Medical Third-Party Administration (TPA) Services

State of Delaware
Department of Human Resources
Statewide Benefits Office
STATE EMPLOYEE BENEFITS COMMITTEE
Request for Proposal for Professional Services
for the State of Delaware's
Medical Third-Party Administration (TPA) Services
DHR26009-MED_TPA
RFP Release Date
Wednesday, May 13, 2026
Intent to Submit Proposal Deadline -
Wednesday, May 27, 2026, 11:00 a.m. ET (Local Time)
Mandatory Pre-Proposal Meeting (Virtual) -
Friday, May 29, 2026, 11:00 a.m. ET (Local Time)
Proposals Due -
Tuesday, June 30, 2026, 1:00 p.m. ET (Local Time)
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Contents:
I. Overview
II. Scope of Services
A. Background and History
1. Overview of the SEBC
2. Program Information
B. Scope of Services
III. Required Information
A. Minimum Requirements
B. General Evaluation Requirements
IV. Professional Services RFP Administrative Information
A. RFP Issuance
B. RFP Submissions
C. RFP Evaluation Process
V. Contract Terms and Conditions
A. Contract Use by Other Agencies (if applicable)
B. Cooperative Use of Award (if applicable)
C. General Information
D. Collusion or Fraud
E. Lobbying and Gratuities
F. Solicitation of State Employees
G. General Contract Terms
VI. RFP Miscellaneous Information
A. No Press Releases or Public Disclosure
B. Definitions of Requirements
C. Production Environment Requirements
D. Intent to Submit Proposal - !!!IMPORTANT!!!
E. Non-Disclosure Agreement
F. No Proposal
G. Definitions
H. Best and Final Offer (BAFO)
I. Performance Guarantees
VII. Attachments
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Appendix A - MINIMUM MANDATORY SUBMISSION REQUIREMENTS
Appendix B - PROFESSIONAL SERVICES AGREEMENT
** Ctrl+Click on the headings above will take you directly to the section.
I. Overview
The State of Delaware, Department of Human Resources ("DHR"), on behalf of the State Employee
Benefits Committee ("SEBC"), seeks professional services to enter for the purpose of administering
its medical insurance benefit (hereafter "medical third-party administrators ("TPA") services"). This
request for proposals ("RFP") is issued pursuant to 29 Del. C. 6981 and 6982 at https://delcode.del-
aware.gov/title29/c069/sc06/index.html
For complete information about the State of Delaware's benefit programs, please go to
https://de.gov/statewidebenefits
The proposed schedule of events subject to the RFP is outlined below. However, these dates and
milestones are not absolute and may change due to unplanned events during the bid proposal and
award process:
Event Target (Local ET Time)
RFP Released Wednesday, May 13, 2026
Intent to Submit Proposal Deadline Wednesday, May 27, 2026, 11:00 a.m.
Mandatory Pre-Proposal Meeting Friday, May 29, 2026, 11:00 a.m.
(Microsoft Teams Meeting)
Questions due to SBO from Monday, June 1, 2026, 9:00 a.m.
Confirmed Vendors
Responses to Questions to Confirmed Vendors By Monday, June 15, 2026
Deadline for Receipt of Proposals Tuesday, June 30, 2026, 1:00 p.m.
Notification of Finalists - August 2026
Invitation to Interview
Finalist Interviews September 2026
Recommendation of Finalist(s) to SEBC November 2026
Anticipated Contract Start Date July 1, 2027
Each proposal must be accompanied by a transmittal letter which briefly summarizes the proposing
firm's interest in providing the required professional services. The transmittal letter must also clearly
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state and justify any exceptions to the requirements of the RFP which the applicant may have taken in
presenting the proposal (applicant exceptions must also be recorded on Attachment 3).
Furthermore, the transmittal letter must attest to the fact, at a minimum, that the vendor shall not store
or transfer non-public State of Delaware data outside of the United States. For all solicitations, ven-
dors shall refer to the Delaware Department of Technology and Information identified terms and con-
ditions included in this solicitation.
