Addendum 1 08-30.doc
The School District of St. Lucie County SUPERINTENDENT
329 N.W. Commerce Park Drive Port St. Lucie FL 34986 Voice – (772)336-6980 Fax – (772)336-6985
ADDENDUM NO. 1
REQUEST FOR PROPOSAL NO
TITLE: Administrative Services Only (ASO) for Self Funded Medical and
Fully Insured Medical and Dental
SCHEDULED OPENING DATE:
: Allen Lee, Purchasing Agent
VENDOR NOTE: PLEASE ACKNOWLEDGE RECEIPT OF THIS ADDENDUM BY SIGNING AND RETURNING IT WITH YOUR BID. ______________________________ ___________________ ______ Authorized Signature Company Name Date
This addendum consists of the following:
Questions and answers to medical questions, (pages 2-5) 39 questions
Questions and answers to dental questions, (pages 6-7) 23 questions
RFP question (page 7) 1 question
Four (4) Excel documents:
Two (2) PDF files:
Rx Retail & Mail Utilization Summary Report
MEDICAL QUESTIONS & ANSWERS
1) Do the deductibles on the PPO plans cross accumulate? Yes.
2) Could you provide the PEPM cost for the Disease Management programs and information on the type
of programs offered? HealthCare Strategies “HealthReach” program PEPM Fee: $5.25
The HealthReach disease management program identifies and stratifies the population at risk for
adverse medical events, typically at high claims levels through the analysis of both medical and
prescription drug claims. Once identified, these high-risk members are targeted for invitation into
the DM program or if diagnosed at a higher risk category they may be referred to the more
intensive “Care Management” program. Up to 5% of the member population may be invited into
the program based on their risk profile. The program is not limited to patients with a specific
diagnosis or condition. In addition, an incentive based Health Risk Assessment (HRA) program
was implemented on February 1, 2008.
3) Should any commission be built into the ASO fees? No.
4) Are large claims over the pooling point included in the monthly paid claims report? Yes. Paid claims include all claims (gross); claims exceeding the stop loss limit are included in
the paid claims.
5) The current plans show a richer benefit for Outpatient and Emergency room care at St. Lucie Medical
Center and Lawnwood Hospital. Is this steerage required in the benefit plan proposed by carriers? No.
6) Must vendor solution encompass Active and Retiree populations? Can a vendor propose solution to
Medicare Eligible segment only? The School District is not considering a Medicare Carve-Out Program at this time. This type of
program may be reviewed and considered in the future.
7) What is School District of St. Lucie County’s GASB-45 Liability? Please refer to question #6.
8) Is the School District of St. Lucie County collecting the Retiree Drug Subsidy (RDS)? How much RDS
has been collected? No.
9) What is School District of St. Lucie County’s contribution to the premium for retiree’s healthcare? The School District does not contribute toward the retiree premium.
10) Can members utilize mail order pharmacy benefit in retail pharmacy setting? A 90-day a retail benefit is available to all active and retiree members at Walgreens Pharmacy.
This program is offered through the current PBM – Ideal Scripts.
11) Can vendor propose fully-insured solutions only? Fully Insured proposals covering all active and retiree members will be considered.
12) Can vendor propose alternative to Medicare Supplement Medical/Rx solution? Only if offered alongside the coverage quoted for active and retirees (under 65) plans.
13) Is there any flexibility in rating requirement? Can a vendor with an A.M Best rating B++ bid on this
opportunity? No, the minimum ratings provided will apply.
A.M. Best: A-
14) Can you provide the Health Plan Analysis report from Web-TPA? Please see the attached 2007 Health Plan Analysis Report.
15) Clarification is needed regarding the Over the Counter Assist benefit. Zyrtec, Claritin & Prilosec OTC are available over the counter with a prescription at $0 copayment.
This program was established in hopes of steering usage from the brand name prescriptions for
Non-Sedating Antihistamines and Proton Pump Inhibitors.
16) What are the terms and conditions of the contract between St. Lucie County School Board and
Employers Community Network? There is no specific contract between Employers Community Network (ECN) and the School
Board. However, this service is provided as part of the “Contract for Services” with EMI. The
contract indicates that access to and management of the ECN PPO network will be provided by
EMI. All re-pricing of ECN network claims and billing for access fees ($3.42/PEPM) is performed
17) Do the Out -of-Pocket Deductibles and Out of Pocket Maximums “cross apply” or are they in addition
to the In-Network Deductibles and Out of Pocket Maximums? Yes. They cross apply.
18) Is the school board willing to accept proposal attachments (such as provider disruption report,
provider directory, etc.) on CD rather than hardcopy? Yes.
19) Please indicate if the current Rx plan is an open or closed formulary. The current Rx program is 2 tier (Generic/Brand) with no formulary.
