attachment-1-rfp-3015-25.pdf

SECTION 7: FINANCIAL SECTION

7.1 ADMINISTRATIVE & PROGRAM FEES - PEPM FIXED FEES

Fees must be provided in the fixed PEPM format requested.

Administrative & Program Fees: All Active Plans Composite Rate Initial Contract Period Optional Extension Years

CY 2026 PEPM CY 2027 PEPM CY 2028 PEPM CY 2029 PEPM CY 2030 PEPM CY 2031 PEPM

Medical Administration / Claims Processing Network Access/Leasing Fees Utilization Management Fees ID Cards Provider Directory Benefit Booklets/SPDs Data and Performance Reporting Data Sharing Disease Management Medical Info Line Incentive Shopper Program COBRA Administration State uses separate vendor. Not part of this RFP.

Start Up/Implementation Costs Other

All Inclusive Fee (PEPM) Total Annual Estimated Aggregate Fees $ $ $ $ $ $

Administrative & Program Fees: Non-Medicare Retiree Composite Rate Initial Contract Period Optional Extension Years

CY 2026 PEPM CY 2027 PEPM CY 2028 PEPM CY 2029 PEPM CY 2030 PEPM CY 2031 PEPM

Medical Administration / Claims Processing Network Access/Leasing Fees Utilization Management Fees ID Cards Provider Directory Benefit Booklets/SPDs Data and Performance Reporting Data Sharing Disease Management Medical Info Line Incentive Shopper Program COBRA Administration State uses separate vendor. Not part of this RFP.

Start Up/Implementation Costs Other

All Inclusive Fee (PEPM) Total Annual Estimated Aggregate Fees $ $ $ $ $ $

DIRECTIONS FOR FEES ABOVE CONFIRM

1. Fees must exclude commissions.

2. Individual fee components are self-supporting for stand alone services.

3. Fees quoted are valid until contract award & guaranteed for each 12-month period.

6. Fees quoted cover services for claims incurred on or after January 1, 2026.

4. We have listed any services/supplies not covered under the fixed PEPM fees quoted above (i.e., custom reports, printing, etc.). We have provide the fees for these services.

5. We have identified separately any start-up costs. (i.e., communications material, orientation meetings).

7. ALL FEES ARE ON A MATURE BASIS AND INCLUDE AT LEAST 18 MONTHS OF RUNOUT ADMINISTRATION.

8. Fees assume the full value of your provider discounts will be passed through to the State on each and every claims and that no portion of the provider discounts are retained to offset the administrative fees.

SONH RFP #3015-25 Administrative Fee - PEPM Fixed

7.1 ADMINISTRATIVE & PROGRAM FEES - ADDITIONAL FEES

Important Information

1) The State requires Bidders to clearly identify all costs for which the State will be responsible.

2) The State will not be responsible for any fees not identified in your proposal.

3) The State requires a transparent billing process where all fees are clearly identified on monthly invoices.

4) The State values a contract that has guarantees and a proposal that offers maximum charge limits will be viewed more favorably.

Provide all the information requested below by plan for the four (4) requested initial contract years.

All Active Plans

CY 2026

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2027

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2028

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2029

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

DIRECTIONS FOR FEES ABOVE CONFIRM

3. All fees and charges that we will collect from the State have been identified and listed in this exhibit, the PEPM Fixed Fee exhibit, or the Wellness Fee exhibit.

2. Individual fee components are self-supporting for stand alone services.

1. * PEPM in columns E & F are based on ALL employees and not just a subset of the total (e.g., attributed members)

SONH RFP #3015-25 Administrative Fee - Additional

Non-Medicare Retiree Plan(s)

CY 2026

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2027

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2028

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

CY 2029

Will these apply to the State?

(Yes/No)

Are these included in your response to the Claims

Repricing in Section 7.2?

(Yes/No)

Describe the Proposed Fee, including the basis (e.g., % of savings, PEPM, PMPM, etc.)

Estimated Cost -

PEPM *

Maximum Fee

Guarantee PEPM *

Confirm this will be identified separately on monthly invoices. Additional Comments Partner Provider Network (e.g., Partner health plan, secondary network, etc.)

