Fully-Insured Medical Plans

The Washington State Health Care Authority (HCA) is issuing RFP 2025HCA5 to procure up to three fully‑insured health‑plan designs for the Public Employees Benefits Board (PEBB) and three for the School Employees Benefits Board (SEBB), together covering all Washington counties. The award will establish a five‑year contract (2029‑2033) with optional one‑year extensions, under which the selected carrier must provide complete plan design, administration, claims processing, member‑portal services, value‑based purchasing participation, health‑equity initiatives, and extensive data‑reporting. The contractor must meet stringent performance standards, submit monthly paid‑claims data, adhere to Washington’s WaTech IT‑security policies, and maintain a disaster‑recovery plan, with penalties applied for missed metrics. Key deliverables include plan design outlines, detailed operations manuals, quarterly AI‑monitoring reports, annual NCQA accreditation, and participation in the Primary‑Care Transformation Initiative. • Design up to six fully‑insured health plans (three for PEBB, three for SEBB) meeting actuarial‑value and network‑adequacy requirements. • Provide end‑to‑end plan administration in the United States, including daily HIPAA‑compliant 834 eligibility file processing, claims adjudication, member‑portal and microsite management, and monthly paid‑claims data submission. • Meet performance‑based metrics (e.g., call‑answer time ≤ 30 seconds, clean‑claim rate ≥ 99 %, CAHPS/ HEDIS targets) with potential penalties up to 9 % of annual premium in Year 1 and 7 % thereafter. • Deliver health‑equity and value‑based purchasing initiatives, maintain NCQA health‑outcomes accreditation, and submit a comprehensive disaster‑recovery plan and annual transformation reports.