICES


Covered Services Special Limits/Circumstances

Ambulance Transportation and Service

Ambulance service to the nearest Hospital

Ambulance service to a Health Plan Member’s home or skilled nursing facility

Ambulance service from a Hospital which is unable to provide proper care to the nearest Hospital that can provide proper care

For services by boat, airplane or helicopter o When the pick-up point is inaccessible by ground

transportation o When the travel distance involved in getting the Health

Plan Member to the nearest Hospital that can provide proper care is too far for medical safety

o When speed in excess of ground vehicle speed is critical for medical safety

Anesthesia Services

Both inpatient and outpatient

Autism Spectrum Disorder

Diagnosis and treatment through speech therapy, occupational therapy, physical therapy, and Applied Behavior Analysis services for an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.

Coverage includes well-baby and well-child screening for diagnosing the presence of Autism Spectrum Disorder, speech therapy, occupational therapy, physical therapy, and Applied Behavior Analysis. Applied Behavior Analysis is covered when provided by Applied Behavioral Analysts, psychologists, clinical social workers, and others within the scope of their license.

Coverage limited to services prescribed by the Health Plan Member’s treating physician in accordance with a treatment plan. The required treatment plan includes, but is not limited to, a diagnosis; proposed treatment by type, frequency and duration of treatment; anticipated outcomes stated as goals; frequency with which treatment plan will be updated; and a signature from the treating physician.

Covered as required by sections 627.6686 and 641.31098, Florida Statutes, and as further amended by state and federal law.

Developmental Disability means a disorder or syndrome that is: 1) attributable to a mental disability, cerebral palsy, autism, spina bifida, or Prader-Willi syndrome, 2) manifests before the age of 18, and 3) constitutes a substantial handicap that can reasonably be expected to continue indefinitely.

Bone Marrow Transplants If the particular use of the procedure is determined to be accepted within the appropriate oncological specialty and not Experimental pursuant to rules adopted by the Florida



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Agency for Health Care Administration.

Includes costs associated with the donor-patient

Cancer Services

Diagnosis and Treatment Includes both inpatient and outpatient diagnostic tests and

treatment (including anti-cancer medications administered by Network providers), including cancer clinical trials as set forth in the Florida Clinical Trial Compact. Does not include Experimental or Investigational Treatment.

Cleft Lip and Cleft Palate Treatment and services for children under 18 years, including medical, dental, speech therapy, audiology and nutrition services only as required by sections 627.64193 and 641.31(35), Florida Statutes.

Clinical Trials Includes routine patient care costs incurred by an insured individual who participates in approved Phase I, II, III or IV clinical trials relating to cancer and other life threatening diseases if those services, including drugs, items and devices, would otherwise be covered under the plan or contract for an insured person not enrolled in a clinical trial program. Experimental treatment is excluded.

Child Health Supervision Services Services include a physical examination, developmental assessment and anticipatory guidance, and immunizations and laboratory tests, consistent with the recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.

Services as defined by the Patient Protection and Affordable Care Act.

Contraceptive Supplies

Insertion and removal of IUD

Diaphragm

Insertion and removal of contraceptive implants

Contraceptive injections

Oral contraceptives

With respect to Women’s Preventive Services (see also Preventive Services), and to the extent required by federal law, coverage is limited to at least one form of contraception in each of the eighteen methods identified in FDA’s most current Birth Control Guide and limited to generic products, when available. o Contraceptive methods – Medical

Barrier: Diaphragm Implanted: IUD Sterilization: Tubal ligations

o Contraceptive methods – Pharmacy Hormonal: All generic oral contraceptives

Other contraceptives may be covered based on medical necessity.

The Plan pays 100 percent of the Network allowed amount.

For additional information on medical coverage, please call the Health Plan’s Member Services Department listed in the



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contact section within this document. For additional information on prescription coverage, please call CVS/caremark at 1-877-531-4793.

