Tool 3, Part III: RFP and Vendor Scoring Medical Plan Vendor Scoring

Transcription

1 Tool 3, Part III: RFP and Vendor Scoring Medical Plan Vendor Scoring ENTER IN COLUMN G FOR MEDICAL PLAN VENDORS. BENEFIT # MEDICAL BENEFITS Does the medical plan offer a network that provides access to a wide range of cancer care providers, including medical oncologists, hematologists, radiation oncologists, oncology surgeons, palliative care specialists and pathologists, both in the community setting and in large, academic cancer centers, including National Cancer Institute (NCI)-designated Comprehensive Cancer Centers and Cancer Centers? A. Medical plan offers a national network of providers that includes at least 90% of indicated specialists in the community and academic medical center settings. Follow-up question: Does the network include academic medical centers/cancer centers and NCI-designated Comprehensive Cancer Centers or NCI-designated Cancer Centers? 1. Academic and NCI-designated Cancer Centers are available throughout the network s geographic area. 2. Academic and NCI-designated Cancer Centers are limited or unavailable in some markets. 3. Network does not provide access to academic and NCI-designated Cancer Centers. B. Medical plan offers a regional network of providers and can demonstrate that it includes at least 90% of indicated specialists in its region within its network. Select and score one option: (A, B, C or D) Score any follow-up questions under chosen option. 3 1 (1, 2 or 3) 1 Up to 12 points (based on adequacy of response) 3 SHOWN 4 Follow-up question: Does the network include academic medical centers/cancer centers and NCI-designated Comprehensive Cancer Centers or NCI-designated Cancer Centers? 1. Yes, academic and NCI-designated Cancer Centers are available throughout the network s geographic area. 2. Academic and NCI-designated Cancer Centers are limited or unavailable in some markets. 3. Network does not provide access to academic and NCI-designated Cancer Centers. C. Medical plan offers access to at least 90% of providers (hospitals and physicians) within the community as part of its network, but offers access to providers outside the community and to academic medical centers/cancer centers (including NCIdesignated Comprehensive Cancer Centers and Cancer Centers) at the network benefit level only upon request and with prior approval. Follow-up question: If prior approval is required, what is actual average turnaround time? 1. Prior approval is required, and actual average turnaround time is 72 hours or less. Confirmed ability to give approval more quickly if there is a critical clinical need. 2. Prior approval is required, and actual average turnaround time is more than 72 hours. D. Medical plan does not provide academic medical centers/cancer centers within its network or access to such centers outside its network when needed for specialized care. (1, 2 or 3) 1 Up to 12 points (based on adequacy of response) 1 (1 or 2) 1 1

2 Does the medical plan offer a Transplant Centers of Excellence (COE) Network program that employs a rigorous qualification process using transplant-specific criteria? Follow-up question 1: Does the transplant COE program employ a rigorous qualification process using transplant-specific criteria? Follow-up question 2: Does the transplant COE program reevaluate transplant centers at least every two years? Follow-up question 3: Does the transplant COE program have criteria and a process to remove a transplant center that no longer meets its criteria? 2. Are transplant COE contracts all-inclusive of hospital services and all applicable physicians, ancillary and other health care professionals (including behavioral health specialists) who provide care during the transplant period? 3. Does the transplant COE program provide access to nurses to guide patients in understanding their condition and choosing an appropriate transplant center? A. Transplant COE program employs nurses with transplant expertise to identify and support candidates for transplant. Nurses are supported by a physician with transplant expertise. B. Transplant COE program does not have nurses available to identify and support candidates for transplant. 4. Does the medical plan cover pre-transplant, transplant and post-transplant care recommended by the transplant center and donor search and typing costs according to specifications? Does the medical plan offer a Cancer Centers of Excellence (COE) Network program that employs a rigorous qualification process? Follow-up question 1: Does the cancer COE program employ a rigorous qualification process using relevant criteria? Follow-up question 2: Does the cancer COE program reevaluate cancer centers at least every two years? Follow-up question 3: Does the cancer COE program have a process in place to remove a cancer center that no longer meets its criteria? 2. Are cancer COE contracts all-inclusive of hospital services and all applicable physicians, ancillary and other health care professionals (including behavioral health specialists) who provide care? 3. Does the medical plan that provides the cancer COE program provide access to nurses to guide patients in understanding their condition and choosing an appropriate cancer center? A. Cancer COE program employs nurses with oncology expertise to identify and support individuals with cancer. Nurses are supported by a physician with oncology expertise to identify and support individuals with cancer. B. Cancer COE program does not have nurses available to identify and support individuals with cancer. If yes, complete this If no, or an external vendor provides this program, proceed to the next If yes, 2 points If no, If yes, 2 points If no, If yes, 2 points If no, If yes, If no, 0 to 4 points, depending on number and importance of excluded providers and/ or services If yes, 4 points If no, If yes, complete this If no, or if an external vendor provides this program, proceed to the next If yes, 4 points If no, If yes, 4 points If no, If yes, 4 points If no, If yes, 8 points If no, 0 to 6 points, depending on number and importance of excluded providers and/ or services SHOWN 2 3 2