The State of Delaware reserves the right to deny any and all exceptions taken to the RFP requirements.
MANDATORY PRE-PROPOSAL MEETING
A mandatory pre-proposal meeting has been scheduled for Friday, May 29, 2026, at 11:00 a.m.
ET (local time) via Microsoft Teams.
Proposals will not be accepted if the interested vendor does not participate in the mandatory pre-pro-
posal meeting. Topics will include general information and administrative requirements for proposal
preparation. The primary contact for the RFP should attend along with anyone who is primarily re-
sponsible for entering responses in ProposalTech as described in Section IV.B. Only one person acting
as the representative from the interested vendor is required to attend, but anyone on the team is wel-
come to participate. Roll call will be taken to confirm attendance.
Meeting minutes may be taken. If new or additional information is provided, an addendum may be
released to address information provided during the mandatory pre-proposal meeting. Questions re-
garding other topics will not be entertained and must be submitted as part of the Questions and An-
swers process as described in Section IV.B.14.
II. Scope of Services
A. Background and History
1. Overview of the SEBC
The SEBC was established by the State Employee Benefits Consolidation Act, 29 Del. C. ch. 96.
The SEBC has control and management of all employee benefits. The SEBC selects all carriers or
third-party administrators necessary to provide coverage to State employees and non-Medicare
and Medicare retirees, enters into contracts for the purpose of general administration of employee
benefits, determines if/whether contracts are to be fully insured or self-insured, and adopts rules
and regulations for the general administration of the employee benefit coverage.
Membership of the SEBC is determined by 29 Del. C. 9602. The Statewide Benefits Office
("SBO") is a division within DHR. SBO functions as the administrative arm of the SEBC and,
with the exception of pension and deferred compensation benefits, is responsible for the admin-
istration of all statewide benefit programs. These programs include, but are not limited to, health
with wellness and disease management programs, prescription drug, dental, vision, disability, life,
flexible spending account program, pre-tax commuter program, employee assistance program,
third-party network of surgeons of excellence and supplemental critical illness and accident
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benefits. Information about the programs can be found online at https://dhr.delaware.gov/benefits/
for information about the programs. Some programs are not offered to all benefits-eligible plan
participants; specific details on the programs relevant to this RFP are described in the next section
further below.
Benefit eligible plan participants include the State's active employees (State agency, school dis-
trict, charter school, Delaware State University, and Delaware Technical Community College em-
ployees) and their dependents; non-Medicare and Medicare retired employees and their depend-
ents; employees of non-State groups (i.e., certain towns, fire companies; these groups are also
referred to as "participating groups" or "non-payroll group" employees) and their dependents; and
COBRA participants. By statute, employee unions cannot negotiate for benefits. Plan participants
are primarily located within the State of Delaware, although a small number of participants reside
in other states and countries.
2. Program Information
Current State of the GHIP
Currently, the State has contracted with Highmark Delaware and Aetna to administer the medical
portion of the Group Health Insurance Plan (GHIP) and CVS Caremark (CVS) for pharmacy ben-
efit management (PBM) services. Because the State utilizes multiple electronic human resources
programs, such as PeopleSoft, and vendor databases at separate locations in various formats to
collect and store participant data, the medical TPAs serve as the medical plan enrollment systems
of record and share enrollment and claims data for all medical plans with the PBM, the third-party
network of surgeons of excellence (currently administered by Lantern), and the GHIP data ware-
house vendor, Merative. The State contracts with Application Software, Inc. COBRA for admin-
istration of COBRA and with Health Advocate for administration of employee assistance services.
