Appendix 4 Self Insured HMO Pricing Worksheet Final.xlsx
XLSX spreadsheet 440 KB Posted
- Attached to
- Self Insured HMO
- Solicitation number
- 26-416CMS-BENF4-B-51689
- Issued by
- Illinois
About this file
Self-Insured HMO Pricing Worksheet Summary
This file is a cost proposal pricing worksheet for the State of Illinois Department of Central Management Services (CMS) solicitation for self-insured HMO plan administration. The worksheet is designed to evaluate medical service costs for employees enrolled in HMO plans through four state programs: the State Employees Group Insurance Program (SEGIP), Local Government Health Plan (LGHP), Teachers Retirement Insurance Program (TRIP), and College Insurance Program (CIP). The solicitation indicates that the Agency is transitioning to self-insured HMO offerings effective July 1, 2027, and requires qualified vendors to serve as medical plan administrators with established provider networks across all Illinois counties.
Offerors must complete all tabs within the cost proposal workbook, submitting pricing in the exact format specified; failure to do so may render the entire proposal non-responsive and ineligible for award. The workbook requires vendors to provide detailed pricing information across six components: ASO fees, network discounts by county, detailed network discount schedules, medical discount guarantees, expected claims and expenses, and stop loss pricing. A critical requirement is the Provider Network Discount Guarantee, which mandates that selected vendors negotiate and maintain specified average discounted rates with in-network providers and agree to performance guarantee adjustments for failure to meet targeted discount standards. The Agency reserves the right to terminate contracts for repeated failure to meet discount guarantees and may engage third-party validators to verify vendor performance and audit all relevant records.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| vendor-disclosure-formerly-forms-a-v26-2~1.docx | DOCX document | |
| request-for-proposal-offer-to-the-state-of-illinois-7-29-2025-v-26-1.pdf | ||
| complete-vendor-guidance-packet-v.24.2~2.pdf | ||
| ipg-active-registered-vendor-disclosure-formerly-forms-b-v-26-1.docx | DOCX document | |
| U-Plan V.25.1~16.pdf | ||
| commitment-to-diversity-vendor-answer-form-v.24.3~2.pdf | ||
| Appendix 3 Detailed Network Discount~1.xlsx | XLSX spreadsheet | |
| Appendix 2 Provider Disruption~1.xlsx | XLSX spreadsheet | |
| Appendix 1 Census Data Self Insured HMO RFP~2.xlsx | XLSX spreadsheet | |
| RFP Self Insured HMO Final Draft .docx | DOCX document |
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Text version
Instructions
State of Illinois Self-Insured HMO
26-416CMS-BENF4-B-
Please complete each tab in this workbook. This component of the Cost Proposal document will be utilized to evaluate the cost of medical services for employees selecting the Self-Insured HMO.
If your proposal includes an offer of more than 1 HMO, you will need to complete a workbook for each HMO separately.
| Contents of this Cost Proposal workbook: | |
| 1 | ASO Fees |
| 2 | Network Discounts by County |
| 3 | Detailed Network Discount |
| 4 | Medical Discount Guarantee |
| 5 | Expected Claims and Expenses |
| 6 | Stop Loss |