Non-Contracted Provider (i.e., Out-of-Network) Savings

Subrogation

Provider Attribution - Performance or Incentive Based

Provider Attribution - Non-Performance or Non-Incentive Based

External Vendor Overpayment Recoveries Enhanced Fraud, Waste, and Abuse (including claims editing, COB, overpayment recoveries, provider code review, investigative FW&A) Add and Provide the Requested Information for All Other Fees Not Included Above (add rows as necessary)

DIRECTIONS FOR FEES ABOVE CONFIRM

1. * PEPM in columns N & O are based on ALL employees and not just a subset of the total (e.g., attributed members)

2. Individual fee components are self-supporting for stand alone services.

3. All fees and charges that we will collect from the State have been identified and listed in this exhibit, the PEPM Fixed Fee exhibit, or the Wellness Fee exhibit.

SONH RFP #3015-25 Administrative Fee - Additional

7.1 ADMINISTRATIVE & PROGRAM FEES - WELLNESS

Fees must be provided in the following formats.

Administrative Fee - Wellness Program: ALL Active Plans Initial Contract Period Optional Extension Years

CY 2026 PEPM CY 2027 PEPM CY 2028 PEPM CY 2029 PEPM CY 2030 PEPM CY 2031 PEPM

Customized Website Health Risk Assessment/Tool (HAT)

HAT Reporting Member Communications Onsite Health Screenings Wellness Promotion/Incentive Program Wellness Counseling Fitness Counseling Educational Sessions - Seminars Educational Sessions - Webinars Telephonic Coaching Workplace Influenza Vaccinations Start Up/Implementation Costs Designated Nurse Health Coach Other

All Inclusive Fee (PEPM) Total Annual Estimated Fees $ $ $ $ $ $

If the State implemented the Wellness Program for the Non-Medicare Retiree Plan, would the above fees apply? If not, please complete a separate chart for this plan.

DIRECTIONS FOR FEES ABOVE CONFIRM

1. Fees must exclude commissions.

2. Individual fee components are self-supporting for stand alone services.

3. Fees quoted are valid until contract award & guaranteed for each 12-month period.

WELLNESS ALLOWANCE ANNUAL

4. We have listed any services/supplies not covered under the fees quoted above (i.e., custom reports, printing, etc.). We have provided the fees for these services.

5. We have identified separately any start-up costs. (i.e., communications material, orientation meetings).

Indicate the amount of an annual allowance you are willing to offer the State to fund its wellness programs.

SONH RFP #3015-25 Administrative Fee - Wellness

7.2 CLAIM COSTS - PROVIDER REIMBURSEMENT & DISCOUNTS: Physician Reimbursement

HMO-like Network: Discounts for the product/network you are proposing for the current Active HMO Plan participants.

AVERAGE PHYSICIAN DISCOUNTS

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

State of New Hampshire

Boston, Massachusetts

Primary Care/Family Practice/Internist Pediatricians/OB/GYN % % % % % % % % Radiology % % % % % % % % Pathology/Lab % % % % % % % % Anesthesia % % % % % % % % Behavioral Health % % % % % % % % Surgical Procedure % % % % % % % % Office Visit (Specialist) % % % % % % % %

ALL PHYSICIAN SERVICES % % % % % % % %

POS/PPO Network: Discounts for the product/network you are proposing for the current Active POS Plan participants.

AVERAGE PHYSICIAN DISCOUNTS

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

State of New Hampshire

Boston, Massachusetts

Primary Care/Family Practice/Internist Pediatricians/OB/GYN % % % % % % % % Radiology % % % % % % % % Pathology/Lab % % % % % % % % Anesthesia % % % % % % % % Behavioral Health % % % % % % % % Surgical Procedure % % % % % % % % Office Visit (Specialist) % % % % % % % %

ALL PHYSICIAN SERVICES % % % % % % % %

POS/PPO Network: Discounts for the product/network you are proposing for the Non-Medicare Retiree Plan participants.

