122435 O5 - Cost Sheet.xlsx
XLSX spreadsheet 127 KB Posted
- Attached to
- Administrative Support Services for the State of Nebraska Employee Health Care Medical Benefit Plans
- Solicitation number
- 122435 O5
- Issued by
- Lancaster County, Nebraska
About this file
This is a cost sheet for the State of Nebraska Department of Administrative Services' Request for Proposal #122435 O5 for self-funded medical administration services. The solicitation seeks a third-party administrator to provide comprehensive medical benefit plan administration for approximately 13,449 enrolled employees across three health plan options: a Regular Plan, a Consumer Focused Health Plan with Health Savings Account (HSA) coverage for approximately 1,183 participants, and WellNebraska. The contract term begins July 1, 2026, and extends through June 30, 2027, with two renewal options available for the periods July 1, 2027 through June 30, 2028, and July 1, 2028 through June 30, 2029, followed by two additional one-year renewal periods through June 30, 2031. Proposals are due by July 17, 2025, at 2:00 p.m. Central Time, with implementation targeted before the May 2026 Open Enrollment period.
The cost sheet requires bidders to provide per-employee-per-month (PEPM) fees on a guaranteed basis for the three-year contract period, with comprehensive services including network access, claims administration, medical management, wellness programs, member services, and compliance support. Section I captures standard service fees; Section II addresses charges passed through the claims wire, such as capitation fees and cost containment program expenses; Section III specifies Health Savings Account custodial fees on a per-participant-per-month (PPPM) basis; and Section IV details potential credits or allowances. Additionally, bidders must complete medical repricing worksheets demonstrating network discounts based on June 2025 contractual arrangements and provide a network discount guarantee with associated penalties for underperformance. The state requires bidders to put a portion of their administration fees at risk and establish a discount guarantee mechanism, with pass/fail or sliding-scale penalty structures capped at a 1.5 percentage point deviation corridor and penalties paid during the respective plan year.
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Text version
SF Medical Admin Fees
| COST SHEET | ||||||
| SOLICITATION NUMBER 122435 O5 | Bidder: | |||||
| Self-Funded Medical Administration Fees | ||||||
| Enter the per Employee per Month (PEPM) fees for Section I - Standard Services below for the plan designs currently in place. Fees on any other basis, (i.e., as a percentage of claims, on a per claim basis or a combination) will NOT be considered. The ASO Fees are to be guaranteed for the three (3) year contract period. Any ancillary service relating to the administration of the health plan not specifically identified in bidder’s proposal is assumed to be included in the ASO fee. IF THE FEE STRUCTURE IS DIFFERENT BY PLAN, COMPLETE THIS SCHEDULE FOR EACH PLAN AND LABEL EACH SCHEDULE ACCORDINGLY. Enrollment figures represent estimated counts. | ||||||
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | ||||
| Section I - Standard Services/Items Included in Fees | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 | |
| Estimated Number of Enrolled Employees => | 13,449 | 13,449 | 13,449 | 13,449 | 13,449 | |
| Medical Plan Administration Fees per Employee per Month (PEPM) | ||||||
| Network Access | ||||||
| Claims Administration | ||||||
| Medical Claims Administration | ||||||
| Claims Fiduciary Liability | ||||||
| Appeals | ||||||
| Subrogation. See details in Medical RFP, Section V. D. Subrogation Requirements | ||||||
| Coordination of Benefits | ||||||
| 12-month Claims Run-out Administration | ||||||
| Audits (internal and external) | ||||||
| Account Management | ||||||
| Attend On-Site and Virtual Meetings | ||||||
| Attendance at Open Enrollment Meetings | ||||||
| Legislative & Compliance Updates | ||||||
| Member ID Cards | ||||||
| Secure Member Website/Portal/Mobile App | ||||||
| Electronic Eligibility Transmittal, Updates, and Reconciliation | ||||||
| Benefit Booklet/Benefit Plan Description (initial and updates) | ||||||
| Summary of Benefits and Coverage (SBC) | ||||||
| Standard Reporting | ||||||
| Custom and Ad-hoc Reporting | ||||||
| Annual Accounting of Funds Received vs Claims Paid | ||||||