20) Please clarify that if the Rx plan uses an open formulary, that the copay for non preferred drugs
remains $25. The School Board does not have a formulary program. All brand name medications have a $25.00
retail copay and $50.00 mail order copay.
21) Please indicate if the current plan uses any cost containment programs, such as Step Therapy,
Mandatory Mail Order Drug, or Automatic Generic Substitution. Cost containment programs under the current rx plan include:
- OTC Assist (see question #15),
- DAW2, whereby members are charged the difference in copay and drug cost between Generic
and Brand. This applies only if directed by the member. If the physician prescribes the Brand
medication indicating DAW, there is no penalty.,
- P.A. (pharmacist approval) for all specialty medications and any drug over $1,000. The P.A.
process includes a review for medical necessity and step therapy.
22) Please clarify if Pharmacy claims are included in the paid claim data provided. If they are, what
percentage of the combined claims does Pharmacy represent (annual average)? If they are not, can you
please provide monthly claims by plan for the same time period as the medical data? Please refer to Exhibit 4, which shows the Medical Paid Claims and Enrollment History by Plan.
Since the prescription drug paid claims are not available by Plan, they are listed in the “Totals for
All Plans” box. In order to calculate the total paid claims, you will need to add the Medical Paid
Claims and Rx Paid Claims. In 2007, the pharmacy claims were 17.6% of the total paid claims.
23) Can you please provide Pharmacy Utilization data to include a split between Brand and Generics for
Retail and MOD separately? Also, if available, what is the split on Generics between Single source and
Multi source? Please see the attached Retail & Mail Utilization Summary reports from 1/1/06 through 3/31/08.
The total paid claims indicated on these reports will differ from the paid claims included in Exhibit
4. This is due to access fees and report timing.
24) Please indicate if there are any custom forms used by the School District of St. Lucie County for
enrollment or other administrative functions, as well as if the carrier can use it’s own forms. The School Board utilizes Fringe Benefits Management Company for all enrollment services.
Enrollment forms through Fringe are customized to the School Board and we prefer to keep this in
place as is.
25) Please indicate if there are multiple agencies that have separate eligibility files and how many will be
sent for interface. Fringe Benefits Management Company enrolls and provides tape downloads to the School
District’s Payroll Department. Fringe also provides an enrollment file to the TPA. The School
District provides a hard copy of each enrollment form to the TPA as well.
26) Please indicate if bank wires are on a checks issued or checks cleared basis and if there is any time
delay between the wire request and the authorization to fund that wire WebTPA maintains a claims account with check writing authority for the District. The School
District and Fringe wire money to the account monthly and WebTPA draws checks directly from
the account to fund claims and fixed costs.
27) Please indicate if there are any legislated time requirements to complete a contract or SPD/employee
booklet once the award is provided. The contract for services must be in place as of the effective date of the program, 1/1/09. The SPD
should be completed and delivered to each employee as near the effective date of coverage as
possible, but no later than 3/31/09.
28) Please indicate the current overall provider discounts being achieved. Please refer to the attached Health Plan Analysis Report for 2007.
29) Please indicate how often members are going to in-network providers.
Please refer to the attached Health Plan Analysis Report for 2007.
30) Please indicate if benefits are collectively bargained. The School Board has an insurance committee in place that makes recommendations, but the
final decisions regarding benefits are made by the Board. The premium cost share is collectively
31) Please itemize the disease management programs currently included in the medical plan rates. Please refer to question #2.
32) Please itemize the wellness programs currently included in the medical plan rates. The School District participates in the Disease Management Program and Health Risk Assessment
through Healthcare Strategies. The District also provides a $250.00 per calendar year wellness
benefit, but no “Wellness Program” is in place at this time.
33) Please indicate the Agent contact at Employers Mutual, Inc. James (Jim) Davis, Vice President of Business Development
34) Please confirm that you are requesting a 24/12 contract. Yes, the stop loss contract should be quoted as 24/12.
35) Would you please provide the total membership number (employee & dependents) for the Medical
Paid Claims – Enrollment History by Plan Reports in Exhibit 4? Please refer to the attached Medical Paid Claims – Enrollment History by Plan report, which now
includes the total number of employees, total number of employees with dependent coverage and
the total membership by month.
36) Please confirm that the Rx Paid Claims in Exhibit 4 need to be added to the Medical Paid Claims to
arrive at the total claims paid. Yes.
37) Are there any total plan average discount reports available? The High Claimant by Dollar Limit
Report shows a plan discount for those individual members so it appears this information is tracked. Please refer to the attached Health Plan Analysis Reports for 2007.
38) We would like to include other alternative plans for your retirees in addition to the current Medicare
Supplemental Plan, is this acceptable? Please refer to question #12.
39) Would the March claims data be available before 4/18/08? No, claims experience through March will not be available by the RFP deadline.
