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Upcoming Procurement Data
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General Information
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Solicitation Title:
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Deputy Insurance Commissioner
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Agency:
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Insurance Department
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Existing Contract Number:
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4400004710
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Contract Expiration Date:
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12/99/9999
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Proposed Method of Procurement:
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Description:
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The Pennsylvania Insurance Department (PID) is requesting quotes for a consultant to provide network adequacy review starting in the spring of 2025, where QHP networks need review starting in May 2025, and PBM templates need drafted by spring of 2025 for first submission in April 2026. As part of the review, the contractor will provide information about the adequacy of qualified health plans (QHP) networks (approximately 35-50 networks) and pharmacy benefit manager (PBM) pharmacy networks (approximately 5-15 networks) based on filings by insurers or PBMs and follow-up information requests. The consultant will be responsible for reviewing network adequacy for both medical/surgical, dental (when applicable), and mental health/substance use disorder providers.
The network adequacy review will allow PID to:
1. Provide templates to PBMs and health insurers to populate network data.
2. Quarterly review QHP issuer networks to ensure that all networks include adequate providers for medical/surgical, MH/SUD, dental, and pharmacy providers (where applicable) to meet the standards outlined in applicable state and federal laws and regulations.
3. Review QHP issuer standalone dental networks to ensure that all networks include adequate pediatric and adult dental providers to meet the standards outlined in applicable state and federal laws and regulations.
4. Annually review PBM networks when contracted with a health benefit plan or health insurer selling pharmacy coverage benefits to the commercial market in Pennsylvania to meet the standards as outlined in applicable state and federal laws and regulations.
5. Confirm to the Pennsylvania Health Insurance Exchange Authority (Pennie™) that network adequacy standards are met for purposes of participation on Pennsylvania’s state-based health insurance exchange.
6. Confirm that off-exchange individual and group health insurance plans subject to network adequacy requirements under state and federal laws and regulations meet such minimum standards prior to issuing coverage.
7. Conduct in-plan-year review of network adequacy based on data provided through complaints, self-reporting, and other indicators of significant network change to determine gaps or inadequacies if a specific provider, facility, or group of providers change.
8. Identify gaps in networks to share with insurers and get justification for how they are going to meet network adequacy standards.
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Review Information
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Issuing Office:
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Contact Person:
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Mark Lapkowicz
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Contact Email:
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mlapkowicz@pa.gov
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