Ext_5.TechProp_FA1_PPO_EPO-SF__DBMHealth_RFP_2025.8.9.docx

DOCX document 550 KB Posted

Attached to
1-DBM Health Plan Admin&Svcs / 2-DBM Medical insurance benefits for State Law Enforcement Officers Labor Alliance (SLEOLA) members / 3-MDOT-MTA Medical/Vision Plan Health Benefits & Admin. Svcs
Solicitation number
BPM051063
Issued by
Maryland

About this file

Written by GovTribe AI ·

This document is a technical proposal for a state and local health plan contract opportunity issued by the State of Maryland's Department of Budget and Management (DBM) for a Self-Funded Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) health insurance plan. The solicitation, numbered F10B6600001, seeks a health insurance administrator to provide comprehensive medical benefits for state employees, retirees, and their dependents, with a contract term beginning January 1, 2027. The proposal includes extensive requirements for network management, claims processing, wellness programs, customer service, reporting, and compliance with various federal and state healthcare regulations.

The solicitation requires detailed technical responses across multiple exhibits, including provider network information, plan designs, performance guarantees, and capabilities in areas such as disease management, case management, claims administration, and technology integration. The contract will involve managing a large population across Maryland, with specific performance metrics including telephone responsiveness, complaint resolution, claims accuracy, and participant satisfaction. Financial terms include potential liquidated damages for failing to meet specified performance standards, with administrative fees subject to annual review and increases capped at the Consumer Price Index. The proposal also emphasizes alignment with Maryland's All-Payer Health Equity Approaches and Development (AHEAD) Model, which aims to improve healthcare outcomes, control total cost of care, and enhance health equity.

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Other files

File Type Posted
Redacted_MSRP-_ORI.pdf PDF
Atch_2_PP_Conf_Form_DBM_Health.pdf PDF
Apdx_9._AcctMgmtScorecard_DBM_Health.SLEOLA.pdf PDF
Apdx_6._Living_Wage_Affidavit.pdf PDF
_DBM_SLEOLA_MDOT-MTA_Medical_JointRFP_6FAs__FINAL_8.9.25_.pdf PDF
Apdx_2.FinProp_FA5__Medical_PPO_Plans__2025.8.9.xlsx XLSX spreadsheet
Apdx_5.VSBEPatGoal_DBM_Health_SLEOLA_MDOT_MTA_RFP_2025.8.9.pdf PDF
Ext_4.IT_ProfSvcsSuptl_DBM_Health_SLEOLA_MDOT_MTA_RFP_2025.8.9.pdf PDF
Apdx_2.FinProp_FA3__PtSol__DBMHealth_RFP_2025.8.9.xlsx XLSX spreadsheet

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Contents

FA1 EXHIBIT 5-1: Plan Information2
FA1 EXHIBIT 5-2: Explanations and Deviations6
FA1 EXHIBIT 5-3: Self-Funded PPO and EPO Plan Designs7
FA1 EXHIBIT 5-4: Participating Physicians22
FA1 EXHIBIT 5-5: Access to Adult PCPs27
FA1 EXHIBIT 5-6: Access to Pediatricians30
FA1 EXHIBIT 5-7: Access to OB/GYNs34
FA1 EXHIBIT 5-8: Access to Hospitals37
FA1 EXHIBIT 5-9: Compliance Checklist40
FA1 EXHIBIT 5-10: Questionnaire60
FA1 EXHIBIT 5-11a: Subcontractors Questionnaire94
FA1 EXHIBIT 5-11b: Subcontractors Questionnaire95
FA1 EXHIBIT 5-11c: Subcontractors Questionnaire96
FA1 EXHIBIT 5-11d: Subcontractors Questionnaire97
FA1 EXHIBIT 5-11e: Subcontractors Questionnaire98
FA1 EXHIBIT 5-11f: Subcontractors Questionnaire99
FA1 EXHIBIT 5-12: Performance Guarantees100
FA1 EXHIBIT 5-13: AHEAD Model112

FUNCTIONAL AREA 1 – SELF-FUNDED PPO AND EPO

FA1 EXHIBIT 5 SELF-FUNDED PPO AND EPO TECHNICAL PROPOSAL

Filename: FA1 EXHIBIT 5 Technical Proposal (Part 2 – Provider Disruption).xlsx

FA1-EXHIBIT 5-14: Provider Disruption (provided after receipt of NDA) - return file in the format provided with network indicator column filled out.

FA1 EXHIBIT 5-1: Plan Information Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: Complete each cell with the requested information. Items in the response column with the words "Choose an Item" contain a drop-down list of options. Select a response from those options as applicable.

