Exhibit C - Cost Exhibit.xlsx
XLSX spreadsheet 306 KB Posted
- Attached to
- Dental Benefits Program
- Solicitation number
- RFP AABA 2027000021 4
- Issued by
- Denver County, Denver City, Colorado
About this file
This is a Cost Exhibit workbook for Colorado's Dental Benefits Program, specifically the Dental Preferred Provider Organization (DPPO) self-funded administrative services organization (ASO) procurement. The exhibit contains standardized Excel forms that offerors must complete to submit pricing and operational information for dental plan administration services. The contract encompasses dental benefits administration for an enrollment base of 37,134 active participants and COBRA members across a five-year period from July 1, 2027, through June 30, 2032, with annual contract periods from Year 1 through Year 5.
Offerors must provide base administration fees per subscriber per month (PSPM) covering dental claim administration, network access, and other specified services, with the option to quote additional services in Section B. The workbook requires pricing for two plan designs: a Basic Plan with 70% basic restorative and 50% major restorative coverage, and a Basic Plus Plan with 80% and 50% coverage respectively, both featuring $1,500 to $3,000 annual maximums and orthodontia benefits. Submissions must include self-funding claims discounts based on the provided claims file, provider network information organized by unique NPIs and locations across 3-digit zip codes, and geographic access analysis demonstrating compliance with urban (1 in 2 miles), suburban (1 in 5 miles), and rural (1 in 10 miles) provider access standards. All responses must be submitted in the original Excel format without modification to pre-labeled rows or columns, and offerors must confirm whether their fees include at least 12 months of runout administration upon contract termination.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Directions
Exhibit Instructions to Offerors
When completing the exhibits in the Excel workbook, please follow the directions below:
| 1. Do not add or delete rows, columns or alter-pre-labeled text in the exhibits |
| 2. Electronic copies of these exhibits must be returned in Excel. Do not PDF the Excel Workbook. Electronic signatures may be required. |
| 3. Do not extract individual worksheets (exhibits) and submit as separate Excel workbooks in the electronic copy. |
Offeror Info
| Colorado DPA |
| OFFEROR INFORMATION |
| Dental ASO Pricing |
| OFFEROR INFORMATION SHEET |
| Organization Name |
| Date Founded |
| Contact Person's Name |
| Title |
| Address |
| County/State |
| Phone Number |
| E-mail Address |
| Website |
| Authorized Signature |
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2026 by Segal. All rights reserved.
&"Calibri"&11&K000000&F_x000D_&1#&"Calibri"&8&K414141Proprietary
Ex.1 DPPO ASO
| Colorado DPA |
| Exhibit 1 - DENTAL PPO SELF FUNDED FEE QUOTATION FORM |
| **********PLEASE READ THE DIRECTIONS CAREFULLY BEFORE COMPLETING THE EXHIBIT********** |
| Please do not alter, add or delete rows. Complete yellow shaded areas only. Failure to complete the exhibit as requested may result in rejection of your offer. In Section A please give a total base fee and in Section B please indicate the cost of any optional services. |
| When entering the pricing in each fee cell for Years 1-5, please follow the directions below: |
| a. If $0.00 is in the fee/pricing cell, the service is automatically considered included at NO additional cost to the client: |
| b. If the fee/pricing cell is blank (no numerical dollar value), the service is automatically included at NO additional cost to the client; and |
| c. If you do not provide any of the services, please type "N/A" in the fee/pricing cell for each service. |
| Please include ALL comments specific to your pricing on this exhibit in the Comment Box (below). Add rows to the Comment Box as needed. |
| Please do not refer to your response to clarify any of the services, pricing or comments included on this exhibit. All of your comments to support your pricing should be on this exhibit. |
| 7/1/2027-6/30/2028 | 7/1/2028-6/30/2029 | 7/1/2029-6/30/2030 | 7/1/2030-6/30/2031 | 7/1/2031-6/30/2032 | |
| A. Base Administration Fees Per Subscriber Per Month | Year 1 | Year 2 | Year 3 | Year 4 | Year 5 |
| Dental Claim Administration Fee PSPM | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Network Access PSPM | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Other (Specify) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Total Base Administration Fees PSPM | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| B. Optional Administration Services (client may choose some or all) | |||||
| Other (Specify) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Other (Specify) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Other (Specify) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Other (Specify) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Total Optional Administration Services PSPM | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| C. All Administration Fees | |||||
| Total Administration Fees (PSPM) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| D. Allowances | |||||
| Implementation/Ongoing Credit | |||||
| Enrollment Assumptions | |||||
| Actives/COBRA | 37,134 | 37,134 | 37,134 | 37,134 | 37,134 |
| * Fees must include services including, but not limited to, claim administration (including runout administration), network access & maintenance, reporting, ID cards (with State logo), and member services |
| Does your fee include the cost of at least 12 months of runout administration upon termination of the contract? | No |
| Describe in comments. |
Comments
| Offeror Name |
| Contact Name |
| Contact Title |
| Contact Phone Number |
| Authorized Signature |
| Unauthorized replication or use of this financial workbook is prohibited. |
Copyright © 2026 by Segal. All rights reserved.
