Attachment B - Price Proposal.xlsx
XLSX spreadsheet 726 KB Posted
- Attached to
- RFP 26-025-CJ GCPS- Employee Medical, Stop Loss, Dental, Vision, Disability & Voluntary Benefits Coverage
- Solicitation number
- RFP-115259
- Issued by
- Frederick County, Virginia
About this file
This is a Price Proposal Exhibit file for a comprehensive health benefits contract opportunity with Gloucester County Public Schools (GCPS), requiring ABC Company to submit detailed pricing and benefit design information across multiple lines of coverage. The RFP solicits proposals for medical plans (self-funded), dental plans (self-funded and fully insured), vision plans (fully insured), and ancillary coverage including accident, critical illness, hospital, short-term disability, and long-term disability plans. Offerors must complete all applicable tabs within the pricing exhibit workbook, documenting enrollment assumptions, fee structures, benefit summaries, and responses to detailed capability questions covering networks, member services, utilization management, health management programs, and data management capabilities. The proposal requires specification of plan designs matching current offerings as closely as possible, with particular attention to medical deductibles, out-of-pocket maximums, prescription drug tiers, dental annual maximums and service categories, vision copays and frequencies, and disability benefit percentages and elimination periods.
Pricing submissions must include all fees transparently labeled, with specific commissions embedded in rates for certain ancillary products (VSTD 20%, VLTD 15%, Accident 20%, Hospital 15%, Critical Illness 20%). Offerors must provide three-tier rates (Employee, Employee+1, Family) for most plans and age-banded rates for voluntary products, along with trend factors for the previous three years broken out by medical and prescription drug components. The proposal requires detailed responses regarding stop loss reinsurance terms, including specific and aggregate limits, rate caps, guaranteed renewability, premium refunds, gene therapy coverage, and run-out liability protection. Offerors must address network adequacy based on geographic matching using employee census zip codes, disclose any upcoming provider contract renegotiations, and specify service guarantees and performance metrics. Additionally, offerors are asked to identify bundling discounts, technology credits, and financial improvements applicable to awarded lines of coverage, and must clarify all administrative fees, capitation arrangements, and other revenue sources included in or excluded from proposed rates.
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Cover Page Pricing Exhibit Data Form
| Name of Offeror: | ABC Company | |
| Lines of Coverage Proposing: | For example, Medical, Dental, Vision | |
| DIRECTIONS | ||
| 1. Please complete all tabs associated with benefits for which you would like to make an offer. |
| TAB CONTENTS: | ||
| Medical Plan - Self Funded | ||
| 1 | Medical & Stop Loss Fees | |
| 2 | Medical Benefit Summary | |
| 3 | Medical Capability Questions | |
| 4 | Stop Loss Capability Questions |
| Dental Plan - Self Funded & Fully Insured | ||
| 5 | Dental Plan & Rates | |
| 6 | Dental - Capability Questions |
| Vision Plan - Fully Insured | ||
| 7 | Vision Plan & Rates | |
| 8 | Vision Capability Questions |
| Worksite | 9 | Accident Plan and Rates |
| 10 | Critical Illness Plan and Rates | |
| 11 | Hospital Plan and Rates |
| Disability | 12 | Short Term Disabilty (ATP - Employer Paid & Voluntary Option) |
| 13 | Long Term Disabilty (Voluntary) | |
| 2. Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer. |
3. Do not change the size of cells on any of the tabs. Please ensure that when this page is printed the text appears as at least a size 11 point font.