| Offeror shall submit pricing in the format shown in this workbook, based on the terms and conditions set forth in this Request for Proposal. Offeror’s price Offer shall serve as the basis for the compensation terms of the resulting contract. Failure to submit pricing as shown in this section may render Offeror’s entire Offer Non-Responsive and ineligible for award. |
| The Agency is moving to self-insured HMO offerings beginning July 1, 2027. As such, the Agency is seeking a medical plan administrator with provider network(s) for the HMO offerings for CIP, LGHP, SEGIP and TRIP. The Agency is requiring Offerors to agree to a Provider Network Discount Guarantee in this solicitation in order to manage Agency’s HMO Medical Claims Spend as detailed in the "Medical Discount Guarantee" tab |
| The selected Vendor(s) shall obtain discounts with network providers and agree to average the discounted rate for network services based upon the pre-determined criteria contained in the "Medical Discount Guarantee" tab. The selected Vendor(s) shall agree to the associated pre-determined Performance Guarantee Adjustments for failure to meet the targeted proposed Provider Network Discount Guarantee. Agency reserves the right to impose any and all Performance Guarantee Adjustments for Vendor’s failure to meet the targeted standards. |
| Offeror shall provide in its proposal, the average percent discount of all in-network, and eligible services in the Proposed Performance Standard column. Provider Network Discount Guarantee will become part of the Contract and will be effective for the entire duration of the Contract. In addition to Performance Guarantee Adjustments, Agency reserves the right to terminate the Contract if Vendor repeatedly fails to meet the Provider Network Discount Guarantee. The Agency reserves the right to have the Provider Network Discount analyzed and verified by an outside third party. Vendor shall agree to cooperate with the third party in the validation of outcomes and provide Agency or its designee with access to any and all records necessary to perform validation. |
&A &P &F
0 Confirm Counties Quote is For
| State of Illinois |
| Confirmation of Service Areas Your Quotation is Covering |
| The State has employees in all counties. Please indicate (with a "Yes or No") which service areas your Offer is covering. Include the "name of the | |
| network" that would be covering each County. | |
| <---------------CMS team, please review |
| Proposed Network Contract Pricing | ||||
| County | Indicate which zipcodes in the County your Organization is Including in your Proposal Offer | If you are not bidding or covering a particular county at all, please indicate here with an "X" | Network Name(s) Being Proposed for Service Area/Zipcodes Indicated in Column C | Comments (if any) |
| ADAMS | ||||
| ALEXANDER | ||||
| BOND | ||||
| BOONE | ||||
| BROWN | ||||
| BUREAU | ||||
| CALHOUN | ||||
| CARROLL | ||||
| CASS | ||||
| CHAMPAIGN | ||||
| CHRISTIAN | ||||
| CLARK | ||||
| CLAY | ||||
| CLINTON | ||||
| COLES | ||||
| COOK | ||||
| CRAWFORD | ||||
| CUMBERLAND | ||||
| DEKALB | ||||
| DEWITT | ||||
| DOUGLAS | ||||
| DUPAGE | ||||
| EDGAR | ||||
| EDWARDS | ||||
| EFFINGHAM | ||||
| FAYETTE | ||||
| FORD | ||||
| FRANKLIN | ||||
| FULTON | ||||
| GALLATIN | ||||
| GREENE | ||||
| GRUNDY | ||||
| HAMILTON | ||||
| HANCOCK | ||||
| HARDIN | ||||
| HENDERSON | ||||
| HENRY | ||||