Cosmetic Surgery

Plastic and reconstructive

Reduction mammoplasty

Repair or alleviation of damage if the result of an accident, which is a sudden, unintentional, and unexpected event or force

Correction of a congenital anomaly for an eligible dependent

Correction of an abnormal bodily function for an area of the body which was altered by the treatment of a disease

All stages of reconstruction of a breast on which a mastectomy was performed in accordance with federal law. However, if there is no evidence of malignancy, such reconstruction and initial prosthetic device shall only be covered if received within two years after the date of the mastectomy.

Dental Care and Accidental Dental Injury Accidental Dental Injury - an injury to sound natural teeth caused by a sudden, unintentional, and unexpected event or force. This term does not include injuries to the mouth, structures within the oral cavity, or injuries to natural teeth caused by biting or chewing, surgery, or treatment for a disease or illness. Sound Natural Tooth - a tooth that is whole or properly restored (restoration with amalgams only) and is not in need of the treatment provided for any reason other than an Accidental Dental Injury. For purposes of this Plan, a tooth previously restored with a crown inlay, inlay or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth.

Only in cases of Dental Care provided to a person under age 8 if the dental condition is likely to result in a medical condition if left untreated and if the child’s dentist and physician determine dental treatment in a Hospital or surgical center is necessary.

Accidental dental injury coverage is limited as defined. General Dental Care is not covered as stated in the Exclusion section of this document.

Benefits for accidental dental injury are limited to care and treatment rendered within 120 days of an accidental dental injury.

Dermatology Services Direct access (without referral or authorization) for up to five office visits annually, including minor procedures and testing, to a Network dermatologist, as required by sections 627.6472(16) and 641.31(33) Florida Statutes.



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Diabetes and pre-diabetes Treatment

All medically appropriate and necessary equipment, supplies and outpatient self-management training and educational services used to treat pre-diabetes and diabetes, if the treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary.

Certain diabetic equipment and supplies are covered through the Health Plan. Those not covered by the Health Plan may be covered by the Prescription Drug Plan. See Prescription Drug Plan section within this document for additional information.

Doctor’s Care

Office visits

Medical treatment in Hospital or outpatient facility or surgery (other than office visit), which includes anesthesia services, concurrent physician care (surgical assistance provided by another physician) and consultations.

Child health supervision services

Adult preventive Medical Services

Allergy treatment – including testing, desensitization therapy and allergy immunotherapy, which includes hyposensitization serum when administered by a health care provider.

Diagnostic procedures, lab tests or x-rays, including their interpretation, for the treatment of a covered condition

For concurrent physician care and surgical assistance: o The additional physician must actively participate in the

treatment o The condition involves more than one body system or is

so severe or complex that one physician cannot provide the care unassisted

o The physicians have different specialties or have the same specialty with different sub-specialties

o Must be authorized by the Health Plan Member’s PCP or the Health Plan

For consultations: o The ordering physician must request the consultation o Consulting physician shall prepare a written report

Durable Medical Equipment

For the care and treatment of a condition covered under this Plan, the Plan shall either rent or purchase medical equipment and supplies including, but not limited to: o Trusses, braces, walkers,

canes, crutches, casts and splints

o Occlusal guards, bite or

Durable Medical Equipment: o Shall not serve as a comfort, hygiene, or convenience

item o Shall not be used for the sole purpose of exercise o Shall not be used by any other party o Shall have been manufactured specifically for medical

use o Shall not include shoe buildups, shoe orthotics, shoe

braces or shoe supports unless the shoe is attached to a brace

o Shall not include water therapy devices, modification to



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dental splints, repositioning devices, and TMJ models for the treatment of temporomandibular joint (TMJ) syndrome

o Commode chairs, bedpans/urinals, decubitus care equipment, and ostomy and urinary products

o Oxygen and rental of equipment for the administration of oxygen, ventilator or other mechanical equipment for the treatment of respiratory paralysis or insufficiency

o Ambulatory home uterine activity monitoring devices (AHUM)

o Wheelchairs, Hospital beds, lumbar-sacral-orthosis (LSO) and thoracic-lumbar-sacral-orthosis (TLSO) braces, and traction equipment

o Other medical equipment and supplies as determined to be Medically Necessary

motor vehicles and/or homes or similar items

Emergency Care

Coverage, without prior authorization, for screening and stabilization based on determination by either an in-Network or non-Network provider

Eye Care

Routine or refractive eye examinations as part of the adult preventive medical care or child health supervision services benefit

For eyeglasses or contact lenses: o Limited to the first pair following an accident to the eye

or cataract surgery o Includes the examination for the prescribing or fitting

thereof o For treatment of a covered condition:

Aphakic patients and soft lenses or sclera shells

Following an injury, disease or accident

Family Planning Services Includes counseling and information on birth control, sex education and the prevention of sexually transmitted



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diseases.

