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B-1 Instructions
| State of Maryland |
| Request for Flexible Spending Account (FSA) Administration Proposal |
| Attachment B-1: Financial Proposal Instructions |
Solicitation No. F10B6600006
| Instructions: |
| 1. | Complete all the attached financial exhibits for the FSA plan. |
| Attachment B-2: Financial Compliance Checklist |
| Attachment B-3: Explanations and Deviations |
| Attachment B-4: FSA Administrative Fees |
| Attachment B-5: Optional Services |
| 2. | Attachment B-2: Financial Compliance Checklist |
| Financial Compliance Checklist: Please indicate your willingness to comply with each requirement by |
| placing a "Yes" or "No" 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 the Attachment B-3 tab, Explanations |
| and Deviations. All "no" 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. | For the Attachment B-3: Explanations & Deviations |
| Use this worksheet to provide additional explanation and deviations that you wish to offer for any questions in B-2 Financial Compliance Checklist for which a "No" response, or a "Yes" response with a qualifier, was given. |
Explanations must be numbered to correspond to the B-2 Financial Compliance Checklist item to which it pertains. If additional space is needed, make a copy of this tab. Please keep all explanations brief.
| 4. | Attachment B-4: Administration Fees |
| All fees are to be quoted on a firm, fixed, maximum basis for Active Employees and must also apply |
| to Satellite Account Employees. |
| For purposes of Attachment B-4, "per employee per month (PEPM)" means a price for each Participant |
| on a monthly basis which is a fully loaded fixed administrative fee, for the performance all services related |
| to the administration of the FSA plans, including all account management services, participant communications |
| services, debit card administration, reimbursement request processing, and all other administrative and other |
| services related to the HCFSA and DCFSA plans. Pricing is requested in the following iterations: |
| Section 1: HCFSA Participants Only |
| Section 2: DCFSA Participants Only |
| Section 3: HCFSA and DCFSA Participants |
| Provide pricing for all three sections in Attachment B-4 (pricing can be the same for all three sections). |
| The Offeror shall provide fees for the two year contract period (labeled contract year 1 and 2), as well as |
| the optional renewal periods (labeled option year 1-3). All offerors will be evaluated on the total cost of the |
| contract which includes both the contract period and the optional renewal period. |
| The Financial price sheet are used for evaluation purposes only. There is no guarantee of enrollment |
| for the FSA plans and all fees must be guaranteed regardless of enrollment. |
| 5. | Attachment B-5: Optional Services |
| Attachment B-5 is intended to capture optional services that may or may not be required by the State. |
| Annual cost is based on an assumption for enrollment. The assumption is not represented as the actual |
| or expected number for the service. Vendor must guarantee the maximum fees quoted regardless |
| of actual enrollment. The fees in this attachment will only apply if selected by the State. |
| Ranking is based on the total cumulative cost for the two contract years and three option years. |
B-2 Financial Compliance Cklst
| Request for Flexible Spending Account (FSA) Administration Proposal |
| Attachment B-2: Financial Compliance Checklist |
Solicitation No. F10B6600006
| Representations made by the Offeror in this proposal become contractual obligations that must be met for the duration of the contract term. |
| Offeror: |
| Date of Submission: |
| Financial Compliance Checklist | | Offeror's Response | Offeror Response |
| | Yes or No | |
| B-1 | Offeror's quoted administration rates are guaranteed maximum rates, regardless of actual enrollment, for the term of the contract. | Select one | Select One |
| B-2 | Offeror's quoted fees exclude commissions / compensation to outside consultants or brokers. | | Select One |
| B-3 | Offeror agrees that all PEPM rates must be quoted on a fully-loaded basis; i.e. fees must include all direct and indirect costs, run-out processing, communications, general and administrative overhead, purchasing burden, profit, and state regulatory assessments. No other fees or charges for the administration of the HCFSA and DCFSA plans 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. | | Select One |
| B-4 | Offeror agrees to provide flat rates over the course of the initial contract period and optional contract extension years. | | Select One |
| B-5 | Offeror agrees to the run-out processing / retainage provision related to the final plan year described in RFP section 3.3.3. | | Select One |
B-3 Explanations & Deviations
| Request for Flexible Spending Account (FSA) Administration Proposal |
| Attachment B-3: Explanations and Deviations |