I.
GENERAL PLAN INFORMATION

Response

1.
Offeror’s Legal Name
Click here to enter text.
2.
Plan Name
Click here to enter text.
3.
Proposed Plan Type
Self-Funded PPO and EPO
4.
Address
Click here to enter text.
5.
City
Click here to enter text.
6.
State
Click here to enter text.
7.
Zip
Click here to enter text.
8.
Web Address
Click here to enter text.
9.
Operational Date
Click here to enter a date.
10.
Corporate Tax Status
Choose an item.
11.
Federal Employer Identification Number
Click here to enter text.
12.
Ownership/Controlling Interest
Click here to enter text.
13.
NCQA Accreditation Status
Choose an item.
14.
JCAHO Accreditation
Choose an item.
15.
URAC Accreditation
Health Plan
Choose an item.
Health Network
Choose an item.
Health Utilization Management
Choose an item.
16.
Commercial Group Membership
Click here to enter text.
17.
PPO Membership Totals 3/1/2025
Click here to enter text.
18.
EPO Membership Totals 3/1/2025
Click here to enter text.
II.
PLAN DESIGN
Offerors must adhere to the proposed plan designs shown in "FA1 EXHIBIT 5-3: Self-Funded PPO and EPO Plan Designs" in preparing the quote.
Select Response
1.
Confirm that the Offer is issued in accordance with the specifications, assumptions and information included in this Request for Proposals, the accompanying worksheets and standard services addressed in the Information Questionnaire. If "No,” indicate deviations in "FA1 EXHIBIT 5-2: Explanations and Deviations" worksheet.
Choose an item.
2.
Review and detail deviations from the proposed plan design shown in the worksheet, "FA1EXHIBIT 5-3: Self-Funded PPO and EPO Plan Designs.”
Choose an item.
3.
The State may decide to make plan changes prior to the effective date. Please indicate whether your organization shall administer the medical plan(s) selected by the State at the rates provided in your Offer.
Choose an item.
4.
Include a concise list of conditions eligible for transitional care and a description of the Offeror’s procedures and processes for handling transition of care by either a participating or non-participating provider. Include details on transition of care for both new and existing Participants. Label as “ResponseFA1.5-1_Transition Care Info.”
Submit a copy and label as “ResponseFA1.5-1_Transition Care Info.”
III.MEDICAL DELIVERY SYSTEM
1.
Describe the proposed geographical service area.
Click here to enter text.
2.
Provide a map of the proposed geographical service area. Label as “ResponseFA1.5-1_Service Area Map.”
Submit a copy and label as “ResponseFA1.5-1_Service Area Map.”
3.
Provide the name of your proposed network and the website address (URL) for your provider directory, including its password, if required.
Click here to enter text.

Participants' Access to Providers The State would like to determine the availability of key PPO and EPO healthcare providers to its employee and Retiree population. Prepare GeoAccess® GeoNetworks® report(s) for each network and plan type that you are proposing, using census data provided by the State and the parameters as described in Table 1.

Provide the reports for three separate populations:

1. Current PPO enrollment,

2. Current EPO enrollment, and

3. Entire census population.

Note that it is important that you follow the exact parameters. The report should show hospital and provider availability by physician specialty for each zip code and county. The report output should show the average distance to each provider group as well as the number of employees who have access according to the parameters in Table 1. See the sections entitled "FA1 EXHIBIT 5-5: Access to Adult PCPs,” "FA1 EXHIBIT 5-6: Access to Pediatricians,” "FA1 EXHIBIT 5-7: Access to OB/GYNs,” and "FA1 EXHIBIT 5-8: Access to Hospitals" for the required format of the output. The data must be supplied in electronic format that has read and write capabilities. Do not send the data in a read-only file.

Use only physicians accepting new patients in your GeoAccess® GeoNetworks® provider file. The census data needed to perform this geographic mapping is available for download upon execution of the Non-Disclosure Agreement (see Exhibit 4: Information Technology (IT) and Professional Services Supplement). Label the completed GeoAccess® GeoNetworks® report as ResponseFA1.5-1_GeoAccess® GeoNetworks® Report. EXHIBIT 5-1 shall be provided electronically via secure file transfer protocol (SFTP). The electronic version should include a system-generated PDF file and an Excel file.

Table 1 Practice Specialty

Number of Providers Available Miles from Employees Residence

Adult Physicians (Family Practice, General Practice, General Internal Medicine)
2
8
General Pediatricians
2
8
Obstetricians/Gynecologists
2
8
Acute Care Hospitals
1
10

Select Response

4.
Has the GeoAccess® GeoNetworks® reporting been completed using the requested parameters?
Choose an item.
5.
Select the geo-mapping method used.
Choose an item.
6.
Which GeoAccess® GeoNetworks® release was used to create the accessibility analysis?
Click here to enter text.
IV.ADMINISTRATIVE AND OPERATIONAL ISSUES
1.
List the location(s) of your service centers (separately identify claims processing centers and customer service centers if in different locations) that would be servicing the State’s Members and the corresponding geographic areas and regions covered by the respective location. Use the"FA1 EXHIBIT 5-2: Explanations and Deviations" worksheet if you need more space.
Service Center Location(s)
Service Provided
Geographic Region(s) Covered
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.

Select Response

2.
Attach a copy of your standard report suite, including a plan experience report, a summary report of wellness activities and performance metrics that would be provided to the State at the end of each quarter and the end of each fiscal year at no additional cost. At a minimum, your submission should include the requirements outlined in the Reporting section of the Compliance Checklist. Label as “ResponseFA1.5-1_Mgmt Reporting Pkg.”
Submit a copy and label as “ResponseFA1.5-1_Mgmt Reporting Pkg.”
3.
Offeror has disclosed their claims appeals (claims decision or coverage) protocols as well as actual response time statistics for the most recent year. Label these reports “ResponseFA1.5-1_Claims Appeals Protocols” in your Offer.
Submit a copy and label as “ResponseFA1.5-1_Claims Appeals Protocols”.

V. REFERENCES

Complete the following tables with the requested reference information.