Hearing Tests Only when associated with a covered ear surgery, in accordance with child and adult preventive health care benefits, or for the diagnosis of a covered condition.

Hearing tests to determine if a hearing aid is needed are not covered.

Hemodialysis for Renal Disease Includes equipment, training and medical supplies for home dialysis and dialysis centers.

Home Health Care

Services by a home health care agency for a Health Plan Member confined and convalescing at home for a covered condition

Home health care services include: o Part-time, intermittent or

continuous nursing care by registered nurses or licensed practical nurses, nurse registries or home health agencies;

o Physical, speech, occupational and respiratory therapy, and infusion therapy

o Medical appliances, equipment, laboratory services, supplies, drugs, and medicines prescribed by the treating physician and other covered services provided by or for a home health agency through a licensed nurse registry or by an independent nurse licensed under chapter 464, Florida Statutes, to the extent that they would have been covered if the person had been confined in a Hospital

For approval of Home Health Care Services by your PCP or the Plan: o The treating physician must submit a home health care

plan of treatment to your PCP o The plan of treatment must document that home health

care is Medically Necessary and that the services are being provided in lieu of hospitalization or continued hospitalization

o Home health care benefits would be less costly than confinement to a Hospital or skilled nursing facility

Services which shall not be covered under this benefit include: o Any service that would not have been covered had the

Health Plan Member been confined to a Hospital o Services which are solely for the convenience of the

Health Plan Member

Therapy is subject to outpatient Limitations described under rehabilitative services

A visit is limited to a period of two hours or less.

Hospice Care

In-home care Hospice treatment program shall:

o Meet the standards outlined by the National Hospice



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o Physician services o Physical, respiratory,

massage, speech and occupational therapy if approved by the Plan

o Medical supplies, drugs and appliances

o Home health aide services o Part-time or intermittent

nursing care by a registered nurse (RN) or licensed practical nurse (LPN) or Private Duty Nursing service

o Oxygen o Infusion Therapy

Hospice Inpatient Care o Room and board and general

nursing care o Inpatient care services same

as inpatient Hospital care o Same covered services as in-

home and outpatient hospice care

o Includes care for pain control or acute chronic symptom management

Hospice outpatient care o Physician services o Laboratory, x-ray, and

diagnostic testing o Ambulance service o Same covered services as in-

home hospice care

Association o Be recognized as an approved hospice program by the

Health Plan o Be licensed, certified, and registered as required by

Florida law, and o Be directed by the Health Plan Member’s PCP or the

Health Plan and coordinated by a registered nurse with a treatment plan that provides an organized system of hospice facility care, uses a hospice team and has around-the-clock care available

For hospice care: o Counseling of terminally ill patients whose doctor has

certified that they have less than one year to live o Primary Care Physician (PCP) must submit a written

hospice care plan or program o Treating physician must submit a life expectancy

certification o All hospice care expenses shall be approved in writing

by the Health Plan on behalf of the Plan o While in the hospice program, plan benefits for

expenses related to the terminal illness are covered by the hospice provider

o Limited to 210 calendar days per lifetime

Hospital Inpatient Care

Hospital room, board and general nursing care for a semi-private room the Plan determines that a private room is Medically Necessary

Room, board and treatment in an intensive, progressive, cardiac or neonatal care unit

Other necessary services and supplies including, but not limited

Services and supplies must be furnished at a Network Hospital and must be authorized by the Primary Care Physician or the Plan in order to be covered. Exceptions to this include emergency services and other special circumstances, as approved by the Health Plan.

