ESBD_486865_1770151667603_Price Proposal Worksheet.docx
DOCX document 27 KB Posted
- Solicitation number
- RFP-01-SBA-26-274
- Issued by
- Texas
About this file
This is a Price Proposal Worksheet for a Self-Insured Employee Group Medical Plan Administration contract with the Texas A&M System, encompassing two distinct health plan products: the A&M Care plan and the 65 PLUS Medicare Advantage plan. The A&M Care component requires proposers to submit a Target Claims Cost (TCC) formula for fiscal year 2027, with detailed documentation of the projection methodology, excluding retirees for whom Medicare is primary. Proposers must also specify formulas and maximum guaranteed trend factors for fiscal years 2028 and 2029. The 65 PLUS Medicare Advantage component requires proposers to define the formula for developing calendar year 2027 premium rates and subsequent renewal rates, along with maximum guaranteed annual trends for calendar years 2027 through 2029. The contract term spans fiscal and calendar years 2027 through 2029, with provisions for renewal negotiations in subsequent years.
The pricing proposal requires a single guaranteed flat monthly administrative fee covering all services, responsibilities, and obligations throughout the contract term and any runout period, with detailed allocation breakdowns across utilization review, claims processing, network management, behavioral health programs, general administration, communication, disease/condition management, and wellness services. For the 65 PLUS Medicare Advantage plan, proposers must specify guaranteed administrative fee rates, risk margin percentages, and Stars Ratings for the entire contract period. One hundred percent of pharmaceutical rebates and other revenues from manufacturers must be credited to the A&M System without impacting the administrative fee. Proposers must also indicate applicable provider reimbursement mechanisms for primary care physicians, specialty care physicians, hospitals, and behavioral health facilities, selecting from options including capitation, discounted fee-for-service, fee schedules, DRG, or per diem arrangements.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| ESBD_486865_1770151668359_3.16 - A&M System Claims Experience.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770151668011_Detail Claims File Instructions.docx | DOCX document | |
| ESBD_486865_1770151667865_Sample Open Enrollment Calendar.pdf | ||
| ESBD_486865_1770151666968_Network.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770154776343_AM Care Plans.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770151670387_3.17 - MAP 2024 AnnualReview.pdf | ||
| ESBD_486865_1771627457725_SBA-26-274 Addendum 1.pdf | ||
| ESBD_486865_1770151667310_Provider Reimbursement.xlsx | XLSX spreadsheet | |
| ESBD_486865_1770149799579_SBA-26-274 Self-Insured Employee Group Health Plan.pdf | ||
| ESBD_486865_1770154774348_Benefit Eligible.xlsx | XLSX spreadsheet |
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Price Proposal – A&M Care
As specified in Section 3.9 of this RFP. The Proposer must provide a Target Claims Cost (TCC). The TCC will be used in the calculation of the health care management performance incentive. Retirees for whom Medicare is primary should be excluded from the TCC calculation. Provide all information as specified below in relation to the TCC.
Formulas
1. Specify the formula and enumerate the variables to be used in developing your final FY 2027 TCC on or before February 1, 2027. The formula shall comply with the requirements and guidelines stated in Section 3.9 of this RFP. Enumerate the variables included in the Proposer’s formula.
Variables are limited to actual FY 2026 claims and the composition of FY 2027 enrollment as discussed herein. All other factors including trend, network usage assumptions, plan design adjustments, network utilization/price adjustments, and factors used to adjust for demographic and geographic changes must be guaranteed for FY2027 and will be negotiated in good faith in subsequent years.
NOTE: The Projected FY 2027 TCC requested below should be based on the current A&M Care benefit structure. If the benefit structure is revised for FY 2027 or for a subsequent plan year, the adjustment factors for benefit change will be subject to good faith negotiation.
2. Specify the formula and enumerate the variables to be used in developing your FY 2028 and FY 2029 TCCs. Maximum trend factors must be guaranteed as indicated below.
Projected FY 2027 TCC Based on the formula specified above, project the FY 2027 TCC. Provide detailed documentation regarding your projection.
FY 2027 TCC
$ PEPM1
1Per Employee/Retired Employee Per Month
FY 2028 and FY 2029 Maximum Guaranteed Trends Specify the maximum guaranteed trends to be used in projecting the TCC for FY2028 and FY2029. These are the maximum rates that will be used; the actual rates will be subject to good faith negotiation between the A&M System and Proposer.