| Solicitation No. F10B6600006 | | |
| Representations made by the Offeror in this proposal become contractual obligations that must be met for the duration of the contract term. | | |
| Offeror: | | 0 |
| Date of Submission: | | 12/31/99 |
| Instructions: Use this worksheet to provide additional explanation or deviation for items included in B-2 Financial Compliance Checklist. Offeror responses should be provided 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 B-2 Financial Compliance Checklist item to which it pertains. If additional space is needed, make a copy of this tab. Please keep all explanations brief. | | |
| Section/ Question # | Indicate "Explanation" or "Deviation" | Offeror Response |
| Select One | |
| Select One | |
| Select One | |
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B-4 Administrative Fees
| Request for Flexible Spending Account (FSA) Administration Proposal |
| Attachment B-4: FSA Administrative Fees |
Solicitation No. F10B6600006
| Representations made by the Offeror in this proposal become contractual obligations that must be met for the duration of the contract term. | |
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| Provide rates for each participant listed below. | |
| Per Employee Per Month (PEPM) | | Enrollment | Contract Year 1 | Contract Year 2 | Option Year 1 | Option Year 2 | Option Year 3 |
| Section 1: HCFSA Participants Only | | | | | | | |
| 1 | Administrative Fees | 20,200 | | | | | |
| 2 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Section 2: DCFSA Participants Only | | | | | | | |
| 3 | Administrative Fees | 2,545 | | | | | |
| 4 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Section 3: HCFSA and DCFSA Participants | | | | | | | |
| 5 | Administrative Fees | 1,506 | | | | | |
| 6 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 7 | Total Price | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 8 | Cumulative Price: Years 1-5 | | | | | | $ - 0 |
| Notes: | | | | | | | | |
| | Enrollment referenced above represents a uniform offeror assumption for purposes of projecting total annual premium. The uniform assumption reflects illlustrative enrollment. Offeror must guarantee the rates quoted above regardless of actual enrollment. | | | | | | |
| Submitted by: | | | | | | | | |
| Offeror: | | | | | | | | |
| Offeror Name (please print or type) | | | | | | | | |
| By: | | | | | | | | |
| Signature of Authorized Representative | | | | | | | | |
| Printed Name: | | | | | | | | |
| Title: | | | | | | | | |
| Date: | | | | | | | | |
| Company Address: | | | | | | | | |
B-5 Optional Services
| Request for Flexible Spending Account (FSA) Administration Proposal | |
| Attachment B-5: Optional Services | |
| Solicitation No. F10B6600006 | |
| Representations made by the Offeror in this proposal become contractual obligations that must be met for the duration of the contract term. | |
| Offeror: | 0 |
| Date of Submission: | 12/31/99 |
| For proposal analysis purposes, provide projected annual expenses for administering a Commuter Benefit Account for enrolled members. These rates will only be applicable if the State elects this option. PEPM fees below should only show commuter benefit account fee component and should not include fee component associated with HCFSA or DCFSA. | |
| Per Employee Per Month (PEPM) | | Enrollment | Contract Year 1 | Contract Year 2 | Option Year 1 | Option Year 2 | Option Year 3 |
| Optional Service: Commuter Benefit Account for Participant with one account (no FSA accounts) | | | | | | | |
| 1 | Commuter Account Administrative Fees | 15,000 | | | | | |
| 2 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Optional Service: Commuter Benefit Account for Participant with two accounts (Commuter + HCFSA) | | | | | | | |
| 3 | Commuter Account Administrative Fees | 6,100 | | | | | |
| 4 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Optional Service: Commuter Benefit Account for Participant with two accounts (Commuter + DCFSA) | | | | | | | |
| 5 | Commuter Account Administrative Fees | 800 | | | | | |
| 6 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| Optional Service: Commuter Benefit Account for Particpant with three accounts (HCFSA and DCFSA) | | | | | | | |
| 7 | Commuter Account Administrative Fees | 500 | | | | | |
| 8 | Total Annual Premium | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 9 | Total Price | | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
| 10 | Cumulative Price: Years 1-5 | | | | | | $ - 0 |
| Notes: | | | | | | | | |
| | Enrollment referenced above represents a uniform offeror assumption for purposes of projecting total annual premium. The uniform assumption reflects illlustrative enrollment. Offeror must guarantee the rates quoted above regardless of actual enrollment. Since this is not an existing benefit, there is no historical enrollment data to be used to project enrollment in the program. | | | | | | |