Nebraska Comprehensive Health Insurance Pool
December 1, 2008
Request for Proposal
to the
Nebraska Comprehensive Health Insurance Pool
for
Administrative Support Services
Effective October 1, 2009
through
September 30, 2012
Return Two Copies of Proposal to:
Nebraska Comprehensive Health Insurance Pool
c/o Vic Kensler, Chairman
2511 North 55th Street
Omaha, NE68104-4205
Telephone: (402) 551-2624Cell: (402) 639-1193
Email:
Statutory Duties/Specifications
This information is provided to outline the scope of work to be provided. The Administrator shall:
1.Perform all eligibility verification functions (includes costs of form printing, mailing and investigatory and corroborative costs).
2.Establish a premium billing procedure on an annual, semiannual, quarterly or monthly mode (includes accounting and bookkeeping costs).
3.Perform all claims payment/consideration functions (includes insured education programs on submitting claims, design and printing of forms and actual handling, review and payment/declination of claims).
4.Establish a customer service function to respond to requests for information and policyholder inquiries.
5.Ability to establish and manage a state preferred provider network for the CHIP.
6.Ability to administer Nebraska’s managed care patient protection laws, noted as: Nebraska Insurance Laws, Chapter 44, Articles 68, 70, 71, 72 and 73.
7.Submit reports to the Board on a monthly basis regarding the operation of the Pool (includes names, verification of their eligibility, age and address of insureds; premiums collected, claims submitted, claims paid and other such information as the Board deems necessary and requires).
8.Submit a year-end report on income and expenses on forms prescribed by the Nebraska Director of Insurance or the Board.
9.Designate a contact person to attend all meetings, as requested by the Board.
10.Provide information to the Board so that they may make periodic estimates of the amount needed from the fund to the Director of Insurance for payment of losses resulting from claims, including a reasonable reserve, and administrative, organizational, and interim operating expenses.
11.Ability to administer Tobacco/non-Tobacco rating.
12.In addition, the Board shall require that the Administrator shall develop and implement a program to publicize the existence of the Pool policy and the eligibility and enrollment requirements and maintain public awareness of the Pool policy.
13.The administrator is responsible to determine, for purposes of eligibility for an individual seeking pool coverage, that the individual is not eligible for a group health plan, Medicare, or medical assistance pursuant to Neb. Rev. Stat. §44-522 or Neb. Rev. Stat. §68-1018 to §68-1025, or any successor program, or any other health insurance coverage.
Administration
The following information is mandatory. Its purpose is to aid in evaluating the bidder’s ability to perform the work required.
1.General Bid Information
a.Name, title, corporate address, and telephone number of official responsible for the proposal and for other personnel similarly authorized to conduct negotiations.
b.Geographic location of facilities to be used for the insurance program.
Agreement that all records, files and reports associated with its program are and remain the property of the Board and are to be turned over to a successor administrator should there be one. Agreement to provide the Board with access to all such records for audit purposes during normal working hours.
2.Organization Information
a.A statement of general background, experience and qualifications of the organization. Make special mention of experience in handling large group accident and health insurance, individual accident and health insurance, and governmental programs. Include a list of clients or organizations which can be used as references for work performed in the area of administrative services. Selected references may be contacted to determine the quality of work performed and personnel.
b.Profiles of the qualifications of management, professional, and technical personnel who will be assigned to this project.
c.A copy of the most recent financial report filed with the insurance department in the organization’s state of domicile or A CPA-audited financial report.
d.Copies of any market conduct examination reports from any state, written in the last three years.
e.Description of how facilities for the Pool will be coordinated with other business. Included should be an agreement to keep Pool records confidential and to refrain from using lists of Pool policyholders for any reason associated with other business, as well as a statement describing current or proposed procedures for maintaining confidentiality.
f.Description of consumer services, including information regarding how long-distance telephone inquiries from Pool policyholders are to be handled.
g.Indication of projected start-up time after award of the contract. Submit a brief timetable for administering carrier functions, including training of staff, taking applications, and issuing policies.