4. Don't Forget to include the following commissions in rates as noted below.
| Line of coverage | |
| VSTD | 20% |
| VLTD | 15% |
| Accident | 20% |
| Hospital | 15% |
| Critical Illness | 20% |
1 Med& SL Fees
| Pricing Exhibit Data Form | ABC Company |
| Plans Quoted This Exhibit: |
| Medical & Stop Loss Fees | |
| ENROLLMENT ASSUMPTIONS | Directions: Please document your enrollment assuptions to the left and complete the fee grid below. |
| POS | Please be sure to disclose ALL fees; any fees without a label you can put in OTHER Fees section |
| HSA Plan |
| POS | HSA Plan | |||
| Medical and Prescription Drug | Medical and Prescription Drug | |||
| REINSURANCE FEES | First Year | |||
| PEPM | Mature Year | |||
| PEPM | First Year | |||
| PEPM | Mature Year |
PEPM
| Specific Stop Loss | ||||
| Coverage includes | Med/Rx | Med/Rx | Med/Rx | Med/Rx |
| Reinsurance Basis (24/12, 12/12, Paid) | ||||
| $200,000 Specific Stop Loss Fee | ||||
| $325,000 Specific Stop Loss Fee | ||||
| $350,000 Specific Stop Loss Fee | ||||
| Terminal Liability (Yes/No). Length of TLO? | ||||
| Terminal Liability Fee (if applicable) | ||||
| No Lasers for length of contract | ||||
| Guaranteed Renewable | ||||
| Gene Therapy Coverage | ||||
| 40% Rate Cap | ||||
| Premium Refund | ||||
| State Premium Tax Included | ||||
| 120-day Rate Lock | ||||
| Annual Maximum |
| Aggregate Stop Loss | 125% | 125% | 125% | 125% |
| Reinsurance Basis (24/12, 12/12, Paid) | ||||
| Max Reimbursement | ||||
| Coverage includes | Med/Rx | Med/Rx | Med/Rx | Med/Rx |
| Annual Maximum |
| RETENTION FEES | First Year | ||
| PEPM | Mature Year | ||
| PEPM | First Year | ||
| PEPM | Mature Year |
PEPM
| Medical Administrative Fee PEPM | |||
| Prescription Drug Administrative Fee | |||
| Network Access Fee | |||
| Wellness/Disease Management Fees | |||
| Vision Fee | |||
| HSA Administrative Fee | |||
| Total Retention PEPM | |||
| Annual Maximum | |||
| OTHER FEES or Claims Related Fees, Capitated claims (include ALL other fees) | First Year | ||
| PEPM | Mature Year | ||
| PEPM | First Year | ||
| PEPM | Mature Year |
PEPM
| Stop Loss Carve Out Fee? | |||
| Other Potential Costs? | |||
| Other Fees? | |||
| Capitation Fees | |||
| Other Sources of Revenue | |||
| ADMIN FEE CREDITS | First Year | ||
| PEPM | Mature Year | ||
| PEPM | First Year | ||
| PEPM | Mature Year |
PEPM
Pharmacy Rebate Admin Credit
| Net Total Fees PEPM |
| Annual Maximum |
| Grand Total |
&"Times New Roman,Bold Italic"&11EXHIBIT: &A
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2 Ben Sum
| Pricing Exhibit Data Form | ABC Company | |
| Medical Benefit Summary | ||
| Please complete the grid below with plan design you are offering (matching current as close as possible) | ||
| Please provide link to or attach copy of Pharmacy Formulary with your proposal (in addition to filling out the grid below). | ||
| Benefits | Traditional Plan | HSA Plan |
| Plan Name | ||
| Plan Type (HMO, POS, etc) | ||
| Plan Network Name | ||
| Referrals Required for Specialist? | ||
| In-Network Deductible (Ind/Fam) | ||
| Out-of-Network Deductible (Ind/Fam) | ||
| Ded. Embedded/Non-embedded | ||
| In-Network Max OOP (Ind/Fam) | ||
| Out-of-Network Max OOP (Ind/Fam) | ||
| Coinsurance (In/Out) | ||
| PCP/Specialist Office Visit | ||
| Preferred Provider (if different) | ||
| Virtual/Telemedicine Visit | ||
| Walk-In/Urgent Care Visit | ||
| Emergency Room | ||
| Outpatient Lab/X-Ray | ||
| Preferred Lab (if different) | ||
| Complex Imaging (MRI, CAT, etc.) | ||
| Outpatient Surgical Facility | ||
| Inpatient Hospital Facility | ||
| Prescription Deductible (Ind/Fam) | ||
| Prescription Max OOP (Ind/Fam) | ||
| Retail Prescription Copays | ||
| Tier 1 | ||
| Tier 2 | ||
| Tier 3 | ||
| Tier 4 | ||
| Mail Order Prescription Copays | ||
| Tier 1 | ||
| Tier 2 | ||
| Tier 3 | ||
| Tier 4 |
3 Med Q&A
| Pricing Exhibit Data Form | ABC Company |
| Medical Capability Questions | Type answers below - Do not change size of fields. |
| NETWORKS AND DISCOUNTS | ||
| 1 | Reporting Request: Geo match based on all networks you are proposing to replace the existing network using each employee’s zip code data provided in the census. Definition: 2 PCPs within 10 miles, 2 specialists within 15 miles and 1 hospital within 20 miles. Summarize the results here, pointing out strengths, explaining any gaps. | |
| 2 | What is your current average negotiated savings percentage for the following types of claims for the providers listed in the claims repricing file provided with this RFP. You may note anything unique about your network in the filed to the right. | |
| a. Inpatient Facilities | ||
| b. Outpatient Facilities | ||
| c. Professional Services | ||
| 3 | How are employees or dependents (i.e., child attending school, COBRA enrollees) who reside outside the network service area covered? How do you define “within the service area”? | |
| 4 | For each network/product proposing, please list your laboratory providers for lab services not provided in a physician’s office (APS service area only). Identify if you are offering “Preferred Labs” in this price quotation/proposal and indicate what the cost differential. | |
| 5 | Are any large physician groups or hospital contracts up for re-negotiation in your network within the next two years? If yes, please provide as much detail as possible. | |
| 6 | Confirm you will negotiate with and attempt to add specific providers to the network at the request of Gloucester. | |
| 7 | What network discount related performance guarantees are you willing to offer? | |
| MEMBER & HR SERVICES | ||
| 1 | Where are your service centers located? Do you outsource any services outside the U.S.? What processes are in place to ensure these functions continue in the event of disaster in one location? | |