AVERAGE PHYSICIAN DISCOUNTS

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

Zip Code:

State of New Hampshire

Boston, Massachusetts

Primary Care/Family Practice/Internist Pediatricians/OB/GYN % % % % % % % % Radiology % % % % % % % % Pathology/Lab % % % % % % % % Anesthesia % % % % % % % % Behavioral Health % % % % % % % % Surgical Procedure % % % % % % % % Office Visit (Specialist) % % % % % % % %

ALL PHYSICIAN SERVICES % % % % % % % %

If multiple networks are proposed, copy the table and provide discounts for the additional network.

Please provide your current (as of March 1, 2025) average physician discounts negotiated in the following areas for your proposed networks. These discounts should assume your GLOBAL NON-FACILITY reimbursements. For services such as Radiology, the average discount should be based on both the professional fee and the technical fee components combined.

These discounts should reflect all applicable fees charged to the State to use the network provider and obtain the discounted charge.

DO NOT PROVIDE PROJECTED OR EXPECTED DISCOUNT PERCENTAGES.

SONH RFP #3015-25 Physician Discount

7.2 CLAIM COSTS - PROVIDER REIMBURSEMENT & DISCOUNTS: Hospital and Outpatient Facility Charges

HMO-like Network: Discounts for the product/network you are proposing for the current Active HMO Plan participants.

AVERAGE HOSPITAL DISCOUNTS

Merrimack County

Hillsborough County

Grafton County

State of New Hampshire

Boston, Massachusetts

Acute Medical/Surgical Inpatient Hospital % % % % % Hospital Based Surgery Center % % % % % Free Standing Surgery Center % % % % % Outpatient Hospital ( i.e., x-ray, lab) % % % % % Hospital Emergency Room Services % % % % % Skilled Nursing Facility % % % % % Inpatient Physical Rehab. Facility % % % % % Acute Mental Health Inpatient % % % % % Addiction/Substance Use Disorder Inpatient % % % % %

ALL INPATIENT HOSPITAL SERVICES % % % % %

ALL OUTPATIENT HOSPITAL SERVICES % % % % %

POS/PPO Network: Discounts for the product/network you are proposing for the current Active POS Plan participants.

AVERAGE HOSPITAL DISCOUNTS

Merrimack County

Hillsborough County

Grafton County

State of New Hampshire

Boston, Massachusetts

Acute Medical/Surgical Inpatient Hospital % % % % % Hospital Based Surgery Center % % % % % Free Standing Surgery Center % % % % % Outpatient Hospital ( i.e., x-ray, lab) % % % % % Hospital Emergency Room Services % % % % % Skilled Nursing Facility % % % % % Inpatient Physical Rehab. Facility % % % % % Acute Mental Health Inpatient % % % % % Addiction/Substance Use Disorder Inpatient % % % % %

ALL INPATIENT HOSPITAL SERVICES % % % % %

ALL OUTPATIENT HOSPITAL SERVICES % % % % %

POS/PPO Network: Discounts for the product/network you are proposing for the Non-Medicare Retiree Plan participants.

AVERAGE HOSPITAL DISCOUNTS

Merrimack County

Hillsborough County

Grafton County

State of New Hampshire

Boston, Massachusetts

Acute Medical/Surgical Inpatient Hospital % % % % % Hospital Based Surgery Center % % % % % Free Standing Surgery Center % % % % % Outpatient Hospital ( i.e., x-ray, lab) % % % % % Hospital Emergency Room Services % % % % % Skilled Nursing Facility % % % % % Inpatient Physical Rehab. Facility % % % % % Acute Mental Health Inpatient % % % % % Addiction/Substance Use Disorder Inpatient % % % % %

ALL INPATIENT HOSPITAL SERVICES % % % % %

ALL OUTPATIENT HOSPITAL SERVICES % % % % %

If multiple networks are proposed, copy the table and provide discounts for the additional network.

Please provide your current (as of March 1, 2025) average hospital discounts negotiated in the following areas for your proposed networks.

These discounts should reflect all applicable fees charged to the State to use the network provider and obtain the discounted charge.

DO NOT PROVIDE PROJECTED OR EXPECTED DISCOUNT PERCENTAGES.