Excludes services and supplies provided when the Health Plan Member is admitted to a Hospital or other facility primarily to provide rehabilitative services.



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to:

Use of operating room, labor room, delivery room and recovery room

Drugs and medicines used by the patient

Intravenous solutions

Dressings, ordinary casts, splints and trusses

Anesthesia and related supplies

Transfusion supplies and services including blood, blood plasma and serum albumin, if not replaced

Respiratory therapy, including oxygen

Diagnostic services, including radiology, ultrasound, laboratory, pathology, and approved machine testing such as electrocardiograms and electroencephalograms

Basal metabolism examinations

X-ray, including therapy

Diathermy

All covered rehabilitative services

Immunizations

Includes flu shots See Preventive Services.

Mammograms

Screening

Diagnostic service

One baseline mammogram for women age 35 through 39

One mammogram every one to two years – ages 40 through 49

One mammogram every year – age 50 and over

At any age if deemed Medically Necessary (diagnostic)

Maternity Care

Pre-natal and post-natal care and monitoring of the mother

Delivery in a Hospital or birth center

Postpartum care

Newborn care and assessment (one time), including initial exam from pediatrician

Medically Necessary clinical tests and immunizations

Covered Hospital stays for the mother and newborn child will be no less than: o 48 hours for a normal delivery o 96 hours for a Cesarean-section delivery unless agreed

to by the provider and the patient

With respect to Women’s Preventive Services, coverage for breast feeding supplies is: o Limited to one manual breast pump per birth



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Routine well-baby nursery services

Midwife services

Breastfeeding support, supplies and counseling

Mental Health, Alcoholism and Substance Abuse Care

Inpatient

Outpatient

Treatment program must be accredited by the Joint Commission or approved by the State.

Providers must be licensed in accordance with applicable law.

For inpatient care: o Alcoholism and substance abuse care includes

detoxification.

For outpatient care: o Mental health and nervous disorders treatment

includes diagnostic evaluation, psychiatric treatment, and individual and group therapy. For learning and behavioral disabilities or mental

disability, coverage is limited to evaluation and diagnosis.

Newborn Care

Coverage includes, but is not limited to: o Coverage for injury or

sickness, including Medically Necessary care or treatment for medically diagnosed congenital defects, birth abnormalities or prematurity.

o The transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn’s condition. Such transportation shall be certified by the attending physician as necessary to protect the health and safety of the newborn child.

Coverage for the unenrolled newborn child of a covered eligible Health Plan Member is limited to well-baby Hospital nursery services.

Newborn must be enrolled in the Health Plan within 60 days of the birth to be covered for other services.

Nutrition Counseling

Nursing Services

Nursing care by a registered nurse (RN) or licensed practical

Includes inpatient Private Duty Nursing when authorized by the Plan.

Includes Home Health Care Services and Hospice Services.



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nurse (LPN)

Oral Surgery

Surgical treatment of non-dental injury to teeth, fractured or dislocated jaw, excision of tumors, cysts, abscesses and lesions of the mouth and surgical treatment of temporomandibular joint (TMJ) syndrome

Treatment of bones or joints of the jaw or facial region as required by section 641.31094, Florida Statutes, when Medically Necessary for conditions caused by congenital or developmental deformity, disease or injury

Does not include care or treatment of the teeth or gums, intraoral prosthetic devices or surgical procedures for cosmetic purposes.

Organ Transplants

Services, care and treatment received for or in connection with the approved transplantation of the following human tissue and organs: o Heart o Heart/lung o Lung o Liver o Kidney o Kidney/pancreas o Bone marrow o Cornea

Covered services include: o Organ acquisition and donor

costs. However, donor costs shall not be payable under this Plan if they are payable in whole or in part by any other insurance health plan, organization or person other than the donor’s family or estate.

Transplantation includes pre-transplant, transplant and post-discharge services, and treatment of complications after

To have a transplant covered: o Prior approval for the transplant must be obtained by

the Health Plan Member’s Participating PCP in advance of the Health Plan Member’s initial evaluation for the procedure;

o The Health Plan shall be given the opportunity to evaluate the clinical results of the evaluation. Such evaluation and approval shall be based on written criteria and procedures established by the Plan; and

o The facility in which the pre-transplant services, transplant procedure and post-discharge services will be performed must be licensed as a transplant facility and authorized by the Health Plan.

