HomeMy WebLinkAboutScope of Services"Attachment B"
Scone of Services
Situationwand `Plan,AnalysisandStra'teg►c Planning
• Review workforce needs and trends to develop a benefits
program that supports the City's overall objectives
Annually
• Compare current benefits program to national and peer
group benchmarks
Annually
• Conduct situation analysis and establish a process to:
o Contain and/or reduce current cost trends
o Optimize vendor and network performance
o Improve the health and productivity of the workforce
o Increase provider quality and improve clinical outcomes
o Identify short and long term benefit plan objectives
o Determine those benefit programs that are necessary
to recruit and retain talent
o Create an equitable and competitive
employee/employer cost sharing structure
o Enhance employee appreciation and satisfaction of
benefit programs
Quarterly
• Perform financial modeling of possible program
modifications and identify the implications to administration
and communications
Annually
• Meet with Senior Executives and Human Resources staff to
review plan performance, discuss recommendations and to
implement strategy
Quarterly
Renewal, FMarketmg, aVendor,S..election,andFImplementation Services
• Request and coordinate renewal activities with all vendors
o Medical/ Stop Loss
o Prescription Drug
o Dental
o Vision
o Life and AD&D
o Disability
o FSA/COBRA
o Elective Benefits —Alternate benefit options including
Retirees
Annually
• Quantify financial impact of renewal and negotiate any
variance between renewal and pre -underwriting projection
Annually
• If necessary, market benefit programs (RFP) to mutually
agreed upon vendors
o Draft RFP with requested bid specifications
o Coordinate RFP release to market
o Respond to carrier questions and data requests
o Negotiate best and final offers
o Work with City of Miami Procurement Department on
process
Annually
(if necessary)
i+
i'
• • Prepare and present a detailed marketing and renewal
report including:
o Total and itemized. costs
o Rate guarantees
o Objective and actuarially -valid network discount
is
Annually
(if necessary)
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•
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analysis
o Provider disruption analysis
o Service capabilities
o Performance guarantees
o Benefit designs and variances
o Carrier financial ratings
Prepare final marketing report
Arrange for and conduct finalist meetings
•
Conduct vendor site visits
As Needed
•
Conduct pre -implementation audit for new, self -insured
medical vendors
As Needed
•
Manage implementation process
o Review and negotiate final agreements and contracts to
ensure they conform to bid specifications
o Review all vendor provided employee communications,
SPDs and benefit booklets
o Coordinate the administrative set-up between the
employer and vendors for reporting, billing, banking and
data transfers
o Assist with the completion and review of all required
applications and other documents as needed to bind
coverage
o Manage a post implementation debriefing with vendors
to discuss performance and needed areas for
improvement
Annually
(if necessary)
•
Prepare and submit Executive Summary of final decisions
Annually
uFine n'ole fManagement.°and Reporting
•
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•
•
•
•
•
Develop budget projection, including large claim probability
modeling
Calculate pre -renewal projection
Calculate accruals and COBRA rates for self -insured plans
Review stop loss contract, deductible levels and attachment
points for adequacy
Develop employee contributions and contribution strategies
Evaluate alternative funding options
Plan design modeling •
.
Annually
(if necessary)
•
Develop Incurred But Not Reported reserves
Quarterly
(if necessary)
•
Financial reporting package:
o Month by month paid claims segregated by medical,
dental and pharmacy
o Month by month enrollment
oActual plan expenses compared to budget
o High claimant activity report including age, gender,
relation, diagnosis, paid claims amount and plan option
elected:
o Historical cost trend analysis
o Analyze carrier/TPA financial accounting of plans
o Reconciliation of premium and claims
• Monthly
1'
Based on data availability
2
r.
"'
o Analysis of insurer manual and experience rated
components as applicable
•
Emerging and projected cost analysis based on historical
paid claims and current market trends
Quarterly
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Comprehensive Medical/Rx utilization management report
detailing cost drivers by:
o Type of service
o Service setting
o Diagnostic category
o Network utilization
o Utilization review effectiveness
o Drug utilization
Quarterly
I'
Ongo,ng .Service .& Vendor Management
•
Facilitate service meetings with vendors to address
issues/problems and measure results against performance
standards
Quarterly
•
Provide daily assistance in resolving vendor service issues
o Claims
0 Billing
o Eligibility
o Coverage appeals
Ongoing
•
Meet as needed to review financials and to discuss/review
other open items
Ongoing
•
Review vendor proposed updates to contracts, SPDs and
benefit summaries for accurate terms, plan requirements
and plan design
Ongoing
•
Monitor and report on carrier financial ratings for contracted
vendors •
At renewal, marketing and
stewardship
•
Coordinate benefit decisions and plan details with vendor(s)
o Plan design decisions
o Facilitate meetings/conference calls between vendors
Ongoing
•
Develop and manage implementation schedule for any plan
changes and/or service changes
Ongoing
•
Manage vendor participation in annual enrollment process
Annually
•
Coordinate with communications resources in the creation
and review of open enrollment materials
o Participate in employee education and enrollment
meetings at each. City of Miami site
Annually
.Accoun.t.Management . '..
•
Completion of stewardship report
o Review prior year accomplishments vs. objectives
o Provide industry overview and benefit trends
o Develop goals and objectives for upcoming year
Annually
•
Meet with your staff to discuss issues, open items and
industry trends
Quarterly or as needed
•
Complete an action plan and update regularly
Ongoing
�orrmplrance an:d Regulatory Support; ........ .. , .W;. _ ....
•
Compliance review of SPD benefit provisions, contracts, .
agreements and plan documents
Monthly
•
Prepare required Summary Annual Reports
Annually
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• Health and Welfare Plan Documentation Limited Review
As needed
Ongoing
• Provide legislative alerts
stomizethEmpinyee(Communication.'
• Custom communications (Printing Additional Cost)
o Professionally developed enrollment guide drafting (2, 4
or 8 page)
• Online benefits website
o Provide detailed explanations of benefits and HR
policies
•
•
•
Iiii cal s:u
Annually
Ongoing and as requested
sic ans/Nurses%Phar;macists
Utilization management performance review
Inpatient vs. outpatient usage
Benefits paid by provider
Benefits paid by diagnostic code
Demographic trends
High cost claimant analysis
Recommend interventions to contain/reduce cost
Wellness
o Evaluate opportunities for wellness intervention
programs
o Identify proper risk measurement and management
tools
o Develop wellness programs
o Wellness vendor review and selection
o Leverage vendor capabilities
o Provide wellness website and tools
o Develop culturally appropriate participation incentives
El ec t►ue _B enefits,.Re v►e w
Obtain cost for new products and services as requested
Utilization review services, EAP, Long term care etc.
Prescription "-3Drug ValueProg_
Review of PBM contracted pricing, negotiation and.
implementation
Semi-annual or as requested
Ongoing
Ongoing and as requested
ram`
Ongoing and as requested
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