1.
Provide three of your employer client references (a minimum of 25,000 covered lives or your largest) offering PPO or EPO services in the area that shall serve most of the State’s employees.
Information
Reference #1
Reference #2
Reference #3
Company Name
Click here to enter text.
Click here to enter text.
Click here to enter text.
Contact Person
Click here to enter text.
Click here to enter text.
Click here to enter text.
Title
Click here to enter text.
Click here to enter text.
Click here to enter text.
Telephone #
Click here to enter text.
Click here to enter text.
Click here to enter text.
E-mail Address
Click here to enter text.
Click here to enter text.
Click here to enter text.
Network Name
Click here to enter text.
Click here to enter text.
Click here to enter text.
# Members Enrolled
Click here to enter text.
Click here to enter text.
Click here to enter text.
Effective Date of Contract
Click here to enter a date.
Click here to enter a date.
Click here to enter a date.
Description of Services provided
Click here to enter text.
Click here to enter text.
Click here to enter text.
2.
Provide three of your terminated employer clients (a minimum of 25,000 covered lives or your largest) that offered PPO and EPO services in the area that shall serve most of the State’s employees.
Information
Reference #1
Reference #2
Reference #3
Company Name
Click here to enter text.
Click here to enter text.
Click here to enter text.
Contact Person
Click here to enter text.
Click here to enter text.
Click here to enter text.
Title
Click here to enter text.
Click here to enter text.
Click here to enter text.
Telephone #
Click here to enter text.
Click here to enter text.
Click here to enter text.
E-mail Address
Click here to enter text.
Click here to enter text.
Click here to enter text.
Network Name
Click here to enter text.
Click here to enter text.
Click here to enter text.
# Members
Click here to enter text.
Click here to enter text.
Click here to enter text.
# Members Enrolled at Date of Termination
Click here to enter text.
Click here to enter text.
Click here to enter text.
Effective Date of Contract
Click here to enter a date.
Click here to enter a date.
Click here to enter a date.
Termination Date of Contract
Click here to enter a date.
Click here to enter a date.
Click here to enter a date.
Reason for Termination
Click here to enter text.
Click here to enter text.
Click here to enter text.

VI. CONTACT INFORMATION

Primary contact of person authorized to execute this Offer

Name
Click here to enter text.
Title
Click here to enter text.
Address
Click here to enter text.
City
Click here to enter text.
State
Click here to enter text.
Zip Code
Click here to enter text.
Telephone #
Click here to enter text.
Cell Phone #
Click here to enter text.
E-mail Address
Click here to enter text.

SOM MEDICAL PART 2: Attachments O-Q DRAFT DATE: 10/29/2013 HEALTH PLAN ADMINISTRATION AND SERVICESRFP, SOLICITATION #: F10B6600001: FUNCTIONAL AREA 1 – SELF-FUNDED PPO AND EPO, TECHNICAL PROPOSAL

SOM Medical RFPPart 2 – Page 75FA1 EXHIBIT 5Attachment T-1
Solicitation No. F10B66000011FA1 EXHIBIT 5-1

FA1 EXHIBIT 5-2: Explanations and Deviations Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: All deviations from the specifications of the Request for Proposals (RFP) must be clearly defined using this worksheet. Explanations must be numbered to correspond to the question number and section number to which it pertains. If additional space is required, submit a separate attachment labeled “FA1.5-2b_Explanations and Deviations” using the same table format. Most importantly, keep all explanations brief. In the absence of any identified deviations, your organization shall be bound to the terms of the RFP.

Section # / Question #
Indicate "Explanation" or "Deviation"
Offeror Response
Click here
Choose an item.
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Indicate if “FA1 EXHIBIT 5-2b: Explanations and Deviations” is provided: Choose an item.

SOM Medical RFPPart 2 – Page 75FA1 EXHIBIT 5Attachment T-2
Solicitation No. F10B66000016FA1 EXHIBIT 5-2

FA1 EXHIBIT 5-3: Self-Funded PPO and EPO Plan Designs Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: Any deviations between the proposed plan design and the proposed plan design of the Offeror must be noted in the space provided below. If there are no deviations in the Offeror's proposed plan design, enter the phrase "No Deviations" in the space provided.

PPO Current Benefits
PPO Proposed Deviations
TYPE OF SERVICE
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK

MAJOR MEDICAL

Annual Deductible

Individual
None
$250
Choose an item.
Choose an item.
Family
None
$500
Choose an item.
Choose an item.

Yearly Maximum Out-of-Pocket Costs

Coinsurance OOP
90%
70%
Choose an item.
Choose an item.
Individual
$1,000
$3,000
Choose an item.
Choose an item.
Family
$2,000
$6,000
Choose an item.
Choose an item.

Copayment OOP

Individual
$1,000
None
Choose an item.
Choose an item.
Family
$2,000
None
Choose an item.
Choose an item.

Total Medical OOP

Individual
$2,000
$3,250
Choose an item.
Choose an item.
Family
$4,000
$6,500
Choose an item.
Choose an item.
Lifetime Benefit Maximum
Unlimited
Choose an item.
Choose an item.
Dependent Coverage
Dependents are eligible for coverage according to COMAR 17.04.13.01 and .03.
No deviations shall be considered.
Medicare Coordination of Benefits (COB)
Retirees or their Dependent(s) must enroll in Medicare Parts A & B upon becoming eligible for Medicare due to age or disability. If the Medicare eligible State Retiree and their Dependent(s) fail to enroll in Medicare, the Medicare eligible State Retiree and their Dependent(s) shall be responsible for any claim expenses that would have been paid under Medicare Parts A or B, had they enrolled in Medicare.

If an employee or covered Dependent's Medicare eligibility is due to End Stage Renal Disease, they must sign up for both Medicare Parts A & B as soon as they are eligible.

No deviations shall be considered.

