VENDOR QUALITY IMPROVEMENT
A Report to the Legislature
For Fiscal Year 2024
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 INTRODUCTION
This report is submitted pursuant to Massachusetts General Laws ch. 32A, § 21, which states as
follows:
The [group insurance] commission is hereby authorized and directed to establish and implement a
vendor quality improvement program for purposes including, but not limited to: the evaluation and
improvement of all health care services as applied to those contracts and the promotion of customer-
oriented quality management techniques. Such program shall include long- and short-term objectives,
quantifiable improvement goals, benchmarks for evaluating vendors and mechanisms to promote
collaboration between the commission and health care vendors to improve health care services. The
commission shall file an annual report with the clerks of the Senate and House of Representatives and
with the governor not later than September 30 concerning such vendor quality improvement program.
Since its formation in 1955, the Group Insurance Commission (GIC) has provided the Commonwealth’s
employees and retirees and their dependents with the highest quality benefits at the most reasonable
cost. With over 440,000 people currently covered under its plans, the GIC has remained focused on
that mission, seeking qualitative and quantitative value in each and every vendor relationship.
This report reflects a variety of quality improvement activities undertaken in Fiscal Year (FY) 2024 that
comprise the oversight and action necessary for the Group Insurance Commission to fulfill its mandate.
GIC STRATEGIC OBJECTIVES FISCAL YEAR 2024
The GIC’s long-term objectives are four-fold:
• Provide access to high-quality, affordable benefit options to employees, retirees and
dependents;
• Limit the financial liability to the state and others (of fulfilling benefit obligations) to sustainable
growth rates
• Use the GIC’s leverage to innovate and otherwise favorably influence the Massachusetts health
care market, and
• Evolve GIC’s existing business and operational environment to meet business demands and
security standards.
To meet these objectives and ensure that our vendors are aligned with our goals, the GIC takes a
comprehensive approach to quality improvement. First, the GIC ensures vendor quality via competitive
procurements. Second, the GIC routinely reviews the performance of its v endors via comprehensive
performance standards and audits. Finally, the GIC collaborates with its vendors to create quality
improvement plans and supports vendor-led initiatives in key strategic areas.
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 PROCUREMENTS
To fulfill its mission of providing members with high-value care at the most reasonable cost, the GIC
regularly engages in procurements and rate renewals, providing a systematic opportunity to routinely
evaluate and improve our plans and their services. All procurement initiatives executed by the Group
Insurance Commission are subject to all Massachusetts public bidding laws and regulations and are
designed to ensure the fair selection of high-quality services at competitive prices. Section four of
Chapter 32A of the Mass General Laws further requires that all contracts for GIC benefits are for no
more than five years.
Additionally, as part of this process, the GIC negotiates the plans’ rates; implements new plan designs
and programs; and reviews and revises its contractual performance guarantees. We also pay particular
attention to best practices, policy developments, legislative or regulatory mandates, and, of course,
the needs and concerns of our diverse membership.
In FY24, the GIC conducted a procurement for claims auditing services. The contract was awarded to
Claims Technologies Incorporated.
GIC QUALITY IMPROVEMENT INITIATIVES
Audit Findings
In FY24, the GIC, through its vendor Claim Technologies Incorporated, conducted an audit of 100
percent of claims of Point32 (Harvard Pilgrim and Tufts) and Mass General Brigham. The audits covered
claims administration for Medicare and non-Medicare plans over the period of July 1, 2022 through
June 30, 2023 and paid through December 31, 2023.
The method tests all claims, such as for eligibility, plan design features, compliance with an
administrator’s policies and procedures, and industry practices. This approach facilitates identifying
hard-to-discover, systemic processing errors and potential overpayment recoveries. It also provides
GIC with a more comprehensive view of vendor performance and a greater ability to recover funds and
create broad improvements in quality.
The audit findings for FY23 claims indicate that, while there are areas where each vendor can improve
upon its performance in claims processing and operations, the GIC vendors are well within industry
standards for claims processing and doing a good job paying claims accurately. The overall results for
this audit cycle were consistent with the results from prior years, which were also positive.
Measuring Vendor Quality, Performance Guarantees
The Group Insurance Commission holds its health care and behavioral health vendors to a set of
performance guarantees. The performance guarantees measure plans’ claims processing; customer
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service; implementation; enrollee communication; account management; data, systems and reporting;
patient safety; and anti-competitive practices.
Customer service-related measures, with potential penalties of a combined $100,000 per year, include
requiring vendors to answer calls within 30 seconds; have a call abandonment rate of less than three
percent; respond to customer complaints within 30 or 60 days; and resolve 80% of complaints during
the member’s first call. The GIC routinely revises these metrics to incorporate feedback from our
members and customer service staff.