| IROQUOIS | ||||
| JACKSON | ||||
| JASPER | ||||
| JEFFERSON | ||||
| JERSEY | ||||
| JO DAVIESS | ||||
| JOHNSON | ||||
| KANE | ||||
| KANKAKEE | ||||
| KENDALL | ||||
| KNOX | ||||
| LA SALLE | ||||
| LAKE | ||||
| LAWRENCE | ||||
| LEE | ||||
| LIVINGSTON | ||||
| LOGAN | ||||
| MACON | ||||
| MACOUPIN | ||||
| MADISON | ||||
| MARION | ||||
| MARSHALL | ||||
| MASON | ||||
| MASSAC | ||||
| MCDONOUGH | ||||
| MCHENRY | ||||
| MCLEAN | ||||
| MENARD | ||||
| MERCER | ||||
| MONROE | ||||
| MONTGOMERY | ||||
| MORGAN | ||||
| MOULTRIE | ||||
| NO COUNTY | ||||
| OGLE | ||||
| OUT OF ST. | ||||
| PEORIA | ||||
| PERRY | ||||
| PIATT | ||||
| PIKE | ||||
| POPE | ||||
| PULASKI | ||||
| PUTNAM | ||||
| RANDOLPH | ||||
| RICHLAND | ||||
| ROCK ISLAND | ||||
| SALINE | ||||
| SANGAMON | ||||
| SCHUYLER | ||||
| SCOTT | ||||
| SHELBY | ||||
| ST.CLAIR | ||||
| STARK | ||||
| STEPHENSON | ||||
| TAZEWELL | ||||
| UNION | ||||
| VERMILION | ||||
| WABASH | ||||
| WARREN | ||||
| WASHINGTON | ||||
| WAYNE | ||||
| WHITE | ||||
| WHITESIDE | ||||
| WILL | ||||
| WILLIAMSON | ||||
| WINNEBAGO | ||||
| WOODFORD |
&A &P &F
1 ASO Fees
| State of Illinois |
| HMO ASO Fees |
| Please complete the following table for the proposed administration fees. |
| Note that all fees in the BASE PEPM Fees section (rows 12:23) are mandatory services. If there is no additional fee for providing this service outside of the base ASO fee then indicate it is included |
| All rates submitted must be divisible by two. If the submitted rate is not divisible by two, it will be adjusted down to the nearest penny for the purposes of scoring. |
| Each month's payment for State (SEGIP) Enrollees will be based upon verified liability for the month ending approximately 55 days prior to the date of payment. For CIP, LGHP and TRIP Enrollees each month’s payment will be based on membership information and will be paid on a monthly basis for the current month. |
| Medical Administration Fees | Non-Medicare and Medicare Enrollees | ||
| Enrollment as of March, 2026 | 62,200 | ||
| BASE PEPM Fees | Contract Year 1 | Contract Year 2 | Contract Year 3 |
| Plan Administration ASO (Should include claims processing, customer service, account service, communications). | $ - 0 | $ - 0 | $ - 0 |
| HMO Access Fees (if separate) | $ - 0 | $ - 0 | $ - 0 |
| Claim Fiduciary Liability (full) | $ - 0 | $ - 0 | $ - 0 |
| HIPAA Administration | $ - 0 | $ - 0 | $ - 0 |
| Standard Utilization Management | $ - 0 | $ - 0 | $ - 0 |
| Standard Reporting (quarterly and annually) | $ - 0 | $ - 0 | $ - 0 |
| Communication Materials (e.g. transition announcement letters) | $ - 0 | $ - 0 | $ - 0 |
| Core Disease Management | $ - 0 | $ - 0 | $ - 0 |
| CAA Compliance | $ - 0 | $ - 0 | $ - 0 |
| Sending/Accepting Eligibility Files (including interfacing with Custom Beneift Solution Vendor) | $ - 0 | $ - 0 | $ - 0 |
| 12 Months of Claims Runout Processing at Termination | $ - 0 | $ - 0 | $ - 0 |
| Other Services (Please list any other services included in the ASO Fee) | $ - 0 | $ - 0 | $ - 0 |
| Total BASE Medical Administrative Fees PEPM | $ - 0 | $ - 0 | $ - 0 |
| OPTIONAL PEPM Fees | Contract Year 1 | Contract Year 2 | Contract Year 3 |
| Optional Disease Management Programs | $ - 0 | $ - 0 | $ - 0 |
| Wellbeing Offerings (if any) | |||