FY 2028 Maximum Guaranteed Trend
FY 2029 Maximum Guaranteed Trend
Administrative Fee Proposal Guarantee Provide a single flat monthly Administrative Fee that is guaranteed for the contract term. The single flat monthly Administrative Fee must cover the cost incurred for the performance of all Services, responsibilities and obligations as described in the RFP and Contract prior to and during the entire Contract Term and during any runout period following termination of the Contract. Proposer shall not be paid any fees or earn any compensation in connection with the Contract except for the Administrative Fee.
Proposer understands and acknowledges that it will not receive any payment of any kind unless it is provided for in the Administrative Fee.
Coverages provided by the A&M System are exempt from any state tax, regulatory fee, or surcharge, including premium or maintenance taxes or fees. The administrative fee, if any, should not include any provision for such taxes or fees.
Specify the guaranteed Administrative Fee per employee / retired employee per month.
FY 2027 – FY2029
$ PEPM
Allocation to Categories List the applicable portion of the overall proposed administrative fee allocated to each of the categories below.
Utilization Review1
$ PEPM
Claims Processing2
$ PEPM
Network Management
$ PEPM
Behavioral Health Program3
$ PEPM
General Administration4
$ PEPM
Communication
$ PEPM
Disease/Condition Management Services
$__________ PEPM
Wellness Services
$__________ PEPM
Other5
$ PEPM
TOTAL
$ PEPM
1Includes all cost containment activities.
2Includes subrogation related costs and related legal expenses as well as Coordination of Benefits.
3Includes any amounts paid to a behavioral health subcontractor for administrative services.
4Includes actuarial, legal, underwriting, reporting and other technical assistance.
5Specify.
Pharmaceutical Rebates One-hundred percent (100%) of all rebates and other revenue received from a pharmaceutical manufacturer in connection with paid claims will be credited to the A&M System. Payment of the rebates and other revenues shall not impact the Administrative Fee provided.
Price Proposal – 65 PLUS MEdicare Advantage
Formulas Specify the formula to be used in developing the CY2027 (January 1, 2027 through December 31, 2027) and renewal premium rates for the 65 PLUS Medicare Advantage plan. Please identify and define all components of the proposed formula.
Maximum Guaranteed Trends Specify the maximum guaranteed annual trend to be used in developing the 65 PLUS Medicare Advantage premium rate for each year during the term of the contract. This is the maximum annual trend rate that will be used in the rate development. The actual trend rate to be used in the rating calculations will be subject to good faith negotiations between the A&M System and the Proposer.
CY 2027 Maximum Guaranteed Trend
CY 2028 Maximum Guaranteed Trend
CY 2029 Maximum Guaranteed Trend
Guaranteed Rating Factors Using the chart directly below, specify the guaranteed administrative fee rate, guaranteed risk margin percentage, guaranteed Stars Rating (for rating purposes only) and any other financial considerations to be used in developing the 65 PLUS Medicare Advantage premium rates for CY2027 through CY2029 The combination of administrative fee rate and risk margin percentage must include provision for all administrative services, risk and profit.
| Administrative Fee Rate Per Participant Per Month Guaranteed for the Period CY2027 through CY2029: |
| $________ |
| Risk Margin Percentage Guaranteed for the Period CY2027 through CY2029: |
| ________% |
| Stars Rating Guaranteed for Rating Purposes for the Period CY2027 through CY2029 |
| __________ |
Other:
(provide a detailed description of any further financial considerations)
Please note Medicare-Primary participants have little or no out-of-pocket cost for medical expenses.
Provider Reimbursement Indicate with an “X” if the reimbursement mechanism is applicable Primary Care Physician
| Capitation |
| Discounted Fee-for-Service |
| Discounted Fee-for-Service with withhold |
| Fee Schedule (1) |
| Other (2) |
Specialty Care Physician
| Capitation |
| Discounted Fee-for-Service |
| Discounted Fee-for-Service with withhold |
| Fee Schedule (1) |
| Other (2) |
Hospital
| Capitation |
| Fee Schedule (1) |
| DRG |
| Per Diem (3) |
| Discounted Fees |
| Other (2) |
Behavioral Health Facility
| Capitation |
| Fee Schedule (1) |
| DRG |
| Per Diem (3) |
| Discounted Fees |
| Other (2) |
Footnotes:
(1) Provide detailed explanation, e.g., if RBRVS is used, explain derivation and relationship to Medicare RBRVS.
(2) If “Other” category is used, provide a complete explanation of such reimbursement mechanism.
(3) If Per Diem is used, list categories of per diem, e.g., normal delivery, medical, surgical, etc.
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