| 2 | Describe your ongoing enrollment procedures and annual open enrollment assistance. Detail the services you would be willing to provide, such as on-site assistance with employees, etc. | |
| 3 | Summarize your biling a payment process? How are bills provided and what are options for paying? How long will you allow retroactive changes to be made to bills? | |
| 4 | Describe how your company will interface on an ongoing basis with the Benefits Staff on administrative issues (including billing, payment arrangements, etc.) and describe your process for resolving administrative problems. If on-line enrollment and eligibility capabilities are available, please explain. | |
| 5 | Do you offer "concierge" type service to members (as a standard service or buy-up). What's included and the cost, if any. | |
| 6 | How do you help members find the best care, meaning high quality providers with the lowest costs and best outcomes? | |
| 7 | What benefits education do you provide for members? How do you help members maximize their benefits? | |
| 8 | Provide a listing or concise explanation of your on-line and telephonic services available to members. Describe the digital experience for both the HR Team and Members? Do you have multiple portals and apps or are they all under one umbrella, one sign on. | |
| 9 | What service related performance guarantees are you willing to offer? | |
| UTILIZATION MANAGEMENT & COST CONTAINMENT PROGRAMS | ||
| 1 | Please describe your utilization management (UM) and prior authorization (PA) programs and protocols at a high level. | |
| 2 | Which programs are automatically carried out as part of base fees/rates? | |
| 3 | Which programs are available as a buy-up? | |
| 4 | What kind of reporting is available regarding impact of these protocols/programs? | |
| HEALTH MANAGEMENT SERVICES | ||
| 1 | Please provide an overview of your wellness, condition management, and any population health management programs. Please note which programs are accredited with URAC (American Accreditation HealthCare/Commission). | |
| a. Provide a bulleted list of services and a short description that you offer at no cost. | ||
| b. Provide a bulleted list of services and a short description for an additional cost; then explain the cost structure and how the additional cost is worth it. | ||
| 3 | Can you conduct on-site wellness seminars, clinical screenings, vaccination clinics, or health risk assessments? Is there an additional cost? | |
| 4 | What programs, services, medical management protocols do you have available that treat obesity? Do you have any unique programs that assist with cost containment if a client covers GLP-1 weight loss drugs? | |
| 5 | Can you administer a program whereby members can complete certain healthy activities or have certain recommended preventive screenings and earn gift cards? What are the funding options for these programs? | |
| 6 | Can you provide member level and identifiable reporting on preventive care and screenings to Gloucester based on claims data if if they wanted to administer their own incentive program? | |
| 7 | How much are you willing to give Gloucester in “wellness dollars” to pay for wellness programs and activities for employees? What restictions are there on how the “wellness dollars” can be spent. Would you be willing to allow roll over of unspent dollars from year to year? | |
| DATA MANAGEMENT | ||
| 1 | Do you offer on-line access to your database which would allow employers/consultant to access certain management and claims reports? | |
| a. If so, is there a cost and what kinds of reports are available? | ||
| b. How frequently is data updated? | ||
| c. Can we produce/request ad-hoc reports? Is there a cost for either? | ||
| 2 | Please provide some examples of how your organization exchanges and/or provides data in order to support population health management strategies. | |
| 3 | If you are not already partnered with USI to share client claim data for analysis by USI’s proprietary 3-D system (Verisk), are you willing to discuss setting this up? | |
| 4 | Do you currently have clients using Employee Navigator for benefit administration? If so, how many, and what types of data connections are available? Are you integrated with EN? | |
| FINANCIAL | ||
| What have your trend factors been for the last 3 years? | Please provide trend % for each product you propose, break out Rx and Medical | |
| 2025 | For example: HMO (8% medical, 12% Rx), PPO (12% medical, 15% Rx) | |
| 2024 | For example: HMO (8% medical, 12% Rx), PPO (12% medical, 15% Rx) | |
| 2023 | For example: HMO (8% medical, 12% Rx), PPO (12% medical, 15% Rx) | |
| What locations are these trend numbers based on? National? Regional? | ||
| Completely explain all services and/or fees that are included in the claims reporting such as capitated services, access fees, etc. | ||
| How far back will you refund premiums for a late notification? | ||
| Are you willing to guarantee a maximum percent increase in premium rates for the second, third, fourth, or fifth year? | ||
| Identify clearly any improvements to your bid response (pricing, guarantees, etc.) should a certain number of medical plans (and/or ancillary coverages) be awarded to you. |
4 Stop Loss Q&A
| Pricing Exhibit Data Form | ABC Company |
| Stop Loss Capability Questions | Type answers below - Do not change size of fields. |
| Assuming you are awarded the contract, will you require any additional claims experience beyond what is provided in this RFP in order to provide final rates and bind the coverage? Please explain. | |
| What rate cap will you offer for all subsequent years? | |
| Confirm no new lasers for length of the contract | |
| Confirm guaranteed renewable for the length of the contract | |
| Do you offer a premium refund? Client desires a 25% premium refund option. If there is a cost for this option, then please provide the cost. | |
| Are state premium taxes included in your proposed fees? | |