| Centers of Excellence for Joint Replacements, bariatric surgeries, etc. | $ - 0 | $ - 0 | $ - 0 |
| Telemedicine | $ - 0 | $ - 0 | $ - 0 |
| Nurseline | |||
| Premier Customer Service (focused on increased advocacy) | $ - 0 | $ - 0 | $ - 0 |
| Performance Based Provider Incentives | $ - 0 | $ - 0 | $ - 0 |
| Fees for Services Based on Utilization (PEPM) | Contract Year 1 | Contract Year 2 | Contract Year 3 |
| ACO and Value Based Shared Savings and Care Coordincation fees | $ - 0 | $ - 0 | $ - 0 |
| Health Risk Assessment | $ - 0 | $ - 0 | $ - 0 |
| Biometric Screenings | $ - 0 | $ - 0 | $ - 0 |
| Health Coaching | $ - 0 | $ - 0 | $ - 0 |
| The State is requesting this information for contractual purposes only and it will not be scored | |||
| Other optional services inculding Cost Containment Programs not outline above (Specify Item and Fee) | Contract Year 1 | Contract Year 2 | Contract Year 3 |
| $ - 0 | $ - 0 | $ - 0 | |
| $ - 0 | $ - 0 | $ - 0 | |
| $ - 0 | $ - 0 | $ - 0 | |
| $ - 0 | $ - 0 | $ - 0 | |
| Implementation allowance/credit | |||
| Question | Response | ||
| 1). Please confirm all quoted premiums and/or administrative fees are guaranteed for a minimum of 3 years | |||
| 2). Please confirm 12 months of run-out administration is included in your quote. | |||
| 3). Please confirm rates are quoted on a mature basis. If not, explain. | |||
| 4). Please confirm rates do not include any commissions. | |||
| 5). If you use a rental or wrap-around network, how is your organization compensated for use? Describe in detail the compensation arrangemnet. | |||
| 6). Are there any other programs where you retain a % of savings (e.g. Subrogation or No Surprises Act). Provide details on each program and compensation arrangement. | |||
| 7). Does your organization negotiate and collect rebates on drugs that are adjudicated through the medical benefit (such as drugs administered in an inpatient setting)? If yes, provide an estimate of the value of those claims (provide for each contract year). | |||
| 8). Confirm there is no charge for sending/receiving Rx data files with the contracted PBM the State utilizes for prescription drug coverage. | |||
| -- if there is a charge, please indicate that charge here. |
&A &P &F
2 Network Discounts by County
| State of Illinois |
| Average Network Discounts by County |
| Please provide your average discount off billed charges for the counties identified below | |
| Please confirm the average you have provided in the table below is based on claims paid through the network (and associated discount schedule) your | |
| organization is proposing for CMS. (Indicate a yes if agree, no if that is not the average provided. | · Ancillary providers typically include labs, imaging (radiology), durable medical equipment (DME), therapy, home health, and other non-physician services. |
| An weighted average will be created taking into consideration service category usage (Hospital IP, Hospital OP, Physicians, Anc Provider) and Enrollment by County. |
| Confirmed | <------ In CellD9, type Yes to confirm; No if not confirmed |
| If no, please provide a descripton of how you calculated the average provided. |
| Proposed Network Contract Pricing | ||||||||
| County | Confirm averages are for the zipcodes you indicated are included in your bid, or all zipcodes you have in the county indicated | Weighted enrollment % by County | ||||||