SONH RFP #3015-25 Hospital Discount

7.2 CLAIM COSTS - PROVIDER REIMBURSEMENT & DISCOUNTS: Claims Repricing Analysis

Repricing of Anthem Medical Claims - Paid January 1, 2024 to December 31, 2024

The State requires a transparent billing process where all fees are clearly identified on monthly invoices.

Confirm you have included an explanation detailing how you re-priced the claims, noting any and all adjustments and methodologies.

Reprice Using the Product/Network you are proposing for the current Active HMO Plan participants.

Proposed Network Name:

"HMO-like" Product Type:

Repricing of Claims Data *

Eligible Amount * Repriced Amount * % of Savings Fees * Partner Provider Network Fees *

Risk-sharing and Incentive Provider

Payments * Other Fees

Described Below * Adjusted

Repriced Amount *

CLAIMS NOT ABLE TO BE REPRICED

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Claims Omitted $0 $0 $0 $0 $0 $0 $0

OUT-OF-NETWORK

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Out-of-Network $0 $0 $0 $0 $0 $0 $0

IN-NETWORK

Inpatient $0 Repricing Check with Data File Outpatient $0 Data File Name: Eligible Amount/Charges Physician/Professional $0 Active HMO Claims to Reprice.xlsx Data File Bidder's Work Subtotal In-Network $0 $0 $0 $0 $0 $0 $0 Inpatient $43,094,623 $0 FALSE

Outpatient $123,254,705 $0 FALSE Grand Total All Repriced Claims $0 $0 $0 $0 $0 $0 $0 Physician/Professional $152,903,112 $0 FALSE

FALSE Total $319,252,439 $0 FALSE Grand Total From HMO Data Files $319,252,439 These 2 columns should match

* DEFINITIONS

Claims should be repriced assuming you are the sole payor and should not assume any savings or average savings from COB or liability of other parties.

Repricing Column Description

Eligible Amount

Repriced Amount

% of Savings Fees

Partner Provider Network Fees Risk-sharing and Incentive Provider Payments

Other Fees (describe)

Confirm your repricing is based on eligible charges and your current (as of March 1, 2025) network provider contractual fee arrangements and is based on actual data and does not include any assumptions regarding projected discounts or assumed increases in billed charges.

ACTIVE HMO CLAIM REPRICING FILES

"ELIGIBLE_CHARGES" as shown on the "HMO Claims To Reprice" data files (3 separate files). Totals should match table on the right.

Eligible amount/charges based on application of your provider specific discounts.

Fees on a percent of savings basis that are charged to the State. These should not include amounts captured in "Partner Provider Network Fees" or "Risk-sharing and Incentive Provider Payments".

Fees paid to a partner provider network (e.g., "host plan") that are charged to the State.

Risk-sharing and incentive payments to providers the State would be liable for.

SONH RFP #3015-25 Repricing- Active HMO Claims

Repricing of Anthem Medical Claims - Paid January 1, 2024 to December 31, 2024

The State requires a transparent billing process where all fees are clearly identified on monthly invoices.

Confirm you have included an explanation detailing how you re-priced the claims, noting any and all adjustments and methodologies.

Reprice Using the Product/Network you are proposing for the current Active POS Plan participants.

Proposed Network Name:

Product (POS, PPO, etc.):

Repricing of Claims Data *

Eligible Amount * Repriced Amount * % of Savings Fees * Partner Provider Network Fees *

Risk-sharing and Incentive Provider

Payments * Other Fees

Described Below * Adjusted

Repriced Amount *

CLAIMS NOT ABLE TO BE REPRICED

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Claims Omitted $0 $0 $0 $0 $0 $0 $0

OUT-OF-NETWORK

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Out-of-Network $0 $0 $0 $0 $0 $0 $0

IN-NETWORK

Inpatient $0 Repricing Check with Data File Outpatient $0 Data File Name: Eligible Amount/Charges Physician/Professional $0 Active POS Claims to Reprice.xlsx Data File Bidder's Work Subtotal In-Network $0 $0 $0 $0 $0 $0 $0 Inpatient $14,099,821 $0 FALSE

Outpatient $44,824,772 $0 FALSE Grand Total All Repriced Claims $0 $0 $0 $0 $0 $0 $0 Physician/Professional $43,109,212 $0 FALSE

FALSE Total $102,033,805 $0 FALSE Grand Total From HMO Data Files $102,033,805 These 2 columns should match

* DEFINITIONS

Claims should be repriced assuming you are the sole payor and should not assume any savings or average savings from COB or liability of other parties.