3 Is the medical plan able to administer a travel and lodging (T&L) assistance program consistent with the eligibility criteria and level of coverage the employer establishes? A. Medical plan currently administers the travel and lodging program consistent with specifications, or describes how it can administer the program according to specifications. B. Medical plan currently administers, or describes how it can administer the program, but cannot fully implement it according to specifications. If the employer does not provide travel and lodging assistance, or if an external vendor operates the program, proceed to the next 1-4 points depending on acceptability of response C. Medical plan is not able to administer the travel and lodging program Does the medical plan cover services that are components of a second opinion (for review of the diagnosis, review of the treatment plan or both) at standard reimbursement levels for individuals with a diagnosis or suspected diagnosis of cancer? A. Medical plan policy specifically states that claims are paid at standard reimbursement for evaluation & management (E&M) services, pathology review, diagnostic radiology services and laboratory tests even if equivalent services were previously billed by other providers and claims were paid. B. Medical plan pays a reduced amount for evaluation & management (E&M) services, pathology review, diagnostic radiology services and laboratory tests when equivalent services were previously billed by other providers and claims were paid. OR Medical plan does not reimburse for these services. (A, B, C or D) 2 Up to 18 points depending on acceptability of response C. Medical plan does not pay for second opinion services. D. Medical plan policy states that, with prior authorization and confirmation that a second opinion is sought from a large, academic cancer center or other large cancer center, medical plan pays claims at standard reimbursement for evaluation 1 & management (E&M) services, pathology review, diagnostic radiology services and laboratory tests even if equivalent services were previously billed by other providers and claims were paid. Indicate which services require prior authorization. Follow-up question: If prior authorization is required, what is actual average turnaround time? 1. Prior approval is required, and actual average turnaround time is 72 hours or less. Confirmed ability to give approval more quickly if there is a critical clinical need. 2. Prior approval is required, and actual average turnaround time is more than 72 hours Does the medical plan cover routine costs of care when the patient is enrolled in a qualified cancer clinical trial, comparable to coverage for services provided outside of a clinical trial? A. Documentation is provided stating that routine costs of care are covered when a cancer patient is enrolled in a qualified clinical trial as specified. B. Documentation is provided stating that routine costs of care are covered when a cancer patient is enrolled in a qualified clinical trial, which is defined more narrowly than in this recommendation. (1 or 2) 3 Up to 1 depending on acceptability of response Follow-up question to either of the two responses above: If prior authorization is required, what is actual average turnaround time? 1. Actual average turnaround time is 72 hours or less. 2. Actual average turnaround time is more than 72 hours. C. Routine costs of care are not covered when a cancer patient is enrolled in a clinical trial. SHOWN 24 points 3 3

4 1.7 Hospice Benefit Complete parts Does the medical plan s standard benefit plan include a hospice benefit as described in this recommendation for individuals with an estimated life expectancy of 12 months or less? A. Medical plan provides documentation stating that it covers hospice services based on eligibility of an estimated life expectancy of 12 months or less. B. Medical plan provides documentation that it provides coverage for hospice services with a shorter life expectancy than 12 months. 1 C. Medical plan does not cover hospice services. 2. Does the medical plan cover routine costs of care for individuals enrolled in a qualified clinical trial while also enrolled in hospice, and are these costs paid separately from the hospice per diem? A. Medical plan covers routine costs of care for individuals enrolled in a qualified clinical trial while also enrolled in hospice and reimburses those costs separately from the hospice per diem. B. Medical plan covers routine costs of care for individuals enrolled in a qualified clinical trial while also enrolled in hospice, but does not reimburse those costs separately from the hospice per diem, or does not cover clinical trials. 3. Does the medical plan cover residential services (in a residential hospice, skilled nursing or assisted living facility or when provided by in-home aides) when an individual is eligible for and enrolled in a hospice program and meets other criteria described in this recommendation? A. Medical plan covers residential services consistent with the options and eligibility criteria consistent with specifications. B. Medical plan covers residential services using narrower eligibility criteria and/or fewer residential care options. 3 points 6 points 3 points C. Medical plan does not cover residential services. 4. Does the medical plan provide care management support for individuals with a diagnosis of cancer, an advanced illness and/or who are terminally ill? A. Medical plan provides a focused care management program targeted to meet the needs of individuals with a diagnosis of cancer, individuals with advanced illness and/or individuals who are terminally ill. Nurses have specific training and experience with these conditions and are supported by a medical director with expertise in cancer, palliative care and/or hospice care. B. Medical plan provides a general care management program that has multiple objectives that include working with individuals with cancer, an advanced illness or those who are terminally ill. Nurses have training and experience with these conditions and are supported by a medical director with expertise in cancer, palliative care and/or hospice care. 6 points 3 points C. Medical plan or other vendor provides a general care management service only. 5. Does the medical plan employ a qualification process for hospice programs to ensure that they have appropriate certification and meet quality standards? A. Medical plan provides a description of a robust set of criteria used to evaluate hospice programs. B. Medical plan does not evaluate hospice programs or does not offer a network of hospice providers. 3 points SHOWN 33 points 4