| (as of July 1, 2025) | Hospital Inpatient | Hospital Outpatient | Physicians | Ancillary Providers | Blended Physician / Ancillary | |||
| ADAMS | 0.77% | 60% | 55% | 50% | 52% | 51% | ||
| ALEXANDER | 0.01% | 57% | 52% | 48% | 51% | 49% | ||
| BOND | 0.07% | 60% | 55% | 50% | 52% | 51% | ||
| BOONE | 0.31% | 57% | 52% | 48% | 51% | 49% | ||
| BROWN | 0.26% | 53% | 51% | 45% | 57% | 39% | ||
| BUREAU | 0.28% | 60% | 55% | 50% | 52% | 51% | ||
| CALHOUN | 0.00% | 57% | 52% | 48% | 51% | 49% | ||
| CARROLL | 0.07% | 60% | 55% | 50% | 52% | 51% | ||
| CASS | 0.34% | 57% | 52% | 48% | 51% | 49% | ||
| CHAMPAIGN | 2.14% | 53% | 51% | 45% | 57% | 39% | ||
| CHRISTIAN | 0.66% | 53% | 51% | 45% | 57% | 39% | ||
| CLARK | 0.20% | 60% | 55% | 50% | 52% | 51% | ||
| CLAY | 0.04% | 57% | 52% | 48% | 51% | 49% | ||
| CLINTON | 0.10% | 60% | 55% | 50% | 52% | 51% | ||
| COLES | 0.68% | 57% | 52% | 48% | 51% | 49% | ||
| COOK | 31.84% | 53% | 51% | 45% | 57% | 39% | ||
| CRAWFORD | 0.15% | 0% | 0% | 0% | 0% | 0% | ||
| CUMBERLAND | 0.10% | 0% | 0% | 0% | 0% | 0% | ||
| DEKALB | 1.54% | 0% | 0% | 0% | 0% | 0% | ||
| DEWITT | 0.15% | 60% | 55% | 50% | 52% | 51% | ||
| DOUGLAS | 0.12% | 57% | 52% | 48% | 51% | 49% | ||
| DUPAGE | 4.79% | 60% | 55% | 50% | 52% | 51% | ||
| EDGAR | 0.08% | 57% | 52% | 48% | 51% | 49% | ||
| EDWARDS | 0.00% | 53% | 51% | 45% | 57% | 39% | ||
| EFFINGHAM | 0.16% | 53% | 51% | 45% | 57% | 39% | ||
| FAYETTE | 0.18% | 53% | 51% | 45% | 57% | 39% | ||
| FORD | 0.10% | 60% | 55% | 50% | 52% | 51% | ||
| FRANKLIN | 0.14% | 60% | 55% | 50% | 52% | 51% | ||
| FULTON | 0.63% | 57% | 52% | 48% | 51% | 49% | ||
| GALLATIN | 0.01% | 60% | 55% | 50% | 52% | 51% | ||
| GREENE | 0.21% | 57% | 52% | 48% | 51% | 49% | ||
| GRUNDY | 0.35% | 53% | 51% | 45% | 57% | 39% | ||
| HAMILTON | 0.01% | 53% | 51% | 45% | 57% | 39% | ||
| HANCOCK | 0.13% | 53% | 51% | 45% | 57% | 39% | ||
| HARDIN | 0.00% | 53% | 51% | 45% | 57% | 39% | ||
| HENDERSON | 0.01% | 53% | 51% | 45% | 57% | 39% | ||
| HENRY | 0.57% | 0% | 0% | 0% | 0% | 0% | ||
| IROQUOIS | 0.15% | 60% | 55% | 50% | 52% | 51% | ||
| JACKSON | 0.41% | 57% | 52% | 48% | 51% | 49% | ||
| JASPER | 0.08% | 60% | 55% | 50% | 52% | 51% | ||
| JEFFERSON | 0.05% | 57% | 52% | 48% | 51% | 49% | ||
| JERSEY | 0.07% | 53% | 51% | 45% | 57% | 39% | ||
| JO DAVIESS | 0.04% | 60% | 55% | 50% | 52% | 51% | ||
| JOHNSON | 0.08% | 57% | 52% | 48% | 51% | 49% | ||
| KANE | 2.96% | 53% | 51% | 45% | 57% | 39% | ||
| KANKAKEE | 1.70% | 60% | 55% | 50% | 52% | 51% | ||
| KENDALL | 1.24% | 57% | 52% | 48% | 51% | 49% | ||
| KNOX | 0.59% | 53% | 51% | 45% | 57% | 39% | ||
| LA SALLE | 1.09% | 60% | 55% | 50% | 52% | 51% | ||
| LAKE | 2.30% | 57% | 52% | 48% | 51% | 49% | ||
| LAWRENCE | 0.00% | 60% | 55% | 50% | 52% | 51% | ||
| LEE | 0.63% | 57% | 52% | 48% | 51% | 49% | ||
| LIVINGSTON | 0.85% | 60% | 55% | 50% | 52% | 51% | ||
| LOGAN | 0.99% | 57% | 52% | 48% | 51% | 49% | ||
| MACON | 0.65% | 53% | 51% | 45% | 57% | 39% | ||
| MACOUPIN | 0.77% | 60% | 55% | 50% | 52% | 51% | ||
| MADISON | 0.82% | 57% | 52% | 48% | 51% | 49% | ||
| MARION | 0.10% | 53% | 51% | 45% | 57% | 39% | ||
| MARSHALL | 0.04% | 0% | 0% | 0% | 0% | 0% | ||
| MASON | 0.27% | 0% | 0% | 0% | 0% | 0% | ||
| MASSAC | 0.02% | 60% | 55% | 50% | 52% | 51% | ||
| MCDONOUGH | 1.35% | 57% | 52% | 48% | 51% | 49% | ||
