Self-Funded Medical/ Pharmacy Plan

The Cincinnati Public Schools (CPS) is seeking a provider for active, self-funded medical and pharmacy plans with an effective date of January 1, 2027. The selected provider should offer integrated medical and pharmacy benefits, including medical care, prescription drug coverage, and preventive services. The provider should also have strong claims administration, regulatory compliance, member support, and wellness programs. The RFP process will consider carve-in pharmacy solutions. Some key requirements for the provider include: * Comprehensive and cost-effective healthcare coverage for CPS employees * Integrated medical and pharmacy benefits * Strong claims administration and regulatory compliance * Member support and wellness programs * Ability to track and record all interactions to ensure consistency and accuracy of information provided * Ability to provide quarterly reporting showing fees, number of participant-specific encounters, impact of such encounters, and outcomes * Ability to provide support for both eligibility management and claims reconciliation for the EGWP population at no additional cost to CPS * Compliance with all state and federal regulations for the duration of any agreement with CPS * Ability to administer an EGWP prescription drug program * Ability to provide both fully insured and self-funded EGWP programs * Ability to support a wrap program for EGWP members to provide coverage consistent with their commercial benefits * Ability to track Maximum Out-of-Pocket (MOOP) amounts for all EGWP members in real-time and in compliance with CMS guidelines * Ability to provide all CMS-required reporting on behalf of CPS and support CMS audits as needed * Ability to maintain a pharmacy network that meets CMS adequacy standards for EGWP members, including rural and underserved areas * Ability to comply with HIPAA and other data security requirements for handling Medicare member information * Some key features of the contract include: * The contract will have an effective date of January 1, 2027 * The contract will be for a term of one year, with the option to renew for additional years * The contract will require the provider to provide comprehensive and cost-effective healthcare coverage for CPS employees * The contract will require the provider to have strong claims administration and regulatory compliance * The contract will require the provider to have member support and wellness programs * The contract will require the provider to be able to track and record all interactions to ensure consistency and accuracy of information provided * The contract will require the provider to be able to provide quarterly reporting showing fees, number of participant-specific encounters, impact of such encounters, and outcomes * The contract will require the provider to be able to provide support for both eligibility management and claims reconciliation for the EGWP population at no additional cost to CPS * Some benefits of the contract include: * Comprehensive and cost-effective healthcare coverage for CPS employees * Integrated medical and pharmacy benefits * Strong claims administration and regulatory compliance * Member support and wellness programs * Ability to track and record all interactions to ensure consistency and accuracy of information provided * Ability to provide quarterly reporting showing fees, number of participant-specific encounters, impact of such encounters, and outcomes * Ability to provide support for both eligibility management and claims reconciliation for the EGWP population at no additional cost to CPS * Compliance with all state and federal regulations for the duration of any agreement with CPS * Ability to administer an EGWP prescription drug program * Ability to provide both fully insured and self-funded EGWP programs * Ability to support a wrap program for EGWP members to provide coverage consistent with their commercial benefits * Ability to track Maximum Out-of-Pocket (MOOP) amounts for all EGWP members in real-time and in compliance with CMS guidelines * Ability to provide all CMS-required reporting on behalf of CPS and support CMS audits as needed * Ability to maintain a pharmacy network that meets CMS adequacy standards for EGWP members, including rural and underserved areas * Ability to comply with HIPAA and other data security requirements for handling Medicare member information * Some potential drawbacks of the contract include: * The contract may require significant upfront costs for implementation and setup * The contract may require ongoing costs for maintenance and support * The contract may have limitations on the types of services that can be provided * The contract may have limitations on the types of benefits that can be offered * The contract may have requirements for reporting and compliance that can be time-consuming and costly * Overall, the contract appears to be a comprehensive and cost-effective solution for providing healthcare coverage to CPS employees. However, it is important to carefully review the terms and conditions of the contract to ensure that it meets the needs of CPS and its employees. • Key features of the contract • Benefits of the contract • Potential drawbacks of the contract • Requirements for the provider • Features of the EGWP program