5 Does the medical plan cover consultation by a network physician with patients and family members about options for care at standard reimbursement rates? A. Medical plan pays claims for evaluation & management (E&M) or consultation services when applicable CPT codes are used even if equivalent services were previously billed by other providers and claims were paid. B. Medical plan pays a reduced amount for evaluation & management (E&M) or consultation services when equivalent services were previously billed by other providers and claims were paid. C. Medical plan does not pay for E&M or consultation services if equivalent services were previously billed by other providers and claims were paid Does the medical plan s standard benefit plan cover nutrition counseling and medical nutrition therapy for individuals with a diagnosis of cancer? A. Medical plan covers nutrition counseling and medical nutrition therapy for individuals with cancer when provided by registered dietitians. B. Medical plan covers nutrition counseling and medical nutrition therapy for individuals with cancer only when provided by registered dietitians with prior authorization. Follow-up question: What is actual average turnaround time? 6 points 3 points 1. Actual average turnaround time is 72 hours or less. 2 points 2. Actual average turnaround time is more than 72 hours. 2. Does the medical plan include registered dietitians within its provider network, including dietitians who are Board-certified in oncology (CSO)? A. Medical plan network includes registered dietitians and employs an accreditation process to ensure that participating dietitians have required qualifications. Through this process, medical plan confirms that, where available, dietitians who are Boardcertified specialists in oncology (CSO) are included in the network. B. Medical plan network includes registered dietitians but does not employ an accreditation process to ensure that dietitians have required qualifications. 2 points 1 point C. Medical plan network does not include registered dietitians Does the medical plan cover dental preventive services and treatments when required prior to, during and after cancer treatment or stem cell transplantation and when not otherwise covered by dental benefits in a way that is consistent with specifications? A. Medical plan covers dental prevention services and treatments in a way that is consistent with these specifications. B. Medical plan covers dental prevention services and treatments to a more limited extent than defined in this recommendation and/or with narrower eligibility criteria for coverage. C. Medical plan covers dental prevention services and treatments only through use of out-of-network benefits. 2. Does the provider network include dentists and oral surgeons, including maxillofacial surgeons (MD/DDS or DDS), on faculty at academic medical centers and cancer centers? Does the medical plan s standard benefit plan cover molecular/biomarker testing based on recommendations in NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines )? 2-4 points depending on adequacy of response If yes, If no, SHOWN 8 points 12 points A. Medical plan covers genetic testing and counseling based on NCCN Guidelines recommendations. A process is in place to ensure that only appropriate services are covered. B. Medical plan covers genetic testing and counseling using criteria other than NCCN Guidelines (e.g., internal medical policy or other resource). A process is in place to ensure that only appropriate services are covered. 3 points 5

6 1.12 Genetic Testing and Counseling Complete parts Does the medical plan cover genetic testing and counseling for risk assessment of individuals with significant family history based on recommendations in NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines )? A. Medical plan covers genetic testing and counseling based on NCCN Guidelines. A process is in place to ensure that only appropriate services are covered. B. Medical plan covers genetic testing and counseling using criteria other than NCCN Guidelines (e.g., internal medical policy or other resource). A process is in place to ensure that only appropriate services are covered. 4 points 2 points C. Genetic testing and counseling are not covered services. 2. Does the medical plan cover genetic counseling services only when provided by professionals certified to provide genetic counseling and medical genetic services, i.e., Board-certified or Board-eligible genetic counselors or medical geneticists (physicians)? Follow-up question: If prior authorization is required, what is actual average turnaround time? If yes, 4 points If no, 1. Actual average turnaround time is 72 hours or less. 2 points 2. Actual average turnaround time is more than 72 hours. 3. Does the medical plan network provide access to Board-certified or Board-eligible genetic counselors and medical geneticists? A. Medical plan network includes certified genetic counselors available throughout the medical plan s geographic coverage area, and confirms their qualifications prior to inclusion in network contracts. B. Medical plan includes genetic counselors within the provider network, but does not specifically address availability of qualified counselors through its geographic coverage area and does not confirm qualifications. C. Medical plan network does not include certified genetic counselors. Services provided by genetic counselors would be paid on an out-of-network basis, or medical plan does not cover genetic counseling Does the medical plan cover standard fertility preservation treatments for iatrogenic infertility (infertility caused by medically necessary cancer treatment) when treatments have been identified as appropriate by applicable professional societies? Has any requirement to demonstrate attempts to conceive before infertility benefits become available been waived? Follow-up question: Is prior authorization or other method employed to confirm that patient is at risk of infertility related to a planned cancer treatment? 4 points 1 point If yes, If no, If yes, what is actual average turnaround time? 1. Actual average turnaround time is 72 hours or less. 1 points 2. Actual average turnaround time is more than 72 hours Does the medical plan cover home health visits in a way that is consistent with this recommendation? A. Provider contract specifies number of home health visits or hours of home health services and conditions under which services are covered in a way that is consistent with the definition in this recommendation. B. Provider contract specifies number of home health visits or hours of home health services and condition under which services are covered in a way that is narrower than the definition in this recommendation 1.15 The stop-loss recommendation is not scored. 0-4 points depending on adequacy of response SHOWN 14 points 6 points 6

