Appendix A Current Plan Documents See Attached Page 1 of 22
Appendix B Census As of April 2017: 27,710: Total Covered Employees and Dependents 15,898: Are Employees (80% female) 11,812: Are Dependents (42% female) Of the 15,898 Employees: 10,891: 69% Elected 'Employee Only' coverage (80% female) 5,007: 31% Elected 'Family' coverage (80% female) Cobra: 143: Former employees have COBRA with 91 dependents See Attached Details Page 2 of 22
Appendix C History of Rates Plan Employee Employee + Year Only Family Employer 2003 $0 $41.41 $19.35 2004 $0 $41.41 $19.35 2005 $0 $41.41 $19.40 2006 $0 $41.41 $19.40 2007 $0 $41.41 $19.45 2008 $0 $41.41 $19.45 2009 $0 $41.41 $19.55 2010 $0 $41.41 $19.55 2011 $6.00 $47.41 $24.21 2012 $6.00 $47.41 $24.21 2013 $6.00 $47.41 $24.21 2014 $6.00 $47.41 $24.21 2015 $6.00 $47.41 $24.21 2016 $6.00 $47.41 $23.83 2017 $6.00 $47.41 $23.93 Page 3 of 22
Appendix D Procedure Experience Report Policy #: 301512 01/01/2016 through 01/01/2017 Type Count Total PPO Claim Remaining Ded. Pd Coinsur. Total % Total Claims Savings Savings Charges by Mem. Pd by Mem. Claims Ben Pd TYPE 1 101,272 $6,665,837 $687,492 $529,393 $5,448,951 $0 $0 $5,448,951 67.5% TYPE 2 19,187 $5,063,815 $689,124 $931,909 $3,442,782 $329,476 $1,615,618 $1,497,687 18.5% TYPE 3 3,964 $3,645,269 $356,004 $1,227,498 $2,061,767 $46,109 $1,080,243 $935,415 11.6% ORTHO 4,096 $431,208 $0 $604 $430,604 $0 $217,995 $212,609 2.6% NON 2,208 $264,240 $12,608 $251,742 -$110 $0 $0 -$110.0% CLASS. CREDITS 66 $0 $0 $17,720 -$17,720 $0 $0 -$17,720 -.2% TOTAL 130,793 $16,070,369 $1,745,228 $2,958,866 $11,366,274 $375,585 $2,913,856 $8,076,832 100.0% PPO Count Total PPO Claim Remaining Ded. Pd Coinsur. Total % Total Claims Savings Savings Charges by Mem. Pd by Mem. Claims Ben Pd Yes 57,169 $7,013,358 $1,745,228 $994,074 $4,274,056 $169,724 $1,208,883 $2,895,449 35.9% No 73,624 $9,057,010 $0 $1,964,791 $7,092,219 $205,861 $1,704,974 $5,181,384 64.2% TOTAL 130,793 $16,070,368 $1,745,228 $2,958,866 $11,366,274 $375,585 $2,913,856 $8,076,833 100.0% Group Count Total PPO Claim Remaining Ded. Pd Coinsur. Total % Total Claims Savings Savings Charges by Mem. Pd by Mem. Claims Ben Pd EXAMS/X- 62,822 $3,600,271 $427,925 $311,910 $2,860,436 $0 $79 $2,860,357 35.4% RAYS CLN/SEAL 38,369 $3,034,803 $256,923 $204,554 $2,573,326 $0 $0 $2,573,326 31.9% /APPL RESTORA 13,202 $4,808,968 $514,894 $1,048,485 $3,245,588 $250,104 $1,547,430 $1,448,055 17.9% TIVE ENDO 760 $646,297 $50,195 $88,109 $507,994 $16,904 $256,659 $234,432 2.9% PERIO 3,206 $759,712 $99,357 $209,883 $450,472 $41,805 $215,296 $193,370 2.4% PROSTH 956 $1,103,316 $131,852 $567,866 $403,598 $7,033 $229,297 $167,268 2.1% ORAL 5,177 $1,419,282 $242,798 $332,804 $843,679 $47,738 $425,831 $370,110 4.6% SRG/ANE STH GEN 1,068 $181,204 $18,683 $94,820 $67,701 $11,850 $21,051 $34,800.4% SERV TMD 78 $10,410 $317 $10,093 $0 $0 $0 $0.0% MISC 1,059 $74,896 $2,283 $89,738 -$17,125 $150 $219 -$17,494 -.2% ORTHO 4,096 $431,208 $0 $604 $430,604 $0 $217,995 $212,609 2.6% TOTAL 130,793 $16,070,368 $1,745,228 $2,958,866 $11,366,274 $375,585 $2,913,856 $8,076,833 100.0% Page 4 of 22
Appendix E Experience & Premium Report Policy #: 301512 01/01/2015 through 01/31/2017 Employee Family Premium Costs Total Loss Only Coverage Employee Family Premium Claims Ratio Jan-15 11175 4455 $ 312,341 $ 308,999 $ 621,340 $ 461,702 74.3% Feb-15 11194 4471 $ 312,872 $ 310,109 $ 622,981 $ 587,800 94.4% Mar-15 11231 4511 $ 313,906 $ 312,883 $ 626,789 $ 589,794 94.1% Apr-15 11306 4531 $ 316,003 $ 314,270 $ 630,273 $ 667,465 105.9% May-15 11218 4536 $ 313,543 $ 314,617 $ 628,160 $ 570,127 90.8% Jun-15 11153 4533 $ 311,726 $ 314,409 $ 626,135 $ 691,034 110.4% Jul-15 11078 4510 $ 309,630 $ 312,814 $ 622,444 $ 810,041 130.1% Aug-15 10894 4489 $ 304,487 $ 311,357 $ 615,844 $ 756,821 122.9% Sep-15 10352 4416 $ 289,338 $ 306,294 $ 595,632 $ 510,223 85.7% Oct-15 10616 4450 $ 296,717 $ 308,652 $ 605,369 $ 595,318 98.3% Nov-15 10817 4461 $ 302,335 $ 309,415 $ 611,750 $ 468,692 76.6% Dec-15 10868 4477 $ 303,761 $ 310,525 $ 614,285 $ 616,428 100.3% 2015 Total $ 7,421,003 $ 7,325,445 98.7% Jan-16 10938 4694 $ 305,717 $ 325,576 $ 631,293 $ 812,052 128.6% Feb-16 10935 4710 $ 305,633 $ 326,686 $ 632,319 $ 670,795 106.1% Mar-16 10986 4699 $ 307,059 $ 325,923 $ 632,981 $ 694,372 109.7% Apr-16 11024 4700 $ 308,121 $ 325,992 $ 634,113 $ 773,152 121.9% May-16 10988 4701 $ 307,115 $ 326,061 $ 633,176 $ 571,103 90.2% Jun-16 10933 4700 $ 305,577 $ 325,992 $ 631,569 $ 712,717 112.8% Jul-16 10877 4682 $ 304,012 $ 324,744 $ 628,756 $ 773,696 123.1% Aug-16 10708 4676 $ 299,289 $ 324,327 $ 623,616 $ 857,911 137.6% Sep-16 10139 4690 $ 283,385 $ 325,298 $ 608,683 $ 505,976 83.1% Oct-16 10580 4741 $ 295,711 $ 328,836 $ 624,547 $ 565,462 90.5% Nov-16 10733 4749 $ 299,987 $ 329,391 $ 629,378 $ 530,256 84.3% Dec-16 10818 4759 $ 302,363 $ 330,084 $ 632,447 $ 609,341 96.3% 2016 Total $ 7,542,878 $ 8,076,833 107.1% Jan-17 10937 4985 $ 305,689 $ 345,760 $ 651,449 $ 825,271 126.7% Feb-17 10937 4997 $ 305,689 $ 346,592 $ 652,281 $ 698,071 107.0% Mar-17 10924 4996 $ 305,326 $ 346,523 $ 651,848 $ 726,957 111.5% 2015-2017 Total $16,919,460 $17,652,577 104.3% Page 5 of 22
Appendix F NOTICE OF INTENT TO PROPOSE Wake County Public School System Purchasing Department Attn: Rick Hunter, Purchasing Manager 1551 Rock Quarry Road Raleigh, NC 27610-4145 FAX: (919) 856-8107 TELEPHONE: (919) 694-8729 This form will provide Wake County Public School System written notification of our Intent to Propose Group Dental Insurance. PROPOSER S NAME PROPOSER S F.E.I.D. INSURER NAME (if different than Proposer) INSURED S F.E.I.D. PROPOSER S ADDRESS TELEPHONE NUMBER FAX NUMBER CONTACT PERSON EMAIL ADDRESS DATE SUBMITTED Page 6 of 22
Appendix G References Please use the format below for submitting references as outlined in the RFP. Organization 1: Point of Contact: Mailing Address: Phone Number: Length of Relationship: Email Address: Type of Insurance Contract No. of covered employees: Insurer Providing Insurance Contract: _ Agent Name (if applicable): Client Reference Type: O Public Sector O Private Client Organization 2: Point of Contact: Mailing Address: Phone Number: Length of Relationship: Email Address: Type of Insurance Contract No. of covered employees: Insurer Providing Insurance Contract: _ Agent Name (if applicable): Client Reference Type: O Public Sector O Private Client Organization 3: Point of Contact: Mailing Address: Phone Number: Length of Relationship: Email Address: Type of Insurance Contract No. of covered employees: Insurer Providing Insurance Contract: _ Agent Name (if applicable): Client Reference Type: O Public Sector O Private Client Page 7 of 22
Appendix H NON-COLLUSION STATEMENT I certify that this proposal is made without prior understanding, agreement, or connection with any corporation, firm or person submitting a proposal for the same services, and is in all respects fair and without collusion or fraud. I agree to abide by all conditions of this proposal and certify that I am authorized to sign this document for the organization and that the organization is in compliance with all requirements of this Request for Proposal including, but not limited to, certification requirements. In submitting a proposal to the Wake County Public School System, the organization offers and agrees that, upon acceptance, the organization is deemed to have sold, assigned, and transferred to the Wake County Public School System all rights, title and interest in and to all causes of action it may now or hereafter acquire under the antitrust laws of the United States and the State of North Carolina relating to the particular commodities or services which may be purchased or acquired by the Wake County Public School System. RFP: Proposer: Authorized Officer: Signature Date Authorized Officer: Printed or typed name Title or Position: Telephone: Page 8 of 22
Appendix I DISCLOSURE INFORMATION Upon reasonable inquiry, the organization discloses, on the lines below: That the following identified owner, officer, director, employee, agent or lobbyist who is/was a current or former member, officer or employee of the Wake County Public School System or any of its units and was, is, or will be significantly involved in preparing or approving this contract, representing the interests of the organization regarding this contract, or doing the work covered under this contract. That the following identified current or former member or employee of the Wake County Public School System owns, directly or indirectly, an interest of five percent (5%) or more of the total assets or capital stock in the company. Name: Title: Name: Title: Name: Title: If none, check here RFP: Name of Proposer: Authorized Officer: Signature Date Authorized Officer: Print or type name Title or Position: Telephone: Page 9 of 22