| MCHENRY | 0.95% | 60% | 55% | 50% | 52% | 51% | ||
| MCLEAN | 3.01% | 57% | 52% | 48% | 51% | 49% | ||
| MENARD | 0.76% | 53% | 51% | 45% | 57% | 39% | ||
| MERCER | 0.09% | 60% | 55% | 50% | 52% | 51% | ||
| MONROE | 0.03% | 57% | 52% | 48% | 51% | 49% | ||
| MONTGOMERY | 0.72% | 53% | 51% | 45% | 57% | 39% | ||
| MORGAN | 1.53% | 60% | 55% | 50% | 52% | 51% | ||
| MOULTRIE | 0.10% | 57% | 52% | 48% | 51% | 49% | ||
| NO COUNTY | 0.00% | 60% | 55% | 50% | 52% | 51% | ||
| OGLE | 0.62% | 57% | 52% | 48% | 51% | 49% | ||
| OUT OF ST. | 1.39% | 53% | 51% | 45% | 57% | 39% | ||
| PEORIA | 1.17% | 60% | 55% | 50% | 52% | 51% | ||
| PERRY | 0.07% | 57% | 52% | 48% | 51% | 49% | ||
| PIATT | 0.18% | 53% | 51% | 45% | 57% | 39% | ||
| PIKE | 0.35% | 60% | 55% | 50% | 52% | 51% | ||
| POPE | 0.01% | 57% | 52% | 48% | 51% | 49% | ||
| PULASKI | 0.02% | 53% | 51% | 45% | 57% | 39% | ||
| PUTNAM | 0.04% | 60% | 55% | 50% | 52% | 51% | ||
| RANDOLPH | 0.05% | 57% | 52% | 48% | 51% | 49% | ||
| RICHLAND | 0.05% | 53% | 51% | 45% | 57% | 39% | ||
| ROCK ISLAND | 0.65% | 57% | 52% | 48% | 51% | 49% | ||
| SALINE | 0.14% | 60% | 55% | 50% | 52% | 51% | ||
| SANGAMON | 12.34% | 57% | 52% | 48% | 51% | 49% | ||
| SCHUYLER | 0.18% | 60% | 55% | 50% | 52% | 51% | ||
| SCOTT | 0.24% | 57% | 52% | 48% | 51% | 49% | ||
| SHELBY | 0.12% | 53% | 51% | 45% | 57% | 39% | ||
| ST.CLAIR | 0.40% | 60% | 55% | 50% | 52% | 51% | ||
| STARK | 0.05% | 57% | 52% | 48% | 51% | 49% | ||
| STEPHENSON | 0.16% | 53% | 51% | 45% | 57% | 39% | ||
| TAZEWELL | 0.96% | 60% | 55% | 50% | 52% | 51% | ||
| UNION | 0.12% | 57% | 52% | 48% | 51% | 49% | ||
| VERMILION | 0.25% | 53% | 51% | 45% | 57% | 39% | ||
| WABASH | 0.02% | 60% | 55% | 50% | 52% | 51% | ||
| WARREN | 0.19% | 57% | 52% | 48% | 51% | 49% | ||
| WASHINGTON | 0.04% | 60% | 55% | 50% | 52% | 51% | ||
| WAYNE | 0.02% | 57% | 52% | 48% | 51% | 49% | ||
| WHITE | 0.01% | 53% | 51% | 45% | 57% | 39% | ||
| WHITESIDE | 0.50% | 60% | 55% | 50% | 52% | 51% | ||
| WILL | 6.05% | 57% | 52% | 48% | 51% | 49% | ||
| WILLIAMSON | 0.35% | 60% | 55% | 50% | 52% | 51% | ||
| WINNEBAGO | 1.24% | 57% | 52% | 48% | 51% | 49% | ||
| WOODFORD | 0.37% | 53% | 51% | 45% | 57% | 39% |
&A &P &F
3 Detailed Network Discount
| State of Illinois |
| Detailed Network Discount Analysis |
Please provide your average discounts for providers in the following file :
Appendix 3 Detailed Network Discount.xlsx
Each Group has 3 tabs (Inpatient, Outpatient, and Professional). Please complete the cells highlighted in yellow.
SEGIP - Inpatient, Outpatient, and Professional LGHP - Inpatient, Outpatient, and Professional TRIP - Inpatient, Outpatient, and Professional CIP - Inpatient, Outpatient, and Professional
&A &P &F
4 Medical Discount Guarantee
| State of Illinois |
| Network Discount Guarantee |
Provider Network Discount Guarantee: In the shaded column of the table below, insert the percentage amount of the Provider Network Discount Vendor is guaranteeing for its discount levels based upon the pre-populated corresponding proposed Performance Guarantee Adjustments column. The proposed guarantee is a sliding scale. This guarantee shall be effective for the entire term of the contract, including any renewal terms. Failure to insert a percentage may result in the proposal being rejected for lack of responsiveness.