Repricing Column Description

Eligible Amount

Repriced Amount

% of Savings Fees

Partner Provider Network Fees Risk-sharing and Incentive Provider Payments

Other Fees (describe)

Confirm your repricing is based on eligible charges and your current (as of March 1, 2025) network provider contractual fee arrangements and is based on actual data and does not include any assumptions regarding projected discounts or assumed increases in billed charges.

ACTIVE POS CLAIM REPRICING FILES

"ELIGIBLE_CHARGES" as shown on the "Active POS Claims To Reprice" data files (3 separate files). Totals should match table on the right.

Eligible amount/charges based on application of your provider specific discounts.

Fees on a percent of savings basis that are charged to the State. These should not include amounts captured in "Partner Provider Network Fees" or "Risk-sharing and Incentive Provider Payments".

Fees paid to a partner provider network (e.g., "host plan") that are charged to the State.

Risk-sharing and incentive payments to providers the State would be liable for.

SONH RFP #3015-25 Repricing- Active POS Claims

Repricing of Anthem Medical Claims - Paid January 1, 2024 to December 31, 2024

The State requires a transparent billing process where all fees are clearly identified on monthly invoices.

Confirm you have included an explanation detailing how you re-priced the claims, noting any and all adjustments and methodologies.

Reprice Using the Product/Network you are proposing for the Non-Medicare Retiree Plan participants.

Proposed Network Name: <-- indicate if more than one network is proposed for the retirees

Product (POS, PPO, etc.):

Repricing of Claims Data *

Eligible Amount * Repriced Amount * % of Savings Fees * Partner Provider Network Fees *

Risk-sharing and Incentive Provider

Payments * Other Fees

Described Below * Adjusted

Repriced Amount *

CLAIMS NOT ABLE TO BE REPRICED

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Claims Omitted $0 $0 $0 $0 $0 $0 $0

OUT-OF-NETWORK

Inpatient $0 Outpatient $0 Physician/Professional $0 Subtotal Out-of-Network $0 $0 $0 $0 $0 $0 $0

IN-NETWORK

Inpatient $0 Repricing Check with Data File Outpatient $0 Data File Name: Eligible Amount/Charges Physician/Professional $0 Retiree POSPPO Claims to Reprice.xlsx Data File Bidder's Work Subtotal In-Network $0 $0 $0 $0 $0 $0 $0 Inpatient $9,996,784 $0 FALSE

Outpatient $29,016,083 $0 FALSE Grand Total All Repriced Claims $0 $0 $0 $0 $0 $0 $0 Physician/Professional $26,064,581 $0 FALSE

FALSE Total $65,077,448 $0 FALSE Grand Total From HMO Data Files $65,077,448 These 2 columns should match

* DEFINITIONS

Claims should be repriced assuming you are the sole payor and should not assume any savings or average savings from COB or liability of other parties.

Repricing Column Description

Eligible Amount

Repriced Amount

% of Savings Fees

Partner Provider Network Fees Risk-sharing and Incentive Provider Payments

Other Fees (describe)

Risk-sharing and incentive payments to providers the State would be liable for.

Confirm your repricing is based on eligible charges and your current (as of March 1, 2025) network provider contractual fee arrangements and is based on actual data and does not include any assumptions regarding projected discounts or assumed increases in billed charges.

RETIREE POSPPO CLAIM REPRICING FILES

"ELIGIBLE_CHARGES" as shown on the "Retiree POSPPO Claims To Reprice" data files (3 separate files). Totals should match table on the right.

Eligible amount/charges based on application of your provider specific discounts.

Fees on a percent of savings basis that are charged to the State. These should not include amounts captured in "Partner Provider Network Fees" or "Risk-sharing and Incentive Provider Payments".

Fees paid to a partner provider network (e.g., "host plan") that are charged to the State.

SONH RFP #3015-25 Repricing-Retiree POSPPO Claims