Appendix J Mandatory Warranties and Requirements Each Proposer shall warrant that they understand, represent, and acknowledge that it is professionally qualified and possesses the requisite skills, knowledge, qualifications and experience to provide the required services. The mandatory requirements included must be verified as follows (if the Proposer cannot so certify to any of following, the Proposer shall submit with its Proposal a written explanation of why it cannot agree and include reasoning for noncompliance. In the following chart please check ( ) each item on the featured outline with an appropriate response. Include all supporting verification and documentation. Name of Proposer: Warranties and Requirements Agree The insurer has a minimum of five years experience in writing, underwriting and servicing Group Dental Insurance. (1.12.1) The experience of the insurer s current book of business includes at least two Group Dental Insurance contracts (policies) having a minimum of 1,500-2,000, covered employees. (1.12.2) All organizations associated with this RFP or the resultant insurance contract (policy), including the agent or any other organization, has experience with at least two Group Dental Insurance contracts (policies) having a minimum of 1,500-2,000, covered employees. (1.12.3) All insurance agents associated with this RFP or the resultant insurance contract (policy) possess a North Carolina resident or nonresident license. (1.12.4) All organizations associated with this RFP or the resultant insurance contract (policy) has a minimum of three years experience in marketing a Group Dental Insurance contract (policy). (1.12.5) The Proposer, including the insurer, agent or any other organization associated with this RFP or the resultant insurance contract (policy), is currently or will be registered with the State of North Carolina, prior to the insurance contract (policy) award. (1.12.6) The Proposer, including the insurer, agent or any other organization associated with this RFP or the resultant insurance contract (policy), is not currently under suspension or debarment by the State or any other governmental authority.(1.12.7) Insurers will submit the most recent years audited financial statement if requested by the Legislature. (1.12.8) To the best knowledge of the person signing the Proposal, the Proposer, its affiliates, subsidiaries, directors, officers, employees or any other organization associated with this RFP or the resultant insurance contract (policy) are not currently under investigation by any governmental authority and have not in the last ten years been convicted or found liable for any act prohibited by law in any jurisdiction, involving conspiracy or collusion with respect to bidding on any public contract. (1.12.9) To the best knowledge of the person signing the Proposal, the Proposer, its affiliates, subsidiaries, directors, officers or any other organization associated with this RFP or the resultant insurance contract (policy) have no delinquent obligations to the State, including a claim by the State for liquidated damages under any other contract. (1.12.10) Page 10 of 22
Warranties and Requirements To the best knowledge of the person signing the Proposal, the Proposer, its affiliates, subsidiaries, directors, officers or any other organization associated with this RFP or the resultant insurance contract (policy) have not within the preceding three years been convicted of or had a civil judgment rendered against them or is presently indicted for or otherwise criminally or civilly charged for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a federal, state, or local government transaction or public contract; violation of federal or state antitrust statutes; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property. (1.12.11) To the best knowledge of the person signing the Proposal, the Proposer, its affiliates, subsidiaries, directors, officers or any other organization associated