Non-Medicare COB
When the State Plan is the secondary payor, payments shall be limited to only that balance of claim expenses that will reach the published limits of the State Plan.
No deviations shall be considered.
Are Referrals Required?
No referrals in this plan
No deviations shall be considered.
Mandated Benefits
All mandated benefits, unless otherwise directed by the State. The State Employee and Retiree Health and Welfare Benefits Program follows most Maryland Stare mandates if they apply to the Program. This does not mean that the Program adheres to ALL Maryland-mandated benefits.
No deviations shall be considered.

HOSPITAL INPATIENT SERVICES (Preauthorization Required)

Inpatient Care
90% of allowed benefit
70% of allowed benefit after deducible
Choose an item.
Choose an item.
Hospitalization
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Acute Inpatient Rehab for Stroke and Traumatic Brain Injury Patients when Medically Necessary
90% of allowed benefit
Not covered
Choose an item.
Choose an item.
Anesthesia
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Surgery
90% of allowed benefit
70% of allowed benefit after deducible
Choose an item.
Choose an item.
Organ Transplant
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

HOSPITAL OUTPATIENT SERVICES (Preauthorization Required)

Chemotherapy/ Radiation
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Diagnostic Lab Work and X-rays*
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Outpatient surgery (Preauthorization Required)
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Anesthesia
90% of allowed benefit

70% of allowed benefit after deductible

Choose an item.
Choose an item.

THERAPIES (Preauthorization required)

Benefit Therapies
$30 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Physical Therapy (PT) and Occupational Therapy (OT)
PT/OT services must be pre-certified after the 20th visit, based on medical necessity; 50 visits maximum per plan year combined for PT/OT/Speech Therapy
Choose an item.
Speech Therapy
Must be pre-certified from the first visit with exceptions and close monitoring for special situations (e.g., trauma, brain injury) for additional visits.
Choose an item.

COMMON AND PREVENTIVE SERVICES

Physician Office Visits - Primary Care
100% of allowed benefit after $15 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Physician Office Visits – Specialist
100% of allowed benefit after $30 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Preventive Health Office Visit and Associated Lab (Adult and Child)
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Routine annual GYN Exam (including PAP test)
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

Hearing Examinations (limited to once every three years)

Hearing Aids (one hearing aid per ear every three years)

100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
70% of allowed benefit after deductible
Choose an item.
Choose an item.
100% of allowed benefit for Basic Model Hearing Aid
70% of allowed benefit after deductible for Basic Model Hearing Aid
Choose an item.
Choose an item.

A basic model hearing aid is a hearing aid worn on the exterior of the ear and is used primarily for hearing amplification. It does not include implant devices. The basic model hearing aid shall not require prior authorization.

Includes Maryland mandated benefit for hearing aids for minor children (ages 0-18), including hearing aids per each impaired ear for minor children.

No deviations shall be considered.

Immunizations
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The immunization benefit covers immunizations required for participation in school athletics and Lyme Disease immunizations when medically necessary.
No deviations shall be considered.

Flu Shots

100% of allowed benefit
Not Covered
Choose an item.
Choose an item.
Mammography Preventive
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Screening: One each year 35+.
No deviations shall be considered.
Mammography Diagnostic
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
No age or frequency limitation on diagnostic mammograms.
No deviations shall be considered.
Physical Exams
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
One exam per plan year for all Members and their Dependents age three (3) and older.
No deviations shall be considered.
Well Baby Care
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Birth – 36months: 13 visits total
No deviations shall be considered.

Sexually Transmitted Infections Screening and Counseling (Including HPV DNA[footnoteRef:1] and HIV[footnoteRef:2]) [1: HPV DNA – Human Papillomavirus (HPV) DNA] [2: HIV – Human Immunodeficiency Virus]

100% of allowed benefit
Not Covered
Choose an item.
Choose an item.
Counseling and screening for sexually active women as mandated by PPACA.
No deviations shall be considered.
Allergy Testing
100% after $15 copay (PCP) or $30 copay (Specialist)
70% of allowed benefit after deductible
Choose an item.
Choose an item.

EMERGENCY TREATMENT

Urgent Care Office Visit
100% of allowed benefit after $30 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Emergency Room (ER) Services –In and Out of Network
100% of allowed benefit after $150 copay
100% of allowed benefit after $150 copay
Choose an item.
Choose an item.
Copays are waived if admitted.
No deviations shall be considered.
If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the $150 copays.
Choose an item.
Choose an item.
Observation – up to 23 hours and 59 minutes - presented via Emergency Department
100% of allowed benefit after $150 copay
Choose an item.
Choose an item.
Choose an item.
Observation – 24 hours or more - presented via Emergency Department
90% of allowed benefit
Choose an item.
Choose an item.
Choose an item.
Ambulance Services – Emergency Transport
100% of allowed benefit
Choose an item.
Choose an item.
Choose an item.
Ambulance Services – Non-Emergency Transport
90% of allowed benefit
Choose an item.
Choose an item.
Choose an item.

MATERNITY BENEFITS

Maternity Benefits
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Prenatal Care
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Newborn Care
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Breastfeeding Support and Counseling (per birth)
100% of allowed benefit
Not Covered
Choose an item.
Choose an item.
Breastfeeding Supplies (per birth)
100% of allowed benefit
Not Covered
Choose an item.
Choose an item.
Covers the cost of rental or purchase of certain breastfeeding pumps and pump equipment through carrier’s Durable Medical Equipment (DME) partner(s).
No deviations shall be considered.