h.Description of record keeping capabilities. The following is an idealized list of records to be kept. Indicate the organization’s capabilities to keep the following data on computer:
In Force or Billing File
Policy Number
Name
Address and Zip Code
Issue Date
Birth Date
Sex Code
Plan Code
Reason for Eligibility Code
Financial Code
Mode Premium Amount
Paid-to-Date
Claim File Record (Indicate whether the two files can be merged)
Policy Number
Claim Number
Date of Loss
Date Loss Reported
Date Paid
Payee’s Name
Cause Code
Benefit Code
Amount of Expense Claimed
Amount of Expense Paid
If the two files cannot be merged, indicate the organization’s capability to keep the following additional data on the claim file record:
Issue Date of Policy
Birth Date of Insured
Zip Code of Insured
Plan Code
Sex Code
Reason for Eligibility Code
i.Any additional information considered useful to the selection committee in evaluating the organization’s ability to administer the program.
3.Claims Administration
a.Degree of current automation and a description of the proposed system for claims administration.
b.Current staffing for claims processing and proposed staffing for Pool administration, including background required and training provided at both processor and supervisory levels.
c.Indication of whether special claims forms would be created for the Pool policy or whether standard industry forms would be used. Provide samples, if possible.
d.Average turnaround from receipt of complete claims to check in the mail for routine major medical claims received.
e.Frequency with which major medical claim checks are mailed.
f.Percentage of processed claims (both paid and denied) which would be audited, indication of staff responsible for conducting audits, and indication of what is considered an acceptable error rate for standard performance.
g.Description of the method of administration of the Pool policy’s required cost-containment and preferred provider managed care activities.
h.Description of determination of usual and customary or reasonable or necessary charges, and guidelines or source material used to determine hospital utilization and length of stay.
i.Description of systems capabilities to change claim payment methodologies, e.g., the ability to change from one method such as usual and customary to another method such as Medicaid or Medicare schedules plus a designated percentage.
j.Description of any processes or procedures for managing prescription drug charges, including any Pharmacy Benefit Manager relationships.
k.Description of methods of obtaining expert medical and legal opinions on difficult and/or complex claims.
l.Description of the make-up and functions of any claim committee, including a description of the types of claims referred to the committee and in the absence of the claim committee, a description of substituted procedures for handling difficult complex claims.
m.Description of existing and anticipated grievance/dispute resolution system which shall include, if applicable:
- Notice;
- Forms;
- Determinators;
- Procedure; and
- Final Determination Process.
n.Any additional information considered useful to the Board in evaluating the efficiency of the organization’s claim-paying procedures.
4.Network Access/Provider Savings
a.Please provide provider access standard reports as follows:
- PPO Hospitals – One hospital within 5 miles, 10 miles, 25 miles
- PPO Physicians – Two providers within 10 miles, two providers within 25 miles
b.Does your managed care network allow for nationwide reciprocity?
c.What are your physician, outpatient and inpatient discounts from billed charges after adjudication?
d.What type of agreements do you have with hospitals and physicians in regards to reimbursements, fee schedules, per diems, DRGs, % of billed charges?
e.What reports are available that will reveal demonstrated savings as a result of the financial agreements with providers established by your managed care program? With what frequency will these reports be produced? Are there any costs associated with these reports? If so, please detail. Please provide sample reports.
Bid
1.Mandatory Services
Bids for the cost of mandatory services are to be based upon and submitted as:
a.Each bidder must bid on a percentum of premium basis on a per person per month basis; and
b.If a bidder desires, additional bids may be submitted showing a lesser cost than paragraph a., above. For example: cost per claim, or a flat fee per member, per month.
All bids must adequately explain the basis for calculation of cost. If an alternative to paragraph a. is submitted, a description of the basis to calculate a lower cost than number 1 must be submitted for that bid to be considered.
2.Optional Services
All bids for optional services must separately state the basis for calculation of the cost of administration.
Each bidder must describe methods to be used to segregate the cost associated with the administration of the Pool business from the bidder’s organization’s normal block of business to ensure that the Pool is paying only for those expenses which actually relate to the Pool administration.
All proposals must be received by February 1, 2009 and should be submitted to:
Nebraska Comprehensive Health Insurance Pool
c/o Vic Kensler, Chairman
2511 North 55th Street
Omaha, NE68104-4205
Telephone: (402) 551-2624Cell: (402) 639-1193
Email:
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