7 Does the medical plan cover depression screening (performed by oncologists and other covered providers) for all cancer patients and other beneficiaries? 2. Does the medical plan administrator reimburse depression screening procedures using a standardized screening instrument? Does the medical plan administrator reimburse approved providers, including oncologists, for screening, assessing and diagnosing behavioral health conditions as a primary or secondary health condition? Does the medical plan cover consultation between an approved provider, a behavioral health specialist and/or a condition management specialist to provide collaborative care for patients with cancer who are diagnosed with a behavioral health disorder but are principally treated in a medical setting? Does the plan administrator credential and contract with behavioral health providers at network cancer centers and children s hospitals? TOTAL If yes, If no, If yes, 2 points If no, If yes, If no, If yes, up to 12 points based on number of covered components addressed in RFP response. If no, If yes, If no, SHOWN 12 points 12 points 7

8 Tool 3, Part III: RFP and Vendor Scoring Pharmacy Plan Vendor Scoring ENTER IN COLUMN G FOR PHARMACY PLAN VENDORS. BENEFIT # PHARMACY BENEFITS Does the pharmacy vendor s plan include a reasonable out-of-pocket threshold, or can it be implemented so that it is consistent with this recommendation? 2. Does the pharmacy plan administrator currently work or agree to work with the medical plan vendor to implement a single out-of-pocket for medical and pharmacy expenditures? 3. Does the Specialty Pharmacy program provide counseling services to individuals obtaining oncology medications? Follow-up question: What are the qualifications of staff who counsel individuals obtaining oncology medications? If yes, If no, If yes, If no, If yes, If no, A. Clinical pharmacists with oncology expertise. 4 points B. Generalist pharmacists. 2 point C. Non-pharmacists. 4. Does the Specialty Pharmacy program provide access to information about programs to assist patients with the costs of prescription drugs? Does the pharmacy plan administrator cover evidence-based cancer treatment paid under the pharmacy benefit based on NCCN Guidelines and NCCN Drugs & Biologics Compendium recommendations for products with Category 1, 2A or 2B level of evidence? A. Pharmacy plan currently determines coverage for drugs and biologics in cancer care based on NCCN Drugs & Biologics Compendium recommendations with Category 1, 2A or 2B level of evidence, or will implement this policy. B. Pharmacy benefit plan uses the NCCN Compendium but not Category 1, 2A or 2B level of evidence to determine coverage. If yes, 1 point If no, 1 C. Medical plan does not utilize the NCCN Compendium to determine coverage. 2.3 A. Does the medical plan administrator currently work or agree to work with the pharmacy plan vendor to establish parity of patient cost sharing between the medical and pharmacy benefit? TOTAL If yes, If no, SHOWN 1 1 8

9 Tool 3, Part III: RFP and Vendor Scoring COE Program Vendor Scoring ENTER IN COLUMN G FOR CENTERS OF EXCELLENCE VENDORS. BENEFIT # CENTERS OF EXCELLENCE BENEFITS Does the Centers of Excellence (COE) program vendor offer a Transplant COE Network program that employs a rigorous qualification process using transplantspecific criteria? Follow up question 1: Does the transplant COE program employ a rigorous qualification process using transplant-specific criteria? Follow up question 2: Does the transplant COE program reevaluate transplant centers at least every two years? Follow up question 3: Does the transplant COE program have criteria and a process to remove a transplant center that no longer meets the criteria? 2. Are transplant COE contracts all-inclusive of hospital services and all applicable physicians, ancillary and other health care professionals (including behavioral health specialists) who provide care during the transplant period? 3. Does the transplant COE program vendor provide access to nurses to guide patients in understanding their condition and choosing an appropriate transplant center? A. Transplant COE program employs nurses with transplant expertise, who are supported by a physician with transplant expertise, to identify and support candidates for transplant. B. Transplant COE program does not have nurses available to identify and support candidates for transplant. 4. Does the COE program vendor implement coverage of pre-transplant, transplant and post-transplant care recommended by the transplant center and cover donor search and typing costs according to specifications? If yes, complete this question If the medical plan provides this program, proceed to the next If yes, 2 points If no, If yes, 2 points If no, If yes, 2 points If no, If yes, If no, 0 to 4 points, depending on number and importance of excluded providers and/ or services. If yes, 4 points If no, SHOWN 2 9

10 Does the Centers of Excellence (COE) program vendor offer a Cancer COE Network program that employs a rigorous qualification process? Follow-up question 1: Does the cancer COE program employ a rigorous qualification process using relevant criteria? Follow-up question 2: Does the cancer COE program vendor reevaluate transplant centers at least every two years? Follow-up question 3: Does the cancer COE program have criteria and a process to remove a cancer center that no longer meets the criteria? 2. Are cancer COE contracts all-inclusive of hospital services and all applicable physicians, ancillary and other health care professionals (including behavioral health specialists) who provide care? 3. Does the COE program vendor provide access to nurses to guide patients in understanding their condition and choosing an appropriate cancer center? A. Cancer COE program employs nurses with oncology expertise, who are supported by a physician with oncology expertise, to identify and support individuals with cancer. B. Cancer COE program does not have nurses available to identify and support individuals with cancer Is COE program vendor able to administer a travel and lodging (T&L) assistance program consistent with the eligibility criteria and level of coverage the employer establishes? A. COE program vendor currently administers the travel and lodging program consistent with specifications, or describes how it can administer the program according to specifications. B. COE program vendor currently administers, or describes how it can administer the program, but cannot fully implement according to specifications. If yes, complete this If the medical plan provides this program, proceed to the next If yes, 4 points If no, If yes, 4 points If no, If yes, 4 points If no, If yes, 8 points If no, 0 to 6 points, depending on number and importance of excluded provides and/ or services If the employer does not provide travel and lodging assistance, or if the medical plan or employer operates the program, skip this 1-4 points depending on acceptability of response C. COE program vendor is not able to administer the travel and lodging program. TOTAL SHOWN 3 10