The SEBC is responsible for the design of the medical plans available to the GHIP's participants
and setting premium rates that can support the projected expenses of the GHIP. The percentage
of employee/retiree and State share of the premium rates is established in Delaware Code as are
the actual plan offerings available to employees and retirees, both of which are outlined in the
chart below. Additional information about plan designs and premiums can be found on the SBO
website:
* Highmark Delaware plan enrollees - active employees and non-Medicare pensioners:
https://dhr.delaware.gov/benefits/agencies/highmark.shtml
* Highmark Delaware plan enrollees - Medicare pensioners: https://dhr.delaware.gov/ben-
efits/medicare/highmark.shtml
* Aetna plan enrollees: https://dhr.delaware.gov/benefits/agencies/aetna.shtml
Premium Cost Share Percentage Split Actives Non-Medicare Medicare Primary
State / Employee State / Retiree State / Retiree
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Highmark Delaware Comprehensive Pre- 86.75% / 13.25% 86.75% / 13.25% N/A
ferred Provider Organization (PPO)
Aetna Health Maintenance Organization 93.5% / 6.5% 93.5% / 6.5% N/A
(HMO)
Aetna Consumer Directed Health (CDH) 95.0% / 5.0% 95.0% / 5.0% N/A
Gold (with Health Reimbursement Ac-
count (HRA))
Highmark Delaware First State Basic 96.0% / 4.0% 96.0% / 4.0% N/A
Highmark Delaware Special Medicfill N/A N/A 100% / 0% *
Supplement 95.0% / 5.0% **
*Retirees with full state share who retired before July 1, 2012.
**Retirees with full state share who retired after July 1, 2012.
Cost and utilization of the GHIP are regularly reported to the SEBC; these publicly available re
ports are available on the SBO's website (https://dhr.delaware.gov/benefits/sebc/sebc-materi-
als.shtml) and include:
* Monthly Fund Report and Financial Updates
* Quarterly Financial Reporting
* Active Employees Diabetes Dashboard
* Incurred Claims Report
* GHIP Trend Assumptions
* Other ad hoc analyses such as:
GLP-1 Trends and weight loss medications
o
Health management programs are provided through Highmark Delaware, Aetna and Aetna's en-
gagement model Aetna One Advocate, (A1A). These programs address both broad-based popula-
tion health focused on closing gaps in care among high-risk plan participants and condition-spe-
cific health concerns such as diabetes, maternity care, and behavioral health. Additional details
about these programs are available to the public on the SBO's website (https://dhr.dela-
ware.gov/benefits/), which interested vendors are encouraged to review. The SBO also partners
with other State agencies to deliver health-related programs and communications to GHIP partic-
ipants, such as the Delaware Department of Health and Social Services' Division of Public
Health's educational campaigns about preventive cancer screenings, high blood pressure and dia-
betes prevention and management. A collection of the GHIP's health and wellness resources can
be found online at https://dhr.delaware.gov/benefits/behavioral-health/index.shtml.
GHIP participants enrolled in a State of Delaware Highmark Delaware or Aetna non-Medicare
health plan also have access to the Lantern Surgeons of Excellence program for elective surgical
procedures. The SEBC adopted the Lantern program as a step toward promoting greater compe-
tition among facility providers in Delaware and to provide plan participants with easier access to
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high quality providers in value-based contracts (i.e., contract based on quality of care and outcomes
delivered, not fee-for-service). Plan participants can choose to use a Lantern provider as a nocost
alternative to their medical plan network providers; however, plan participants are required to ob-
tain bariatric surgery through a Lantern provider under the Lantern benefit. Lantern shares data on
member utilization of this program with the medical TPAs. Additional details about the Surgeons
of Excellence Program, including the financial incentives available to members who use a Lantern
provider for elective surgeries, can be found online at https://dhr.delaware.gov/benefits/lantern/in-
dex.shtml.
GHIP participants and their spouses/dependents over age 18 enrolled in a State of Delaware High-
mark Delaware or Aetna non-Medicare health plan have access to Hinge Health a no cost virtual
exercise therapy program. The SEBC adopted the Hinge Health program as a step toward promot-
ing greater value in musculoskeletal care for plan participants and to provide members with easier
access to highquality, evidencebased digital physical therapy. The program supports improved
outcomes through personalized care plans, licensed physical therapy guidance, and datadriven
interventions designed to reduce reliance on costly inperson care and avoid unnecessary proce-
dures. Additional details about the Hinge Health program, can be found online at https://dhr.dela-
ware.gov/benefits/msp/index.shtml.
