This is an appeal by Louisiana Health Service and Indemnity Company, Inc., d/b/a Blue Cross Blue Shield of Louisiana (Blue Cross) from a judgment of the district court, acting in an appellate capacity, reversing the final decision of the Commissioner of Administration, which had upheld the validity of a contract awarded by the Office of Group Benefits to Blue Cross. For the reasons that follow, we reverse the judgment of the district court.
In October of 2009, the State of Louisiana through the Division of Administration, Office of Group Benefits (OGB), issued notices of intent to contract (NICs) for administrative services only (ASO) for health benefit plans for state employees, dependents, and retirees. Since the existing contracts for the administration of the Health Maintenance Organization (HMO) plan by Humana Insurance Company (Humana) and the Exclusive Provider Organization (EPO) plan by United Healthcare Insurance Company (UHC) would expire on June 30, 2010, OGB solicited proposals for two new contracts to become effective on July 1, 2010.
OGB received three proposals in response to the HMO NIC. Responders were Humana, UHC, and Blue Cross. OGB also received three proposals in response to the EPO NIC. Responders were Blue Cross, UHC, and FARA Benefit Services, Inc. (FARA).
The proposals were evaluated and scored by OGB and its actuarial consultants, Buck Consultants, Inc. (Buck Consultants). Based on the points awarded to Blue Cross in the evaluation and scoring process, Buck Consultants recommended that Blue Cross be awarded the contract for the HMO plan. Blue Cross's proposal for the EPO plan also received the highest scores in the evaluation and scoring process. According to OGB, at that stage of the review process, OGB reached the conclusion that Blue Cross's proposals under both NICs offered the same quality of health care providers and the same cost of coverage, thereby eliminating the need for two contracts. Moreover, although OGB concluded that Blue Cross was entitled to be awarded both contracts since Blue Cross received the highest scores on both proposals, OGB further concluded that one contract would be less costly to the state. Thus, it made the decision to withdraw the EPO NIC and to award the HMO contract to Blue Cross. OGB announced the award of the HMO contract to Blue Cross on its website and by notification letter to the other proposers.
Humana and UHC filed protests and supplemental protests with OGB in which they claimed that they were prejudiced by a flawed procurement process.
Humana and UHC argued that, in the announcement of the award, OGB acknowledged that Blue Cross's HMO proposal included a nationwide network. Humana and UHC further alleged that, either the nationwide network offered by Blue Cross in response to the HMO NIC violated the specifications contained in the NIC or OGB changed the HMO NIC specifications after the NIC was issued and failed to notify other proposers. They also alleged that they were prejudiced by OGB's actions, which denied them the opportunity to submit comparable bids.
In its denial of Humana and UHC's protests, OGB stated that the proposal by Blue Cross conformed to the specifications contained in the HMO NIC and was evaluated and scored based on those specifications. OGB further stated that Blue Cross did not offer a nationwide network in its HMO proposal and that a nationwide network was not used in evaluating Blue Cross's HMO proposal. OGB concluded that Humana and UHC were not prejudiced, because the decision to merge OGB's HMO and EPO plans was made only after Blue Cross scored the highest on both proposals.
UHC and Humana then appealed OGB's decisions, which denied their protests, to the Division of Administration (DOA), through the Commissioner of Administration. DOA affirmed the award and OGB's decisions denying the protests. DOA acknowledged that the website announcement and the notification letter stated that the HMO and EPO plans were being consolidated because OGB could provide, through its HMO plan, a nationwide network of health care providers. DOA denied that there was any prejudice to Humana or UHC, because Blue Cross scored the highest on both proposals, which were evaluated and scored independently. DOA stated that OGB's intent was not to provide a nationwide network in its HMO plan, but stated that there was no prohibition against proposers using a nationwide network for out-of-state services.
UHC and Humana separately filed petitions for judicial review of the DOA's decision with the Nineteenth Judicial District Court. The two suits were consolidated, and Blue Cross was permitted to intervene.
After a hearing, the district court remanded the case to OGB for consideration of additional evidence, in accordance with LSA-R.S. 49:964(E). Subsequently, OGB issued its second decision in which it affirmed the award of the contract to Blue Cross.
Under the facts of this case, a party who is aggrieved by an award of a contract must submit a protest with OGB, at which time OGB must notify the Office of Contractual Review that a protest has been lodged. See LAC 34: V.145(A)(8); LSA-R.S. 39:1490(B)(5). If the aggrieved party is not satisfied with OGB's decision, then that party may appeal the decision, in writing, to the Commissioner of Administration. See LAC 34:V.145(A)(11); LSA-R.S. 39:1490(B)(5).
The Commissioner must then render a decision in writing, which decision is final. LAC 34:V.145(A)(11). The aggrieved party may seek review of an adverse decision by filing a petition for judicial review with the Nineteenth Judicial District Court. See LSA-R.S. 39:1526(A).