| Provider Network Discount Guarantee | |
| Performance Guarantee Adjustments (Percentage of Total Annual ASO Fees by Fiscal Year) | |
| This Performance Guarantee shall be measured and reported to Agency annually. The report and supporting documentation shall be submitted to Agency within 90 days of the end of the plan year, unless otherwise agreed to by both parties. | |
| Proposed Performance Standard | Proposed Performance Guarantee Adjustments |
| In the blanks below, place the percentage of the Provider Network Discount that Offeror is willing to guarantee for the term of the contract, including all renewal years, Percentages should be provided in 1% increments, and a maximum of a 2% corridor. | |
| Greater than ___% | 0% |
| ___% up to ___% | 5% |
| ___% up to ___% | 10% |
| ___% up to ___% | 15% |
| ___% up to ___% | 20% |
| Below ___% | 25% |
| The following methodologies are to be utilized when establishing and calculating the above Provider Network Discount Guarantee chart: |
| - Provider Network Discount is a composite or average discount for eligible medical services provided by network providers. |
| - Total Network Eligible Charges are the total billed charges from a network contracted provider, less billed charges not eligible under the plan. |
| - Total Allowed Network Charges are the Total Network Eligible charges after the network provider contract adjustments have been applied. |
| - The Provider Network Discount is calculated as 1 minus (Total Allowed Network Charges divided by Total Network Eligible Charges). |
| - Use one single combined percentage result based upon the different levels of percentage discounts by a broad range of service types (e.g. physician office visits, inpatient and outpatient hospital services). |
| - Guarantee a single combined result for all Agency administered benefit plans. |
| - Compare the actual discounts achieved to the Proposed Performance Standard and provide supporting documentation to substantiate the measurement. |
| - Offeror shall include: |
| Services provided to non-Medicare Enrollee population only. |
| Services of all in-network providers only. |
| Claims for services incurred by Enrollees prior to the termination or expiration of the Agreement. |
| Bonus payments and fees to providers based on outcomes or other performance measures. |
| - Offeror shall Exclude: |
| Services that involve payment of in-network benefits to out-of-network providers. |
| Claims where the provider bills the contracted rate. |
| If applicable, claims for capitated services. |
| - Vendor shall assume that network provider rates (e.g. hospital charge masters and billed charges for other providers) remain flat or increased (do not include or factor in rate decreases). Charge master shall mean a standard set of charges that a hospital bills for services provided to all patients. |
| Confirm that you understand and utilized the above methodologies in the box below: |
&A &P &F
5 Expected Claims and Expenses State of Illinois
| Please provide an estimate of claims and administration fees based on your underwriting estimates and the terms proposed in this RFP | |||
| Medical Claims & Expense Estimate | |||
| Contract Year 1 | Contract Year 2 | Contract Year 3 | |
| Estimated Projected Medical Claims | $ - 0 | $ - 0 | $ - 0 |
| Administration Fees | |||
| a.) Medical Fees | $ - 0 | $ - 0 | $ - 0 |
| b.) Other Fees (as applicable) | $ - 0 | $ - 0 | $ - 0 |
| Total Claims and Expenses | $ - 0 | $ - 0 | $ - 0 |
| COMMENTS: | |||
| Describe any adjustments and/or explanation required for the calculation above |
&A &P &F
6 Stop Loss
| State of Illinois |
| Stop Loss (MEDICAL ONLY + IP/OP RX PAID UNDER MEDICAL PLAN) |
| Currently, the State has no stop loss; however, they are requesting this information for contractual purposes only and it will not be scored |
| Please provide a quote for specific stop loss coverage. 1The stop loss should include medical claims paid under the HMO plan, plus any inpatient and outpatient Rx covered under the plan. Claims paid by the PBM should not be included in the quotation. |
| Please provide a quote for both options 1 and 2 listed below | ||||
| Option 1: Stop Loss aggregated across all 4 groups | ||||
| Contract Year 1 | Individual Stop Loss | Aggregate Stop Loss | ||
| Alternative | Current | Alternative 1 | Current | Alternative 1 |
| Contract Basis | 12/18 | 12/24 | 12/18 | 12/24 |
| Covered Claims | Medical 1 |
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={E1E71436-873E-4B05-A89F-02BDCD814C27}: [Threaded comment]
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={5FC8D2CA-9EEF-4B58-A112-042A328F53B2}: [Threaded comment]
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={64058DC1-94E5-420E-AC0B-014855A9DD76}: [Threaded comment]
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
| Lifetime Maximum | Unlimited | Unlimited | Unlimited | Unlimited |
| Covered Participants | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 |
| Deductible | $2,500,000 | $2,500,000 | $2,500,000 | $2,500,000 |
| Aggregate Attachment Point | N/A | N/A | 125% | 125% |
| Single Premium | ||||
| Single + 1 Premium | ||||
| Family Premium | ||||
| Composite Premium | ||||
| Second Year Rate Guarantee or Cap | ||||