OTHER SERVICES AND SUPPLIES

Acupuncture Services for Chronic Pain Management
100% of allowed benefit after $30 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Chiropractic Services
100% of allowed benefit after $30 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Cardiac Rehabilitation
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Dental Services
Not covered except as a result of accident or injury or as mandated by Maryland or federal law.
No deviations shall be considered.
Diabetic Nutritional Counseling
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Durable Medical Equipment
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Must be medically necessary as determined by the attending physician
No deviations shall be considered.
Extended Care Facilities
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Skilled nursing care and extended care facility benefits are limited to 180 days per calendar year as long as skilled nursing care is medically necessary. Inpatient care primarily for or solely for rehabilitation is not covered.
No deviations shall be considered.
Family Planning
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

Contraception

100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Includes Intrauterine Device (IUD) insertion and tubal ligation. For information on coverage of prescription contraceptives refer to the prescription drug benefit summary on the State’s website.
No deviations shall be considered.
Contraceptive Counseling
100% of allowed benefit
Not Covered
Choose an item.
Choose an item.
Fertility Testing (Preauthorization Required)
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
In-Vitro Fertilization (IVF) and Artificial Insemination (AI) (Preauthorization Required)
90% of allowed benefit (outpatient hospital) or

100% after $30 of allowed benefit copay (physician office)

70% of allowed benefit after deductible
Choose an item.
Choose an item.

IVF and AI benefits are limited to 6 attempts of AI, and 3 attempts of IVF per live birth. Not covered following reversal of elective sterilization

Covered per Maryland state mandate, Insurance article § 15-810.

No deviations shall be considered.

Hospice Care (Preauthorization Required)
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

Home Healthcare (Preauthorization Required)

90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Home Healthcare benefits are limited to 120 days per plan year.
No deviations shall be considered.
Medical Supplies
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Including surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law.
No deviations shall be considered.

Private Duty Nursing

90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

Whole Blood Charges

90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.

MENTAL HEALTH AND SUBSTANCE USE DISORDERS

Office Visit
100% of allowed benefit after $15 copay
70% of allowed benefit after deductible
Choose an item.
Choose an item.

Inpatient Hospital Care

90% of allowed benefit

70% of allowed benefit after deductible
No deviations shall be considered.

Partial Hospitalization Services

90% of allowed benefit

70% of allowed benefit after deductible

Outpatient Services (Including Intensive Outpatient Services)
90% of allowed benefit
70% of allowed benefit after deductible
Residential Crisis Services
90% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Habilitative Services, which include occupational therapy, physical therapy, speech therapy, and applied behavior analysis, are covered for children under the age of 19 with congenital or genetic birth defects including autism, autism spectrum disorder, and cerebral palsy.
No deviations shall be considered.

VISION SERVICES– ADULT

Vision - Medical (services related to the medical health of the eye)

100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Vision - Routine Exam (per plan year)
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Frames (one per plan year)
100% of allowed benefit up to $45
70% of allowed benefit after deductible up to $45
Choose an item.
Choose an item.
Prescription Lenses
100% of allowed benefit up to $52 Single Vision, $82 Bifocal, $101 Trifocal, or $181 Lenticular
70% of allowed benefit up to $52 Single Vision, $82 Bifocal, $101 Trifocal, or $181 Lenticular
Choose an item.
Choose an item.
Contact Lenses
100% of allowed benefit up to $285 Medically Necessary, or $97 Cosmetic
70% of allowed benefit up to $285 Medically Necessary, or $97 Cosmetic
Choose an item.
Choose an item.
Obtain vision services from the provider of your choice. Pay entire cost upfront, then submit claim for reimbursement up to the above-allowed amounts. Contacts in lieu of Frames or Lenses.
No deviations shall be considered

VISION SERVICES– PEDIATRIC

Vision – Medical “sick” visit
100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Vision – Routine exam (one per plan year)
100% of allowed benefit
70% of allowed benefit after deductible
Choose an item.
Choose an item.
Frames (one per plan year)
100% of allowed benefit up to $70
70% of allowed benefit after deductible up to $70
Choose an item.
Choose an item.
Basic Prescription Lenses
100% priced at charge
100% priced at charge
Choose an item.
Choose an item.
Contact Lenses
100% of annual supply (2 refills per plan year)
70% of annual supply (2 refills per plan year)
Choose an item.
Choose an item.
Limited to Dependent children age 18 and under. Medically necessary Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses.
No deviations shall be considered

*In-network laboratory testing services related to diabetes, hypertension, coronary artery disease, asthma and Chronic Obstructive Pulmonary Disease are paid at 100%, including test strips for diabetics.

EPO Current Benefits
EPO Proposed Deviations
TYPE OF SERVICE
IN-NETWORK ONLY
IN-NETWORK

MAJOR MEDICAL

Annual Deductible

Individual
None
Choose an item.
Family
None
Choose an item.

Yearly Maximum Out-of-Pocket Costs

Copayment OOP

Individual
$1,500
Choose an item.
Family
$3,000
Choose an item.

Total Medical OOP

Individual
$1,500
Choose an item.
Family
$3,000
Choose an item.
Lifetime Benefit Maximum
Unlimited
Choose an item.
Dependent Coverage
Dependents are eligible for coverage according to COMAR 17.04.13.01 and .03.
No deviations shall be considered.
Medicare COB
Retirees or their Dependent(s) must enroll in Medicare Parts A & B upon becoming eligible for Medicare due to age or disability. If the Medicare eligible State Retiree and their Dependent(s) fail to enroll in Medicare, the Medicare eligible State Retiree and their Dependent(s) shall be responsible for any claim expenses that would have been paid under Medicare Parts A or B, had they enrolled in Medicare.