| Do you cover Gene Therapy? Is there a cost? Please explain. | |
| Outline your renewal methodology for SSL charge calculations. | |
| Confirm your reinsurance proposal waives “actively at work” and “dependent non-confinement”. | |
| Will you guarantee that future renewals will be released at least 120-days in advance of the renewal date? Will renewal quotes released in advance be contingent upon any additional claims and/or enrollment information? Please explain. | |
| Are you willing to offer an unlimited maximum on the specific limits? | |
| Are SSL Rates and Terms firm? If not, when will firm rates be provided? | |
| Are you willing to provide “Run-Out” specific reinsurance liability protection in the event the contract is terminated? If so, does the client have to purchase it at initial effective date of contract or upon renewal, or do they have the option of purchasing at time of termination? | |
| Within what period of time will any reimbursement be made under the contract? Is SSL reimbursement immediate? If not, explain. | |
| What kind of notification by the medical administrator and pharmacy vendor, or the client is required for a claim to be paid? Please explain the process. | |
| Do you have a client portal available where clients have the ability to go on-line to certify eligibility of claimants (this only applies to carved-out reinsurance carriers), or another way outside of completing a claim form that you can offer? | |
| Provide a complete listing of the exclusions and limitations included in your stop loss contracts. | |
| Please document here all underwriting assumptions and caveats. | |
| Outline any fees/expenses NOT included in your specific reinsurance. |
5 Den Rates
| Pricing Exhibit Data Form | ABC Company |
| Dental Plan & Rates |
Directions: Please complete the grid below with plan designs you are offering (matching current as close as possible)
| Low Plan | High Plan | ||
| Benefit Coverage Outline | Member Cost Share | ||
| For In Network | Member Cost Share | ||
| For Out of Network | Member Cost Share | ||
| For In Network | Member Cost Share |
For Out of Network
| Carrier |
| Plan Type |
| Deductible (Individual / Family) |
| Roll over benefits? |
| Waived For Preventive? |
| Annual Maximum |
| Preventive Services |
| How many cleanings per year? |
| Basic Services |
| Major Services |
| Waiting periods? |
| Endodontics / Periodontics |
| Implants |
| Orthodontia |
| Eligibility (max age for children, adults, etc.) |
| Lifetime Maximum |
| Out of Network Reimbursement Level (MAC, 90% U&C, etc.) |
| Participation Requirements? |
| Rate Guarantee (Years) |
| Please list the services that fall into each of these following categories. Star (*) anything unique compared to other carriers. |
| Preventive Services |
| Basic Services |
| Major Services |
| Endodontics / Periodontics |
| Proposed 3 Tier Rates for Fully insured Dental | Low Plan | High Plan |
| Employee | ||
| Employee + 1 | ||
| Family |
If you are also proposing a Self Funded Option, please outline fees below:
| Notes | ||
| Base Administrative Fee (PEPM) | $ - 0 | put any notes here |
| Network Access Fee | $ - 0 | put any notes here |
| Other Fees (please explain) | $ - 0 | put any notes here |
| Other Fees (please explain) | $ - 0 | put any notes here |
| Other Fees (please explain) | $ - 0 | put any notes here |
Please describe any special programs, services, benefits that you feel set you apart from other carriers.
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
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6 Den Q&A
| Pricing Exhibit Data Form | ABC Company |
| Dental - Capability Questions | Type answers below - Do not change size of fields. |
| Network | |
| 1 | Do you own your dental network, or do you rent one or more networks from other major carriers? If you rent, please name who you use. |
| 2 | If you send enrollment to another carrier how much of a delay is there between when you get data from client and it is loaded with them? |
| 3 | Do you offer telehealth virtual dental visits? Please briefly explain this service if you do. |
| 5 | Reporting Request: Geo match based on all networks you are proposing using each employee’s zip code data provided in the census. Definition: 2 dental providers within 10 miles. Summarize the results here, pointing out strengths, explaining any gaps. |
| MEMBER & HR SERVICES | |
| 1 | Where are your service centers located? Do you outsource any services outside the U.S.? What processes are in place to ensure these functions continue in the event of disaster in one location? |
| 2 | Describe your ongoing enrollment procedures and annual open enrollment assistance. Detail the services you would be willing to provide, such as on-site assistance with employees, etc. |
| 3 | Summarize your biling a payment process? How are bills provided and what are options for paying? How long will you allow retroactive changes to be made to bills? |
| 4 | Describe how your company will interface on an ongoing basis with the Benefits Staff on administrative issues (including billing, payment arrangements, etc.) and describe your process for resolving administrative problems. If on-line enrollment and eligibility capabilities are available, please explain. |
| 5 | Do you provide dental ID cards? Will you mail hard cards or are they all digital? |
| 6 | How do you help members find the best care, meaning high quality providers with the lowest costs and best outcomes? |
| 7 | What benefits education do you provide for members? How do you help members maximize their benefits? |
| 8 | Provide a listing or concise explanation of your on-line and telephonic services available to members. Describe the digital experience for both the HR Team and Members? |
If you send enrollment to another carrier will the employee also be using their website to find a provider, see benefits, get customer service?