Plans are evaluated on a quarterly basis, with financial penalties if vendors fail to meet the stipulated
targets. The GIC reviews its performance guarantees annually to evaluate their efficacy and to consider
new ones as appropriate.
VENDORS IMPROVING QUALITY, CUSTOMER SERVICE AND ADMINISTRATION
PHARMACY BENEFIT MANAGER
CVS Health (CVS Caremark and SilverScript)
Effective July 1, 2023, CVS Caremark administers prescription drug benefits for GIC members enrolled
in non-Medicare health plans, while SilverScript continued to administer pharmacy benefits for
Medicare members. In FY24, CVS and the GIC worked together to successfully transition non-Medicare
GIC members from Express Scripts to CVS Caremark.
CVS Caremark and SilverScript focused its efforts on prioritizing plan member access and safety, quality
improvement, and client support in FY24. The organization highlighted health equity and social
determinants of health initiatives in its goals and objectives.
Key accomplishments:
• Transitioned to an enhanced video conferencing platform to improve the telehealth experience
for members and clinicians
• Enhanced disease state assessment flowsheets for diabetes, weight management, and maternal
health
• Embedded a Community Resource Directory link within the member’s chart to identify local
resources to address Social Determinants of Health (SDOH) disparities
• Developed new tools for identifying high-risk SDOH members and members with low
adherence
• Completed its 2023 Annual Evaluation of CVS Caremark Utilization Management Program
• Implemented Medicare Star Rating improvement initiatives geared towards elevating the
member experience and improving clinical outcomes
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 HEALTH INSURANCE CARRIERS
July 1, 2023 marked the beginning of a new health insurance contract cycle and presented an
opportunity to implement plan design changes aimed to align plan design by product type , reduce
portfolio complexity, utilize tiering strategy to encourage use of higher value providers, and create
meaningful choice for members. In FY24 the GIC offered 1 national plan (available to members residing
outside of New England), 4 broad-network plans, 2 limited network plans, and 1 regional plan.
Enhancements to benefits across all medical plans in FY24 include:
• Increasing the hearing aid benefit for age 22 and older changed from $1,700 every to years to
$1,700 per ear ($3,400 total)
• Removing the speech therapy limit of 20 visits/year
• Expanding coverage of retrieval and storage of reproductive tissue to all (coverage was previously
limited to gender affirmation)
• Aligned Physical Therapy/Occupational therapy benefits across plans to eliminate time -based
benefit limits
Point32 (Harvard Pilgrim Health Care & Tufts Health Plan)
Membership services enhancements:
• Point32Health’s GIC membership was migrated to one commercial platform effective 7/1/2023,
paving the way for a more cohesive and consistent member experience
• Continuous assessments of and updates to the GIC Microsite to enhance its content with the goal
of making it a more user-friendly platform, with forms, provider directories, and plan information
easily accessible with minimal scrolling
• Multi-factor authentication was implemented on the Member Portal, adding another layer of
security to personal member accounts
• A new process was implemented for Point32’s secure online portal email routing, carving out GIC
membership to a dedicated email box so that responses can be prioritized with the intent to reply
to emails from GIC members within one business day or less
• Enhanced partnership with United Healthcare Shared Services to streamline support for out-of-
area members seeking care
Havard Pilgrim Health Care-
In FY24, Harvard Pilgrim launched the Good Measured Healthy Weight Program and Behavioral
Services Navigation Programs.
The Good Measures Programs delivers personalized one-on-one telephonic and virtual coaching with a
registered dietitian and helps participants prevent and manage health conditions like type 2 diabetes,
high blood pressure, and heart disease.
The Behavioral Services Navigation Program focused on increasing access to behavioral health care,
enhancing personalized interactions, and utilizing innovative programs and services .
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Wellpoint (formerly UniCare)
In FY24, Wellpoint made several quality, behavioral health, benefit, and process improvements.
• Quality improvements include enhancements to Wellpoint Health Aids (concierge service), Sydney
Health (dynamic health app), and Building Healthy Families (maternal health program); and new
offerings (musculoskeletal program and a new oncology support model).
• Guided by the MA Roadmap for Behavioral Health Reform, Wellpoint expanded BH services to their
members by including community-based health centers (CBHCs), some of which include rapid
access to crisis support. Wellpoint also established a dedicated CBHC/ED liaison to provide regular
outreach to hospitals and EDs to health member placement or transition.
• Wellpoint expanded their BH network to include access to a national network of unique platforms
to address specific needs such as opiate use, suicide prevention, and youth-intensive outpatient
services.
• Process improvements include increasing number of emails retained to bolster a digital-first
communications strategy, adding a tool to compare Wellpoint to other plans on their website, and
automated claims processing to improve turnaround time and accuracy.