Transplant services shall not be covered when: o Expenses are eligible to be paid under any private or

public research fund, government program, or other funding program, whether or not such funding was applied for or received;

o The expense relates to the transplantation of any non-human organ or tissue;

o The service or supply is in connection with the implant of an artificial organ, including the implant of the artificial organ;

o The organ is sold rather than donated to the person; o The expense relates to the donation or acquisition of an

organ for a recipient who is not covered by the Plan except in the case of the donor costs for bone marrow transplants; or



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transplantation

For bone marrow transplants: o Includes the harvesting,

transplantation and chemotherapy components

o Donor costs are covered in the same way as costs for the Health Plan Member, including Limitations and non-covered services

o A denied transplant is performed; this includes follow-up care, immunosuppressive drugs, and complications of such transplant

The following services and supplies shall not be covered: o Artificial heart devices used as a bridge to transplant; o Drugs used in connection with diagnosis or treatment

leading to a transplant when such drugs have not received FDA approval for such use; or

o Any service or supply in connection with identification of a donor from a local, state, or national listing.



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Outpatient Care

Treatment as an outpatient in a Hospital, a health care provider’s office, an ambulatory surgical center or other licensed outpatient health care facility

Clinical laboratory services

Services for outpatient surgery and outpatient treatment of an injury

Includes Medically Necessary supplies provided or used by the facility during the surgery or treatment, such as: o Use of operating room, and

recovery room o Use of covered drugs and

medicines used by the patient o Intravenous solutions,

dressings, ordinary casts, splints and trusses

o Anesthesia, related supplies and their administration

o Transfusion supplies and services including blood, blood plasma and serum albumin, if not replaced

o Respiratory therapy, including oxygen

o Diagnostic services, including radiology, ultrasound, laboratory, pathology, and approved machine testing such as electrocardiograms and electroencephalograms

o Basal metabolism examinations

o X-ray, including therapy o Diathermy o Services provided by a

birthing center licensed pursuant to section 383.30-383.335, Florida Statutes

Other covered necessary services and supplies



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Pathologist Services


Pre-admission Tests Tests shall be: o Ordered or authorized by the Health Plan Member’s

PCP; and o Performed in a facility accepted by the Hospital and the

Health Plan in lieu of the same tests which would normally be done while Hospital confined.

Preventive Services

Additional Women’s Preventive Services: to the extent required by federal law; the following services are covered for all female Health Plan Members: o Human papillomavirus (HPV)

testing; o Counseling for sexually

transmitted infections; o Counseling and screening for

human immune-deficiency virus (HIV);

o Counseling and screening for interpersonal and domestic violence;

o Screening for gestational diabetes;

o Counseling and support for breastfeeding and supplies (limited to one breast pump per birth); and

Annual well woman visits expanded to include prenatal care, contraceptive counseling and at least one form of contraception in each of the eighteen methods identified in FDA’s most current Birth Control Guide and limited to generic products, when available (see Contraceptive Services)

Preventive Medical Services will be as defined by the Patient Protection and Affordable Care Act, which include: o Evidence-based items or services that have in effect a

rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;

o Assessment of the risk of falls for older adults is included during the preventive care wellness examination or evaluation and management (E&M) visit;

o Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved.

o With respect to infants, children, and adolescents, evidence-informed preventive care and screenings are provided to the extent required by the comprehensive guidelines supported by the Health Resources and Services Administration.

o With respect to Women’s Preventive Health Services, coverage is provided to the extent mandated by federal law.

o For additional information on immunizations and preventive health care services go to: www.healthcare.gov www.uspreventiveservicestaskforce.org/uspstf/us

psabrecs.htm www.healthcare.gov/law/resources/regulations/w

omensprevention.html, and www.healthcare.gov/new/factsheets/2010/09/aff

ordable_care_act_immunization.html

Prostheses and Orthotic Devices

Initial placement of the most cost effective prosthetic or orthotic device, fitting, adjustments and repair

Replacements covered if due to growth or change and approved by the Plan as Medically Necessary.