If an employee, a Retiree or covered Dependent's Medicare eligibility is due to ESRD, they must sign up for both Medicare Parts A & B as soon as they are eligible.

No deviations shall be considered.

Non-Medicare COB
When the State Plan is the secondary payor, payments shall be limited to only that balance of claim expenses that shall reach the published limits of the State Plan.
No deviations shall be considered.
Are Referrals Required?
No referrals in this plan
No deviations shall be considered.
Mandated Benefits
All mandated benefits, unless otherwise directed by the State.
No deviations shall be considered.

HOSPITAL INPATIENT SERVICES (Preauthorization Required)

Inpatient Care
100% of allowed benefit
Choose an item.
Hospitalization
100% of allowed benefit
Choose an item.

Acute Inpatient Rehab for Stroke and Traumatic Brain Injury Patients when Medically Necessary

100% of allowed benefit
Choose an item.
Anesthesia
100% of allowed benefit
Choose an item.
Surgery
100% of allowed benefit
Choose an item.
Organ Transplant
100% of allowed benefit
Choose an item.

HOSPITAL OUTPATIENT SERVICES (Preauthorization Required)

Chemotherapy/ Radiation
100% of allowed benefit
Choose an item.
Diagnostic Lab Work and X-rays*
100% of allowed benefit
Choose an item.
Outpatient surgery(Preauthorization Required)
100% of allowed benefit
Choose an item.
Anesthesia
100% of allowed benefit
Choose an item.

THERAPIES (Preauthorization required)

Benefit Therapies
$30 copay
Choose an item.
Physical Therapy (PT) and Occupational Therapy (OT)
PO/OT services must be pre-certified after the 20th visit, based on medical necessity; 50 visits maximum per plan year combined for PT/OT/Speech Therapy
Choose an item.
Speech Therapy
Must be pre-certified from the first visit with exceptions and close monitoring for special situations (e.g., trauma, brain injury) for additional visits.
Choose an item.

COMMON AND PREVENTIVE SERVICES

Physician Office Visits - Primary Care
100% of allowed benefit after $15 copay
Choose an item.
Physician Office Visits – Specialist
100% of allowed benefit after $30 copay
Choose an item.
Preventive Health Office Visit and Associated Lab (Adult and Child)
100% of allowed benefit
Choose an item.
Routine annual GYN Exam (including PAP test)
100% of allowed benefit
Choose an item.

Hearing Examinations (limited to once every three years)

Hearing Aids (limited to once every three years per year)

100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
Choose an item.
100% of allowed benefit for Basic Model Hearing Aid
Choose an item.

A basic model hearing aid is a hearing aid worn on the exterior of the ear and is used primarily for hearing amplification. It does not include implant devices. The basic model hearing aid shall not require prior authorization.

Includes Maryland mandated benefit for hearing aids for minor children (ages 0-18), including hearing aids per each impaired ear for minor children.

No deviations shall be considered.

Immunizations
100% of allowed benefit
Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The immunization benefit covers immunizations required for participation in school athletics and Lyme Disease immunizations when medically necessary.
No deviations shall be considered.

Flu Shots

100% of allowed benefit
Choose an item.

Mammography Preventive

100% of allowed benefit
Choose an item.
Screening: One each year 35+.
No deviations shall be considered.

Mammography Diagnostic 100% of allowed benefit

No age or frequency limitation on diagnostic mammograms.
No deviations shall be considered.
Physical Exams
100% of allowed benefit
One exam per plan year for all Members and their Dependents age three (3) and older.
No deviations shall be considered.
Well Baby Care
100% of allowed benefit
Birth – 36months: 13 visits total
No deviations shall be considered.
STI Screening and Counseling (Including HPV DNA and HIV)
100% of allowed benefit
Counseling and screening for sexually active women as mandated by PPACA.
No deviations shall be considered.
Allergy Testing
100% after $15 copay (PCP) or $30 copay (Specialist)

EMERGENCY TREATMENT

Urgent Care Office Visit
100% of allowed benefit after $30 copay
Emergency Room (ER) Services –In and Out of Network
100% of allowed benefit after $150 copay
Copays are waived if admitted.
No deviations shall be considered.

If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the $150 copays.

If Out-of-Network and true emergency, charges should be paid in full as opposed to allowed amount.
No deviations shall be considered.
Observation – up to 23 hours and 59 minutes - presented via Emergency Department
100% of allowed benefit after $150 copay
Observation – 24 hours or more - presented via Emergency Department
100% of allowed benefit
Choose an item.
Ambulance Services – Emergency Transport
100% of allowed benefit
Choose an item.
Ambulance Services – Non-Emergency Transport
100% of allowed benefit
Choose an item.

MATERNITY BENEFITS

Maternity Benefits
100% of allowed benefit
Choose an item.
Prenatal Care
100% of allowed benefit
Choose an item.
Newborn Care
100% of allowed benefit
Choose an item.
Breastfeeding Support, and Counseling (per birth)
100% of allowed benefit
Choose an item.
Breastfeeding Supplies (per birth)
100% of allowed benefit
Choose an item.
Covers the cost of rental/purchase of certain breastfeeding pumps and pump equipment through carrier’s DME partner(s).
No deviations shall be considered.