| No New Laser Provision | Yes / No | Yes / No | Yes / No | Yes / No |
| Option 2: Stop Loss specific to each program and plan (SEGIP, LGHP, TRIP, and CIP) | ||||||||||||||||||||||||
| Contract Year 1 | State - QCHP Individual Stop Loss | State - QCHP Aggregate Stop Loss | State - CDHP Individual Stop Loss | State - CDHP Aggregate Stop Loss | LGHP - LCHP Individual Stop Loss | LGHP - LCHP Aggregate Stop Loss | LGHP - CDHP Individual Stop Loss | LGHP - CDHP Aggregate Stop Loss | TRIP Individual Stop Loss | TRIP Aggregate Stop Loss | CIP Individual Stop Loss | CIP Aggregate Stop Loss | ||||||||||||
| Alternative | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 | Current | Alternative 1 |
| Contract Basis | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 | 12/18 | 12/24 |
| Covered Claims | Medical 1 |
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={0BFBFC69-6B67-40D5-9231-F1BCC879D2BB}: [Threaded comment]
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Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={01AB735F-B71C-49E5-9B1E-367BB73B7263}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
tc={64058DC1-94E5-420E-AC0B-014855A9DD76}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx. Medical 1 tc={5EBCEC9B-D771-4FE6-A9A5-0BC69A6CC5EB}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
tc={7FD8223A-5138-4E17-A083-570E84767717}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
tc={C91135FA-A400-4436-B8EE-3494C80D9D78}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
tc={E1E71436-873E-4B05-A89F-02BDCD814C27}: [Threaded comment]
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Comment:
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
tc={0BFBFC69-6B67-40D5-9231-F1BCC879D2BB}: [Threaded comment]
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Comment:
| Just confirming that each of these are to be quoted on medical only, and not medical+Rx. | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | Medical | |||||||||||||||
| Lifetime Maximum | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | Unlimited | |||||||||||
| Covered Participants | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | Actives & Pre-65 | |||||||||||
| Deductible | $2,000,000 | $2,000,000 | $2,000,000 | $2,000,000 | $500,000 | $500,000 | $500,000 | $500,000 | $100,000 | $100,000 | $100,000 | $100,000 | $50,000 | $50,000 | $50,000 | $50,000 | $2,000,000 | $2,000,000 | $2,000,000 | $2,000,000 | $100,000 | $100,000 | $100,000 | $100,000 | |||||||||||
| Aggregate Attachment Point | N/A | N/A | 125% | 125% | N/A | N/A | 125% | 125% | N/A | N/A | 125% | 125% | N/A | N/A | 125% | 125% | N/A | N/A | 125% | 125% | N/A | N/A | 125% | 125% | |||||||||||
| Single Premium | |||||||||||||||||||||||||||||||||||
| Single + 1 Premium | |||||||||||||||||||||||||||||||||||
| Family Premium | |||||||||||||||||||||||||||||||||||
| Composite Premium | |||||||||||||||||||||||||||||||||||
| Second Year Rate Guarantee or Cap | |||||||||||||||||||||||||||||||||||
| No New Laser Provision | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No | Yes / No |
| Question | Response |
| 1). Please confirm that stop loss rates are firm. | |
| 2). Please confirm that the demographic and claims information provided in the RFP meets all disclosure requirements to bind coverage. | |
| 3). Please confirm that stop loss rates are guaranteed for at least one year and include all claims paid by the plan | |
| 4). Please confirm the stop loss contract duplicates the underlying self-insured medical plans (covered charges and limitations) without exception. | |
| 5). Please confirm you agree to accept run-out claims reporting (at no charge) from the State's legacy medical claims administrator (if applicable) and integrate the medical claims information such that the reconciliation for stop loss reimbursements includes all claims for all eligible employees. | |
| 6). Please confirm the proposal provides currently covered participants continued coverage on a no-loss, no-gain basis. The actively-at-work requirement is to be waived for all current participants, including those individuals on COBRA continuance and short-term and long-term disability. All individuals must be covered under the new stop loss policy. | |
| 7). If there is an error in reporting claims, causing delays in receipt of carrier reports, will you pursue them with the State's administrators and if you cannot obtain them, advise both the State and broker/consultant of the issue? | |
| 8). Please confirm you will accept self-reported premium remittances. | |
| 9). Please confirm you will provide ISL premium and claim activity reports required for renewal assessment and budget projections and reimbursement reconciliation. | |
| 10). Please confirm that reports will be provided in an electronic basis in the identified formats and frequencies. | |
| 11). Please confirm annual renewal may be quoted and bound with nine (9) months of claims data. | |
| 12). Describe any adjustments and/or explanation required for the proposal |
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
Just confirming that each of these are to be quoted on medical only, and not medical+Rx.
&A &P &F
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