Shoe orthotics shall be covered only when attached to a brace.

http://www.healthcare.gov/

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

http://www.healthcare.gov/law/resources/regulations/womensprevention.html

http://www.healthcare.gov/law/resources/regulations/womensprevention.html

http://www.healthcare.gov/new/factsheets/2010/09/affordable_care_act_immunization.html

http://www.healthcare.gov/new/factsheets/2010/09/affordable_care_act_immunization.html



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Penile prosthesis shall be covered only when necessary to treat organic impotence resulting from diabetes mellitus, peripheral neuropathy, medical endocrine causes of impotence, arteriosclerosis/postoperative bilateral sympathectomy, spinal cord injury, pelvic-perineal injury, postprostatectomy, postpriapism, and epispadias and exstrophy.

Rehabilitative Services

Spine and back disorder treatment

Manipulative services

Physical therapy

Speech therapy

All services shall be provided by licensed therapists, chiropractors and physicians for the purpose of aiding in the restoration of normal physical function.

Requires the Health Plan approval of a written plan of treatment, including documentation that the Health Plan Member’s condition should improve significantly within 60 days of the date therapy begins.

Outpatient rehabilitative services limited to 60 visits per injury; inpatient rehabilitative services limited to the duration of Hospital confinement.

Rehabilitative services shall not be covered when: o The Health Plan Member was admitted to a Hospital or

other facility primarily for the purpose of providing rehabilitative services; or

o The services or supplies maintain rather than improve a level of physical function, or where it has been determined that the services shall not result in significant improvement in the Health Plan Member’s condition within a 60-day period.

Respiratory Therapy


Services of respiratory or inhalation therapists

Oxygen

Second Medical Opinions

May be requested by the Health Plan Member or the Health Plan for: o Elective surgery o When the appropriateness or

necessity of a covered surgical procedure is questioned

o Serious injury or illness

Health Plan Member: o Must provide prior notice to the Health Plan o The use of second medical opinions in connection with

a particular diagnosis or treatment may be restricted to a maximum of three per calendar year.

Health Plan shall review the second medical opinion, once rendered, and make a determination about whether the services are covered under the Plan. Any treatment obtained that is not authorized by the Plan shall be at the Health Plan Member’s expense.

Covered expenses for the second opinion:



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o If a Network physician is selected, the only cost to the Health Plan Member will be the applicable Copayment/Coinsurance.

o If a non-Network physician is selected, the Health Plan Member may be required to pay for up to 40 percent of the usual and customary charges for those services in the community where they were rendered as determined by the Health Plan.

Skilled Nursing Facility Care

Room, board and general nursing care

Services and supplies for necessary treatment

Primary Care Physician (PCP) or the Health Plan shall approve a written plan of treatment

Health Plan Member must require skilled care for a condition (or a related condition) which was treated in the hospital and such care can be provided at a skilled nursing facility in lieu of hospitalization or continued hospitalization

The Health Plan Member must be admitted to the facility immediately following discharge from the Hospital

Skilled nursing care or services are provided on a daily basis

Limited to 60 days of confinement per calendar year

Services shall be ordered by and provided under the direction of a physician

Surgical Procedures


Surgical Sterilization Limited to tubal ligations and vasectomies

Tobacco Cessation Products Tobacco screening, cessation counseling and tobacco cessation medications, including prescription and over-the-counter medications, when prescribed by a health care provider and that have a current rating of A or B by the United States Preventive Services Task Force.

Wigs Covered only when hair loss is caused by chemotherapy, radiation therapy, or cranial surgery. Coverage is limited to a maximum payment of $40 for one wig and fitting in the 12 months following treatment or surgery.



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Limitations and Exclusions

The following services and supplies are excluded from coverage under this Plan unless a specific

exception is noted. Exceptions may be subject to certain coverage Limitations.

LIMITATIONS AND EXCLUSIONS

Abortion Which is elective, performed at any time during a pregnancy.

Acupuncture Services, supplies, care or treatment in connection with acupuncture (except when used in lieu of an anesthetic agent for covered surgery).