DENTAL QUESTIONS & ANSWERS
1) We are considering offering a bid for the dental but need to know the approximate number of eligible employees. All full time employees are eligible for benefits. As of 3/25/08, the School District has 5,129 eligible
2) Current plans are self funded. Why is it that the group is to be moved to fully insured? The School Board is interested in reviewing fully insured dental proposals as the coverage is voluntary with
no employer contribution. The School Board would like to cap the plan costs, which will eliminate the
possibility of subsidizing the self-insured dental plan.
3) Is there an opportunity to continue with self funded? If the School Board decides to remain self-insured, they will likely continue the current program. If you
would like to state your AS O fee and expected plan costs for administering the dental plan on a self-insured
basis, it will be given consideration.
4) Under the current arrangement, one of the plans is an in network only plan. In FL, we can only offer under a self
funded arrangem ent. If you are unable to quote the plan as currently structured, please quote a plan that closely resembles the
plan benefits indicated and list all deviations. All options will be fully considered.
5) Is the school board interested in offering a low option PPO with In and Out of Network Benefits? Please quote the current dual option PPO and Indemnity Dental Plans. Also provide a quote for the
Alternative Plan as indicated in the RFP, which would replace the current plans if selected. If you wish to
quote additional options, they will be given full consideration.
6) Can the claim and enrollment history be split by plan? Please see the attached claim report, which provides the claim experience by plan from 1/1/06 through
2/29/08. The enrollment history by plan is not available. Please refer to the dental census provided, which
shows the current enrollment by plan (Covg Level). PPO DENTAL shows enrollment for the PPO Plan and
INDM DENTAL shows enrollment for the Indemnity Dental Plan.
7) The plan information provided does not appear to be consistent in the RFP and Exhibit Summary. Is there a more
complete outline of the plans available? There are no discrepancies between the RFP document and Exhibit for the current PPO and Indemnity Dental
plan benefits. The Dental plan outline is contained in Exhibit 1.
8) The 90th percentile of MDR? Can we get clarification on the definition of MDR? Do they use Ingenix for UCR
information and simply use another name? MDR is the UCR schedule that is marketed by Ingenix. Please quote coverage at 90% of Ingenix UCR.
9) Will the 3rd option replace the current Indemnity/PPO rather than be a third choice? Yes, the alternative plan would replace the current plans.
10) Would you like to see a DHMO with two PPO’s? The School District is not interested in a DHMO program at this time. However, should you wish to quote
additional options, they will be given full consideration.
11) Can we obtain a current census summary based on a 3 tier enrollment? Please see the attached dental census summary by plan based on the 3 tier enrollment.
12) The census and RFP state approximately 4500 enrolled in the dental, but nothing for the eligible number. Please
provide the total number of eligible employees. Please refer to question #1.
13) Can the dental experience be broken out between the 2 current plans that are being offered? Please refer to question #6 and attachment.
14) We are unable to offer a plan that resembles the current PPO plan that has no out of network benefits. We can
quote a plan similar to the other option that provides in and out of network benefits. Will the inability to provide a plan
with in network only benefits prevent us from being considered for this opportunity? Please refer to question # 4 and #5.
15) How many employees are on each plan? Please refer to question #11 and attachment.
16) Please provide experience and current enrollment broken out by plan in order to rate appropriately. Please refer to question #6, #11 and attachment.
17) Please provide list of current dental providers. Please see the attached listing of ECN dental providers.
18) Please define Voluntary. (Ex: Is it 100% Employee Paid?) Yes, dental coverage is 100% employee paid.
19) Please confirm blended 3 tier funding rate? Funding rates are three tier and as follows:
Employee + 1:
20) Please provide top 38 procedure codes and associated fees for Preferred Panel Plan and Indemnity Plan. The fee schedule information is proprietary and not available for release per the dental provider contracts.
21) Please confirm what MDR stands for. Please refer to question #8.
22) Is the school board willing to accept proposal attachments (such as provider disruption report, provider directory,
etc.) on CD rather than hardcopy? Yes.
23) The RFP indicates that the Dental Program has been self-funded for over 10 years but the RFP request is only
for fully insured. Could you please explain why you are not requesting self-funded proposals for Dental? Please refer to question #2 and #3.
RFP PROPOSAL QUESTION AND ANSWER
Please provide greater clarification of the "Funding Out" provision being requested in the RFP.
School Districts are not allowed to commit to funds in future fiscal years .
Nos. 2006-1213, -1313 Plaintiff/Counterclaim Defendant-Appellant, MERRELL PHARMACEUTICALS, INC., AND CARDERM CAPITAL L.P., Defendant/Counterclaimant-Appellee, On appeal from the United States District Court for the District of New Jersey in consolidated case Nos. 01-CV-3627 and 03-CV-0487, Judge Joseph A. Greenway, Jr. BRIEF OF PATIENTS NOT PATENTS, INC., AS AMICUS CURIAE IN SU
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