with this RFP or the resultant insurance contract (policy) have not within a three-year period preceding this certification had one or more federal, state, or local government public transactions terminated for cause or default. (1.12.12) The proposed Group Dental Insurance contract shall be provided by one insurer; however, insurers may submit proposals through multiple agents and agents may submit proposals through multiple insurers. (1.13.1) All commission, if any, should be provided and shall be included in the rate quoted to the WCPSS. (1.13.2) The proposed Group Dental Insurance contract (policy) shall meet or exceed all Group Dental Insurance benefits provided in the WCPSS current Group Dental Insurance contract (policy). (1.13.3) The person signing the Proposal has the authority to bind the Proposer. (1.13.4) The Proposer must have a detailed plan to provide continued service and support of the resultant insurance contract in the event the Proposer s company is no longer the servicing carrier for any reason, including going out of business, merging with another company or is otherwise unable to fulfill its obligation under the insurance contract. (1.13.5) The Proposer will satisfactorily provide all services requested as specified in the RFP, and the completion of those services will be the responsibility of the successful Proposer. (1.13.6) The Proposer shall at all times during the insurance contract (policy) term remain responsive and responsible. (1.13.7) The Contractor shall maintain Commercial General Liability Insurance with limits sufficient to cover losses resulting from, or arising out of, Contractor action or inaction in the performance of the Contract by the Contractor, its agents, employees, or subcontractors, but no less than a Combined Single Limit for Bodily Injury, Property Damage, and Personal and Advertising Injury Liability of $1,000,000 per occurrence and $2,000,000 aggregate. (1.13.8) The Contractor shall maintain Errors and Omissions/Professional Liability insurance with minimum limits of $1,000,000 per occurrence. (1.13.9) The Contractor shall maintain Automobile and/or Commercial Truck Insurance as appropriate with Liability, Collision, and PIP of $100,000 per occurrence and $300,000 aggregate where the vehicle(s) is registered but in no case less than those required by the State of North Carolina.(1.13.10) Agree Page 11 of 22
Warranties and Requirements The Contractor shall maintain Employee Theft Insurance with minimum limits of $1,000,000 per occurrence. (1.13.11) Within five (5) Business Days of execution of a Contract with the WCPSS, the Contractor shall provide the Contract Monitor with current certificates of insurance, and shall update such certificates from time to time but no less than annually in multi-year contracts, as directed by the Contract Monitor. Such copy of the Contractor s current certificate of insurance shall contain at minimum the following: a. Workers Compensation The Contractor shall maintain such insurance as necessary and/or as required under Workers Compensation Acts and the Federal Employers Liability Act. b. Commercial General Liability as required in Section 1.13.8. c. Errors and Omissions/Professional Liability as required in Section 1.13.9. d. Automobile and/or Commercial Truck Insurance as required in Section 1.13.10. e. Employee Theft Insurance as required in Section 1.13.11. (1.13.12) Agree The WCPSS shall be named as an additional named insured on the policies with the exception of Worker s Compensation Insurance and Professional Liability Insurance. Certificates of insurance evidencing coverage shall be provided prior to the commencement of any activities in the Contract. All insurance policies shall be endorsed to include a clause that requires that the insurance carrier provide the WCPSS, by certified mail, not less than 45 days advance notice of any non-renewal, cancellation, or expiration. In the event the WCPSS receives a notice of non-renewal, the Contractor shall provide the WCPSS with an insurance policy from another carrier at least 30 days prior to the expiration of the insurance policy then in effect. All insurance policies shall be with a company licensed by the State to do business and to provide such policies. (1.13.13) The Contractor shall require that any subcontractors providing services under this Contract obtain and maintain similar levels of insurance and shall provide the WCPSS with the same documentation as is required of the Contractor. (1.13.14) Name of Proposer: Name of Insurer: Name of Agency or any organization that will assist in the placement, service or any other capacity: List all Agents that will assist in the placement, service or any other capacity: Page 12 of 22