11 Tool 3, Part III: RFP and Vendor Scoring Clinical Support & Condition Management Vendor Scoring ENTER IN COLUMN G FOR CARE MANAGEMEN VENDORS. BENEFIT # CLINICAL SUPPORT & CONDITION MANAGEMENT BENEFITS Does the vendor provide assistance related to a cancer diagnosis via a nurseline service that offers information on cancer-related clinical issues and community resources? 2. Does the vendor employ appropriately trained nurses and/or others to staff the nurseline program? A. Vendor employs nurses with training on oncology-related issues as described in this recommendation. B. Vendor employs nurses but does not provide training on oncology-specific issues; scripting on such issues is available. If yes, If no, 2 points C. Vendor employs non-nurses Does the vendor offer a cancer case management/disease management program? A. Vendor offers a cancer-specific case management program staffed by oncology nurses and supported by a physician with oncology expertise. B. Vendor offers a general case management program that serves individuals with a range of complex conditions, including cancer; the program is staffed primarily by generalist nurses with training on oncology issues and employs some oncology nurses. Nurses are supported by a physician who does not have expertise in oncology. C. Vendor offers a general case management program that serves individuals with a range of complex conditions; the program is staffed by generalist nurses. Nurses are supported by a physician who does not have expertise in oncology. 2. Does the case management program include social workers with oncology experience to support patients and their families? TOTAL Up to 8 points (based on adequacy of response) 1 point If yes, 2 points If no, SHOWN 12 points 11

12 Tool 3, Part III: RFP and Vendor Scoring Short-Term Disability (STD) Vendor Scoring ENTER IN COLUMN G FOR STD VENDORS. BENEFIT # SHORT-TERM DISABILITY (STD) Does the STD plan vendor integrate with the employer s EAP in terms of policies, procedures and practices? If managed by the employer, skip the A. STD vendor provided evidence of policies, procedures and practices for integration of EAP. B. STD vendor did not provide evidence of integration of STD with EAP Does the STD vendor utilize industry-recognized, cancer-specific guidelines to assist in certifying and managing STD cases? A. STD vendor identified guidelines by name and provided evidence of how the guidelines were used in making disability determinations, return-to-work decisions and development of accommodations Does the STD vendor require and provide evidence that case managers have a working knowledge of evidence-based treatment guidelines (e.g., NCCN Clinical Practice Guidelines in Oncology) for serious and/or chronic illnesses, including cancer? A. STD vendor provided evidence that case managers have a working knowledge of evidence-based treatment guidelines for working with those with cancer. B. STD vendor did not provide evidence that case managers have a working knowledge of guidelines for working with those with cancer. 2. Did the STD vendor provide access to an oncology-certified nurse for consultation? A. STD vendor provided evidence of having a team of oncology-certified nurses and identified which nurses staff has access to. B. STD vendor does not provide access to oncology-certified nurses Does the STD program have policies, procedures and practices to ensure that STD case managers conduct structured interviews with treating physicians, case managers and other providers involved in an employee s care to gather treatment information necessary to qualify a disability and determine the duration of leave? If managed by the employer, skip the A. STD vendor provided evidence of policies, procedures and practices that ensure case managers conduct structured interviews with physicians and others involved in an employee s treatment and care to make disability determinations. B. STD vendor did not provide evidence of such policies, procedures and practices Do STD case managers have access to health psychology/behavioral medicine specialists or health coaches trained to work with employees with serious and/or chronic illnesses, including cancer? A. STD vendor provided evidence that STD case managers have access to health psychology/behavioral medicine specialists or health coaches trained to work with employees with serious and/or chronic illnesses, including cancer. B. STD vendor did not provide evidence that case managers have access to these specialists. If managed by the employer, skip the SHOWN 15 point 12

13 Does the STD vendor have an established protocol for STD staff to use in identifying and managing comorbid behavioral health issues in individuals on disability for a serious and/or chronic illness, including cancer? If managed by the employer, skip the A. STD vendor provided evidence of a protocol for STD staff to follow in identifying and managing a comorbid behavioral health diagnosis in individuals on disability with a serious and/or chronic illness. B. STD vendor did not provide evidence of an established protocol Does the STD vendor have established standards to ensure that STD case managers have the requisite training to understand an employee s work requirements (physical, cognitive and emotional readiness)? A. STD vendor provided evidence of standards to ensure that case managers have the requisite training to understand an employee s physical, cognitive and emotional work requirements. B. STD vendor did not provide evidence of standards. 2. Did the STD vendor provide evidence that case managers have the requisite training to understand the clinical delivery system and resources available to help employees return to work? A. STD vendor provided evidence of standards to ensure that case managers have the knowledge and training to understand the clinical delivery system and resources available to help employees return to work. B. STD vendor did not provide the required evidence Does the STD vendor have established criteria for determining when accommodations are appropriate and what accommodations should be considered for cancer patients returning to work? A. STD vendor provided evidence that it has established criteria for determining when and what accommodation should be considered for cancer patients returning to work. B. STD vendor did not provide evidence of established criteria Does the STD vendor have policies and practices regarding employees with serious and/or chronic illnesses, including cancer, who return to work and need additional STD leave for the same illness, to permit continuation of the original disability period? If managed by the employer, skip the A. STD vendor provided evidence that employees who return to work and need additional disability leave for treatment of the same illness will remain on the original disability period. B. STD vendor did not provide evidence of this policy or practice. TOTAL SHOWN 15 point 13