Arch Supports Orthopedic shoes, sneakers, or support hose, or similar type devices/appliances, regardless of intended use.

Autologous transfusion In which blood is removed from a donor and stored before it is returned to the donor's circulation.

Autopsy

Biofeedback services And other forms of self-care or self-help training and any related diagnostic testing, hypnosis, meditation, mind expansion, elective psychotherapy such as Gestalt therapy, transactional analysis, transcendental meditation, Z-therapy, and Erhard seminar training (EST).

Complications of non-covered services

Including the diagnosis or treatment of any condition which arises as a complication of a non-covered service.

Cosmetic surgery/services Including plastic and reconstructive surgery (except as noted as a covered service), dental care, and any other service and supply to improve the Health Plan Member’s appearance or self-perception.

Costs incurred by the Plan related to…

Health care services resulting from accidental bodily injuries arising out of a motor vehicle accident to the extent such services are payable under any medical expense provision of any automobile insurance policy, and telephone consultations, failure to keep a scheduled appointment or complete any form and/or medical information.

Custodial care Including any service or supply of a custodial nature primarily intended to assist the Health Plan Member in the activities of daily living. This includes rest homes (facilities), nursing homes, skilled nursing facility, home health aides (sitters), home mothers, domestic maid services and respite care. Also includes services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking and taking oral medications. “Custodial Care” also means services and supplies that can be safely and adequately provided by persons other than licensed Health Professionals, such as dressing changes and catheter care, or that ambulatory patients customarily provide for themselves, such as ostomy care, administering insulin and



Page 142


measuring and recording urine and blood sugar levels.

Dental care Or any treatment relating to the teeth, jaws, or adjacent structures (e.g.

periodontium), including but not limited to extraction or cleaning of the

teeth; implants, braces, crowns, bridges, fillings, dentures, x-rays,

periodontal, orthodontic treatment; rapid palatial expanders;

continuous passive motion (CPM) devices.

Dietary regimens Treatments, food, food substitutes, vitamins or exercise programs for

reducing or controlling weight.

Experimental/Investigational

or Not Medically Necessary

Treatment

With the exception of routine care in connection with a clinical trial in

cancer, pursuant to the Florida Clinical Trial Compact and the Patient

Protection and Affordable Care Act.

Eye care Including the purchase, examination, or fitting of eyeglasses or contact lenses, except as specifically provided for in the covered benefits section;

Radial keratotomy, myopic keratomileusis, and any surgery which involves corneal tissue for the purpose of altering, modifying, or correcting myopia, hyperopia, or astigmatic error; and

Training or orthoptics, including eye exercises.

Foot care (routine) Including any service or supply in connection with foot care in the

absence of disease, injury or accident. This Exclusion includes, but is not

limited to, treatment of bunions, flat feet, fallen arches, and chronic

foot strain, removal of warts, corns, or calluses, or trimming of toenails,

unless determined by the Plan to be Medically Necessary.

Gender reassignment or

modification services and

supplies

Genetic tests To determine paternity or sex of a child.

Hearing aids External or implantable or the examination, including hearing tests, for

the prescription or fitting of hearing aids, including tinnitus maskers.

Human Growth Hormone For diagnosis and/or treatment of idiopathic short stature.

Hypnotism Medical hypnotherapy or hypnotic anesthesia.

Immunizations and physical

examinations

When required for travel, or when needed for school, employment,

insurance or governmental licensing, except insofar as such

immunizations and examinations are within the scope of, and coincide

with, the periodic health assessment examination and/or state law



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requirements and/or the preventive care requirements of the Patient

Protection and Affordable Care Act.

Infertility treatment and

supplies

Including infertility testing; treatment of infertility, diagnostic

procedures and artificial insemination to determine or correct the cause

or reason for infertility or inability to achieve conception, in-vitro

fertilization, ovum or embryo placement or transfer, gamete intra-

fallopian tube transfer, or cryogenic or other preservation techniques

used in such or similar procedures.