Appendix K Technical/Reference Proposal (Questionnaire) In submitting a Proposal, each Proposer understands, represents, and acknowledges all the conditions of the RFP (if the Proposer cannot so certify to any conditions of the RFP, the Proposer shall submit with its Proposal a written explanation of why it cannot do so). Responses to the questions below will be scored using a scale grading based on minimum to top responses by an evaluation committee and will provide the basis of each Proposer s initial score.. Scores from the Technical/Reference Proposal (Questionnaire) below and scores from the Premium (cost) Proposals will be used to determine the successful Proposer, therefore responses to questions should be complete. Proposers are encouraged to provide simple, easy to understand terms in lieu of industry jargon. Answer all questions below. Those questions requiring additional space, information or attachments, should be included with the question, response, information and attachments including a reference to the additional information. All differences being proposed that conflict with any requirement provided within the RFP should be outlined in the response. Technical/Reference Evaluation Areas Available Points Warranties (Experience)-Section 1.12.1, 1.12.2, 1.12.3, 1.12.5 8 Group Dental Insurance Plan Type 3.3 6 Group Dental Insurance Coverage 3.4 10 Dental Procedures 3.4.2 5 Claims-Section 3.8 4 Customer Service 3.9 5 Reporting Requirement 3.11 4 Usual, Customary & Reasonable 3.12 5 Explanation of Benefits 3.13.6 5 Enhancements-Section 3.15 4 Statement of Compliance 3.16 2 References-Section 5.3.2.1 & 5.3.2.2 2 Maximum Available Technical/Reference Points 60 Page 13 of 22
Technical/Reference Questionnaire Possible Points Name of Proposer: Warranties (Experience): Number of years experience in writing, underwriting and servicing a self-insured Group Dental Insurance? Minimum requirements listed in Section 1.12.1 Number of insured s having a minimum of 1,500-2,000, covered employees within current book of business. Minimum requirements listed in Section 1.12.2 What is the average number of employees currently provided by each Group Dental Insurance Policy? Minimum requirements listed in Section 1.12.3 Size (number of covered employees) of largest policyholder within current book of business Minimum requirements listed in Section1.12.3 8 Number of years experience in marketing and servicing Group Dental Insurance? Minimum requirements listed in Section1.12.5 Group Dental Insurance Plan requirements listed in Section 3.3: Passive Preferred Provider Organization Dental Plan Offered? Included? Yes No If No, please explain below: 6 How often are changes (additions, deletions & corrections) to the directory of participating providers updated? Participating Providers requirements listed in Section 3.3.1: Provide the number of participating providers including general dentist or dental specialist that are within each Zip Code and County: Zip Code: County: No. of General Dentist No. of Dental Specialist Page 14 of 22
Technical/Reference Questionnaire Possible Points Name of Proposer: Group Dental Insurance Coverage minimum requirements in Section 3.4: SCHEDULE OF BENEFITS *Preventive and Diagnostic Services *Basic Services *Major Services TABLE OF ALLOWANCE **PP **NPP Deductible Amount Benefit Percentage % % Deductible Amount Benefit Percentage % % Deductible Amount Benefit Percentage % % 10 *Maximum Benefit Amount per benefit period Orthodontia Services $ Deductible Amount Benefit Percentage % % Maximum Benefit Amount per lifetime $ **PP-Participating Provider; NPP Non-Participating Provider Dental Procedures: Confirm that all dental procedures currently provided under Ameritas, will be provided or identify any dental procedures that will not be covered. Minimum requirements listed in Section 3.4.2 Additional Codes provided: 5 Claims: Explain in detail the claims filing process, claims counseling services provided and claims processing guidelines including the review process and monitoring procedures. Minimum requirements listed in Section 3.8 4 Page 15 of 22