14 Tool 3, Part III: RFP and Vendor Scoring Family Medical Leave (FML) Vendor Scoring ENTER IN COLUMN G FORFML VENDORS (IF APPLICABLE). BENEFIT # FAMILY MEDICAL LEAVE (FML) When accepting inquiries about FML or applications for it, does the FML vendor provide information about other employer-sponsored benefits that may be helpful to individuals with a serious and/or chronic illness or who are providing caregiver services? If FML is managed by the employer, skip this A. FML vendor provided evidence of policies and practices showing that individuals inquiring about FML or applying for it have been provided with up-to-date information on employer-sponsored benefits and programs that may be helpful to them. B. FML vendor did not provide evidence of such practices When accepting inquiries about FML or applications for it, does the FML vendor provide information about caregiver stress and depression and tell employees about resources that may be available to assist them? If FML is managed by the employer, skip this A. FML vendor provided evidence of policies and practices to ensure that individuals inquiring about FML or applying for it receive information on caregiver stress and depression and resources that may be able to assist them. B. FML vendor did not provide evidence of such practices. 2. Does the FML vendor train staff to screen FML applicants for depression using a standardized instrument? A. FML vendor provided evidence of policies and practices to train staff to screen FML applicants for depression using a standardized instrument. B. FML vendor did not provide evidence of such practices. 3. Does the FML vendor consistently screen individuals applying for FML for depression using a standardized instrument? A. FML vendor provided evidence of policies and practices that demonstrate consistent screening of applicants for FML for depression. B. FML vendor did not provide evidence of such policies and practices When accepting inquiries about FML or applications for it, does the FML vendor provide information about financial counseling and assistance that is available through the EAP or other resources? If FML is managed by the employer, skip this A. FML vendor provided evidence of policies and practices to ensure that individuals inquiring about FML or applying for it receive information about financial counseling and assistance. B. FML vendor did not provide evidence of such policies and practices. TOTAL SHOWN 1 14

15 Tool 3, Part III: RFP and Vendor Scoring Employee Assistance Programs (EAPs) Vendor Scoring ENTER IN COLUMN G FOR EAP VENDORS. BENEFIT # EMPLOYEE ASSISTANCE PROGRAMS (EAPs) Does the EAP vendor integrate with the employer s STD in terms of policies, procedures and practices? If EAP is managed by the employer, skip this A. EAP vendor provided evidence of policies, procedures and practices for integrating with the employer s STD. B. EAP vendor did not provide evidence of such policies, procedures or practices Do the vendor s hiring and credentialing processes require that EAP professionals have basic training and knowledge about the cognitive, emotional and physical issues associated with serious and/or chronic illnesses, including cancer? A. EAP vendor provided evidence that its hiring and credentialing processes require EAP professionals to have basic training and knowledge about the cognitive, emotional and physical issues associated with serious and/or chronic illnesses, including cancer. B. EAP vendor did not provide evidence of its hiring and credentialing processes. 6.3 Do the policies and procedures of the EAP vendor: for each of the following three questions. If EAP is managed by the employer, skip this 1. Define when and how EAP staff are responsible for providing consultation to HR professionals and supervisors of employees with a serious and/or chronic illness? A. EAP vendor provided evidence of policies and procedures that define when and how EAP staff are responsible for providing consultation to HR staff and supervisors of employees with a serious and/or chronic illness. B. EAP vendor did not provide evidence of such policies or procedures. 2. Define how EAP staff can work effectively with employees and their dependents who are coping with cancer and other serious and/or chronic illnesses? A. EAP vendor provided evidence of policies and procedures that define how staff can work effectively with employees and their dependents who are coping with cancer and other serious and/or chronic illnesses.. B. EAP vendor did not provide evidence of such policies or procedures. 3. Define how the EAP vendor evaluates effectiveness of staff in a way that is consistent with specifications in the RFP question? A. EAP vendor provided evidence that demonstrates effective evaluation of staff performance. B. EAP vendor did not provide evidence as required Does the EAP vendor s orientation and training for employees supervisors and managers provide information and resources about addressing serious and/or chronic illness in a way that is consistent with the specifications in the RFP question? A. EAP vendor provided evidence of orientation and training information and resources for supervisors and managers. B. EAP vendor did not provide evidence of orientation and training for managers and supervisors. SHOWN 3 15

