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Atch 1 Vison Fin Prop Instr
| Request for Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Appendix 2: Vision Self-Funded Financial Proposal |
Solicitation No. AGY-24-026-SR-A
Instructions:
| 1. | Complete the attached financial exhibits for the proposed functional area(s). Monthly claims and enrollment experience for the Vision plan is provided for your use in the Excel file labeled "FA6 Attachment 6 Vision Claim File." |
| FA6 FP Attachment 2: Financial Compliance Checklist |
| FA6 FP Attachment 3: Explanations and Deviations |
| FA6 FP Attachment 4: Administrative Services Only (ASO) Rates |
| FA6 FP Attachment 5: Claims Reprice |
| FA6 FP Attachment 6: Offeror's Financial Proposal Summary |
| FA6 FP Attachment 7: Vision Provider Match |
| 2. | FA6 FP Attachment 2: Financial Compliance Checklist |
| Complete the Offeror and Date of Submission cells. |
| 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 "FA6 FP Attachment 3V: 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. | FA6 FP Attachment 4: Administrative Services Only (ASO) Fees |
| All fees are quoted on a fully loaded firm, fixed cost, maximum basis. |
For purposes of FA6 FP Attachment 4, "per employee per month (PEPM)" means a 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.
All PEPM fees must be quoted on a fully-loaded basis, i.e., all direct and indirect costs, general and administrative overhead, cost of processing run-out claims, purchasing burden and profit. No other fees or charges may be added to the contract after award, nor will the contractor be compensated on any basis other than the applicable fully loaded PEPM fees.
| 4. | FA6 FP Attachment 5: Claims Re-Pricing Analysis |
| Please re-price the claims for the provided claims in the claims re-pricing data file in FA6 Attachment 8a Supporting Data. 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 vision 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. | FA6 FP 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 Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Appendix 2: Financial Compliance Checklist |
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. | | |
Atch 3 Explan and Deviations
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| Request for Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Appendix 2: Explanations and Deviations |
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. | 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: |
| Date of Submission: |
| Request for Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Attachment 4: Administration and Network Access Fees |
| 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. |
| 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. |
These firm, fixed fees can be the same in all five years, or vary year to year beginning in contract year four, at the vendor's discretion. Please provide documentation to support the establishment of the fees in all eleven 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 1 | Option 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. | | Discount on Administration Fees b | | | | | | | | |
| Total Administration Fees | | | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| | Vision Enrollees c | | 3,941 | | | | | | | |
| 2. | Annualized Cost (Administration + Network Access Fees) | | | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 3. | Total Cumulative Cost (of Line 3.) 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.), vendor share |
| | of MTA's annual open enrollment costs, network access fees, run out administration and all other administrative expenses. |
| b. | Vendors who are proposing for both FA5 and FA6, 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. | "Vision Enrollees" referenced above represent a uniform carrier assumption for purposes of evaluating proposals. The uniform assumption reflects current combined enrollment for the Vision plan, and is not represented as the actual or expected enrollment for a particular vendor. Vendor 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 Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Appendix 2: Claims Re-Pricing Analysis |
| 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. |
| Please re-price the provided claims in FA8 Attachment 8a: Vision 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 FA6 FP Attachment 7: Vision 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 | | | |
| $ 2,391,641.89 | $0.00 | $ - 0 |
| Provider Aggregate Discount Percentage (repriced claims) | | 0.0% | |
| 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. |
| 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: | 0 |
| Date of Submission: | 12/31/99 |
| Request for Vision (Self-Funded) Proposal for Maryland Transit Administration (MTA) |
| Functional Area 6: Vision, Self-Funded |
| FA6 FP Appendix 2: Financial Proposal Summary |
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. | | | | | | | | | | | |
| The table below takes the allowed charges from the claims re-pricing analysis in FA6 FP Attachment 5, trended to January 1, 2026. Administrative Fees from FA6 FP Attachment 4 are then added to each contract year. Ranking is based on the total cumulative cost for the seven years. | | | | | | | | | | | |
| Allowed Charges (from FA6 FP Attachment 5V)a | $ 242,444 | | | | | | | | | | |
| Contract Year 1 | Contract Year 2 | Contract Year 3 | Contract Year 4 | Contract Year 5 | Option 1 Year 1 | Option 1 Year 2 | Option 1 Year 3 | Option 2 Year 1 | Option 2 Year 2 | Option 2 Year 3 |
| Trend Factor | 1.025 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 | 1.010 |
| Projected Allowed Charges | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Annualized Cost (Administration + Network Access Fees) (from FA6 FP Attachment 4) | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Total Projected Expenses | $ - | $ - | $ - | $ - | $ - | $ - | | | | | $ - |
| Seven-Year Total Cumulative Cost | $ - |
| Notes: | |
| a. Allowed Charges for provided claims data set of 12 months. | |
| 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 FA6 FP Attachment 4). | |
| Submitted by: |
| Offeror: |
| Offeror Name (please print or type) |
| By: |
| Signature of Authorized Representative |
| Printed Name: |
| Title: |
| Date: |
| Company Address: |