Technical/Reference Questionnaire Possible Points Name of Proposer: Customer Service: Explain the customer service provided to insureds and the customer service satisfaction tools used including complaint resolution. Minimum requirements listed in Section 3.9 5 Reporting Requirements: Explain in detail the ability to process weekly and monthly claim reports for the below reports, including any capability for custom reporting. Experience Report that includes; date of birth, gender, description of dental procedure and paid claim amount monthly report Billing Report that includes; benefit type, employee ID number, full name, plan year, date of birth, check number, check date, amount of check paid weekly report Fiscal Year-End Report that includes; same fields as the billing report but isolated for only claims paid for July and August annual report due by Sept 1 4 Usual, Customary and Reasonable (UCR) Fees: Explain in detail how UCR fees are determined, what reimbursement percentile is used to determine UCR amounts and how often your organization s UCR fees are updated? Minimum requirements listed in Section 3.12 5 Explanation of Benefits: Provide a sample of the EOB that will be used by your organization. Minimum requirements listed in Section 3.13.6 Enhancements: Explain in detail the enhancements offered by your organization, including additional services, comparable services or support services that would better serve the insured and provide broader benefits. Referenced in Section 3.15 5 4 Statement of Compliance: Provide a statement of compliance that the resultant dental plan will not reduce Group Dental Insurance benefits for insureds or a written explanation of why your organization cannot certify compliance. Referenced in Section 3.16 2 References: Provide references on Appendix G included in the RFP. Requirements in Section 5.3.2.1 & 5.3.2.2. 2 Total Score: 60 Page 16 of 22
Appendix L Premium (Cost) Proposal Rate Form-Three Year Insurance Contract (Policy) Term Dental Insurance Rate Form The Premium (Cost) Proposal must not contain any Technical/Reference information. L-Insured Person Rate $ M-Insured Person Rate w/dependents $ N-Combined Average Rate (Average of L&M) [To be completed by the WCPSS] O-Total Annual Administrative Cost $ P-Projected Percentage of Network Usage % Rate Guarantee (expressed in years) 3 Year Proposers must complete the Insured Person Rate and Insured Person Rate w/dependents above, if proposing a three year insurance contract (policy) term. Name of Proposer: Page 17 of 22
Appendix M General Business Information The Proposer, including the insurance agency, insurer and any other organization associated with this RFP, must indicate the name, address, telephone number, email address, FAX number, and Employer Identification Number (EIN) of the legal entity with which the insurance contract (policy) is to be administered by and written through. Name of Proposer: Name of Agency: Primary Point of Contact: Mailing Address: Phone Number: Fax Number: Email Address: Employer Identification No.: Agent s Name and License Number: Name of Insurer: Primary Point of Contact: Mailing Address: Phone Number: Fax Number: Email Address: Employer Identification No.: Company Name: (any other organization associated with this RFP) Primary Point of Contact: Mailing Address: Phone Number: Fax Number: Email Address: Employer Identification No.: Page 18 of 22