16 Does the EAP vendor have a network of credentialed health psychology/behavioral medicine specialists and health coaches who are skilled at working with employees and their dependents dealing with serious and/or chronic illnesses, including cancer? A. EAP vendor provided evidence of an adequate number of skilled health psychology/behavioral medicine specialists and health coaches capable of providing telephone consultation. B. EAP vendor did not provide evidence of a sufficient network of health psychology/ behavioral medicine specialists and health coaches. 2. Does the EAP vendor describe how specialists work with supervisors and/or provide direct services to employees and their dependents? A. EAP vendor described and provided evidence of supervisors consultation services and how and when direct services are provided to employees and their dependents. B. EAP vendor did not describe services provided by these specialists Does the EAP network include health psychology and/or behavioral medicine specialists who are trained to coordinate with STD case managers about employees with depression and other behavioral health issues in a way that is consistent with the specifications in the RFP question? A. EAP vendor provided evidence of an adequate number of health psychology/ behavioral medicine specialists who are trained to coordinate with STD staff about employees with depression and other behavioral health issues. B. EAP vendor did not provide evidence of a network of these specialists Do EAP staff and counselors have training to understand the potential for cognitive impairment associated with cancer and other serious and/or chronic illnesses? A. EAP vendor provided evidence that EAP staff and counselors have the training necessary to understand the potential for cognitive impairment associated with cancer and other serious and/or chronic illnesses. B. EAP vendor did not provide evidence of training necessary for understanding the potential for cognitive impairment Does the EAP maintain a network of referral sources sufficient to meet the needs of a heterogeneous and diverse workforce? A. EAP vendor provided evidence of an ethnically and racially diverse network of culturally competent EAP providers trained to meet the needs of those with serious and/or chronic illnesses, including cancer. B. EAP vendor did not provide evidence of an ethnically and racially diverse network of providers. TOTAL SHOWN 16

17 Tool 3, Part III: RFP and Vendor Scoring Health Improvement Programs (HIPs) Vendor Scoring ENTER IN COLUMN G FOR HIP VENDORS. BENEFIT # HEALTH IMPROVEMENT PROGRAMS (HIPs) Does the vendor provide a comprehensive health improvement program in terms of policies, practices, scope of services and staff competencies that can be tailored to the needs of your employees and their dependents? A. The vendor provided evidence of policies, practices, scope of services and staff competencies for a comprehensive health improvement program that can be tailored to the needs of my employees and their dependents. B. The vendor provided evidence of policies, practices, scope of service and staff competencies that presented limited evidence of a comprehensive health improvement program. C. The vendor did not provide evidence of policies, procedures, scope of services and staff competencies for providing a comprehensive health improvement program Does the vendor operationally integrate with other health and productivity benefit programs, including short-term disability (STD), long-term disability (LTD), employee assistance program (EAP), family and medical leave (FML) and workers compensation (WC), in terms of policies, practices and scope of services? A. The vendor provided evidence of policies, practices and scope of services for integrating with other health and productivity programs, including STD, LTD, EAP, FML and WC. B. The vendor did not provide evidence of policies, practices and scope of services for integrating with other health and productivity programs Does the vendor s hiring process require that health improvement program staff have basic training and knowledge about the cognitive, emotional and physical issues associated with serious and/or chronic illnesses, including cancer? A. The vendor provided evidence that the hiring process ensures that health improvement program staff has basic training and knowledge about the cognitive, emotional and physical issues associated with serious and/or chronic illnesses, including cancer. B. The vendor did not provide evidence that the hiring process ensures that health improvement program staff has basic training and knowledge about serious and/or chronic illnesses, including cancer Does the vendor have a clear goal and objectives for conducting health assessments, which include biometrics, to identify and manage those at risk for developing serious and/or chronic illnesses, including cancer? A. The vendor provided evidence of a clear goal and objectives for conducting health assessments, which include biometrics, to identify and manage those at risk for developing serious and/or chronic illnesses, including cancer. B. The vendor did not provide evidence of goals and objectives for conducting health assessments, which include biometrics, to identify and manage those at risk for developing serious and/or chronic illnesses, including cancer SHOWN 15 point 17

18 Does the vendor s program include a dedicated approach for promoting evidencebased preventive services? Is the vendor s staff knowledgeable about the relationship between lifestyle choices and risks and the development of cancer? SHOWN A. The vendor provided evidence of a dedicated approach for promoting evidencebased preventive services supported by a staff knowledgeable about the relationship between lifestyle choices and risks and the development of cancer. B. The vendor did not provide evidence of a dedicated approach for promoting evidence-based preventive services supported by a staff knowledgeable about the relationship between lifestyle choices and risks and the development of cancer Does the vendor s health improvement program provide education, programs and services to support employees and their dependents who are being treated for cancer or have been treated for it in the past for the purpose of helping them manage their cancer risk? What is being done to help healthy individuals manage their cancer risk? A. The vendor provided evidence that the health improvement program has education, programs and services to help those being treated for cancer or who have been treated for it in the past to manage their cancer risk. The vendor also provides these programs for healthy individuals to help them manage their risk for developing cancer. B. The vendor did not provide evidence of education, programs and services for those who are currently being treated or have been treated for cancer in the past. The vendor did not provide evidence of services to help healthy individuals manage their risk for developing cancer Does the vendor s health improvement program staff provide coaching to employees and/or their dependents, including those with serious and/or chronic illnesses such as cancer, to promote healthy lifestyle choices to reduce risks associated with developing and surviving cancer? Is coaching available to employees and dependents serving as caregivers? A. The vendor provided evidence that staff offers coaching to employees and their dependents, including those with chronic and/or serious illnesses such as cancer, to promote healthy lifestyle choices to reduce risks associated with developing and surviving cancer. The vendor also provided evidence that coaching is available to those serving as caregivers. B. The vendor did not provide evidence that staff provides coaching to this population Does the vendor s health improvement staff have access to health psychology and behavioral medicine specialists or health coaches trained to work with employees with serious and/ or chronic illnesses, such as cancer, through the employer s EAP? A. The vendor provided evidence that the health improvement staff has access to health psychology and behavioral medicine specialists or health coaches through the employer s EAP. B. The vendor did not provide evidence that the health improvement staff has access to health psychology and behavioral medicine specialists or health coaches through the employer s EAP. 7.9-a 1. Does the vendor s health improvement program staff coordinate with you to train staff about resources made available by [the employer], including but not limited to the Cancer Benefits and Resource Guide and cancer-related Fact Sheets, which provide accurate information about cancer, health care benefits, cancer treatment, recovery and survivorship, support and advocacy groups and other topics? A. The vendor provided evidence that it coordinates with the employer to train staff about available resources that provide accurate information about cancer and other important topics. B. The vendor did not provide evidence that it coordinates with the employer to train staff about available resources that provide accurate information about cancer and other important topics. 18