OTHER SERVICES AND SUPPLIES

Acupuncture Services for Chronic Pain Management
100% of allowed benefit after $30 copay
Choose an item.
Chiropractic Services
100% of allowed benefit after $30 copay
Choose an item.
Cardiac Rehabilitation
100% of allowed benefit
Choose an item.
Dental Services
Not covered except as a result of accident or injury or as mandated by Maryland or federal law.
No deviations shall be considered.
Diabetic Nutritional Counseling
100% of allowed benefit
Choose an item.
Durable Medical Equipment
100% of allowed benefit
Choose an item.
Must be medically necessary as determined by the attending physician
No deviations shall be considered.
Extended Care Facilities
100% of allowed benefit
Skilled nursing care and extended care facility benefits are limited to 180 days per calendar year as long as skilled nursing care is medically necessary. Inpatient care primarily for or solely for rehabilitation is not covered.
No deviations shall be considered.
Family Planning
100% of allowed benefit

Contraception 100% of allowed benefit

Includes IUD insertion and tubal ligation. For information on coverage of prescription contraceptives, see the prescription drug benefits summary on the State’s website.
No deviations shall be considered.
Contraceptive Counseling
100% of allowed benefit
Choose an item.
Fertility Testing (Preauthorization Required)
100% of allowed benefit
Choose an item.
In-Vitro Fertilization (IVF) and Artificial Insemination (AI) (Preauthorization Required)
100% of allowed benefit (outpatient hospital) or 100% of allowed benefit after $30 copay (physician office)
Choose an item.

IVF and AI benefits are limited to 6 attempts of AI, and 3 attempts of IVF per live birth. Not covered following reversal of elective sterilization

Covered per Maryland state mandate, Insurance article § 15-810.

No deviations shall be considered.

Hospice Care (Preauthorization Required)

100% of allowed benefit
Choose an item.

Home Healthcare (Preauthorization Required)

100% of allowed benefit
Choose an item.
Home Healthcare benefits are limited to 120 days per plan year.
No deviations shall be considered.

Medical Supplies

100% of allowed benefit

Includes surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law.
No deviations shall be considered.
Private Duty Nursing
100% of allowed benefit
Choose an item.
Whole Blood Charges
100% of allowed benefit
Choose an item.

MENTAL HEALTH AND SUBSTANCE USE DISORDERS

Office Visit
100% of allowed benefit after $15 copay
Choose an item.
Inpatient Hospital Care
100% of allowed benefit
No deviations shall be considered.
Partial Hospitalization Services
100% of allowed benefit
Outpatient Services (Including Intensive Outpatient Services)
100% of allowed benefit
Residential Crisis Services
100% of allowed benefit
Habilitative Services, which include occupational therapy, physical therapy, speech therapy, and applied behavior analysis, are covered for children under the age of 19 with congenital or genetic birth defects including autism, autism spectrum disorder, and cerebral palsy.
No deviations shall be considered.

VISION SERVICES– ADULT

Vision - Medical (services related to the medical health of the eye)

100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
Choose an item.
Vision - Routine Exam (per plan year)
100% of allowed benefit
Choose an item.
Frames (one per plan year)
100% of allowed benefit up to $45
Choose an item.
Prescription Lenses
100% of allowed benefit up to $52 Single Vision, $82 Bifocal, $101 Trifocal, or $181 Lenticular
Choose an item.
Contact Lenses
100% of allowed benefit up to $285 Medically Necessary, or $97 Cosmetic
Choose an item.
Obtain vision services from provider of your choice. Pay entire cost up front, then submit claim to carrier for reimbursement up to the above allowed amounts. Contacts in lieu of Frames/Lenses.
No deviations shall be considered

VISION SERVICES – PEDIATRIC

Vision – Medical “sick” visit
100% of allowed benefit after $15 copay (PCP) or $30 copay (Specialist)
Choose an item.
Vision – Routine exam (one per plan year)
100% of allowed benefit
Choose an item.
Frames (one plan per year)
100% of allowed benefit up to $70
Choose an item.
Basic Prescription Lenses
100% priced at charge
Choose an item.
Contact Lenses
100% of annual supply (2 refills per plan year)
Choose an item.
Limited to Dependent children age 18 and under. Medically necessary Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses.
No deviations shall be considered

In-network laboratory testing services related to diabetes, hypertension, coronary artery disease, asthma and Chronic Obstructive Pulmonary Disease are paid at 100%, including test strips for diabetics.

HEALTH PLAN ADMINISTRATION AND SERVICES RFP, SOLICITATION #: F10B6600001: FUNCTIONAL AREA 1 – SELF-FUNDED PPO AND EPO, TECHNICAL PROPOSAL

SOM Medical RFPPart 2 – Page 75FA1 EXHIBIT 5Attachment T-3
Solicitation No. F10B660000120FA1 EXHIBIT 5-3

FA1 EXHIBIT 5-4: Participating Physicians Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions:

A. Please define your organization’s criteria for designating high quality, high efficiency, and low-cost physicians (e.g., tiered or centers of excellence, “providers of distinction”, “premium providers”, Patient Centered Medical Home Models):

Click here

B. Provide the total number of participating physicians by specialty:

Total Number of Participating Physicians

County/ Metro Area

Family Practice, General Practice
General Internal Medicine
General Pediatrics
Obstetrics/Gynecology
All Other Specialists
Total Physicians

Central Maryland

Anne Arundel County
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore City
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore County
Click here
Click here
Click here
Click here
Click here
Click here
Carroll County
Click here
Click here
Click here
Click here
Click here
Click here
Harford County
Click here
Click here
Click here
Click here
Click here
Click here
Howard County
Click here
Click here
Click here
Click here
Click here
Click here

