Specifications include, but are not limited to: • Timely issue all enrolled and approved stop loss policies to the County. • Timely notify the County of any amendments or changes to the policy which must be mutually agreed upon between respondent and the County within one (1) week of receiving final claims experience. • Maintain a stop loss claims database for all submitted stop loss claims using information provided by the County or its designated representatives, e.g., Blue KC and MedImpact. o Receive and process stop loss reimbursement claims from Blue KC and possibly MedImpact (MedImpact reports claims to Blue KC so the latter should have all reimbursable claim records and documents). o Timely request (within one week) any additional information needed by respondent to determine, and document claim submission enabling issuance of reimbursement to Johnson County. o Notify Blue KC and copying the County (specifically FMA-Benefits at fmabenefits@jocogov.org) of any pended or denied stop loss reimbursement claim within three (3) business days. o Accept the County’s and Blue KC’s records of who is an eligible member (employee, spouse, or dependent) under the Plan. o Accept Blue KC’s determination of medical necessity and usual, customary, and reasonable. o Protect and maintain protected health information (PHI) in accordance with HIPAA statutes and any other applicable federal and state regulations. Respondent will be required to execute a HIPAA Business Associate Agreement provided by the County. See Attachment B. o Consider providing the County with a rate or premium reduction due to its cost containment philosophy and commitment, as evidenced by the programs in place to mitigate claims costs, including: High-Cost Claimant review process utilizing Mercer’s clinicians within their stop loss practice. The program allows Mercer to select high-cost claimants which are then addressed during a monthly video call involving a Blue KC Medical Director, claims staff, and case manager. County Benefits Manager reviews the Blue KC monthly claims detail report to identify any suspect claims warranting additional review. The County contracts with Tria Health, a medication therapy management vendor to offer eligible members the following programs: pharmacy advocacy (member discusses medications and purpose with a pharmacist to increase adherence), weight management, diabetes management, blood pressure management, and pharmacogenomics program. The County contracts with TouchCare, a health advocacy vendor that assists members with identifying and scheduling lower cost, high quality providers, helping members traverse the health care industry, arrange for virtual second medical opinions, and resolve claim issues. A wellness program focused on meeting target biometrics and tobacco cessation where employees and spouses can earn up to $150 per month ($1,800) per year off the cost of medical coverage. This incentive structure results in the County having much higher than norm participation of 69.4% employees, 59.3% spouses, and 92% tobacco. A fitness program through FitOn allowing employees and spouses to access fitness credits that can be used toward the cost of virtual and on-site fitness classes and monthly memberships at over 180 network facilities. The County also has several buildings that have an on-site fitness center located in them. The County also offers a “narrow”, high performing network (BlueSelect Plus) through Blue KC that offers as much as a 30% additional provider discount than the primary provider network (Preferred Care Blue). The County amended its medical plan to exclude a site of care not medically necessary to assist with ensuring services are rendered in the most efficient and economic manner. The County has implemented all clinical programs MedImpact offers and continues to evaluate other programs in the market to encourage MedImpact to adopt if not already offered. The County also coordinates the J-Code block analysis involving Mercer, Blue KC, and MedImpact to ensure that the vendor with the greatest savings and/or clinical program administers the medication and the other will block it under the other respective plan.