Ex.2 Self-Funded Discounts
| Colorado DPA |
| Exhibit 2 - SELF-FUNDING CLAIMS DISCOUNTS |
| Offeror Name |
| Contact Name |
| Contact Phone Number |
| Authorized Signature |
| **********PLEASE READ THE DIRECTIONS CAREFULLY BEFORE COMPLETING THE EXHIBIT********** |
| Please provide the re-priced claims for the full file provided in the claims files released. |
All claims should be priced based on the Offeror's most current provider contracts.
| Dental ASO Claims Pricing | DPPO Network |
| A. Offerors Discounted Claims | |
| Total Billed Charges | |
| In Network Claims | |
| Billed Charges | |
| Discount Percentage | |
| Excluded Claims | |
| Allowed Claims | |
| Out of Network Claims | |
| Billed Charges | |
| Discount Percentage | |
| Excluded Claims | |
| Allowed Claims | |
| Total Allowed Claims | $0 |
| B. Discount Guarantee | |
| Offeror Discount Guarantee (Provide Details in the Comments Below) |
Comments
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2026 by Segal. All rights reserved.
&1#&"Calibri"&8&K414141Proprietary
Ex.3 Provider Cnts NPI
| Colorado DPA |
| Exhibit 3 - DENTAL PROVIDER COUNTS - UNIQUE NPI |
| Authorized Signature |
| Offeror Name |
| Contact Name |
| Contact Phone Number |
Provide the number of unique providers (based on NPI) who have their PRIMARY location in the indicated area. Each unique provider should be counted only once. If you are proposing more than one network, please duplicate this exhibit for each network.
| Network Name: | ||||||||
| DPPO Network | ||||||||
| Provider Type>> | General Dentist | Pediatric Dentist | Periodontist | Endodontist | Oral Surgeon | |||
| 3-Digit Zip Code | # of Unique Providers | % Open To | ||||||
| New Members | # of Unique Providers | % Open To | ||||||
| New Members | # of Unique Providers | # of Unique Providers | # of Unique Providers | |||||
| 800 | ||||||||
| 801 | ||||||||
| 802 | ||||||||
| 803 | ||||||||
| 804 | ||||||||
| 805 | ||||||||
| 806 | ||||||||
| 807 | ||||||||
| 808 | ||||||||
| 809 | ||||||||
| 810 | ||||||||
| 811 | ||||||||
| 812 | ||||||||
| 813 | ||||||||
| 814 | ||||||||
| 815 | ||||||||
| 816 | ||||||||
| Unauthorized replication or use of this financial workbook is prohibited. |
Copyright © 2026 by Segal. All rights reserved.
Ex.4 Provider Cnts Location
| Colorado DPA |
| Exhibit 4 - DENTAL PROVIDER COUNTS - LOCATIONS |
| Authorized Signature |
| Offeror Name |
| Contact Name |
| Contact Phone Number |
Provide the number of contracted provider locations in the indicated area. Locations may be counted more than once if multiple locations exist but do not count a location with multiple providers more than once. If you are proposing more than one network, please duplicate this exhibit for each network.
| Network Name: | ||||||||
| DPPO Network | ||||||||
| Provider Type>> | General Dentist | Pediatric Dentist | Periodontist | Endodontist | Oral Surgeon | |||
| 3-Digit Zip Code | # of Locations | % Open To | ||||||
| New Members | # of Locations | % Open To | ||||||
| New Members | # of Locations | # of Locations | # of Locations | |||||
| 800 | ||||||||
| 801 | ||||||||
| 802 | ||||||||
| 803 | ||||||||
| 804 | ||||||||
| 805 | ||||||||
| 806 | ||||||||
| 807 | ||||||||
| 808 | ||||||||
| 809 | ||||||||
| 810 | ||||||||
| 811 | ||||||||
| 812 | ||||||||
| 813 | ||||||||
| 814 | ||||||||
| 815 | ||||||||
| 816 | ||||||||
| Unauthorized replication or use of this financial workbook is prohibited. |
Copyright © 2026 by Segal. All rights reserved.