In reviewing the decision of OGB in this case, the district court applied the standard of review set forth in LSA-R.S. 49:964(G); however, LSA-R.S. 49:964(A)(1) makes clear that it only applies to "an adjudication."
The general principle governing the standard of review to be used when reviewing the findings of an administrative agency is that, if the evidence, as reasonably interpreted, supports the agency's determinations, then the agency's decisions are accorded great weight and will not be reversed or modified in the absence of a clear showing that the administrative action was arbitrary or capricious. Summers v. Sutton, 428 So.2d 1121, 1129 (La. App. 1st Cir.1983). An administrator, vested with authority to exercise discretion,
OGB is the state agency within the Office of the Governor, Division of Administration, vested with the responsibility to establish and administer group benefit plans for state employees, dependents, and retirees.
In this case, OGB drafted and issued two separate NICs in order to procure two contracts for the administration of two of its health benefit plans. As required by law, the HMO NIC clearly stated the relative importance of price and other evaluation factors and clearly defined the tasks to be performed under the contract and the criteria to be used in evaluating the proposals.
The HMO plan was designed for members who would seek health care primarily in the state of Louisiana. The HMO NIC required proposers to submit a statewide network of providers to insure complete statewide coverage. The HMO NIC stated that OGB would not accept proposals for individual or grouped regions, making it clear that OGB sought coverage in every area of the state. The HMO NIC also stated that OGB sought to contract with a third-party administrator, insurer, or health maintenance organization, for administrative services only, to administer a self-insured HMO Plan on a statewide basis. The HMO NIC also required proposers to provide access to health care providers out of state. It stated: "Contractor must be capable of providing all services and benefits set forth in the Plan of Benefits (exhibit 1)." The "Plan of Benefits" is summarized in a chart which forms part of the HMO NIC. The chart identifies covered
The HMO NIC required proposers to submit a statewide network of participating providers, which would be evaluated and scored for the quality of network. It also required proposers to reprice in-state claims using their in-state network. However, proposers were required to reprice out-of-state claims as well. The HMO NIC does not direct proposers to use a specific network to reprice out-of-state claims, nor does it prohibit the use of a specific network for that purpose.
The HMO proposals submitted by Humana, UHC, and Blue Cross were evaluated and scored by OGB and Buck Consultants in accordance with the criteria set forth in the HMO NIC. OGB and Buck Consultants concluded that all three proposals complied with the HMO NIC. All three proposers submitted statewide networks to be evaluated and scored for quality of network, and they repriced in-state claims using their statewide network. According to OGB, all proposers also repriced out-of-state claims using discounts for out-of-state health care providers.
OGB also received three proposals in response to the EPO NIC, which sought an ASO contract that would provide members with access to nationwide networks of health care providers. Proposers were to submit their best statewide network in Louisiana and their best out-of-state network, offering discounted rates outside of Louisiana. Proposers were Blue Cross, UHC, and FARA.
As required by law, the EPO NIC also clearly stated the relative importance of price and other evaluation factors and clearly defined the tasks to be performed under the contract and the criteria to be used in evaluating the proposals. See LSA-R.S. 39:1503(B). The evaluation criteria set forth in the EPO NIC was the same as the criteria contained in the HMO NIC. However, under the EPO NIC, the qualitative/network assessment was based on a nationwide network, in addition to the statewide network, whereas under the HMO NIC, the qualitative/network assessment was based only on the statewide network.
After evaluating and scoring the EPO proposals, Buck Consultants reported to OGB that Blue Cross's EPO proposal achieved the highest total score. OGB then recognized that the member benefits available under the Blue Cross proposals for the HMO plan and EPO plan offered the identical quality of network and cost of
In protesting this award, Humana's and UHC's primary complaint was that the HMO NIC sought "a statewide network only" and that the proposal submitted by Blue Cross utilized contracted discounts with out-of-state health care providers when it performed the repricing exercise for out-of-state claims. Humana argued that the use of these contracted discounts to reprice out-of-state claims constituted use of a nationwide network, which it believed was prohibited by the HMO NIC. On the other hand, UHC stated, in a reply brief filed in the district court, that it used a nationwide network to reprice some out-of-state claims. Nevertheless, Humana argued that it did not use a nationwide network to reprice the out-of-state claims, because it believed that the HMO NIC sought a statewide network only. Humana argued that OGB did not have competitive cost proposals before it since Humana refrained from offering its best contracted discounts for out-of-state claims.
While Humana may have refrained from utilizing a nationwide network to reprice out-of-state claims in its HMO proposal, we find that the language of the HMO NIC does not prohibit the use of a nationwide network for that purpose. Further, since the state sought contracts that would be in the best interests of the state and participating plan members, proposers were aware of the importance of offering the broadest statewide network at the best possible price, along with the best possible price for health care services out-of-state.
