1. Be licensed to do business in the Commonwealth ofVirginia. 2. Provide high quality, efficient program administration and services including but not limited to: a. Maintaining central claims and membership files for each covered member (including dates of coverage, type of coverage, etc.). b. Maintaining paymentrecords. c. Provide state-of-the-art data tracking and claims payment services. d. Furnish quarterly statements, including monthly enrollment, premiums, paid claims, capitation expenses charged, detailed list of expenses charged, and claims exceeding the specific stop-losslimit. e. Provide claims, enrollment, and utilization information for hospital, physician, and prescription drug expenses at a level of detail that will allow for the identification of the true cost drivers of the plan. Include normative data in conjunction with groupspecific data. f. Provide identification cards directly to all covered members prior to the effective date of the program (October 1, 2025). During the contract year, provide identification cards within ten (10) business days of receipt ofrequest. g. Meet with the appropriate Employers’ management staff(s) within fifteen (15) days after the contract award date to present the proposed communication material, and to jointly establish a preliminary implementation plan and open enrollment program and schedule. h. Provide employees and covered family members with customer service access via phone and virtually (web site and mobile app), in order to view benefits information, access tools and resources, and to ask questions regarding coverage. Employees and family members should also have the ability to access their personal claims information, explanation of benefit statements, as well as ID cards if applicable. 3. Furnish to each employee enrolled in the plan a benefit booklet outlining and defining all covered services, limitations and exclusions for each plan offered, procedures for receiving services, schedule of benefits, and Summary of Benefits Covered (SBCs). The initial booklet proof must be provided to WJCCPS on a timely basis but not later than April 15th of each year. WJCCPS shall review and approve the booklets prior to distribution. 4. Provide WJCCPS with the administrative services and reinsurance contracts, as well as any other contractual documents necessary to this coverage by the effective date of the contract (October 1, 2025). 5. Provide specific rates and performance guarantees that must be approved by the effective date of the contract (October 1, 2025). Performance guarantees should be annual in nature and should be made available each year of the contract. 6. Maintain complete and total compliance with the HIPAA and HITECH legislation as it pertains to Private Health Information. 7. Commit to supporting WJCCPS with implementation of all state and/or federal legislation mandates that impact the administration of the health care program. Offerors shall provide this service without additional charges/fees.