Ex.5 Basic Plan Design
| Colorado DPA |
| Exhibit 5 - BASIC PLAN BENEFIT DESIGN |
| Authorized Signature |
| Offeror Name |
| Contact Name |
| Contact Phone Number |
Complete the grid indicating the benefit design you are proposing.
| Basic Plan | ||
| Current / Requested | Proposed | |
| In-Network & Out-of-Network | In-Network & Out-of-Network | |
| Basic Restorative (Class II) | 70% |
Major Restorative (Class III) 50%
| Calendar Yr. Maximums: | |
| Class II & III Services | $1,500 |
| Deductible | $50/$150 |
| Deductible applies | Basic & Major |
| Orthodontia | 50% |
| Lifetime Orthodontia Maximum | $1,500 |
| Child or Adult Coverage | Child |
Dependent Age 26
| Fillings | Basic |
| Simple Extractions | Basic |
| Oral Surgery | Basic |
| Endodontics | Basic |
| Periodontics | Basic |
| Crowns | Major |
| Dentures | Major |
| Bridges | Major |
| Implants | Major |
| Orthodontics | Not Covered |
| Fillings | Once every 12 months per surface |
| Surgical Periodontics | Once every 36 months |
| Crowns | Once every 60 months per tooth |
| Dentures | Once every 60 months |
| Bridges | Once every 60 months |
| Implants | Once every 60 months per tooth |
| Out-of-Network Percentile of UCR |
| Comments |
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2026 by Segal. All rights reserved.
Ex.6 Basic Plus Plan Design
| Colorado DPA |
| Exhibit 6 - BASIC PLUS PLAN BENEFIT DESIGN |
| Authorized Signature |
| Offeror Name |
| Contact Name |
| Contact Phone Number |
Complete the grid indicating the benefit design you are proposing.
| Basic Plus Plan | ||
| Current / Requested | Proposed | |
| In-Network & Out-of-Network | In-Network & Out-of-Network | |
| Basic Restorative (Class II) | 80% |
Major Restorative (Class III) 50%
| Calendar Yr. Maximums: | |
| Class II & III Services | $3,000 |
| Orthodontia (Lifetime Max. for EE & Dep.) | $3,000 |
| Deductible | $50/$150 |
| Deductible applies | Basic & Major |
| Orthodontia | 50% |
| Lifetime Orthodontia Maximum | $1,500 |
| Child or Adult Coverage | Child |
Dependent Age 26
| Fillings | Basic |
| Simple Extractions | Basic |
| Oral Surgery | Basic |
| Endodontics | Basic |
| Periodontics | Basic |
| Crowns | Major |
| Dentures | Major |
| Bridges | Major |
| Implants | Major |
| Orthodontics | Major |
| Fillings | Once every 12 months per surface |
| Surgical Periodontics | Once every 36 months |
| Crowns | Once every 60 months per tooth |
| Dentures | Once every 60 months |
| Bridges | Once every 60 months |
| Implants | Once every 60 months per tooth |
| Out-of-Network Percentile of UCR |
| Comments |
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2026 by Segal. All rights reserved.
Ex. 7 GeoAccess - Dentists
| Colorado DPA |
| Exhibit 8 - GeoAccess Summary |
| Directions: Complete the following table based on a standard GeoAccess analysis of your proposed dental provider network using the census file provided with this RFP. Include only those individuals who hold one of the following licenses: Doctor of Medicine in Dentistry or Doctor of Dental Medicine (DMD), Doctor of Dental Surgery (DDS) in your analysis. Access standards are shown below. |
| Area | Access Standard |
| Urban Areas | 1 in 2 miles |
| Suburban Areas | 1 in 5 miles |
| Rural Areas | 1 in 10 miles |
| Urban | Suburban | Rural | Total | ||||||||||||||||
| Participants Matched | Participants Not Matched | Participants Matched | Participants Not Matched | Participants Matched | Participants Not Matched | Participants Matched | Participants Not Matched | ||||||||||||
| 5-Digit ZIP Code | State | Total Number Plan Participants | Total Number of In-Network Providers | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider | Number of Participants | Average Distance to In-Network Provider |
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2026 by Segal. All rights reserved.
File details come from the government source that posted it. Updated .