Appendix N Drug Free Workplace Certification Form Preference shall be given to businesses with drug-free workplace programs. Whenever two or more submittals which are equal with respect to price, quality, and service are received by the State or by any political subdivision for the procurement of commodities or contractual services, a submittal received from a business that certifies that it has implemented a drug-free workplace program shall be given preference in the award process. In order to have a drug-free workplace program, a business shall: 1) Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2) Inform employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, the penalties that may be imposed upon employees for drug abuse violations. 3) Give each employee engaged in providing the commodities or contractual services that are under contract a copy of the statement specified in subsection (1). 4) In the statement specified in subsection (1), notify the employees that, as a condition of working on the commodities or contractual services that are under contract, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5) Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available who is so convicted. 6) Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this respondent complies fully with the above requirements. I certify that has a drug-free workplace program as noted above. Corporate Name of Respondent (Typed) Authorized Officer s Signature Title Date Page 19 of 22
Appendix O Electronic Verification Compliance E-VERIFY REQUIREMENTS FOR CONTRACTORS As a requirement and condition of this Agreement, the Contract must use the Department of Homeland Security s E-Verify system when hiring new employees for the term of the contract. E-Verify is an electronic system designed to verify the documentation of job applicants. It is operated by the U.S. Department of Homeland Security. Further information on E-Verify can be found at the following website: http://www.uscis.gov/e-verify This requirement shall apply to the Contractor and any and all sub-contractors that may be hired during the performance of this contract. Subcontractors, if any, shall also be required to sign an Affidavit of Compliance and retain that Affidavit for four (4) years after the end of the contract. E-Verify must be used ONLY for newly hired employees during the term of the contract. It is NOT to be used for existing employees. E-Verify must be used to verify the documentation of ANY new employee during the term of the contract, not just those directly or indirectly working on deliverables related to this contract. Contractor shall retain a copy of the E-Verify Memorandum of Understanding that they execute with the Department of Homeland Security. Sign and submit to the WCPSS an Affidavit of Compliance with the executed contract. The WCPSS reserves the right to audit the Contractor s compliance with these requirements. AFFIDAVIT OF COMPLIANCE WITH DEPARTMENT OF HOMELAND SECURITY S E-VERIFY SYSTEM As the person duly authorized to enter into such commitment for, (Company or Organization Name) I hereby certify that the Company or Organization named herein will (Check one box below) Be in compliance with all of the requirements of E-Verify for the duration of the contract entered into between the WCPSS and the Company or Organization OR Hire no employees for the term of the contract between the WCPSS and the Company or Organization Authorized Officer s Signature Title Date Page 20 of 22
Appendix P PERFORMANCE GUARENTEES CATEGORY Plan Implementation DEFINE COMMITMENT MEASURABLE TIME FRAME PENALTY Benefit Availability Enrollment Assistance Claim Turnaround Time Claim Savings PPO Savings Member Satisfaction Account Management Financial Accuracy Reporting Accuracy Processing Accuracy Call Center Service Level Call Center Abandonment Rate Call Center Wait Time Page 21 of 22
Appendix Q CHECKLIST Vendor Name: This checklist is provided to assist the Proposer in preparation of its Proposal. Because this checklist is just a guideline, the Proposer must read and comply with the RFP in its entirety. RFP Cover Sheet, Completed and Signed-Page 1. Notice of Intent to Propose (Submitted by deadline) Appendix F. References Appendix G. Non-Collusion Statement Appendix H. Disclosure Information Appendix I. Mandatory Warranties and Requirements Appendix J. Technical/Reference Questionnaire Appendix K. Premium (cost) Rating Form Three Year Appendix L. Copies 1 original, 6 copies + 1 CD-ROM of Technical/Reference & 1 original, 1 copy + 1 CD ROM of Premium (cost) General Business Information Appendix M. Drug Free Workplace Appendix N. Electronic Verification Compliance Appendix O. Performance Guarantees Appendix P. Copy of Proposer s standard Group Dental Insurance Policy. Page 22 of 22