Attachment A - Dental Plan Proposal Package_Final.xls

XLS spreadsheet 1 MB Posted Apr 30, 2020

Attached to: Supplemental Dental Benefits Federal contract opportunity
Solicitation number: 9523ZY-20-R-0001
Issued by: Commodity Futures Trading Commission

About this file

Written by GovTribe AI · Dec 28, 2023

This document outlines a federal contract opportunity for supplemental dental benefits administration and insurance. The Commodity Futures Trading Commission seeks proposals for a contractor to administer and insure its supplemental dental plan covering approximately 700 employees in Washington, D.C., New York, New York, Chicago, Illinois, and Kansas City, Missouri for a one year base period and four one-year options. The resulting contract is anticipated to begin in January 2021. The agency will issue a request for proposals on April 6, 2020 to be submitted electronically through FBO.gov within 30 calendar days. The procurement will follow FAR Part 12 and 15 procedures.

View the file

Other files for this federal contract opportunity

Other files attached to Supplemental Dental Benefits, newest first.
File	Type	Posted
9523ZY-20-R-0001 - Solicitation - Final.pdf	PDF	Apr 30, 2020
Attachment B - NDA - Final.pdf	PDF	Apr 30, 2020
Attachment C_Past Performance - Final.pdf	PDF	Apr 30, 2020

On GovTribe

Work with this file on GovTribe

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

Instruct

General	1.	ABC Co. to ABC Company
	2.	Change logo to new log
	3.	Delete blank row 3 on worksheets that I haven't done it on
	4.	Reformat into new format
	5.	Search for MetLife - Replace with The Client
	6.	All dates - change to variable format [MM, DD, YYYY, if appropriate]
	7.	References to Attachments are to be as follows: Attachment: [Name of Attachment]
Questionnaire	1.	Add consultant instructin to row 5
	2.	Change Auto Number & Color macro to Auto Number; ut in rows 7-8
	3.	Delete extra rows
	4.	delete row 36
	5.	Aon logo on row 10
Worksheets	1.	Variable [], red font indicator for question #
	2.	use same formatting for the question as in the Questionnaire (double border, with blue fill)
	3.	delete row 3 in all supplemental worksheets

Listbox

List Box Name	Value
ListSentCensusOn	diskette
	hard copy
	email
	CD
ListReplaceSupp	replace
	supplement
ListYesNoSeeExplain	Yes
	No - See "Explanation"
ListYesExplain	Yes - See "Explanation"
	No
	N/A
ListYesNo	Yes
	No
ListYesNoNA	Yes
	No
	N/A
ListYesNoNotRequested	Yes
	No
	Not Requested
ListYN_NSeeExpNotReq	Yes
	No
	No - See "Explanation"
	Not Requested
ListCompleted	Completed
	Not Completed
ListCompNotExplain	Completed
	Not Completed - See "Explanation"
ListAttached	Attached
	Not Attached
ListABC	a
	b
	c
ListYesNotRequested	Yes
	No
	Requested
ListABC_G	a
	b
	c
	d
	e
	f
	g
ListABC_H	a
	b
	c
	d
	e
	f
	g
	h
ListYears	< 2 years
	2 to 5 Years
	5 to 10 Years
	> 10 Years
ListAccreditation	Excellent
	Commendable
	Accredited
	Provisional
	Denied
	Appealed by Plan
	In Process
	Revoked
	Scheduled
	Suspended
	Under Review by NCQA
	NHP Accreditation
	NHP Under Review
	NHP Expired
	NHP NCQA Discretionary Review
	NHP Initial Decision Pending
	NHP Future Review Scheduled
ListNameInsureEntity	Offered
	Not Offered
ListJCAHO	Accreditation Not Requested
	Accreditation With Commendation
	Accreditation Without Type I Recommendations
	Accreditation With Type I Recommendations
	Provisional Accreditation
	Conditional Accreditation
	Preliminary Denial of Accreditation
	Accreditation Denied
	Accreditation Watch
ListTaxStatus	For-Profit
	Not-For-Profit
ListModel	Group
	IPA
	Mixed
	Network
	Staff
	PPO Platform
ListMetNotMet	Met
	Not Met
ListUnderwriting	Individual Statement of Health
	Employer Statement acting as gatekeeper)
	Other; specified in "Explanation"
ListProposedRating	Community Rating
	Group Specific (Adjusted) Community Rating
	Community Rating by Class
	Community Rating by Age
	Experience Rated/Non-Div Eligible (Prospectively-rated)
	Experience Rated/Div Eligible (Retrospectively-rated)
ListCommissions	Standard commissions are included in basic premium rates regardless of whether they are paid.
	Standard commissions require an increase to basic premium rates.
	No commissions available.
ListGeo	Zip code dispersion
	Center of zip code
	Geo-coding (employee zip code address)
ListStates	Alabama
	Alaska
	Arizona
	Arkansas
	California
	Colorado
	Connecticut
	Delaware
	District of Columbia
	Florida
	Georgia
	Hawaii
	Idaho
	Illinois
	Indiana
	Iowa
	Kansas
	Kentucky
	Louisiana
	Maine
	Maryland
	Massachusetts
	Michigan
	Minnesota
	Mississippi
	Missouri
	Montana
	Nebraska
	Nevada
	New Hampshire
	New Jersey
	New Mexico
	New York
	North Carolina
	North Dakota
	Ohio
	Oklahoma
	Oregon
	Pennsylvania
	Puerto Rico
	Rhode Island
	South Carolina
	South Dakota
	Tennessee
	Texas
	Utah
	Vermont
	Virginia
	Washington
	West Virginia
	Wisconsin
	Wyoming
ListAnnYrEndDays	30
	60
	90
	120
	180
ListPayFrequency	weekly
	bi-weekly
	monthly
	quarterly
	semi-annually
	annually
ListPnltyFeeList	premium
	administrative fees
ListAdvRenewNoticeDays	30
	60
	90
	120
	180
ListAccreditationPPO	Full
	One - Year
	Provisional
	Denied
	Under Review
	NCQA Discretionary Review
ListPlanType	HMO
	PPO
	POS
	HMO/PPO
	PPO/POS
	HMO/POS
	HMO/PPO/POS
	Not Applicable
	No - See "Explanation"
	Not Applicable - See "Explanation"
ListURAC	Accredited
	Not Accredited
ListGuaranteeType	financial
	service
ListProEnforce	proposed
	inforce
ListSTDPayFreq	weekly
	bi-weekly
	monthly
	quarterly
	annually
ListAgreeDisagree	Agree
	Disagree
ListRated	Rated
	Not Rated
	See "Explanation"
ListIncluNotIncluNA	Included
	Not Included
	N/A - No Additional Costs
ListRateChange	No Change
	Rating Improved
	Rating Worsened
	Not Rated
ListTeleElecTransFaxMail	Telephone
	Electronic transmission
	Fax and mail
ListIncluded	Included
	Not Included
ListHoursofOperation	12:00 AM
	12:30 AM
	1:00 AM
	1:30 AM
	2:00 AM
	2:30 AM
	3:00 AM
	3:30 AM
	4:00 AM
	4:30 AM
	5:00 AM
	5:30 AM
	6:00 AM
	6:30 AM
	7:00 AM
	7:30 AM
	8:00 AM
	8:30 AM
	9:00 AM
	9:30 AM
	10:00 AM
	10:30 AM
	11:00 AM
	11:30 AM
	12:00 PM
	12:30 PM
	1:00 PM
	1:30 PM
	2:00 PM
	2:30 PM
	3:00 PM
	3:30 PM
	4:00 PM
	4:30 PM
	5:00 PM
	5:30 PM
	6:00 PM
	6:30 PM
	7:00 PM
	7:30 PM
	8:00 PM
	8:30 PM
	9:00 PM
	9:30 PM
	10:00 PM
	10:30 PM
	11:00 PM
	11:30 PM
	24 hours / 7 days
	Not Open
	Other - See Explanation
ListGracePeriod	30 days
	60 days
	90 days
	120 days
	Other - See Explanation
ListNotedNotNoted	Noted
	Not Noted
ListContributions	Contributory
	Non-Contributory
ListBeforeAfterTax	Before-Tax
	After-Tax
	Both Before-Tax and After-Tax
ListClassSchedule	Flat
	Schedule
	Formula
ListClassEligibility	Active, FT salaried ee's regularly working min 30 hrs/wk.
	Active, FT hourly ee's regularly working min 30 hrs/wk.
	Active, FT ee's regularly working min 30 hrs/wk.
	Active, FT ee's regularly working min 30 hrs/wk, excluding Class(es) X already covered under this Policy.
	Active, FT salaried EE regularly working min 30 hrs/wk who earn more than X per X.
	Active, FT hourly ee's regularly working min 30 hrs/wk who earn more than X per X.
	Active, PT ee's regularly working min 17.5 hrs/wk.
	Other active, PT ee's regularly working min 17.5 hrs/wk, excluding Class(es) X already covered under this Policy.
	Other active, FT ee's regularly working min 17.5 hrs/wk, excluding Class(es) X already covered under this Policy.
	Active, FT Union ee's regularly working min 30 hrs/wk.
	Active, FT Non-Union ee's regularly working min 30 hrs/wk.
ListCompNotComp2	Completed - information requested provided
	Not completed - no recent or planned activities
	Not completed - information available, but not provided
ListClaimsRetention	Claims
	Retention
ListStateGovern	Pay exactly as mandated
	May pay more than as mandated for some/all of the states - See "Explanation"
ListStateNotGovern	No interest credited
	Interest is credited - See "Explanation"
ListWillingNAExplain	Willing
	Not Willing
	Not Applicable
	Not Willing - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListModelDent	PPO
	DHMO
	See "Explanation"
ListYNNAExplain	Yes
	No
	Not Applicable
	No - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListYNNoExplain	Yes
	No
	No - See "Explanation"
ListAgreeNAExplain	Agree
	Do Not Agree
	Not Applicable
	Do Not Agree - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListRCInfo	HIAA
	MDR
	Internally Developed
	Other
	See "Explanation"
ListAttachedNAExplain	Attached
	Not Attached
	Not Applicable
	Not Attached - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListNCQA	Accreditation Not Requested
	Excellent
	Full
	Commendable
	One-year
	Accredited
	Provisional
	Denied
	Appealed by Plan
	In Process
	Revoked
	Scheduled
	Suspended
	Under Review by NCQA
	NCQA Discretionary Review
	NHP Accreditation
	NHP Denial
	NHP Under Review
	NHP Expired
	NHP NCQA Discretionary Review
	NHP Initial Decision Pending
	NHP Future Review Scheduled
ListProvidedNAExplain	Provided
	Not Provided
	Not Applicable
	Not Provided - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListCompletedNAExplain	Completed
	Not Completed
	Not Applicable
	Not Completed - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListClmMailAreaTime	24 hours
	48 hours
	Greater than 48 hours
ListIncludedNAExplain	Included
	Not Included
	Not Applicable
	Not Included - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListOffered	Offered
	Not Offered
ListYNNA	Yes
	No
	Not Applicable
ListYNYesExplain	Yes
	No
	Yes - See "Explanation"
ListOwnLease	Owned
	Leased
	Both
ListEitherHMOPPO	HMO
	PPO
	Either HMO or PPO
	Other - See Below
ListYNPlanDesignExplain	Yes
	No - See "PlanDesignExplain" Worksheet
ListHMOEPOPPOPOS	HMO/EPO
	PPO
	POS
	HMO/EPO, PPO, POS
	Other - See Below
ListSubcontractServ	Changed in Last 12 Mo's
	Planned for Next 12 Mo's
	N/A - No Changes
	N/A - Not Subcontracted
ListYNNAWebsite	Yes
	No
	Not Applicable - No Website
	No - See "Explanation"
ListConfirmed	Confirmed
	Not Confirmed
	Not Applicable
ListProposedRatingCDHC	Community Rating
	Group Specific (Adjusted) Community Rating
	Community Rating by Class
	Community Rating by Age
	Experience Rated/Non-Div Eligible (Prospectively-rated)
	Experience Rated/Div Eligible (Retrospectively-rated)
	Partially Experience Rated/Non-Div Eligible (Prospectively-rated)
	Partially Experience Rated/Div Eligible (Retrospectively-rated)
	Other - See "Explanation"
ListProvidedExplain	Provided - See "Explanation"
	Not Provided
ListNotCompletedExplain	Completed
	Not Completed
	Not Completed - See "Explanation"
ListNotAttachedExplain	Attached
	Not Attached
	Not Attached - See "Explanation"
ListAttachedExplain	Attached
	Not Attached
	Attached - See "Explanation"
	Not Attached - See "Explanation"
ListYPlanDesignExplainN	Yes - See "PlanDesignExplain" Worksheet
	No
ListYNNANoExplain	Yes
	No
	No - See "Explanation"
	N/A
ListYExplainNNAWebsite	Yes - See "Explanation"
	No
	Not Applicable - No Website
ListLeasedNetwork	Not Applicable - No Leased Networks
	< 4 Leased Networks - See Data Below
	> 4 Leased Networks - See "Explanation"
ListServiceCenter	< 2 Service Centers - See Data Below
	> 2 Service Centers - See "Explanation"
ListNCQADMProgAccred	Patient & Practitioner Accreditation
	Patient-Oriented Accreditation
	Practitioner-Oriented Accreditation
	Accreditation In-Process
	Accreditation Not Requested
	Accreditation Denied
	Other - See "Explanation"
ListNCQADMProgCert	Program Design Certification
	Systems Certification
	Contact Certification
	Certification In-Process
	Certification Not Requested
	Certification Denied
	Other - See "Explanation"
ListJCAHODiseaseCert	Certificate of Distinction Awarded
	Certification In Process
	Certification Not Requested
	Certification Denied
	Other - See "Explanation"
ListURACDMAccred	Full Accreditation
	Conditional Accreditation
	Provisional Accreditation
	Accreditation Not Requested
	Accreditation Denied
	Accreditation In-Process
	Accreditation Voluntarily Withdrawn
	Corrective Action
	Reaccreditation In-Process
	Other - See "Explanation"
ListMinSizeDMProg	< 1,000
	1,000
	2,000
	5,000
	10,000
	Other - See "Explanation"
ListRecommendFreq	Daily
	Weekly
	Monthly
	Quarterly
	Annually
	Other - See "Explanation"
ListStandReportFreq	Per Occurrence
	Weekly
	Monthly
	Quarterly
	Annually
ListPropFeeLenTime	18 months
	24 months
	36 months
	48 months
	Other - See "Explanation"
ListMinLeadTime	1 month
	2 months
	3 months
	4 months
	6 months
	Other - See "Explanation"
ListPropRequirement	Accept
	Refuse
	See Modified Language
ListMethDataReceipt	Disk
	Tape
	On-Line File Transfer
	Paper
	Other
	Other - See "Explanation"
ListServOfferedOnline	Included in Your Basic Package
	Available for an Additional Cost
	Neither Included in the Basic Package Nor for an Additional Cost
ListInOutBound	Both in-bound/out-bound
	In-bound only
	Out-bound only
ListSubcontractedNAExplain	Subcontracted
	Not Subcontracted
	Not Applicable
	Not Subcontracted - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListAvailabilityOfService	Included in Your Basic Package
	Available for an Additional Cost
ListCoreAddServ	Core Service
	Additional Service
ListFrequentlySys	Weekly
	Bi-Weekly
	Monthly
	Bi-Monthly
	Quarterly
	Other
ListFrequentlyRptProd	Daily
	Weekly
	Monthly
	Quarterly
	Other
ListSTDLTDWCServices	Internal Staff
	Subsidiary
	Contracted Providers
ListMedClarif	Phone
	Fax
	Other
ListBenPymt	Directly to insured/patient
	Assigned to a family member or provider
	Both - Directly and Assigned
ListCMInEx	Performed internally
	External vendor used
ListCommExper	Community rated/pooled
	Experience-rated
ListFullPartial	Full
	Partial
ListMandatory	Voluntary
	Mandatory
	Not Applicable
ListYesExempt	Yes
	No
	No - Exempt b/c Fully-Insured
	No - See "Explanation"
	N/A
ListOffWksheet	Officer Worksheet Completed and Faxed
	Officer Worksheet Not Completed
ListProvideNa	Provided
	Not Provided
	N/A
	Not Provided - See "Explanation

OldListbox

ListWilling	Willing
	Not Willing
	Not Applicable
	Not Willing - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListModel	PPO
	DHMO
	See "Explanation"
ListYesNo	Yes
	No
	Not Applicable
	No - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListYNNoExplain	Yes
	No
	No - See "Explanation"
ListAgree	Agree
	Do Not Agree
	Not Applicable
	Do Not Agree - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListRCInfo	HIAA
	MDR
	Internally Developed
	Other
	See "Explanation"
ListAttached	Attached
	Not Attached
	Not Applicable
	Not Attached - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListRated	Rated
	Not Rated
	See "Explanation"
ListCompleted	Completed
	Not Completed
	Not Applicable
	Not Completed - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"
ListGeo	Zip code dispersion
	Center of zip code
	Geo-coding (employee zip code address)
ListProvided	Provided
	Not Provided
	Not Applicable
	Not Provided - See "Explanation"
	Not Applicable - See "Explanation"
	See "Explanation"

Introduction

To Consultant: This RFP is only a template. You must review the content of this RFP and customize it for your clients. All the Dark Red font color wording must be reviewed and modified to customize this RFP for your client. To help you locate these texts, we placed [ ] around them. This way you can locate the Dark Red text by searching for [ . After you customize the RFP, and BEFORE you create the Vendor Copy, you must change the Dark Red font color to match the rest of the document's text font color. You must hide all the rows that are comments or with information/questions that do not apply to your client.
Request for Dental Proposal (RFP) for Commodity Futures Trading Commission
Commodity Futures Trading Commission hereinafter referred to as CFTC
Background and Administrative Information
Introduction
Commodity Futures Trading Commission (CFTC) is soliciting proposals from qualified dental carriers to provide a program for their active employees effective no later than January 3, 2021.
The following dental carriers have been invited to submit responses to this RFP: [Dental Carrier 1, Dental Carrier 2, etc.]
Company Description
See the Statement of Work.
More information may be obtained by accessing the agency's web site at www.CFTC.gov.
Benefit/Health Care Strategy
[Describe benefit/health care strategy]
[Address the classes/groups of employees and/or retirees/dependents that will be covered under the dental program; provide aggregate enrollment/eligibility figures in the chart below]
Classes/Groups	Eligible Employees	Enrolled Lives
[insert name of class/group]	[xx,xxx]	[xx,xxx]
[insert name of class/group]	[xx,xxx]	[xx,xxx]
[insert name of class/group]	[xx,xxx]	[xx,xxx]
Total	0	0
[The objectives of the dental program are: ]
Aon's Role/Compensation
The Client has retained Aon Consulting to prepare these specifications, analyze all proposals, and make recommendations to The Client for this Dental plan marketing. The specific payment of Aon's fees may be made through [commissions and/or fee-for-service] arrangements. The following addresses our compensation arrangement with The Client for each line of coverage included in this marketing and whether your quote should [(1) include commissions, or (2) be made net of commissions.]
[Aon Consulting, Inc. is the broker of record for The Client and receives compensation for all or a part of our services through commissions. Therefore, include [commission description].
[The Client does not pay a commission to a broker or agent for the administration of the [net commission description] coverage(s). Therefore, please quote rates net of commissions for the [net commission description] plan(s).]
[Address any other issues relating to Aon compensation here].
Timeline and Due Dates
Please note the timeline and due dates may be subject to change. CFTC will notify proposed bidders of any updates to the timeline as soon as possible.
Event			Due Date
Release of Dental RFP			Friday, May 15, 2015
Vendor Questions Regarding RFP			Friday, May 22, 2015
Responses to Vendor Questions Posted			Friday, May 29, 2015
Submission of RFP Responses			Monday, June 15, 2015
Best and Final Offers			Saturday, August 15, 2015
Contract Award Date			Wednesday, September 30, 2015
Implementation			Thursday, October 01, 2015
Open Enrollment			November - December 2015
Effective Date			Sunday, January 10, 2016
Current Plan Information
A detailed description of CFTC's current plan design can be found in the "Plan Design - Current" worksheet. CFTC offers 1 fully-insured PPO dental plan currently insured by MetLife. CFTC is looking to enhance current maximum reimbursements for Classes I-III and Orthodontia. The proposed changes can be found in the "Plan Design - Proposed" worksheet.
CFTC pays the full cost of dental coverage for all eligible employees.
All employees eligible to enroll in the Federal Employees Health Benefits (FEHB) Program, employees on temporary appointments who will be working a schedule of less than six months per year, and intermittent employees who are expected to work 130 hours per month or more for at least 90 days, are eligible for dental benefits. Eligible dependents: spouses, including domestic partners of CFTC employees and same-sex spouses, and children up to age 26; and unmarried children age 26 and older who are mentally or physically incapable of earning their own living (if FEHB expands the definitions of eligible dependents beyond these limits during the contract period, the Plan shall likewise expand its coverage). Retirees are not eligible for the Plan and will remain ineligible, despite being covered under FEHB.
Enrollment, rates changes and paid claims are included in the "Enroll_Claims" worksheet. The dental plan is fully-insured.
[Second paragraph on enrollment, rates and claims]
Financial
Use the following assumptions in preparing your quote:
Rate Assumptions: Referring to the census data provided (see "Census" worksheet), determine eligibility and participation assumptions for each program being quoted. Using these assumptions, develop rate quotes for the covered employee population.
Plan Design Assumptions: Please base your quotations on the proposed plan design also contained in the "Plan Design-Proposed" worksheet and explain any proposed plan changes in general. Use the "Explanation" spreadsheet if you need additional space.
[Contribution Assumptions: Explain employee/employer contributions here]
[Eligibility Assumptions: Dental coverage is offered to (insert the group and dependents that this program will be offered to and explain eligibility).]
Rate Guarantees: Bill to add
Network Access
Please prepare a “Geo-Access” report using the parameters in the table below. Note that it is important that you follow the exact parameters. The report should show provider availability for General/Family Dentists (GFD’s) and specialists as indicated Please also provide information on those zip codes where the access standard is not met. See the "Census" worksheet for census information. Your report should note the 5-digit zip code, city name and county. Label Attachment: Geo Access Report.
Type of Dentist		Number of Dentists	Miles from Residence
General/Family Dentist		2	8
Specialist Dentists		2	8
[Endodontists]
[Oral Surgeons]
[Periodontists]
[Prosthodontists]
[Orthodontists]
[Other Dentists]
Proposal Objectives
CFTC wants to accomplish at least the following objectives with the new dental program:
* Minimize the cost and rate of future rate increases
* Establish performance targets to assess and monitor Vendor's performance
* Develop a business partnership with Vendor predicated on continuous quality improvement
* Offer dental PPO networks for the vast majority of employees [and retirees].
Selection Criteria
The Client is committed to offering health care programs which promote cost-effective and patient-oriented care. Listed below are the primary selection criteria that will enter into The Client's decision-making process:
* Program costs
* Reimbursement discounts
* Performance guarantees
* Access to dental providers of choice
* Quality assurance
* Claims processing
* Reporting
* Claims administration system
* Member service support
* Account management staff
* Program implementation
* Partnership
Proposal Process
This is a confidential marketing effort. No data or details of this RFP are to be shared with outside parties. The RFP questions and spreadsheets should be treated as confidential business documents and may not be shared with outside parties without the prior written approval of Aon Consulting.
CFTC and Aon Consulting reserve the right to:
* Reject any or all proposals tendered
* Negotiate exclusively with one or more vendors of choice
* Terminate or modify the process at any time
We want this to be an interactive process. We will make every reasonable effort to provide you with sufficient data for your responses. You are invited to ask questions during the proposal process and to seek additional information, if needed.
Please do not contact any employee of CFTC about this RFP or the Dental program selection process.
All questions regarding this proposal should be directed to:
Consultant's Name
Consultant's Title
Aon Consulting	Aon Consulting
Address
Address (Optional)
City, State, Zip
Phone Number
Cell Number
Fax Number
E-mail Address
	OR
Consultant's Name
Consultant's Title
Aon Consulting	Aon Consulting
Address
Address (Optional)
City, State, Zip
Phone Number
Cell Number
Fax Number
E-mail Address
Timetable/Deadlines
The following timetable is expected to apply during this marketing effort:
Event		Target Date
RFP mailed to selected vendors		5/1/10
Receive confirmation to bid		5/15/10
Deadline for RFP responses		6/1/10
Notification of finalists		7/1/10
Finalist Interviews/Site Visits		mid-July
Selection of Vendor		9/1/10
Plan Effective Date		1/1/11
Finalists selected at the end of the vendor analysis may be asked to participate in vendor interviews at CFTC's offices or at the finalist's facility. Please keep the week of July 12, 2010 open for interviews.
Proposal Format
Your completed proposal will consist of 3 parts, all of which must be received in a single electronic submission by the deadline indicated in the RFP to be considered for this marketing. Below is an overview of what each of these three parts is intended to address.
Part 1: Questionnaire File: The Questionnaire and a sheet to provide Explanations are contained in this Excel file. You are expected to respond to the Questionnaire by entering your responses in this file. The majority of the questions in the Questionnaire have been structured to elicit declarative responses through the use of drop down boxes.
To record your response:
* Click on the response cell in the Response column;
* Click on the down arrow which appears directly to the right of the cell;
* Click on the response that best describes your answer.
To enter your responses where a numeric, percent or ratio value is indicated as the answer format, simply enter the value in the corresponding response cell.
Next to each response cell, additional space is available for a brief text explanation. However, if the length of the explanation is greater than 400 characters, you must go to the "Explanation" worksheet to provide your detailed explanation. All explanations must be numbered to correspond to the questions to which they pertain and should be brief.
If you have any difficulty entering data in the appropriate cells, please contact [Consultant's Name] at [xxx-xxx-xxxx].
Part 2: Data and Response worksheets: Worksheets to enter the requested information are contained within the companion Excel file. Generally, the types of information that you will be entering into this file are your plan design deviations, provider reimbursement data, etc., if requested. You are expected to provide the requested information by completing this workbook. In addition, this file may also contain reference information (rate history, enrollment data, etc.) that will assist you in putting together your quote.
Part 3: Electronic File Attachments: Any attachments that you are being asked to provide about your organization must also be submitted electronically. An explanation of each attachment that you are required to provide appears in the Questionnaire; please be sure to follow the naming conventions that are provided for each attachment.
In order to help you organize your proposal and ensure that it is complete, please review the following list to ensure that you have provided each required item.
Part 1. Questionnaire File:
Worksheets			Name of Worksheet
Questionnaire (RFP)			Questionnaire
Explanations, if necessary			Explanation
Part 2. Data and Response Files:
Worksheets			Name of Worksheet
MemTot			MemTot
Current Plan Design			Plan Design - Current
Proposed Plan Design			Plan Design - Proposed
Network Access			GeoAccess
Performance Metrics			Performance Metrics
Provider Network Disruption Report			Provider List
Reimbursement (Primary Network)			Reimbursement - Best Discount
Reimbursement (Secondary Network, if applicable)			Reimbursement - Lesser Discount
Reimbursement (Out-of-Network)			Reimbursement - No Discount
Census Information			Census
Plan Measures			Plan Measures	Hide, do not need for this RFP
Enrollment, Claims and Rate History			Enroll_Claims
Hold Harmless Language			Hold Harmless
Officer Certification			Officer
Account Manager Biography			Bio
Implementation Plan			Implement
Account Management Plan			Acct Manage
Part 3. Electronic File Attachments
Attachments
Most Recent Audited Financial Statement
Annual Report
Geo Access Report
Provider Directories
Marketing Materials
Sample Enrollment Materials
Sample Employer Contract
Management Reporting Package
Implementation Schedule
Charge Level Chart
Client Termination List
Submission Format
As noted in the preceding Proposal Format section, your completed proposal must be submitted electronically, in a single submission. You are requested to submit your proposal [on CD to the address noted above OR a zipped file sent to the email address noted above].
[In addition, please provide xx hard copies of the three parts set forth above comprising your completed proposal.]
Proposal Requirements
Vendor Errors/Omissions
Neither CFTC will be responsible for errors or omissions made in your proposal. You will be permitted to submit only one proposal. You may not revise or withdraw a submitted proposal after the applicable deadline. After submission, revisions to your original submission will not be allowed, except as requested by CFTC. Therefore, please take care to make your bid sound and competitive.
Cost of Submitting Proposal
All costs associated with your proposal, including preparation and presentation, will be borne by your organization and not CFTC.
Basis of Cost Proposal
Your proposal should be based on your estimated cost of all expenses for the services and funding arrangements requested.
Confidentiality
All information contained in this RFP is confidential and may not be used for any other purposes than preparation of your proposal.
Officer Certification
All vendors participating in this RFP will be required to have a company officer attest to compliance with RFP specifications and the accuracy of all responses provided. Instructions are given in the "Officer" worksheet for the completion of this sign-off.
Completeness
We ask that your proposal be complete and that it comply with all aspects of these specifications. Any missing information could disqualify your proposal. Unless you note to the contrary, we will assume that your proposal conforms to our specifications in every way.
Termination Clause
The Client reserves the right to terminate its contract at any time, provided such notification is given 30 days in advance.

&L&"Arial,Italic"&8&A&C&8Page &P&R&"Arial,Italic"&8CFTC Solicitation #CFHRB-15-SO-0132

Questionnaire

			Request for Dental Proposal (RFP) for CFTC
			Questionnaire
			To Vendor: Use Column Q to provide a brief explanation. However if the length of the explanation is greater than 400 characters, you must use the "Explanation" worksheet to provide your detail explanation.
			Dental RFP 2021	List/Expected Response	Answer Format	Field Name	Format Type	Response	Explanation
I.			PLAN IDENTIFICATION/CONTACTS		Answer Format		Format Type	Response	Explanation
	1.		Organization Name	Text	text	respOrgName	Text
	2.		Street Address	Text	text	respAddress	Text
	3.		City	Text	text	respCity	Text
	4.		State	Text	text	respState	Text
	5.		Zip	Text	text	respZip	Text
	6.		Web Address	Text	text	respWebAddress	Text
			Contacts		Answer Format		Format Type	Response	Explanation
			Please indicate the contact who can answer questions related to this RFP.
	7.		Primary Contact
		a.	Name	Text	text	respPrContNa	Text
		b.	Title	Text	text	respPrTitle	Text
		c.	Address	Text	text	respPrStreet	Text
		d.	City	Text	text	respPrCity	Text
		e.	State	Text	text	respPrState	Text
		f.	Zip	Text	text	respPrZip	Text
		g.	Phone Number	Text	text	respPrPhone	Text
		h.	Fax Number	Text	text	respPrFax	Text
		i.	E-mail Address	Text	text	respPrEmail	Text
	8.		Secondary Contact
		a.	Name	Text	text	respScContNa	Text
		b.	Title	Text	text	respScTitle	Text
		c.	Address	Text	text	respScStreet	Text
		d.	City	Text	text	respScCity	Text
		e.	State	Text	text	respScState	Text
		f.	Zip	Text	text	respScZip	Text
		g.	Phone Number	Text	text	respScPhone	Text
		h.	Fax Number	Text	text	respScFax	Text
		i.	E-mail Address	Text	text	respScEmail	Text
I.			REFERENCES	List/Expected Response	Answer Format	Field Names	Format Type	Response	Explanation
	1.		Please provide three of your current employer client references of similar size to CFTC.
		a.	Reference #1
			Company Name	Text	text	respReference1a	Text
			Contact Person	Text	text	respReference1b	Text
			Title	Text	text	respReference1c	Text
			Phone Number	Text	text	respReference1d	Text
			Fax Number	Text	text	respReference1e	Text
			E-mail Address	Text	text	respReference1f	Text
			Network Name	Text	text	respReference1g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respReference1h	Number,0
		b.	Reference #2
			Company Name	Text	text	respReference2a	Text
			Contact Person	Text	text	respReference2b	Text
			Title	Text	text	respReference2c	Text
			Phone Number	Text	text	respReference2d	Text
			Fax Number	Text	text	respReference2e	Text
			E-mail Address	Text	text	respReference2f	Text
			Network Name	Text	text	respReference2g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respReference2h	Number,0
		c.	Reference #3
			Company Name	Text	text	respReference3a	Text
			Contact Person	Text	text	respReference3b	Text
			Title	Text	text	respReference3c	Text
			Phone Number	Text	text	respReference3d	Text
			Fax Number	Text	text	respReference3e	Text
			E-mail Address	Text	text	respReference3f	Text
			Network Name	Text	text	respReference3g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respReference3h	Number,0
	2.		Please provide three of your terminated employer client references of similar size and to CFTC
		a.	Reference #1
			Company Name	Text	text	respTerminate1a	Text
			Contact Person	Text	text	respTerminate1b	Text
			Title	Text	text	respTerminate1c	Text
			Phone Number	Text	text	respTerminate1d	Text
			Fax Number	Text	text	respTerminate1e	Text
			E-mail Address	Text	text	respTerminate1f	Text
			Network Name	Text	text	respTerminate1g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respTerminate1h	Number,0
			Program Termination Date		text	respTerminate1g	Text
		b.	Reference #2
			Company Name	Text	text	respTerminate2a	Text
			Contact Person	Text	text	respTerminate2b	Text
			Title	Text	text	respTerminate2c	Text
			Phone Number	Text	text	respTerminate2d	Text
			Fax Number	Text	text	respTerminate2e	Text
			E-mail Address	Text	text	respTerminate2f	Text
			Network Name	Text	text	respTerminate2g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respTerminate2h	Number,0
			Program Termination Date		text	respTerminate1g	Text
		c.	Reference #3
			Company Name	Text	text	respTerminate3a	Text
			Contact Person	Text	text	respTerminate3b	Text
			Title	Text	text	respTerminate3c	Text
			Phone Number	Text	text	respTerminate3d	Text
			Fax Number	Text	text	respTerminate3e	Text
			E-mail Address	Text	text	respTerminate3f	Text
			Network Name	Text	text	respTerminate3g	Text
			Network Plan Members Enrolled	Numeric	number, 0	respTerminate3h	Number,0
			Program Termination Date		text	respTerminate1g	Text
II.			SPECIFICATIONS		Answer Format		Format Type	Response	Explanation
	1.		[Guaranteed Rate/Fee: All rates/fees for 24 months from the plan's effective date.]	Listbox: Willing; Not Willing	drop down box	respGuarRateFee	Listbox, ListWillingNAExplain
	1.		Audit Rights: It will be the right of CFTC or its representative(s) to audit claims at any time.	Listbox: Willing; Not Willing	drop down box	respAudRights	Listbox, ListWillingNAExplain
	2.		CFTC Logo: CFTC may wish to have its logo appear on various printed materials. The designated vendor must agree to this at no additional cost and must ensure that logo placement and color requirements are met.	Listbox: Willing; Not Willing	drop down box	respCompanyLogo	Listbox, ListWillingNAExplain
	3.		Vendor can meet COB requirements.	Listbox: Willing; Not Willing	drop down box	respVenCOBReq	Listbox, ListWillingNAExplain
		a.	If an employee is covered through an alternative health care program (e.g., TRICARE), please confirm that the CFTC plan would be primary.		drop down box	respVenCOBReq	Listbox, ListWillingNAExplain
	4.		Vendor can administer eligibility requirements.	Listbox: Willing; Not Willing	drop down box	respVenAdminEligReq	Listbox, ListWillingNAExplain
	6.		Aon Consulting Compensation [State basis or commissions].	Text	text	respAonComp	Text
III.			GENERAL PLAN INFORMATION		Answer Format		Format Type	Response	Explanation
	1.		Model Type	Listbox: PPO; DHMO	drop down box	respModelType	Listbox, ListModelDent
	2.		Year network organized	Year	# of years	respYearOrg	Number, 0
	3.		Network ownership/controlling interest	Text	text	respNetOwnConInt	Text
			Do you have a minimum participation requirement?	Listbox: Yes; No	drop down box	respMinPartReq	Listbox, ListYNNAExplain
			If yes, please indicate the smallest number of members that you would accept.	Number, 0	number, 0	respSmNumMem	Number, 0
	4.		In the worksheet "MemTot," provide the total number of PPO members for the specified network locations noted in the worksheet.
	5.		DHMO membership totals:	Number, 0	number, 0	respDHMOMemTot	Number, 0
	5.		Total network PPO membership as of 1/1/2020	Number, 0	number, 0	respPPOMemTot1	Number, 0
	6.		Total network PPO membership as of 1/1/2019	Number, 0	number, 0	respPPOMemTot2	Number, 0
	7.		Total network PPO membership as of 1/1/2018	Number, 0	number, 0	respPPOMemTot3	Number, 0
IV.			PLAN DESIGN AND FINANCIAL INFORMATION		Answer Format		Format Type	Response	Explanation
	1.		A detailed description of CFTC's current plan design can be found in the "Plan Design-Current" worksheet. Additional information is included in the attached SPD. CFTC is considering plan design changes and can be found in the "Plan Design - Proposed" worksheet. Please base your quotations on the proposed plan design in the worksheets "Plan Design - Current" and "Plan Design - Proposed". Please note any deviations in your plan design from the proposed plan design in the "Plan Design" worksheet, using the column marked "Deviations."	ListCompletedNAExplain: Completed; Not Completed; Not Applicable; Not Completed - See "Explanation" Worksheet; Not Applicable - See "Explanation" Worksheet; See "Explanation" Worksheet	drop down box	respPlanDesign	Listbox,ListCompletedNAExplain
			Provide any recommended benefit enhancements and cost impact as a result of each proposed enhancement		text	respNetOwnConInt	Text
	2.		Please complete the lives assumptions by self and family in the table below.
		a.	PPO Active Enrollment Assumptions
			Self	Number, 0	number, 0	respPPOEnrollInd	Number, 0
			Family	Number, 0	number, 0	respPPOEnrollHusWife	Number, 0
			[Tier 3]	Number, 0	number, 0	respPPOEnrollFam	Number, 0
			[Tier 4]	Number, 0	number, 0	respPPOTier4	Number, 0
			[Tier 5]	Number, 0	number, 0	respPPOTier5	Number, 0
			[Tier 6]	Number, 0	number, 0	respPPOTier6	Number, 0
		b.	DHMO Active Enrollment Assumptions Family Status/Class
			[Tier 1]	Number, 0	number, 0	respDHMOEnrollInd	Number, 0
			[Tier 2]	Number, 0	number, 0	respDHMOEnrollHusWife	Number, 0
			[Tier 3]	Number, 0	number, 0	respDHMOEnrollFam	Number, 0
			[Tier 4]	Number, 0	number, 0	respDHMOTier4	Number, 0
			[Tier 5]	Number, 0	number, 0	respDHMOTier5	Number, 0
			[Tier 6]	Number, 0	number, 0	respDHMOTier6	Number, 0
			Financial Information For Self-Insured Program		Answer Format		Format Type	Response	Explanation
	3.		All quotes must be good for +/-15% enrollment fluctuations for each 12 month period.
		a.	Fees Per Employee Per Month
			[MM/YYYY-MM/YYYY] Immature
			Claims Administration	Dollar, 2	dollar, 2	respClmAdminImm	Dollar, 2
			General Overhead	Dollar, 2	dollar, 2	respGenOverImm	Dollar, 2
			Network Access Fees	Dollar, 2	dollar, 2	respNetAccFeeImm	Dollar, 2
			Utilization Review Fees	Dollar, 2	dollar, 2	respUtilRevFeeImm	Dollar, 2
			Other Fees (please describe)	Dollar, 2	dollar, 2	respOthFeeImm	Dollar, 2
			[MM/YYYY-MM/YYYY] Mature
			Claims Administration	Dollar, 2	dollar, 2	respClmAdminMat	Dollar, 2
			General Overhead	Dollar, 2	dollar, 2	respGenOverMat	Dollar, 2
			Network Access Fees	Dollar, 2	dollar, 2	respNetAccFeeMat	Dollar, 2
			Utilization Review Fees	Dollar, 2	dollar, 2	respUtilRevFeeMat	Dollar, 2
			Other Fees (please describe)	Dollar, 2	dollar, 2	respOthFeeMat	Dollar, 2
		b.	Claims Assumptions
			Immature
			Expected Paid Claims (per employee per month)	Dollar, 2	dollar, 2	respExpPaidClmImm	Dollar, 2
			Mature
			Expected Paid Claims (per employee per month)	Dollar, 2	dollar, 2	respExpPaidClmMat	Dollar, 2
		c.	Total Monthly Cost
			Immature
			Fees per month	Dollar, 2	dollar, 2	respFeePerMonImm	Dollar, 2
			Claims per month	Dollar, 2	dollar, 2	respClmPerMonImm	Dollar, 2
			Total per month	Dollar, 2	dollar, 2	respTotPerMonImm	Dollar, 2
			Mature
			Fees per month	Dollar, 2	dollar, 2	respFeePerMonMat	Dollar, 2
			Claims per month	Dollar, 2	dollar, 2	respClmPerMonMat	Dollar, 2
			Total per month	Dollar, 2	dollar, 2	respTotPerMonMat	Dollar, 2
	4.		What will be the maximum % increase in fees for the first year renewal?	Percentage, 1	percentage, 1	respMaxPerIn1	Percent, 1
	5.		What will be the maximum % increase in fees for the second year renewal?	Percentage, 2	percentage, 2	respMaxPerIn2	Percent, 2
	6.		Indicate if the following items are included in your retention charges. If there is an additional charge, indicate the charge and the basis for the charge.
		a.	Pure Insurance or Reinsurance	Listbox: Yes; No	drop down box	respPureInsur1	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge1	Dollar, 2
		b.	800 Telephone Links (installation and usage)	Listbox: Yes; No	drop down box	resp800TeleLinks1	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge2	Dollar, 2
		c.	Reporting	Listbox: Yes; No	drop down box	respReporting1	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge3	Dollar, 2
		d.	Large Case Management	Listbox: Yes; No	drop down box	respLgCaseMgmt	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge4	Dollar, 2
		e.	Capitation Charges	Listbox: Yes; No	drop down box	respCapCharge1	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge5	Dollar, 2
			Financial Information For Fully-Insured Program Proposed Premiums		Answer Format		Format Type	Response	Explanation
	3.		Provide first year rates below:
		a.	Self	Dollar, 2	dollar, 2	resp1stYrRateTier1	Dollar, 2
		b.	Family	Dollar, 2	dollar, 2	resp1stYrRateTier2	Dollar, 2
		c.	[Tier 3]	Dollar, 2	dollar, 2	resp1stYrRateTier3	Dollar, 2
		d.	[Tier 4]	Dollar, 2	dollar, 2	resp1stYrRateTier4	Dollar, 2
		e.	[Tier 5]	Dollar, 2	dollar, 2	resp1stYrRateTier5	Dollar, 2
		f.	[Tier 6]	Dollar, 2	dollar, 2	resp1stYrRateTier6	Dollar, 2
	8.		[Provide second year maximum rate increase.]	Percentage, 2	percentage, 2	resp2ndYrMaxRateIncrease	Percent, 2
	4.		[Provide second year rates below:]
		a.	Self	Dollar, 2	dollar, 2	resp2ndYrRateTier1	Dollar, 2
		b.	Family	Dollar, 2	dollar, 2	resp2ndYrRateTier2	Dollar, 2
		c.	[Tier 3]	Dollar, 2	dollar, 2	resp2ndYrRateTier3	Dollar, 2
		d.	[Tier 4]	Dollar, 2	dollar, 2	resp2ndYrRateTier4	Dollar, 2
		e.	[Tier 5]	Dollar, 2	dollar, 2	resp2ndYrRateTier5	Dollar, 2
		f.	[Tier 6]	Dollar, 2	dollar, 2	resp2ndYrRateTier6	Dollar, 2
			Retention Charges		Answer Format		Format Type	Response	Explanation
	2.		Indicate if the following items are included in your retention charges. If there is an additional charge, indicate the charge and the basis for the charge.
		a.	Network Access Fee	Listbox: Yes; No	drop down box	respNetAccFee	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge6	Dollar, 2
		b.	Administrative Overhead	Listbox: Yes; No	drop down box	respAdminOverhead	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge7	Dollar, 2
		c.	Claims Processing Fee	Listbox: Yes; No	drop down box	respClmProcessFee	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge8	Dollar, 2
		d.	Utilization Review	Listbox: Yes; No	drop down box	respUtilReview	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge9	Dollar, 2
		e.	800 Telephone Links (installation and usage)	Listbox: Yes; No	drop down box	resp800TeleLinks2	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge10	Dollar, 2
		f.	Reporting	Listbox: Yes; No	drop down box	respReporting2	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge11	Dollar, 2
		g.	ACA Fees	Listbox: Yes; No	drop down box	respCapCharge2	Listbox, ListYNNAExplain
			Additional Charge	Dollar, 2	dollar, 2	respAddCharge12	Dollar, 2
			General Financial Information		Answer Format		Format Type	Response	Explanation
	3.		Please confirm that your proposal is issued in accordance with the specifications/assumptions stated in this Request for Proposal. If there are deviations, please identify them clearly. If you need more space, please use the "Explanation" column and/or worksheet. Indicate the question answered.	Text	text	respSpecAssump	Text
	4.		Provide your company's most recent rating or filing (identify date) from each of the following:
		a.	A.M. Best	Listbox: Rated; Not Rated	drop down box	respAMBest	Listbox, ListRated
			Rating	Text	text	respAMBestRating	Text
			Date	Month Day, Year	Month Day, Year	respAMBestDate	Date
		b.	Moody's	Listbox: Rated; Not Rated	drop down box	respMoody	Listbox, ListRated
			Rating	Text	text	respMoodyRating	Text
			Date	Month Day, Year	Month Day, Year	respMoodyDate	Date
		c.	Standard & Poor's	Listbox: Rated; Not Rated	drop down box	respStandPoors	Listbox, ListRated
			Rating	Text	text	respStandPoorsRating	Text
			Date	Month Day, Year	Month Day, Year	respStandPoorsDate	Date
		d.	Fitch	Listbox: Rated; Not Rated	drop down box	respFitch	Listbox, ListRated
			Rating	Text	text	respFitchRating	Text
			Date	Month Day, Year	Month Day, Year	respFitchDate	Date
	5.		If your rating has changed within the past 12 months for any of the rating agencies, discuss changes. If you need more space, please use the "Explanation" column and/or worksheet. Indicate the question answered.	Text	text	respRatingExplain	Text
	6.		Provide a copy of your most recently audited financial statement. Name the file: [Your Organization's Name]_Most Recent Audited Financial Statement.	Listbox: Attached; Not Attached	drop down box	respAttAudFinStmt	Listbox, ListAttachedNAExplain
	7.		Please provide a copy of your company's most recent annual report. Name the file: [Your Organization's Name]_Annual Report.	Listbox: Attached; Not Attached	drop down box	respAttAnnRprt	Listbox, ListAttachedNAExplain
	16.		[For self-funded plans: do you require use of a specific bank?]	Listbox: Yes; No	text	respSelfFundPlan	Listbox, ListYNNAExplain
		a.	[If yes, indicate bank name. If you need more space, please use the "Explanation" column and/or worksheet. Indicate the question answered.]	Text	text	respBankName	Text
	9.		Claim amount paid will be the negotiated amount. In other words, services will pay actual negotiated amount; none of the savings will be retained by your organization or shared with any other organization.	Listbox: Agree; Disagree	drop down box	respNegotAmt	Listbox, ListAgreeNAExplain
	18.		Do you have a minimum participation requirement?	Listbox: Yes; No	drop down box	respMinPartReq	Listbox, ListYNNAExplain
		a.	If yes, please indicate the smallest number of members that you would accept.	Number, 0	number, 0	respSmNumMem	Number, 0
V.			PPO NETWORK INFORMATION		Answer Format		Format Type	Response	Explanation
	1.		Provide the Geo-Access report requested in the Introduction worksheet. Your report should note the 5-digit zip code, city name and county. Name the file: [Your Organization's Name]_Geo Access Report.	Listbox: Attached; Not Attached	drop down box	respAttGeoAccRpt	Listbox, ListAttachedNAExplain
	2.		Please note the geo-mapping method used:	Listbox: Zip code dispersion; Center of zip code; Geo-coding (employee zip code address)	drop down box	respGeoMapping	Listbox, ListGeo
	3.		Number of general/family dentists (GFDs) in network
		a.	DC Suburbs, MD	Number, 0	number, 0	respGFDNetA	Number, 0
		b.	Northern, VA	Number, 0	number, 0	respGFDNetB	Number, 0
		c.	Washington, DC	Number, 0	number, 0	respGFDNetC	Number, 0
		d.	Chicago, IL	Number, 0	number, 0	respGFDNetD	Number, 0
		e.	New York City, NY	Number, 0	number, 0	respGFDNetE	Number, 0
		f.	Kansas City, MO	Number, 0	number, 0	respGFDNetE	Number, 0
	4.		Number of GFDs practicing in the market.
		a.	DC Suburbs, MD	Number, 0	number, 0	respGFDPracMktA	Number, 0
		b.	Northern, VA	Number, 0	number, 0	respGFDPracMktB	Number, 0
		c.	Washington, DC	Number, 0	number, 0	respGFDPracMktC	Number, 0
		d.	Chicago, IL	Number, 0	number, 0	respGFDPracMktD	Number, 0
		e.	New York City, NY	Number, 0	number, 0	respGFDPracMktE	Number, 0
		f.	Kansas City, MO	Number, 0	number, 0	respGFDNetE	Number, 0
	5.		Number of GFDs accepting new patients.
		a.	DC Suburbs, MD	Number, 0	number, 0	respGFDAccNewPatA	Number, 0
		b.	Northern, VA	Number, 0	number, 0	respGFDAccNewPatB	Number, 0
		c.	Washington, DC	Number, 0	number, 0	respGFDAccNewPatC	Number, 0
		d.	Chicago, IL	Number, 0	number, 0	respGFDAccNewPatD	Number, 0
		e.	New York City, NY	Number, 0	number, 0	respGFDAccNewPatE	Number, 0
		f.	Kansas City, MO	Number, 0	number, 0	respGFDNetE	Number, 0
	6.		Average number of members per general/family dentist
		a.	DC Suburbs, MD	Number, 0	number, 0	respGFDAvgMemA	Number, 0
		b.	Northern, VA	Number, 0	number, 0	respGFDAvgMemB	Number, 0
		c.	Washington, DC	Number, 0	number, 0	respGFDAvgMemC	Number, 0
		d.	Chicago, IL	Number, 0	number, 0	respGFDAvgMemD	Number, 0
		e.	New York City, NY	Number, 0	number, 0	respGFDAvgMemE	Number, 0
		f.	Kansas City, MO	Number, 0	number, 0	respGFDNetE	Number, 0
	7.		Length of GFD contract
		a.	DC Suburbs, MD	Text	text	respGFDLengContA	Text
		b.	Northern, VA	Text	text	respGFDLengContB	Text
		c.	Washington, DC	Text	text	respGFDLengContC	Text
		d.	Chicago, IL	Text	text	respGFDLengContD	Text
		e.	New York City, NY	Text	text	respGFDLengContE	Text
		f.	Kansas City, MO	Text	text	respGFDLengContE	Text
	3.		Number of GFDs who left the network during 2019 (due to both voluntary and involuntary reasons):
		a.	DC Suburbs, MD	Number, 0	number, 0	respGFDNumLeftNetA	Number, 0
		b.	Northern, VA	Number, 0	number, 0	respGFDNumLeftNetB	Number, 0
		c.	Washington, DC	Number, 0	number, 0	respGFDNumLeftNetC	Number, 0
		d.	Chicago, IL	Number, 0	number, 0	respGFDNumLeftNetD	Number, 0
		e.	New York City, NY	Number, 0	number, 0	respGFDNumLeftNetE	Number, 0
		f.	Kansas City, MO	Number, 0	number, 0	respGFDNetE	Number, 0
	4.		Reimbursement - Percent of GFDs' services paid by:
		a.	DC Suburbs, MD
			Capitation	Percentage, 1	percentage, 1	respGFDReimACap	Percent, 1
			Fee Schedule	Percentage, 1	percentage, 1	respGFDReimAFeeSched	Percent, 1
			Discounted fees	Percentage, 1	percentage, 1	respGFDReimADisFees	Percent, 1
			Incentive programs (bonus, withholds)	Percentage, 1	percentage, 1	respGFDReimAIncProg	Percent, 1
		b.	Northern, VA
			Capitation	Percentage, 1	percentage, 1	respGFDReimBCap	Percent, 1
			Fee Schedule	Percentage, 1	percentage, 1	respGFDReimBFeeSched	Percent, 1
			Discounted fees	Percentage, 1	percentage, 1	respGFDReimBDisFees	Percent, 1
			Incentive programs (bonus, withholds)	Percentage, 1	percentage, 1	respGFDReimBIncProg	Percent, 1
		c.	Washington, DC
			Capitation	Percentage, 1	percentage, 1	respGFDReimCCap	Percent, 1
			Fee Schedule	Percentage, 1	percentage, 1	respGFDReimCFeeSched	Percent, 1
			Discounted fees	Percentage, 1	percentage, 1	respGFDReimCDisFees	Percent, 1

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Apr 30, 2020.