| Customer/Member Services | ||||||
| Toll-free Member Services Line | ||||||
| Designated Service Team | ||||||
| Clinical Services | ||||||
| Wellness Resources | ||||||
| Health Risk Assessment | ||||||
| Utilization Review/Management | ||||||
| Case Management/Medical Management | ||||||
| Behavioral Health Management | ||||||
| Disease Management | ||||||
| Telehealth Services (virtual telehealth services provided by one's own provider) | ||||||
| Telemedicine (typically provided by a third-party vendor) | ||||||
| 24 Hour Nurse Line | ||||||
| Enrollment and Program Communications | ||||||
| Other Required Communications | ||||||
| Postage/Mailing Costs | ||||||
| Fees related to data sharing and data feed exchanges with the State's vendor partners | ||||||
| Dependent eligibility verification services. See details in Medical RFP, Section V. F. Plan Requirements, item 11 | ||||||
| Section I - Standard Services MONTHLY TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||||
| Section II - Charges Passed Through the Claims Wire (est.) | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 | ||
| List and describe any and all administration charges that will be assessed/billed through the claim wire, and the estimated monthly total for each item. Examples may include, but are not limited to, capitation fees, ACO attribution fees, performance/value based provider payments, various cost containment program fees, various wellness program participation/case fees, silent/wrap network fees, etc. | |||||||
| Add lines, as needed to accommodate all fees. | Estimated |
Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees
| Service Description | Service Fee and Structure | ||||
| (PEPM, PMPM, X% of Savings, etc.) | 13,449 | 13,449 | 13,449 | 13,449 | 13,449 |
Section II - Charges Passed Through the Claims Wire MONTHLY TOTAL $0.00 $0.00 $0.00 $0.00 $0.00
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||
| Section III - HSA Standard Services/Items Included in Fees | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 |
| Enter the per Participant per Month (PPPM) fees for each plan year. For each service/item listed, indicate whether the service is "included" in the standard PPPM fee. If the service is not included in the standard PPPM fee, enter "N/A" or the applicable cost of adding that service. Add any standard services not included in the pre-populated list, along with the corresponding fee. Include documentation for any additional services as appropriate. | Estimated |
Number of Participants Estimated Number of Participants Estimated Number of Participants Estimated Number of Participants Estimated Number of Participants
| Estimated Number of Participants => | 1,183 | 1,183 | 1,183 | 1,183 | 1,183 |
| HSA Standard Services per Participant per Month (PPPM) | |||||
| HSA - Healthcare Spending Account Custodial Fees | |||||
| Account Set-up / Welcome Kit | |||||
| Debit Card | |||||
| Paper Checks | |||||
| Paper Statements | |||||
| Interest Earned (enter interest rate as of 6/1/25) => | |||||
| Investment Options (enter minimum investment balance) => | |||||
| Website/Portal | |||||
| Section III - HSA Standard Services MONTHLY TOTAL | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||
| Section IV - Credits/Allowances | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 |
| Indicate your willingness to offer one or more of the listed credits/allowances ("Y/N"). If "Y", then indicate the annual dollar amount of the credit/allowance for each plan year. | Estimated |
Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees
| Description | Y/N | 13,449 | 13,449 | 13,449 | 13,449 | 13,449 |
| One-time Implementation Credit | ||||||
| Annual 3rd-Party Audit Credit/Allowance | ||||||
| Annual Communication Credit/Allowance | ||||||
| Annual Wellness Credit/Allowance | ||||||
| Annual WMBE Credit/Allowance | ||||||
| Annual Discretionary or Universal Credit/Allowance | ||||||
| Other . . . |
Section IV - Credits/Allowances ANNUAL TOTAL $0.00 $0.00 $0.00 $0.00 $0.00
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||
| Section V - Additional and/or Optional Services | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 |
| List and describe any additional and/or optional services proposed, the associated administration charges, and the average expected monthly total for each service. |
Add lines as needed to accommodate all fees.