Mass General Brigham Health Plan (MGB)
In FY24 MGB initiated several direct and plan-wide programmatic and plan changes:
MGB initiated the GIC HEDIS Gap Closure Pilot Program for GIC members to close prioritized HEDIS
gaps and ensure members follow up as recommended on a routine basis, both for preve ntive
screenings and management of chronic conditions.
Lyra Health was made available to GIC members. Lyra is a virtual first behavioral health vendor that
expands access to outpatient behavioral health care. Lyra provides our members with care options
including Lyra Essentials with self-guided exercises and videos, guided self-care with a coach, mental
health coaching, therapy, and medication management. An email campaign for GIC members
promoted the availability and usage of Lyra.
In the summer of 2023, MGB launched the Depression Disease Management Program, which screens
members for signs and symptoms of depression, provides education and resources to connect
members to care, and comprehensively assesses members with depression who are in care
management for the development of a member-centered individual care plan.
MGB also leveraged educational texting campaigns to spread awareness to members of any health
care gaps, and the impact to their health of not closing those gaps. These campaigns are also u sed to
redirect care to clinically appropriate settings and promote clinically appropriate preventative care to
benefit the overall health of members and reduce the cost of care.
MGB continued to use a digital approach to offer resources to GIC coordinators and employees and
provide information needed for enrollment.
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Health New England
In FY24, HNE renewed multi-year contracts with key providers and expanded their behavioral provider
and urgent care networks. Member support enhancements included an upgrade to HNE’s phone
systems to improve the routing of calls and the implementation of a Member Experience Committee to
collect, analyze and act on feedback to continually improve the overall member experience.
HNE demonstrated their focus on improving access to behavioral health resources in FY24 by
implementing a Dual Diagnosis Care Management program, which focuses on member with Serious
Persistent Mental Illness (SPMI) or Substance Use Disorder (SUD) and a chronic medical condition
(diabetes, CHF, COPD). HNE also continued their ongoing relationship with FindHelp, formerly Aunt
Bertha, a comprehensive resource directory to help our members find and connect with community
and social services in their area.
ANCILLARY INSURANCE VENDORS
Dental
MetLife
The GIC is authorized to provide dental and vision benefits to a specific subgroup of the active
employees eligible for GIC benefits. This group consists primarily of managers, legislators and their
staff, and certain executive office employees who are not covered by collective bargaining. The GIC
also provides a separate retiree dental benefit to all Commonwealth retirees as well as certain
municipal retirees whose municipality elects to join the plan. The GIC’s dental vendor is Met Life.
In FY24, MetLife made enhancements to data security. They implemented alternate member IDs ,
ensuring that social security numbers are no longer used as the primary identifier, and PGP encryption
for active and retiree eligibility files. MetLife also expanded its existing member communications to
include outreach to enrollees who are overdue for a dental exam and a welcome email to all new
active employees to confirm their enrollment.
Vision
Davis Vision
During Fiscal Year 2024, Davis Vision’s parent company, Versant Health continued to make
improvements to the member and provider on-line portals as well as adding key retailers and providers
to their networks. Davis Vision continues to focus its quality improvement efforts on easier, faster, and
accurate access for all of its partners and members.
Flexible Spending Account
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TASC
In FY24, TASC promoted account security by distributing communications to participants that included
security tips and best practices for online safety, highlighting common scams. Additionally, TASC
introduced Saturday customer care phone coverage for Commonwealth of MA employees during the
FY25 Annual Enrollment period in April 2024 to improve support accessibility.
Life Insurance & Long Term Disability (LTD)
MetLife
In FY24, MetLife revamped their GIC microsite and updated plan materials. MetLife also made
improvements to facilitate the accurate reporting and payment of claims. For LTD, MetLife made
necessary adjustments to align with updated GIC eligibility rules.
Mass4YOU: Employee Assistance Program (EAP)
Optum
Mass4YOU, administered by Optum, is available to employees and their dependents who are eligible
for GIC benefits. It offers a range of services and resources to promote work -life balance in addition to
workplace trainings.
In FY24 Optum migrated from Sanvello to Self-care by Able To, to improve access to Cognitive
Behavioral Therapy tools and enhances member experience. Optum continues to update its training
course offerings and improve the Mass4YOU website to make navigation simpler for members.
CONCLUSION
In FY24, the GIC continued to make progress toward advancing strategic objectives as highlighted in
our vendors’ efforts to align with our expectations for quality of care and support provided to our
members. Our vendors have made improvements in access to medical and behavioral health services,
which encourage a more inclusive health care environment and help to address the needs of our
diverse membership. The focus on enhancing the member experience and advancements in privacy
and claims processing efficiencies demonstrate our commitment to high services standards. Innovative
use of digital communications has proven instrumental in educating our members and equipping them
with the necessary tools to navigate their health care options effectively. This not only facilitates
improved