Title 16, Delaware Code, Section 10312 requires that the TPA(s) selected from this RFP be an
active participant in the Delaware Health Information Network (DHIN) to create a single interface
for providers and patients to access health information that supports care coordination, perfor-
mance reviews and patient engagement, and eliminates duplicative reporting burdens.
DHIN is a statutory (16 Del. C. 10311) not-for-profit instrumentality of the State of Delaware,
created to promote the design, implementation, operation and maintenance of facilities for public
and private use of healthcare information in the state.
A public-private partnership, DHIN serves as the state-designated health information exchange,
facilitating the sharing of clinical and financial healthcare information (as appropriate) among pro-
viders and stakeholders, including hospitals, physicians, state agencies, payers, employers and
labs, with the goal of improved efficiencies in the health care delivery system.
At a glance, DHIN:
* Covers nearly all of Delaware: Every acute care hospital and Federally Qualified Health
Center, as well as nearly 100% of the state's medical providers, voluntarily participate with
DHIN.
* Supports regional health information exchange: DHIN's Community Health Record stores
patient data by health systems from all or parts of six states and the District of Columbia.
* Delivers data daily: DHIN delivers 184 million results annually, adding up to more than
150 million clinical results and reports delivered since its inception in 2007. To date, more
than 3 million patients from all 50 states can be found in DHIN's master patient index.
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In addition to its robust clinical data repository, DHIN has also been tasked with housing and
managing Delaware's All Payer Claims Database (APCD). Additional details about the ACPD can
be found online at https://dhin.org/healthcare-claims-database/.
The SEBC requires that the TPA(s) selected from this RFP will, prior to the time in which services
to the SEBC are provided under an awarded contract:
* Enter into appropriate agreements and stand ready to submit data to the Health Care Claims
Database pursuant to the enabling legislation, associated DHIN regulations, and the Data
Submission Guide. Information on the Delaware Health Care Claims Database is available
online at https://dhin.org/healthcare-claims-database. All required data must be submitted
in a timely fashion and pursuant to DHIN requirements, unless explicitly exempted by
Delaware or federal law.
* Contract with DHIN at DHIN's prevailing per member, per month rate for all members to
the suite of services provided to payers by DHIN. Such services shall include access to the
Community Health Record, Event Notification Services, and Clinical Gateway. A three-
party agreement with DHIN, the SEBC and the medical TPA will be required. Payment to
DHIN for DHIN services shall be timed to begin concurrently with the services provided
to SEBC under any awarded contract.
The SEBC expects that the tools and associated data provided by DHIN will be used by the suc-
cessful TPA(s) in support of administrative efficiencies in data gathering to support Healthcare
Effectiveness Data and Information Set (HEDIS) reporting, audits of providers for clinical quality
purposes, care coordination, and other requested clinical reporting as applicable.
In addition to the foregoing requirements, and in further support of these efforts, the SEBC expects
any successful TPA(s) to:
* Help to alleviate and retire, to the fullest extent possible, reporting burdens currently placed
on providers and other entities or individuals contracted to deliver care, if and to the extent
such reports contain information already available in DHIN.
* Leverage their contracting power with providers and other entities or individuals contracted
to deliver care, to encourage and promote the use of DHIN services, including the Com-
munity Health Record, Event Notification Services, and the submission of clinical encoun-
ter data (including point of care lab test results) to DHIN for inclusion in its clinical data
repositories.
To the extent that the successful TPA(s) owns or enters into contracts with tele-
o
health providers, walk-in or urgent care clinics, home health services, rehabilitative
services, skilled nursing and long term care facilities or other care organizations, it
will require such providers to contract with DHIN to provide clinical encounter data
to the DHIN database and use DHIN services in order to improve care coordination
and provide administrative simplicity with respect to audits and compliance.