9 What service related performance guarantees are you willing to offer?
7 Vis Rates
| Pricing Exhibit Data Form | ABC Company |
| Vision Plan & Rates |
Directions: Please complete the grid below with plan design you are offering (matching current as close as possible)
| Benefit Outline | Member Cost Share | |
| For In Network | Out of Network Benefits | Limitations, Maximums, Etc. |
| Network Name | ||
| Exam Copay | ||
| Materials Copay | ||
| Exam | ||
| Lenses | ||
| Single | ||
| Bifocal | ||
| Trifocal | ||
| Lenticular | ||
| Frames | ||
| Elective Contacts | ||
| Lasik Surgery Discount | ||
| Benefit Frequencies (E / L / F / C) | ||
| Room to list other benefits you offer | ||
| Room to list other benefits you offer | ||
| Room to list other benefits you offer | ||
| Participation Requirements? | ||
| Rate Guarantee (Years) |
| Proposed 3 Tier Rates | |
| Employee | |
| Employee + 1 | |
| Family |
Please describe any special programs, services, benefits that you feel set you apart from other carriers.
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
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8 Vis Q&A
| Pricing Exhibit Data Form | ABC Company |
| Vision Capability Questions | Type answers below - Do not change size of fields. |
| Network | |
| 1 | Do you own your vision network, or do you rent one or more networks from other major carriers (e.g. VSP or EyeMed)? If you rent, please name who you use. |
| 2 | If you send enrollment to another carrier (e.g. VSP or EyeMed) how much of a delay is there between when you get data from client and it is loaded with them? |
| 3 | What online vision materials providers are available/covered by the plan as in-network? |
| 4 | List the notable "big box" stores in the network. How many of these stores are within 15 miles from Gloucester County Center? |
| 5 | Reporting Request: Geo match based on all networks you are proposing using each employee’s zip code data provided in the census. Definition: 2 vision providers within 10 miles. Summarize the results here, pointing out strengths, explaining any gaps. |
| MEMBER & HR SERVICES | |
| 1 | Where are your service centers located? Do you outsource any services outside the U.S.? What processes are in place to ensure these functions continue in the event of disaster in one location? |
| 2 | Describe your ongoing enrollment procedures and annual open enrollment assistance. Detail the services you would be willing to provide, such as on-site assistance with employees, etc. |
| 3 | Summarize your biling a payment process? How are bills provided and what are options for paying? How long will you allow retroactive changes to be made to bills? |
| 4 | Describe how your company will interface on an ongoing basis with the Benefits Staff on administrative issues (including billing, payment arrangements, etc.) and describe your process for resolving administrative problems. If on-line enrollment and eligibility capabilities are available, please explain. |
| 5 | Do you provide Vision ID cards? Will you mail hard cards or are they all digital? |
| 6 | How do you help members find the best care, meaning high quality providers with the lowest costs and best outcomes? |
| 7 | What benefits education do you provide for members? How do you help members maximize their benefits? |
| 8 | Provide a listing or concise explanation of your on-line and telephonic services available to members. Describe the digital experience for both the HR Team and Members? |
If you send enrollment to another carrier (e.g. VSP or EyeMed), will the employee also be using their website to find a provider, see benefits, get customer service?