19 7.9-b 1. Does the vendor have a process in place to review and approve informational resources on health improvement topics? A. The vendor provided evidence of a process to review and approve informational resources on health improvement topics. B. The vendor did not provide evidence of a process to review and approve informational resources on health improvement topics Does the vendor describe how it coordinates with you to provide orientation and training for supervisors and managers about the health improvement program? Does the vendor provide information and resources to supervisors and managers about working with employees with serious and/or chronic illnesses, including cancer? A. The vendor provided evidence that it coordinates with the employer to provide training and resources to supervisors and managers about the health improvement program. B. The vendor did not provide evidence that it coordinates with the employer to provide training and resources to supervisors and managers about the health improvement program. TOTAL SHOWN 19

20 Tool 3, Part III: RFP and Vendor Scoring A National Business Group on Health SM Toolkit which should be cited accordingly. Copyright 2013 National Business Group on Health SM. Written by: National Business Group on Health: Ron Finch, EdD, Vice President and Principal Investigator; Demian Kendall, former Program Associate; Brenna Shebel, MS, CHES, Director and Project Manager, Wendy Slavit, MPH, CHES, former Manager National Comprehensive Cancer Network: Elizabeth Danielson, MHA, Director, Payer & Employer Initiatives; Trish Goldsmith, former Executive Vice President/Chief Operating Officer Please contact healthservices@businessgrouphealth.org for more information. About the National Advisory Committee on Employer Services for the Cancer Continuum of Care The National Advisory Committee on Employer Services for the Cancer Continuum of Care serves as the expert advisory body for the Employer s Guide, ensuring that all information and recommendations are relevant to employers and their partners. The Committee helps develop recommendations for the design, quality assurance, structure, and integration of resources, programs and services around the full spectrum of employer benefits and programs. This includes the health plan, health and productivity programs and health improvement programs. The Committee consists of benefit managers, clinical cancer experts, medical directors, health plan representatives, pharmaceutical representatives, health care consultants, disability managers, EAP professionals and health improvement program professionals. An Employer s Guide to Cancer Treatment & Prevention National Business Group on Health 20 F Street, N.W., Suite 200 Washington, D.C Phone (202) Fax (202) Helen Darling, President and CEO, National Business Group on Health Members of the National Advisory Committee on Employer Services for the Cancer Continuum of Care Len Lichtenfeld, M.D., American Cancer Society; Wayne Burton, M.D., American Express; Evan Falchuk, J.D., Best Doctors, Inc.; Michelle Martin, CBS Corporation; Rick Heine, Consultant; Lynn Zonakis, Delta Air Lines, Inc.; Thomas D Amico, M.D., Duke Comprehensive Cancer Center; Jack Mahoney, M.D., Florida Health Care Coalition; Mike Lanning, Arthur Small, M.D., Thomas Weisman, M.D., Genentech, Inc; Angela Cafferillo, General Electric Company; Bryan Loy, M.D., Humana Inc.; Ahmad Naim, M.D., Johnson & Johnson Healthcare Systems; Daniel Conti, Ph.D., JPMorgan Chase; Jill Berger, Rebecca Spencer, Marriott International, Inc.; Jane Barlow, M.D., Milayna Subar, M.D., Medco Health Solutions; Robert Carlson, M.D., Trish Goldsmith, William McGivney, Ph.D., National Comprehensive Cancer Network; Michael Schoenbaum, Ph.D., National Institute of Mental Health; Brian Denton, Duane Putnam, Pfizer Inc.; Mary Bradley; Pitney Bowes, Inc.; Don Weber, PricewaterhouseCoopers; Michael Rosen, M.D., OptumHealth; Mary Lou Smith, J.D., Research Advocacy Network; Shelly Wolff, Towers Watson; Samuel Silver, M.D., Ph.D., University of Michigan Medical School; Robert Jacob, Unum; Bruce Sherman, M.D., Wal-Mart Stores, Inc.; Alan Rosenberg, M.D., Wellpoint, Inc.; Ken Mitchell, Ph.D., WorkRx Group Cassell & Fenichel Communications, L.L.C., Publications Management PlusOne Studios LLC, Graphic Design