Appendix 4 SIMP Pricing Revised.xlsx
XLSX spreadsheet 422 KB Posted
- Contract number
- 26-416CMS-BENF4-P-92831
- Issued by
- Illinois
About this file
SIMP Pricing Summary
This document is a revised pricing appendix for the Statewide Information Management Program (SIMP), a collaborative contract vehicle. The pricing structure applies across multiple state and local jurisdictions that are parties to this cooperative purchasing agreement. The primary entities involved include state agencies and local governments utilizing this centralized contracting mechanism, along with approved vendors who provide goods and services through the SIMP framework.
The appendix details pricing schedules for various product and service categories available under the SIMP contract, establishing standard rates and cost structures that participating agencies may utilize for their procurement needs. The pricing terms define unit costs, volume discounts where applicable, and any tiered pricing models based on order quantities or contract duration. The document serves as the authoritative reference for cost calculation across all participating jurisdictions, ensuring consistency and cost control throughout the contract period. Specific pricing may be subject to annual adjustments or renewal terms as outlined in the master agreement, with all participating entities required to reference these established rates for budget planning and purchase order execution.
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Other files
| File | Type | Posted |
|---|---|---|
| Addendum 2 Self Insured Medical Plan RFP Rebid.docx | DOCX document | |
| Appendix 3 Discount Analysis Revised.xlsx | XLSX spreadsheet | |
| CertifiedBEPFirmsDirectory SIMP RFP_~1.xlsx | XLSX spreadsheet | |
| B-48962 notice of award form SIMP Rebid.pdf | ||
| Appendix 5 Medical Claims.xlsx | XLSX spreadsheet | |
| Addendum 1 Self Insured Medical Plan RFP Rebid~1.docx | DOCX document | |
| request-for-proposal-offer-to-the-state-of-illinois-v-26-1.pdf | ||
| Appendix 2 Disruption Analysis Revised.xlsx | XLSX spreadsheet | |
| Self Insured Medical Plan RFP Rebid Final ~2.docx | DOCX document | |
| Appendix 6 Large Claim Exhibit.xlsx | XLSX spreadsheet | |
| vendor-disclosure-formerly-forms-a-v26-2.docx | DOCX document | |
| Appendix 1 Census Data July 2025.xlsx | XLSX spreadsheet |
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Text version
Instructions
State of Illinois CMS Bureau of Benefits Self Insured Medical Plan
| 26-416CMS-BENF4-B-48962 | |
| 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. |
| Contents of this Cost Proposal workbook: | |
| 1 | ASO Fees |
| 2 | Network Discounts by ZIP Code |
| 3 | Detailed Network Discount |
| 4 | Medical Discount Guarantee |
| 5 | Expected Claims and Expenses - Will not be evaluated, for information purposes only. |
| 6 | Stop Loss - Will not be evaluated, for information and contractual purposes only. |
| Offeror shall submit pricing in the format shown in this workbook, based on the terms and conditions set forth in Section 1 of 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. |
| Agency is seeking a medical plan administrator with provider network(s), including but not limited to Centers of Excellence for transplants and hip, knee and other joint replacements for QCHP, TCHP, CCHP, LCHP,and LCDHP. Agency is requiring Offerors to agree to a Provider Network Discount Guarantee in this solicitation in order to reduce Agency’s Medical Claims Spend as detailed in the "Medical Discount Guranatee" 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 Guranatee" 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
1 ASO Fees
| State of Illinois |
| ASO Fees |
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 |
| Please complete the following table for the proposed administration fees. | |||
| Note that all fees in the BASE PEPM Fees section (rows 13:23) 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. | |||
| Please respond to the 8 questions provided at the bottom (starting on B47). | |||
| Medical Administration Fees | Non-Medicare and Medicare Enrollees | ||
| Estimated Enrollment as of May 1, 2025 | 43,239 | ||
| 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 |
| 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 |
| 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 |
| Centers of Excellence for Joint Replacements, bariatric surgeries, etc. | $ - 0 | $ - 0 | $ - 0 |
| Telemedicine | $ - 0 | $ - 0 | $ - 0 |