The decision as to whether a proposal meets the criteria of a NIC or RFP is within the discretion of the agency. OGB and its evaluation committee had discretion to choose the responsible offerer whose proposal was "most advantageous to the state, taking into consideration review of price and the evaluation factors set forth" in the NIC. See Fleetcor Technologies Operating Co., LLC v. State ex rel. Div. of Admin., Office of State Purchasing, 09-0976 (La.App. 1st Cir. 12/23/09), 30 So.3d 102, 111. OGB and the evaluation committee concluded that all three proposals received in response to the HMO NIC were responsive to the HMO NIC. We find that the agency did not abuse its discretion in arriving at this conclusion.
We find no abuse of discretion by OGB in its decision to cancel the EPO NIC under these circumstances. OGB followed the appropriate procedure in issuing the two separate NICs and in receiving proposals and evaluating and scoring each based on specifications in the respective
Blue Cross argued that competitive "bidding" is not required for a contract for the administration of health care benefit plans, because it is a contract for "professional services," which does not require competitive bidding or competitive negotiation under LSA-R.S. 39:1494. We disagree. A contract for administrative services only for the state's health benefit plans is in the nature of a contract for consulting services as defined in LSA-R.S. 39:1484(A)(4). Louisiana Revised Statute 39:1496(B) requires that contracts for consulting services that have a total maximum amount of compensation of fifty thousand dollars or more shall be awarded through a request-for-proposal process. The process utilized by OGB in search of an administrator for its self-insured health benefit plans was a competitive negotiation and not a competitive bid process. Cf. LSA-R.S. 39:1484(A)(2) and (A)(3). The statutory scheme gives OGB the discretion to negotiate contracts that are in the best interest of the state. While OGB's authority is not unlimited, its decision should not be disturbed absent a finding that it was arbitrary or capricious.
Accordingly, having thoroughly reviewed the entire record in the matter before us and considering the arguments raised, we reverse the judgment of the district court on its judicial review of this administrative decision. All costs of this appeal are cast to Humana Insurance Company.
HIGGINBOTHAM, J., concurs with reasons.
HIGGINBOTHAM, J., concurring.
I respectfully concur and write separately to stress that the HMO NIC issued by OGB does not clearly define the tasks to be performed under the contract and the criteria to be used in evaluating the proposals, as required by statute. See La. R.S. 39:1503(B); LAC 34:V.145(A)(6).
It was not until after the aggrieved proposers filed protests that Tommy Teague, former Chief Executive Officer of OGB, succinctly explained in an affidavit that the HMO plan was designed primarily for members who would seek health care in Louisiana through a statewide network of health care providers, but the plan also took into account the fact that some members would need health care out-of-state; therefore, it required a "statewide" network of providers. Teague explained that OGB never intended to preclude access to out-of-state providers in the HMO plan. Teague's affidavit also explained that the EPO plan was designed for members who would need more access to health care out-of-state; therefore, it required a nationwide network of health care providers.
In contrast, the actual NICs do not make this distinction or contain this simple explanation. There is no mention or discussion in the HMO NIC of a "statewide" or "nationwide" network of providers. The NIC states that contractors must be capable of providing all services and benefits set forth in the Plan of Benefits (Exhibit 1). Exhibit 1 is not a document outlining "services and benefits," rather Exhibit 1 instructs proposers to go to the OGB Home Page, under "Welcome to Group Benefits," click "A Visitor," then click "Health Plans," then click the appropriate plan link. Exhibit 1 does not attach a print out from the website. The NIC does attach, as Exhibit 2, the "OGB HMO Summary of Benefits Chart," but there is no mention or explanation in the NIC as to the purpose of Exhibit 2 or the contents of Exhibit 2.
In the Proposers' "Requirements-Questions" section of the HMO NIC, one of the questions states, "Do you agree to reprice the attached claims utilizing the discounts contained in your
The HMO NIC explains that proposals will be scored on cost of coverage and qualitative/network assessment, with each component worth up to 500 points. Fifteen scoring points are listed under the "Qualitative/Network Assessment," and there is no indication as to whether one point is entitled to greater weight than the others. One of the listed scoring points for the "Qualitative/Network Assessment" is "[p]lan [m]ember disruption and plan member continuity of care." The evaluations of the proposals demonstrate that this "disruption" factor accounted for 200 of the available 500 points for this scoring component.
OGB has now acknowledged that in developing the HMO NIC, it was aware that
Nevertheless, I do agree with the majority opinion that the agency did not abuse its discretion in finding that all three proposals received in response to the HMO NIC were responsive to the HMO NIC. Although the HMO NIC could have been written more clearly to avoid this protracted litigation, there is no language in the HMO NIC expressly prohibiting the consideration of enhanced benefits, including a nationwide network.
Furthermore, as noted by the majority opinion, the process utilized by OGB for this procurement of services was a competitive
For this reason, I concur with the majority opinion.
Louisiana Administrative Code Title 34, Part V, Subchapter B, Section 145(A)(6) provides, in pertinent part: