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Atch 1 HMO Finan Prop Instr
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5: Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Financial Proposal Instructions |
| Solicitation No. AGY-24-026-SR-A |
| AMENDMENT #4 | |
Instructions:
| 1. | Complete all the attached financial exhibits for the self funded HMO plan. De-identified, aggregate claims and enrollment experience for the current HMO plan are provided for your use in the Excel file labeled "FA5 Attachments 6b and 6c: Medical HMO Claim File and Medical PPO Claim File." |
| Attachment FA5 FP HMO Attachment 2: Financial Compliance Checklist |
| Attachment FA5 FP HMO Attachment 3: Explanations and Deviations |
| Attachment FA5 FP HMO Attachment 4: Administration and Network Access Fees |
| Attachment FA5 FP HMO Attachment 5: Claims Repricing Analysis |
| Attachment FA5 FP HMO Attachment 6: Financial Proposal Summary |
| Attachment FA5 FP HMO Attachment 7: HMO Provider Match |
| 2. | FA5 FP HMO Attachment 2: Financial Compliance Checklist |
| Please indicate the name of your organization and date of proposal submission at the top of the page. |
| Please indicate your willingness to comply with each requirement by selecting "Yes" or "No" from the drop down list in the response column of each item. |
| If you provide a "No" response, or a "Yes" response with a qualifier, please provide an explanation for why you cannot comply with the requirement in full in "FA5 FP HMO Attachment 3: Explanations and Deviations." All negative responses must have a corresponding explanation or alternative. All explanations must be numbered to correspond to the questions to which they pertain and they must be brief. |
| 3. | FA5 FP HMO Attachment 4: Administration and Network Access Fees |
| All fees that are quoted on a firm, fixed basis for employees and retirees plan participants. |
For the purpose of FA5 FP HMO Attachment 4, "per employee per month (PEPM)" means the cost for each employee or retiree on a monthly basis.
Also provide a detailed explanation to support the derivation of your administration costs for the five year base contract and two three-year option. Please quote all administration fees on a mature basis for all contract years. Offeror will be responsible for run out claims administration fees.
MTA shall not pay network access fees for any Participant who is Medicare-eligible and has Medicare as their primary coverage. The network access fee component of the administration fees must be adjusted accordingly.
| 4. | FA5 FP HMO Attachment 5: Claims Re-Pricing Analysis |
| Please re-price the claims provided in the claims re-pricing data file in "FA5 Attachment 6b: Medical HMO Claim File." The re-pricing should be based on eligible charges (column “Net Billed Amount”) and your current (as of June 1, 2024) network provider contractual fee arrangements. The claims re-pricing amounts shall be based on actual data and shall not include any assumptions regarding projected discounts or assumed increases in billed charges. |
| Provide an explanation detailing how you re-priced the claims noting any and all adjustments and methodologies. Provide a reconciliation that ties your claims re-pricing back to the total eligible charges provided. |
| Include a full description of any capitated arrangements that will be utilized, including the services capitated. |
| Provide a guaranteed provider aggregate discount percentage and associated administrative fees at risk. |
| Additionally, the MTA requires a "repriced claim" file as part of your submission. |
| Please return the detailed medical claim file with the following additional fields appended to the original file: |
| - Allowed Charge |
| - Discount |
| - Scheduled Payment Amount (if applicable) |
| - Indicator that claim is included in capitated payments/programs (if applicable) |
| - Indicator that another reimbursement methodology is utilized - provide sufficient detail to evaluate |
| (add fields as needed) |
| - Network Provider Indicator |
| ` | Additionally, the MTA requires a "Provider match" file as part of your submission. |
| Please return the Provider medical file with the following additional fields appended to the original file: |
| - Par to indicate the provider is contracted within your network |
| - Non-Par to indicate the provider is not contracted within your network |
| Cost Proposal responses are due in the electronic Excel format provided. |
| Repriced claims detail does not need to be provided in Excel, as long as the file is provided electronically |
| and the data can be readily manipulated electronically. Please also provide a data dictionary and/or file layout. |
| 5. | FA5 FP PPO Attachment 6: Financial Proposal Summary |
| Responses are due in the electronic Excel format provided. |
| Total Projected Expenses will be adjusted to account for assessments associated with projected |
| Provider Discount Guarantee shortfalls. |
Costs should represent the actual contractual amount before any copay or coinsurance is considered.
Atch 2 Finan Compl Checklist
| Offeror: |
| Date of Submission: |
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5: Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Financial Compliance Checklist |
| AMENDMENT #4 |
Solicitation No. AGY-24-026-SR-A
| Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. | | | Yes |
| | | No |
| Financial Questionnaire | | Offeror's Response | |
| | Yes or No | |
| F-1 | Offeror's quoted administrative and network access fees, including the fees for claim runout administration are guaranteed, regardless of actual enrollment, for the term of the contract. | | |
| F-2 | Offeror's quoted fees exclude commissions/compensation to outside consultants or brokers. | | |
| F-3 | All PEPM fees must be quoted on a fully-loaded basis, i.e., fees must include all direct and indirect costs, general and administrative overhead, purchasing burden, profit, and state regulatory assesments. No other fees or charges may be added to the contract after award, nor will the Offeror be compensated on any basis other than the applicable fully loaded PEPM rate. | | |
| F-4 | Quoted fees include costs for all communication materials. | | |
| F-5 | Offeror agrees to that the current contractor will pay the run-out claims for the current contract. | | |
| F-6 | Offeror agrees to hold administration fees flat for the first three years of the contract. | | |
| F-7 | Offeror agrees that annual increases, after the initial three years of the contract, will not exceed 4%. | | |
| F-8 | Offeror will offer a implementation credit for the successful implementation of the program. If yes, please provide the total credit in the Explanations and Deviations section of this financial proposal. | | |
| F-9 | By September 1st of each calendar year for the subsequent contract year (beginning January 1), Offeror will prepare a claims projection and fee validation for the upcoming contract year. If warranted based on negotiations with the MTA, Offeror will reduce its fees quoted in its proposal for the upcoming contract year. | | |
| F-10 | Please confirm that “Covered Expenses” include all claims paid at the network rate, or at reasonable and customary charges. | | |
| F-11 | Does the Offeror confirm that the stop loss policy covers all Active and Non-Medicare participants without any exceptions (i.e., no excluded, "lasered" individuals or claims). | | |
| F-12 | Are there any contingencies in the Stop Loss rate quote. If so, please describe in the explanation and deviations FA5 FP HMO Attachment 3. | | |
| F-13 | Does the Offeror agrees that provide annual renewal rate increase cap. If so, please provide the cap as an explanation in FA5 FP HMO Attachment 3. | | |
| F-14 | Offeror agrees Medical is included in the stop loss rate provided. | | |
| F-15 | Offeror agrees that the stop loss rate provided is reflective or a contract term of 24/12 for the first contract year. The offeror will then convert this to a paid basis contract the remainder of the contract. | | |
Atch 3 Explan and Deviations
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5: Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Explanations and Deviations |
| Solicitation No. AGY-24-026-SR-A |
| AMENDMENT #4 |
| Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. | Explanation |
| Deviation |
| Instructions: Use this worksheet to provide additional explanation that you wish to offer for any questions for which a "No" response, or a "Yes" response with a qualifier, was given. | |
| Explanations must be numbered to correspond to the Financial Compliance Checklist item to which it pertains. Please keep all explanations brief. | |
Section # / Question # Indicate "Explanation" or "Deviation" Offeror Response
* Ability to accept a self-bill and monthly carrier reconciliation, faxing and/or emailing discrepancies to the City's Benefits Office
Plan Design (PPO, Indemnity, Medicare Supplement)
Atch 4 Admin and NAF
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5: Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Administration and Network Access Fees |
| Solicitation No. AGY-24-026-SR-A | |
| AMENDMENT #4 | |
| Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. |
| Provide guaranteed Administration fees on a composite basis, per employee per month (PEPM), on a mature basis for all contract years. Offeror will be responsible for run out administration fees. In addition, the MTA shall not pay network access fees for participants who are Medicare-eligible and has Medicare as their primary coverage. The network access fee component of the administration fee must be adjusted accordingly. |
These firm, fixed fees can be the same in all five years, or vary year to year beginning in contract year four, at the offeror's discretion. Please provide documentation to support the establishment of the fees in all seven years (e.g. assumed increase in fees, baseline fee).
| Per Employee Per Month (PEPM) | | | | Enrollment | Contract Year 1 | Contract Year 2 | Contract Year 3 | Contract Year 4 | Contract Year 5 | Option Year 1 | Option Year 2 | |
| Firm Fixed Fee Quote PEPM (guaranteed regardless of actual enrollment) | | | | | | | | | | | | |
| | | | Enrollment | Mature Fees | Mature Fees | Mature Fees | Mature Fees | Mature Fees | Mature Fees | Mature Fees | |
| 1. | Administration Fees | | | | | | | | | | | |
| A. | | Plan Administration Fees a | | | | | | | | | |
| B. | | Wellness & Disease Management | | | | | | | | | |
| C. | | Discount on Administration Fees b | | | | | | | | | |
| Total Administration Fees | | | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 2. | Stop Loss Rates (Active and Non-Medicare Retirees) | | | | | | | | | | | |
| | | Employee(Retiree) contracts | 3,160 | | | | | | | | |
| | | Members | 5,655 | | | | | | | | |
| 3. | Network Access Fees | | | | | | | | | | | 0% |
| 5. | Total Fees | | | | | | | | | | | |
| | HMO Enrollees - Actives/Under Age 65 Retirees c | | 1,082 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| | HMO Enrollees - Over Age 65 Retirees c | | 615 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 6. | Annualized Cost (Administration + Stop Loss + Network Access Fees) | | | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 7. | Total Cumulative Cost (of Line 4.) d | | | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | ERROR:#REF! | $ - 0 | |
| Notes: | | |
| a. | Includes claims administration/payment, customer service, corporate and other overhead, taxes, profit, utilization review, care management, up to 15 annual ad hoc |
| | reporting requests, member communication materials (ID cards, booklets, wellness tools, etc.), offeror share |
| | of MTA's annual open enrollment costs, network access fees, run out administration and all other administrative expenses. |
| b. | Offerors who are proposing for both FA5 and FA6 FA7 and FA8, and would like to offer a discount on administration fees contingent upon award of both contracts should include the total discount in this section. This discount will be subtracted from the the Plan Administration Fees in row 17. |
| c. | HMO Enrollees" referenced above represent a uniform carrier assumption for purposes of evaluating proposals. The uniform assumption reflects current combined enrollment for the HMO plan, and is not represented as the actual or expected enrollment for a particular vendor. Offeror must guarantee the fees quoted above regardless of actual enrollment. |
| c. | Administration Fees will be evaluated based on cumulative cost for Contract Years 1 through 5 and One Renewal Option for years 1 and 2 of the total firm, fixed fees quoted. |
| Submitted by: |
| Offeror: |
| Offeror Name (please print or type) |
| By: |
| Signature of Authorized Representative |
| Printed Name: |
| Title: |
| Date: |
| Company Address: |
Atch 5 Claims Reprice
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5: Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Claims Re-Pricing Analysis |
| Solicitation No. AGY-24-026-SR-A |
| AMENDMENT #4 |
| Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. |
| Please re-price the claims provided in FA5 Attachments 6b and 6c: Medical HMO Claim File and Medical PPO Claim File (column "Net Billed Amount") based on your current (as of June 1, 2024) network provider contractual fee arrangements. Please also complete the network provider matched in FA5 FP HMO Attachment 7 HMO Provider Match by indicating a Par or non Par |
Billed Amount a Provider Discount Amountb Re-priced Amountc
In Network Claims
Out of Network Claims
| Total Claims | | | |
| $ 35,874,628.40 | $0.00 | $ - 0 |
| Provider Aggregate Discount Percentage (repriced claims) | | 0.0% | |
| Guaranteed Provider Aggregate Discount Percentaged |
| Percentage of Annualized Cost (Administration + Network Access Fees) at risk for failing to deliver the Guaranteed Aggregate Discount Percentaged |
| Notes: | |
| a. | Billed Amount reflects the field "Net Billed Amount" as shown on the Claims Re-pricing data file. |
| b. | Provider Discount Amount can include differences between Billed Amount Total and capitation rates for capitated services. |
| For services that are capitated, include a detailed description of the capitated program(s), including covered services. |
| Other differences may be included in this field and should account for the difference between the Billed and Allowed/Repriced |
| totals, but WITHOUT adjustments for changes in utilization. |
| c. | Re-priced Amount reflects charges based on application of your current provider specific discounts. Total Billed must equal Repriced Claims + Discounted Claims. |
| d. | Propose an aggregate guaranteed provider discount, expressed as a percentage of billed charges. Also provide a percentage of proposed |
| administrative fees (including network access fees) that will be at risk for meeting the discount guarantee. |
| The measurement and assessment will be annual. This guarantee is to be provided without limitations for membership size, |
| benefit design, or employee premiums. Total Projected Expenses (on Tab FA7 FP HMO Attachment 6) will be adjusted to account |
| for assessments associated with projected Provider Aggregate Discount Guarantee shortfalls. |
| Submitted by: |
| Offeror: |
| Offeror Name (please print or type) |
| By: |
| Signature of Authorized Representative |
| Printed Name: |
| Title: |
| Date: |
| Company Address: |
Atch 6 Finan Prop Sum
| Offeror: |
| Date of Submission: |
| Request for HMO Proposal for Maryland Transit Administration (MTA) |
| Functional Area 5:Health Maintenance Organization, Self-Funded (HMO-SF) |
| FA5 FP HMO Appendix 2: Financial Proposal Summary |
| Solicitation No. AGY-24-026-SR-A |
| AMENDMENT #4 |
| Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term. | | | | | | | | | | | |
| The table below takes the allowed charges from the claims re-pricing analysis in FA5 FP HMO Attachment 5, trended to January 1, 2026. Administrative Fees from FA5 FP HMO Attachment 4 are then added to each contract year. Ranking is based on the total cumulative cost for the eleven years. | | | | | | | | | | | |
| Allowed Charges (from FA5 FP HMO Attachment 5) | $ - 0 | | | | | | | | | | |
| Contract Year 1 | Contract Year 2 | Contract Year 3 | Contract Year 4 | Contract Year 5 | Option Year 1:1 | Option Year 1:2 | Option Year 1:3 | Option Year 2:1 | Option Year 2:1 | Option Year 2:3 |
| Trend Factor | 1.145 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 | 1.070 |
| Projected Allowed Charges | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Annualized Cost (Administration + Network Access Fees) (from Attachment T-4) | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Assessment for failing to meet Guaranteed Provider Aggregate Discounts b | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | | | | | $ - 0 |
| Total Projected Expenses | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Eleven-Year Total Cumulative Cost | $ - |
| Notes: | |
| a. Allowed Charges for rolling 12 month period. | |
| b. Total Projected Expenses will be adjusted to account for assessments associated with projected Provider Discount | |
| Guarantee shortfalls. In the event of a discount guarantee shortfall, the assessment will be based on the Total Administration and Network | |
| Access Fees paid during the contract year (Annualized Cost from Item 4 in FA5 FP HMO Attachment 4). | |
| PPO Trend | 7% |
| Base Claims Data | 1/1/2014-12/31/2014 |
| Base Midpoint | 7/1/14 |
| Projection Midpoint | 7/1/16 |
| Trend Months | 24 |