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In support of the development of value-based payment models and cost, quality,
o
efficiency and population health studies that further the goals of the State and the
DHIN, the successful TPA(s) will require that any data submitted to DHIN by its
contracted care providers be permitted to be used for all purposes authorized under
the DHIN governing statute, regulations, and relevant federal law.
* Promote the use of Health Check Connect, DHIN's personal health record, as a mode of
accessing all of the patient's clinical health data from a single source.
B. Scope of Services
On behalf of the State of Delaware, the SEBC is seeking proposals to provide TPA services for
the GHIP. Enrolled in the GHIP are approximately 124,780 active and retired employees of the
State of Delaware and their dependents, including approximately 6,286 employees, retirees and
their dependents from non-State groups that are allowed to participate in the GHIP according to
Delaware Code (e.g., municipalities, local fire departments).
Currently, there are four medical plan options for active employees and non-Medicare pensioners,
and one plan option for Medicare-eligible pensioners:
* Highmark Delaware currently administers the Comprehensive PPO and First State Basic
plans
* Aetna currently administers the HMO and CDH Gold plans
* The Special Medicfill Medicare Supplement plan is administered by Highmark Delaware
The State's contracts with both TPAs, Aetna and Highmark Delaware, will expire on June
30, 2027 for the non-Medicare plans, and on December 31, 2027 for the Medicare Supplement
plan.
The SEBC desires to contract with an organization specializing in providing non-Medicare medi-
cal insurance with an anticipated effective date of July 1, 2027, and Medicare Supplement insur-
ance with an anticipated effective date of January 1, 2028. The Medicare Supplement plan being
solicited must duplicate the current Medicare Supplement plan in full, without any deviations. Bids
for any other arrangements are not being solicited and will not be considered by the SEBC. The
organization must have prior experience directly related to the services requested in this RFP and
must be able to demonstrate clearly their ability to perform the required scope of services within
the timeline requested. TPA(s) will be expected to include innovative healthcare organizations,
which may offer solutions that expand access to primary care, behavioral health, metabolic and
weight management services, care navigation, or measurable workforce wellness and assessment
capabilities. All proposed solutions must demonstrate the ability to reduce cost of medical care for
the State. The selected organization shall be required to provide the following services, at a mini-
mum:
* Support the goals of the GHIP Strategic Framework, which were updated and approved by
the SEBC on April 20, 2026 where the full detail can be found in Attachment 38 - FY26-
FY29 GHIP Strategic Framework;
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* Offer solutions that increase GHIP spend through advanced alternative payment models;
* Offer solutions that reduce costs for targeted conditions, including diabetes, musculoskel-
etal conditions, and behavioral health.
* Offer solutions that limit total cost of care inflation for GHIP participants at a level com-
mensurate with the Health Care Spending Benchmark by the end of FY2025 by focusing
on specific components, which are inclusive of, but not limited to:
outpatient facility costs;
o
inpatient facility costs; and
o
pharmaceutical costs.
o
* Offer point-of-enrollment and/or point-of-care engagement platform and/or consumerism
tools along with solutions to increase GHIP member engagement in those tools;
* Provide competitive financial terms and performance guarantees (PG);
Competitive provider reimbursement rates and administrative fees;
o
Service level guarantees including accountability for supporting the GHIP Strategic
o
Framework goals;
Offer solutions that uphold and support;
o
Investments in primary care; and
Affordability Targets of the Delaware Department of Insurance's Office of
Value Based HealthCare Delivery.
* Support GHIP's programs and plan offerings;
Administer current plans;
o
Support plan provisions that optimize effectiveness of GHIP benefit offerings;
o
Integrate with other programs and vendors supporting the GHIP, which is inclusive
o
of data file feeds to those vendors (Health Data Warehouse, PBM, Center of Excel-
lence (COE), etc.);
Maintain a provider network that meets current and future State goals of the GHIP;
o
Provide supplemental coverage to Medicare eligible retirees and their Medicare-
o
eligible dependents in the form of a Medicare Supplement plan that duplicates the
current Medicare Supplement plan without deviation. Bids for any other arrange-
ments are not being solicited and will not be considered by the SEBC.
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