Marriage counseling

Massage therapy

Non-prescription drugs and

supplies

Including any non-prescription medicine, remedy, biological product,

pharmaceuticals or chemical compounds, vitamins, mineral

supplements, fluoride products, health foods or blood pressure kits

except as specifically provided for in the covered benefits section under

prescription drugs.

Obesity and weight

reduction treatment

Including surgical operations and medical procedures for the treatment

of morbid obesity, such as intestinal or stomach by-pass surgery and a

weight loss program required by the Health Plan Member’s Primary

Care Physician prior to surgery, unless determined to be Medically

Necessary by the Plan.

Occupational therapy Unless provided as a home health service or hospice service or as

treatment for Autism Spectrum Disorder.

Orthomolecular therapy Including nutrients, vitamins, and food supplements.

Personal comfort, hygiene or

convenience items

Including but not limited to beauty and barber services, radio and

television, guest meals and accommodations, telephone charges, take-

home supplies, massages, travel expenses other than Medically

Necessary ambulance services that are specifically provided for in the

covered benefits section, motel/hotel or other housing

accommodations (even if recommended or approved by a physician), air

conditioners, humidifiers, dehumidifiers, air purifiers or filters, or

physical fitness equipment. Also excluded are services not directly used

to render treatment.

Recreational therapy

Reversal of voluntary,

surgically-induced sterility

Including the reversal of tubal ligations and vasectomies.



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Sexual deviations, disorders

or psychosexual

dysfunctions services and

supplies

Sleep therapy

Tobacco cessation programs

and products

Including any service or supply to eliminate or reduce a dependency on,

or addiction to, tobacco including but not limited to nicotine withdrawal

programs, vapor and e-cigarettes, nicotine gum, patches, lozenges, or

inhalers, unless specifically provided by law.

Training and educational

programs

Including programs primarily for pain management or vocational

rehabilitation unless specifically provided by law.

Volunteer services Or services which would normally be provided free of charge to a Health

Plan Member.

Weight control/weight loss

programs

Work related condition

services

To the extent the Health Plan Member is covered or required to be covered by a workers’ compensation law. If the Health Plan Member enters into a settlement giving up rights to recover past or future medical benefits under a workers’ compensation law, this Plan shall not cover past or future Medical Services that are the subject of or related to that settlement. In addition, if the Health Plan Member is covered by a workers’ compensation program that limits benefits if other than specified health care providers are used and the Health Plan Member receives care or services from a health care provider not specified by the program, the Health Plan shall not cover the balance of any costs remaining after the program has paid.

Additional Exclusions

include, but are not limited

to:

Bulk powders, bulk chemicals, and proprietary bases used in compounded medications and over-the-counter products used in compounded medications.

Services or supplies not Medically Necessary as determined by the Plan and/or the Prescription Drug Plan clinical staff and the State.

Services or supplies that are not specifically listed in the covered benefits section unless such services are specifically required by state or federal law.

Court ordered care or treatment, unless otherwise covered by this Plan, including testing required as a condition of parole or probation;

Testing for aptitude, ability, intelligence or interest.



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Treatment of a condition resulting from:

War or an act of war, whether declared or not;

Participation in any act which would constitute a riot or rebellion, or commission of a crime punishable as a felony;

Engaging in an illegal occupation;

Services in the armed forces;

Services or supplies received prior to a Health Plan Member’s effective date or received on or after the date a Health Plan Member’s coverage terminates under this Plan, unless coverage is extended in accordance with extension of benefit provisions;

Services provided by a physician or other health care provider who normally resides in the Health Plan Member’s home;

Services rendered from a medical or dental department maintained by or on behalf of a public health entity;

Non-medical conditions related to hyperkinetic syndromes, learning disabilities, intellectual disability, or inpatient confinement for environmental change;

Services or supplies supplied at no charge, or determined by the Plan not to be the most cost-effective setting, procedure or treatment.

The following services:

o Social work

o Bereavement and pastoral

o Financial

o Legal

o Dietary counseling

o Day care

o Homemaker and chore

o Funeral

Documents

STATE OF FLORIDA DEPARTMENT OF … Scoring of Financial Replies ... The Florida Department of Management Services invites interested vendors to submit replies to ... b. Is a fully-insured