9 What service related performance guarantees are you willing to offer?
9 Acc
| Pricing Exhibit Data Form | ABC Company |
| Accident Plan and Rates |
| Directions: Please complete the grid below with plan design you are offering (matching current as close as possible) | ||||
| Accident | Proposed Low Plan | Proposed High Plan | Current Low Plan | Current High Plan |
| 24-Hour Coverage | 24 Hour coverage | 24 Hour coverage | ||
| Accidental Death Benefit | Employee: $25,000 Spouse: $12,500 Child: $6,250 | Employee: $100,000 Spouse: $50,000 Child: $25,000 | ||
| Common Carrier Benefit | Employee: $25,000 Spouse: $12,500 Child: $6,250 | Employee: $100,000 Spouse: $50,000 Child: $25,000 | ||
| Dismemberment | Up to 50% of AD Benefits | Up to 50% of AD Benefits | ||
| hand, foot, sight | Single Loss: 15% of AD Benefit Double Loss: 30% of AD Benefit | Single Loss: 15% of AD Benefit Double Loss: 30% of AD Benefit | ||
| Thumb/Index Finger Same, Hand, Four Fingers Same, Hand, All Toes Same Foot | Up to 5% of AD Benefit | Up to 5% of AD Benefit | ||
| Paralysis | Quadriplegia: 50% of AD Benefits Paraplegla: 30% of AD Benefits | Quadriplegia: 50% of AD Benefits Paraplegla: 30% of AD Benefits | ||
| Seatbelts and Airbags | 10% of AD benefit | 10% of AD benefit | ||
| Emergency Accident Treatment | $100 | $200 | ||
| Emergency Accident Follow Up Treatment | $50 | $70 | ||
| Dislocation and Fractures | Dislocations: Up tp $3,000 Fractures: Up to $5,500 Chip frature: 25% | Dislocations: Up tp $7,000 Fractures: Up to $10,500 Chip frature: 25% | ||
| Lacerations | Up to 2" long: $50 2"-6" Long: $100 More than 6" long: $400 | Up to 2" long: $100 2"-6" Long: $400 More than 6" long: $800 | ||
| Appliance | $50 | $200 | ||
| Torn Knee Cartilage or Ruptured Disc Surgery Benefit | Torn Knee Cartilage: $400 Ruptured Disc: $400 | Torn Knee Cartilage: $1,000 Ruptured Disc: $1,000 | ||
| Eye Surgery Benefit | $150 | $300 | ||
| Coma Benefit | $5,000 | $15,000 | ||
| Concussion Benefit | $100 | $200 | ||
| Skin Graft (% of burns) | 25% of burn benefit | 50% of burn benefit | ||
| 2nd & 3rd Degree Burns | Second Degree: Less than 15% of body surface covered: $100 More than 15% of body surface covered: $500 Third Degree: Less than 15% of body surface covered: $1,500 More than 15% of body surface covered: $7,500 | Second Degree: Less than 15% of body surface covered: $500 More than 15% of body surface covered: $1,500 Third Degree: Less than 15% of body surface covered: $7,500 More than 15% of body surface covered: $12,500 | ||
| Open Abdominal or Thoracic Surgery | $1,000 | $2,000 | ||
| Tendon & Ligament | Up to $600 | Up to $1,500 | ||
| Blood, Plasma & Platelets | $150 | $600 | ||
| Exploratory Surgery without Surgical Repair | $150 | $250 | ||
| Physical Therapy | $50/up to 2 days | $50/ up to 4 days | ||
| Prosthesis | Up to $500 | Up to $2,000 | ||
| Emergency Dental Work | Repaired with crown: $150 Resulting in extractions: $50 | Repaired with crown: $350 Resulting in extractions: $150 | ||
| Non-Emergency Accident Treatment | $50 | $60 | ||
| Non-Emergency Follow Up Treatment | $50 | $60 | ||
| MRI/CT/CAT/PET/US | $100 | $300 | ||
| X-rays | $25 | $60 | ||
| Ambulance | Air Ambulance: $600 Ambulance: $200 | Air Ambulance: $1,500 Ambulance: $600 | ||
| Outpatient Hospital or Ambulatory Surgical Center | $50 | $500 | ||
| Hospital Admission / Daily Benefits | Admission: $500 Confinement: $100 per day | Admission: $1,500 Confinement: $400 per day | ||
| ICU Admission/ Daily Benefits | Admission: $500 Hospital Intensive Care: $200 per day | Admission: $1,000 Hospital Intensive Care: $200 per day | ||
| Anesthesia | Not included | Not included | ||
| Transportation | $100/day | $200/day | ||
| Lodging | $150/day | $200/day | ||
| Youth Sports Benefit | 25% additional of total benefits | 25% additional of total benefits | ||
| Line of Duty Benefit | 2x AD&D benefits ofr any loss associated with an on-the-job loss for public safety workers | 2x AD&D benefits ofr any loss associated with an on-the-job loss for public safety workers | ||
| Annual Routine Physical Exam | $50 | $60 | ||
| Portability Benefit | Included | Included | ||
| Monthly Rates | Low Plan | High Plan | ||
| Employee | ||||
| Employee + Child(ren) | ||||
| Employee + Spouse | ||||
| Family | ||||
| Participation Requirement | ||||
