Specifications include, but are not limited to: The Employee Benefits Division seeks to provide high quality, cost-effective benefits to its retirees and their families. EBD is soliciting proposals for a fully-insured, national MA-PD passive Preferred Provider Organization (PPO) Plan with the same benefits for services rendered in or out-of-network. The proposed MA-PD PPO Plan must meet the minimum requirements set by CMS and must mirror EBD’s current benefits design for Medicare-eligible State and Public School retirees (see Attachment B: Schedule of Benefits). The MA-PD PPO Plan must offer the same benefits for services rendered whether the Medicare-eligible retiree or their Medicare-eligible dependent sees a provider in-network or a provider outside the network that accepts Medicare. Prospective Contractors are encouraged to identify and offer features or enhancements that provide additional value without adding cost to EBD or its members, as well as any creative solutions that will achieve EBD's goals. Of particular interest are programs that focus on wellness, medical management, maximization of CMS funding, and minimization of claims cost. The following services must be provided under a resulting contract: • Member Services • Claims Adjudication • Data Reporting • Member Enrollment and Eligibility Maintenance • Revenue Maximization • Medical Management • Network Access and Network Management • Provider Advocacy and Assistance with Claims Issues • Formulary and Clinical Program Management • Medicare Advantage and Part D Administrative Assistance • Effective Member Communications • Patient and Family/Caretaker Education and Assistance