Note: This section will not count toward Evaluation Scoring. Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees Estimated Number of Enrolled Employees
| Service Description | Service Fee and Structure | ||||
| (PEPM, PMPM, X% of Savings, etc.) | 13,449 | 13,449 | 13,449 | 13,449 | 13,449 |
| Outside Stop Loss Integration/Reporting Fee | |||||
| Disease Management Point Solutions - i.e. weight mgmt, physical therapy, wellness (lifestyle modifications), musculoskeletal | |||||
| Other Services… |
Section V - Additional/Optional Services MONTHLY TOTAL $0.00 $0.00 $0.00 $0.00 $0.00
SF Medical Repricing
| COST SHEET |
| SOLICITATION NUMBER 122435 O5 |
| Medical Repricing |
| A Medical Repricing File will be provided, upon confirmation of an executed NDA on file with Segal. |
| Please re-price claims provided in the file. The re-pricing should be based on the eligible charges provided in the file, and your June 2025 network provider contractual fee arrangements. The repriced amounts should be based on actual data (current contracts) and should not include any assumptions regarding projected discounts or expected increases in eligible charges. |
| In the grid(s) below, please provide the sum of all re-priced claims by network and non network, based on the eligible charges. If you are proposing multiple networks, please complete a separate grid for each network. Clearly label each grid with the network name and type (PPO, POS, ACO, HMO/EPO, etc.). Insert additional grids, as needed. |
Bidder Name and Network:
| Repricing of Medical Claims Data | |||
| PPO/POS Network | |||
| Eligible Amount * | Repriced Amount ** | ||
| NETWORK | $0 | $0 | |
| NON NETWORK | $0 | $0 | |
| Grand Total From Data File | $0 | ||
| Grand Total Repriced | $0 |
Bidder Name and Network:
| Repricing of Medical Claims Data | |||
| Other Proposed Network | |||
| Eligible Amount * | Repriced Amount ** | ||
| NETWORK | $0 | $0 | |
| NON NETWORK | $0 | $0 | |
| Grand Total From Data File | $0 | ||
| Grand Total Repriced | $0 |
| *Eligible Amount reflects Eligible Charges as shown on the Claims Repricing data file. |
| **Repriced Amount reflects charges based on application of your June 2025 provider-specific discounts. |
You must also include a detailed description of each network proposed, an explanation summarizing how you repriced the claims, noting any and all assumptions made.
SF Med Ntwk Discnt Guarantee
| COST SHEET | ||||
| SOLICITATION NUMBER 122435 O5 | Bidder: | |||
| Self-Funded Medical Network Discount Detail & Guarantee | ||||
| The State seeks the most favorable discounts from providers in the selected managed care provider network. Upon completion of each plan year, the State requires an analysis of actual discounted savings of the selected network, which were realized over the course of the plan year, and use this analysis to compare to the results of the expected discounts. The State is looking for Bidders to put a portion of their administration fees at risk. | ||||
| Provide detail as to how your discount was derived. | ||||
| In-Network Discount Accumulation | Example | |||
| Claims Data using June 2025 Contracts | 50.0% | |||
| Indicate the increase in discounts attributed to each of the following: | ||||
| Discounts as of Repricing Date (e.g., 6/1/25) | 51.0% | |||
| Current Letters of Intent | ||||
| (Do not include assumed increases in eligible charges) | 51.4% | |||
| Known Contract Improvements | ||||
| (Do not include assumed increases in eligible charges) | 52.5% | |||
| Assumed Increases in eligible Charges | 53.5% | |||
| Anticipated Contract Improvements | ||||
| (Based on in-hand Letters of Intent) | 54.0% | |||
| Other (please clarify) | 54.0% | |||
| Expected July 2026 Discounts | 54.0% |
| Indicate the level of discounts that will be guaranteed from year to year over the contract term. | |||||
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||
| Service Category | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 |
| Guaranteed Overall Discounts |
Indicate the penalty to be paid back to the State if the discount guarantee listed above is not achieved. The schedule can either be of a "pass/fail" nature or be a sliding scale, with higher penalties for greater deviations of actual discounts relative to guaranteed levels. "Pass/fail" is the preferred metric. In the case of a sliding scale, the "risk-free corridor" cannot extend beyond 1 percentage point from the guaranteed discount, and the full penalty must be paid for any deviation beyond 1.5 percentage points from the guaranteed discount.
| Initial Contract Term | 1st Renewal Option | 2nd Renewal Option | |||
| Service Category | 07/01/26 -06/30/2027 | 07/01/27 -06/30/2028 | 07/01/28 -06/30/2029 | 07/01/29 -06/30/2030 | 07/01/30 -06/30/2031 |
| Flat Dollar Amount or Percent of Administration Fees at Risk for Discount Guarantee* | |||||
| * paid during the respective plan year |
How do you propose to ascertain actual savings (i.e., the formula for determining the actual performance against expected or ‘quoted’ discounts)?
Describe the management information that you will provide the State to support the year-end performance results.
Provide samples of existing agreements, if any, that your network has used with other large plan sponsors to meet network discount targets.
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