| Rate Guarantee | ||||
| Commission Rate | 20% | 20% | ||
| Please describe any special programs, services, benefits that you feel set you apart from other carriers (auto adjudication, integration with medical, disability). |
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
10 CI
| Pricing Exhibit Data Form | ABC Company |
| Critical Illness Plan and Rates |
| Directions: Please complete the grid below with plan design and rates you are offering (matching current as close as possible) | ||
| Proposed Plan | Current Plan | |
| Employee Benefit Amount | Employee: $10,000, $20,000 or $30,000 | |
| Spouse and Child(ren) Amount of Employee Benefit | Spouse: 100% of Employee Amount Child(ren): 50% of Employee Amount | |
| Guaranteed Issue | All Guaranteed Issue | |
| Covered Conditions: | ||
| Cancer (Internal or Invasive) | 100% | |
| Carcinoma In Situ | 25% | |
| Skin Cancer | Not Included | |
| Heart Attack (Myocardial Infarction) | 100% | |
| Stroke (Apoplexy or Cerebral Vascular Accident) | 100% | |
| Major Organ Transplant | 100% | |
| Paralysis | 100% | |
| Coma | 100% | |
| Severe Burn | Not Included | |
| Blindness | 100% | |
| End Stage Renal Failure | 100% | |
| Coronary Artery Bypass Surgery | 25% | |
| First Occurrence Benefit | Up to 100% of benefit depending on diagnosis | |
| Re-Occurrence Benefit | Once benefits have been paid for a covered critical illness, benefits are payable for that same illness when the date of the diagnosis is seperated by at least 6 consecutive months. | |
| Additional Occurrence Benefit | no seperation period required | |
| Child Coverage | Automatically covered with 50% of primary insured's amount. | |
| Infectious Disease Coverage (i.e. COVID) | Hepatitis and HIV: 100% | |
| Additional Cancer Benefits | ||
| Other Benefits | Benign Brain Tumer: 100% Advanced Alzheimer's: 100% Advanced Parkinson's: 100% Multplie Sclerosis: 100% 21 childhood diseases: 100% ALS: 100% | |
| Plan Provisions | ||
| Perpetual Guarantee Issue | Included | |
| Payouts: Unlimited | Unlimited | |
| No Elimination / Waiting Periods | none | |
| Pre-Ex Limitations / Exclusions | none | |
| Health Screening Benefit | $100 | |
| Portability | Included | |
| Participation Requirement | 10 enrolled | |
| Rate Guarantee | 36 months | |
| Commission Rate | 20% | 20% |
| Unitobacco Rates / Attained Age | |
| Monthly Premiums | Employee Rate; Children included at no cost; Spouse based on EE age |
| Age Bands | Per $10K |
| 18-29 | $ - 0 |
| 30-39 | $ - 0 |
| 40-49 | $ - 0 |
| 50-59 | $ - 0 |
| 60-69 | $ - 0 |
| 70+ | $ - 0 |
| Please describe any special programs, services, benefits that you feel set you apart from other carriers (auto adjudication, integration with medical, disability). |
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
11 Hos
| Pricing Exhibit Data Form | ABC Company |
| Hospital Plan and Rates |
| Directions: Please complete the grid below with plan design and rates you are offering (matching current as close as possible) | ||
| Benefit | Proposed Plan | Current Plan |
| H.S.A. Compatible | Yes | |
| Annual Open Enrollment | Yes |
| Admission / Confinement | Admission: $1,500 Confinement Per Day: $150 (365 day maximum) |
| ICU Admission / Confinement | Admission: No additional benefit Confinement Per Day: $200/day for 15 days, paid in addition to the Hospital confinement benefit |
| Portability | Included |
| No Elimination / Waiting Periods | No waiting period |
| Pre-Ex Limitations / Exclusions | None |
| Wellness Screening Benefit | $50 |
| Monthly Rates | Proposed Plan |
| Employee | |
| Employee + Child(ren) | |
| Employee + Spouse | |
| Family | |
| Participation Requirement | |
| Rate Guarantee | |
| Commission Rate | 15% |
| Please describe any special programs, services, benefits that you feel set you apart from other carriers (auto adjudication, integration with medical, disability). |
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
12 STD
| Pricing Exhibit Data Form | ABC Company |
| Short Term Disabilty (ATP - Employer Paid & Voluntary Option) |
Directions: Please complete the lavender fields in the grid below rates for ATP STD services for GCPS's STD plans. Please confirm if you can adminsiter Hybrid Employee required benefit design. Then quote two potential new Vol STD options for Hybrids year 1.