| 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 Coach | $ - 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 5 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)? | |||
| 8). If applicable, confirm you agree to pass through all rebates on drugs that are adjudicated through the medical benefit (such as drugs administered in an inpatient setting) |
&A &P &F
2 Network Discounts by ZIP Code
| State of Illinois |
| Average Network Discounts by ZIP Code |
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 |
| Please provide your average discount off billed charges for the 3-digit zip codes identified below |
| Proposed Network Contract Pricing | |||||
| 3 Digit Zip | Hospital Inpatient | Hospital Outpatient | Physicians | Ancillary Providers | Blended Physician / Ancillary |
| 606 | 0% | 0% | 0% | 0% | 0% |
| 604 | 0% | 0% | 0% | 0% | 0% |
| 601 | 0% | 0% | 0% | 0% | 0% |
| 600 | 0% | 0% | 0% | 0% | 0% |
| 605 | 0% | 0% | 0% | 0% | 0% |
| 618 | 0% | 0% | 0% | 0% | 0% |
| 627 | 0% | 0% | 0% | 0% | 0% |
| 629 | 0% | 0% | 0% | 0% | 0% |
| 617 | 0% | 0% | 0% | 0% | 0% |
| 610 | 0% | 0% | 0% | 0% | 0% |
| 609 | 0% | 0% | 0% | 0% | 0% |
| 626 | 0% | 0% | 0% | 0% | 0% |
| 614 | 0% | 0% | 0% | 0% | 0% |
| 613 | 0% | 0% | 0% | 0% | 0% |
| 603 | 0% | 0% | 0% | 0% | 0% |
| 620 | 0% | 0% | 0% | 0% | 0% |
| 625 | 0% | 0% | 0% | 0% | 0% |
| 628 | 0% | 0% | 0% | 0% | 0% |
| 611 | 0% | 0% | 0% | 0% | 0% |
| 624 | 0% | 0% | 0% | 0% | 0% |
| 615 | 0% | 0% | 0% | 0% | 0% |
| 623 | 0% | 0% | 0% | 0% | 0% |
| 612 | 0% | 0% | 0% | 0% | 0% |
| 607 | 0% | 0% | 0% | 0% | 0% |
| 463 | 0% | 0% | 0% | 0% | 0% |
| 616 | 0% | 0% | 0% | 0% | 0% |
| 602 | 0% | 0% | 0% | 0% | 0% |
| 619 | 0% | 0% | 0% | 0% | 0% |
| 608 | 0% | 0% | 0% | 0% | 0% |
| 531 | 0% | 0% | 0% | 0% | 0% |
| 339 | 0% | 0% | 0% | 0% | 0% |
| 342 | 0% | 0% | 0% | 0% | 0% |
| 853 | 0% | 0% | 0% | 0% | 0% |
| 321 | 0% | 0% | 0% | 0% | 0% |
| 852 | 0% | 0% | 0% | 0% | 0% |
| 341 | 0% | 0% | 0% | 0% | 0% |
| 631 | 0% | 0% | 0% | 0% | 0% |
| 334 | 0% | 0% | 0% | 0% | 0% |
| 337 | 0% | 0% | 0% | 0% | 0% |
| 857 | 0% | 0% | 0% | 0% | 0% |
| 805 | 0% | 0% | 0% | 0% | 0% |
| 535 | 0% | 0% | 0% | 0% | 0% |
&A &P &F
3 Detailed Network Discount
| State of Illinois |
| Detailed Network Discount Analysis |
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 |
| Please provide your average discounts for providers in the following file: |
Appendix 3 - Discount Analysis.xlsx]
The file has multiple tabs by program (Inpatient, Outpatient, and Professional). Please fill complete the cells highlighted in yellow.
&A &P &F
4 Medical Discount Guarantee
| State of Illinois |
| Network Discount Guarantee |
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 |
| 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 | |||
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 | |||
| 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 Claims | $ - 0 | $ - 0 | $ - 0 |
| Administration Fees | |||
| a.) Medical Fees | $ - 0 | $ - 0 | $ - 0 |
| b.) Individual Stop Loss Premium Assuming Current Deductible & Terms | $ - 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 | ||||
| Self Insured Medical Plan 26-416CMS-BENF4-B-48962 | ||||
| The State is requesting this information for contractual purposes only and it will not be scored | ||||
| Please provide a quote for specific stop loss coverage based on the terms provided in the table | ||||
| Please provide a quote for both options 1 and 2 listed below | ||||
| Please respond to the 12 questions provided at the bottom (starting on B41). | ||||
| 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 | Medical | Medical | Medical |
| 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 (State - QCHP, State - CDHP, LGHP - LCHP, LGHP - CDHP) | ||||||||||||||||
| 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 | ||||||||
| 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 |
| 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 |
| Covered Claims | 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 |
| 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 |
| 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 |
| 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% |
| 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 |
| 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 | |
| 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 |
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