Attachment A – Price Rate Sheet IFB 6100066211.pdf

QUESTIONS

Any questions in reference to this IFB must be submitted individually and in writing via email by the date and time listed in the solicitation.

Please include “IFB 6100066211” in the subject line of your email. Only questions submitted via the L & I Central Resource Account will receive a response. Questions submitted to the issuing officer by email or telephone call will NOT receive a response. All questions and responses are considered an addendum to and part of this IFB. The Issuing Office shall not be bound by any verbal information, nor shall it be bound by any written information that is not either contained within the IFB or formally issued by the Issuing Office. The Issuing Office does not consider questions to be a protest of solicitation.

Select the Price Sheet Tab at the bottom of this page.

LI, Procurement <RA-li-OIT-BAS-Procur@pa.gov>

For each Territory, enter your company’s pricing only in the yellow highlighted cells under Hourly Price, and only for territories your company is able to service in their entirety. Bidders shall only bid on territories they can effectively service.

If your company is not bidding on a particular Territory, leave the applicable Hourly Price cell(s) blank.

List the rates for SWIF Medical Case Management Services at a fixed hourly price by Territory.

Estimated Quantities:

It shall be understood and agreed that any quantities listed in the Contract are estimated only and may be increased or decreased in accordance with the actual requirements of the Commonwealth and that the Commonwealth in accepting any bid or portion thereof, contracts only and agrees to purchase only the materials and services in such quantities as represent the actual requirements of the Commonwealth. The Commonwealth reserves the right to purchase materials and services covered under the Contract through a separate competitive procurement procedure, whenever Commonwealth deems it to be in its best interest.

NOTE: The hourly price shall include all costs necessary to provide the Medical Case Management Services, except for expenses separately reimbursable by SWIF in accordance with the Statement of Work.

PRICE SHEET TAB

Attachment A Cost Submittal Instructions

SWIF Medical Case Management Services

IFB 6100066211

The Cost Submittal Worksheets contained in this workbook shall constitute the Cost Submittal. Please read the instructions carefully.

SUPPLIER INFORMATION TAB

Select the Supplier Information Tab at the bottom of this page.

NOTE: The information you supply must match the information listed within your company's PA Supplier Portal account.

GENERAL INSTRUCTIONS FOR COMPLETING THIS WORKBOOK

Fill-in all yellow highlighted cells with your company's contact information.

Phone Number

Supplier Number

Bidder Address E-mail Address

Attachment A Cost Submittal Supplier Information

SWIF Medical Case Management Services

IFB 6100066211

Bidder Name Contact Person

Territory Yearly Cost Estimate

TERRITORY A:

Philadelphia District Office

$0.00

TERRITORY B:

Harrisburg, Pottsville, Sunbury, and Scranton District Offices

$0.00

TERRITORY C:

Pittsburgh, Johnstown, and Erie District Offices

$0.00

MSA Yearly Cost Estimate

Workers’ Compensation Medicare Set-Aside

$0.00

$0.00 $0.00

Attachment A Cost Submittal Price Sheet

SWIF Medical Case Management Services

IFB 6100066211

Description Estimated Annual

Usage Hourly Price

Bucks, Chester, Delaware, Montgomery, and Philadelphia Counties 8000.00 $0.00

Adams, Berks, Bradford, Carbon, Centre, Clinton, Columbia, Cumberland, Dauphin, Franklin, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Northumberland, Perry, Pike, Potter, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, and York Counties

4000.00 $0.00

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Somerset, Venango, Warren, Washington, and Westmoreland Counties

8000.00 $0.00

1 Year Total:

3 Year Total

Description Total Estimate of

Each Case Each Case Amount*

In order to comply with 42 U.S.C. § 1395y(b)(2) and § 1862(b)(2)(A)(ii) of the Social Security Act, Medicare may not pay for a beneficiary's medical expenses when payment “has been made or can reasonably be expected to be made under a workers’ compensation plan, an automobile or liability insurance policy or plan (including a self-insured plan), or under no-fault insurance.” Medicare must always be secondary if another payment source is primary. If settling both the indemnity and medical portions of a workers’ compensation claim where the claimant is a Medicare beneficiary, or may become a beneficiary, a Workers’ Compensation Medicare Set-Aside (WCMSA) may be done. A WCMSA provides an allocation or projected future lifetime projection for all future work-injury-related medical expenses reimbursable by Medicare, to ensure that Medicare’s interests are protected.

25.00 $0.00