| 1. Employer Paid STD for Plan 1 and 2 Employees | Offeror Proposed Plan Design | Current Design |
| Benefit Amount | Percentage of Income | Percentage of Income |
| Benefit Percentage | 66.67% | 66.67% |
| Maximum Weekly Benefit | $1,500 | $1,500 |
| Funding | Self-Funded | Self-Funded |
| Elimination Period | 14/14 | 14/14 |
| Benefit Duration | 24 Weeks | 24 Weeks |
| Contribution Level | Employer Paid | Employer Paid |
| Rates | ||
| Advice to Pay Rate | $2.25/ PEPM | |
| Rate Guarantee | ||
| Commissions | NONE | NONE |
| Contribution Level | Employer Paid | Employer Paid |
| 2. Hybrid Disability Plan | Current - The Standard | |
| Under § 51.1-169, GCPS has opted out of the state VLDP option by providing a "comparable" plan. The Standard currently administers theyse plans for GCPS. Do you offer plans that meet the requirements for disability coverage for Hybrid employees participating in the Virginia hybrid retirement program described in §51.1-169 of the Code of Virginia? |
| See Attachment V – Hybrid STD Benefit Summary for more information about requirements. | Yes | ||
| 3. POSSIBLE NEW Voluntary STD for Plan 1 and 2 Employees and Hybrid Year 1 | Option 1 | Option 2 | |
| Benefit Amount | Percentage of Income | Percentage of Income | |
| Benefit Percentage | 66.67% | 60.00% | |
| Maximum Weekly Benefit | $1,500 | $1,500 | |
| Funding | Fully Insured | Fully Insured | |
| Elimination Period | 14/14 | 14/14 | |
| Benefit Duration | 24 Weeks | 24 Weeks | |
| Contribution Level | Voluntary | Voluntary | |
| Age Band | Rate (per $10) | Rate (per $10) | |
| Under 25 | |||
| 25 - 29 | |||
| 30 - 34 | |||
| 35 - 39 | |||
| 40 - 44 | |||
| 45 - 49 | |||
| 50 - 54 | |||
| 55 - 59 | |||
| 60 - 64 | |||
| 65 - 69 | |||
| 70 - 74 | |||
| 75+ | |||
| Rate Guarantee | |||
| Commissions | Flat 20% | Flat 20% |
13 LTD
| Pricing Exhibit Data Form | ABC Company | |||
| Long Term Disabilty (Voluntary) | ||||
| Directions: Please complete the grid below with plan design and rates offered (matching current as close as possible) and answer the question as to if you can offer an LTD plan compliant with Virgina Code § 51.1-169. | ||||
| Benefits | Proposed Plan 1 | Proposed Plan 2 | Current Option 1 | Current Option 2 |
| Benefit Percentage | 50% | 60% | ||
| Maximum Monthly Benefit | $6,000 | $6,000 | ||
| Minimum Monthly Benefit | $100 | $100 | ||
| Elimination Period | 180 Days | 180 Days | ||
| Disability Definition | 2 Year Own Occupation | 2 Year Own Occupation | ||
| Benefit Duration | 2 Year | SSNRA | ||
| Additional Benefit Details | ||||
| Residual Disability | Included | Included | ||
| Benefit Integration/Social Security Offset | Included | Included | ||
| Limitations | ||||
| Mental/Nervous | 24 Months | 24 Months | ||
| Drug/Alcohol | 24 Months | 24 Months | ||
| Self-Reported Limitations | 24 Months | 24 Months | ||
| Pre-Existing | 3/12 | 3/12 | ||
| Employee Assistance Program | Included | Included | ||
| Age Band | Proposed Rate (per $100) | Proposed Rate (per $100) | ||
| Under 25 | $0.020 | $0.080 | ||
| 25 - 29 | $0.020 | $0.080 | ||
| 30 - 34 | $0.020 | $0.080 | ||
| 35 - 39 | $0.060 | $0.120 | ||
| 40 - 44 | $0.070 | $0.190 | ||
| 45 - 49 | $0.100 | $0.300 | ||
| 50 - 54 | $0.130 | $0.450 | ||
| 55 - 59 | $0.180 | $0.560 | ||
| 60 - 64 | $0.180 | $0.560 | ||
| 65 - 69 | $0.180 | $0.560 | ||
| 70 - 74 | $0.180 | $0.560 | ||
| 75+ | $0.180 | $0.560 | ||
| Rate Guarantee | ||||
| Participation Requirement | ||||
| Contribution Level | Voluntary | Voluntary | ||
| Commissions | 15% | 15% | ||
| 2. Hybrid Disability Plan | Offerer Response | Current - The Standard | ||
| Under § 51.1-169, GCPS has opted out of the state VLDP option by providing a "comparable" plan. The Standard currently administers theyse plans for GCPS. Do you offer plans that meet the requirements for disability coverage for Hybrid employees participating in the Virginia hybrid retirement program described in §51.1-169 of the Code of Virginia? |
| See Attachment W – Hybrid LTD Benefit Summary for more information about requirements. | Yes | |
| Please describe any special programs, services, benefits that you feel set you apart from other carriers (auto adjudication, integration with medical, disability). |
Summarize any bundling discounts, tech credits, and/or financial improvements that would apply to the lines of coverage for which you are making an offer.
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File details come from the government source that posted it. Updated .