Eastern Shore

Caroline County
Click here
Click here
Click here
Click here
Click here
Click here
Cecil County
Click here
Click here
Click here
Click here
Click here
Click here
Dorchester County
Click here
Click here
Click here
Click here
Click here
Click here
Kent County
Click here
Click here
Click here
Click here
Click here
Click here
Queen Anne's County
Click here
Click here
Click here
Click here
Click here
Click here
Somerset County
Click here
Click here
Click here
Click here
Click here
Click here
Talbot County
Click here
Click here
Click here
Click here
Click here
Click here
Wicomico County
Click here
Click here
Click here
Click here
Click here
Click here
Worcester County
Click here
Click here
Click here
Click here
Click here
Click here

Southern Maryland

Calvert County
Click here
Click here
Click here
Click here
Click here
Click here
Charles County
Click here
Click here
Click here
Click here
Click here
Click here
St. Mary's County
Click here
Click here
Click here
Click here
Click here
Click here

Washington Metro

District of Columbia
Click here
Click here
Click here
Click here
Click here
Click here
Montgomery County
Click here
Click here
Click here
Click here
Click here
Click here
Prince George's County
Click here
Click here
Click here
Click here
Click here
Click here

Western Maryland

Allegany County
Click here
Click here
Click here
Click here
Click here
Click here
Frederick County
Click here
Click here
Click here
Click here
Click here
Click here
Garrett County
Click here
Click here
Click here
Click here
Click here
Click here
Washington County
Click here
Click here
Click here
Click here
Click here
Click here

Totals Per Practice

C. Of the participating physicians by specialty, provide the total number who are designated as high quality, high efficiency, and low cost:

Total Number of High Quality, High Efficiency, and Low-Cost Physicians

County/ Metro Area

Family Practice, General Practice
General Internal Medicine
General Pediatrics
Obstetrics/Gynecology
All Other Specialists
Total Physicians

Central Maryland

Anne Arundel County
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore City
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore County
Click here
Click here
Click here
Click here
Click here
Click here
Carroll County
Click here
Click here
Click here
Click here
Click here
Click here
Harford County
Click here
Click here
Click here
Click here
Click here
Click here
Howard County
Click here
Click here
Click here
Click here
Click here
Click here

Eastern Shore

Caroline County
Click here
Click here
Click here
Click here
Click here
Click here
Cecil County
Click here
Click here
Click here
Click here
Click here
Click here
Dorchester County
Click here
Click here
Click here
Click here
Click here
Click here
Kent County
Click here
Click here
Click here
Click here
Click here
Click here
Queen Anne's County
Click here
Click here
Click here
Click here
Click here
Click here
Somerset County
Click here
Click here
Click here
Click here
Click here
Click here
Talbot County
Click here
Click here
Click here
Click here
Click here
Click here
Wicomico County
Click here
Click here
Click here
Click here
Click here
Click here
Worcester County
Click here
Click here
Click here
Click here
Click here
Click here

Southern Maryland

Calvert County
Click here
Click here
Click here
Click here
Click here
Click here
Charles County
Click here
Click here
Click here
Click here
Click here
Click here
St. Mary's County
Click here
Click here
Click here
Click here
Click here
Click here

Washington Metro

District of Columbia
Click here
Click here
Click here
Click here
Click here
Click here
Montgomery County
Click here
Click here
Click here
Click here
Click here
Click here
Prince George's County
Click here
Click here
Click here
Click here
Click here
Click here

Western Maryland

Allegany County
Click here
Click here
Click here
Click here
Click here
Click here
Frederick County
Click here
Click here
Click here
Click here
Click here
Click here
Garrett County
Click here
Click here
Click here
Click here
Click here
Click here
Washington County
Click here
Click here
Click here
Click here
Click here
Click here

Totals per Practice

D. Of the participating physicians by specialty, provide the total number who are accepting new patients:

Total Number of Participating Physicians

County/ Metro Area

Family Practice, General Practice
General Internal Medicine
General Pediatrics
Obstetrics/Gynecology
All Other Specialists
Total Physicians

Central Maryland

Anne Arundel County
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore City
Click here
Click here
Click here
Click here
Click here
Click here
Baltimore County
Click here
Click here
Click here
Click here
Click here
Click here
Carroll County
Click here
Click here
Click here
Click here
Click here
Click here
Harford County
Click here
Click here
Click here
Click here
Click here
Click here
Howard County
Click here
Click here
Click here
Click here
Click here
Click here

Eastern Shore

Caroline County
Click here
Click here
Click here
Click here
Click here
Click here
Cecil County
Click here
Click here
Click here
Click here
Click here
Click here
Dorchester County
Click here
Click here
Click here
Click here
Click here
Click here
Kent County
Click here
Click here
Click here
Click here
Click here
Click here
Queen Anne's County
Click here
Click here
Click here
Click here
Click here
Click here
Somerset County
Click here
Click here
Click here
Click here
Click here
Click here
Talbot County
Click here
Click here
Click here
Click here
Click here
Click here
Wicomico County
Click here
Click here
Click here
Click here
Click here
Click here
Worcester County
Click here
Click here
Click here
Click here
Click here
Click here

Southern Maryland

Calvert County
Click here
Click here
Click here
Click here
Click here
Click here
Charles County
Click here
Click here
Click here
Click here
Click here
Click here
St. Mary's County
Click here
Click here
Click here
Click here
Click here
Click here

Washington Metro

District of Columbia
Click here
Click here
Click here
Click here
Click here
Click here
Montgomery County
Click here
Click here
Click here
Click here
Click here
Click here
Prince George's County
Click here
Click here
Click here
Click here
Click here
Click here

Western Maryland

Allegany County
Click here
Click here
Click here
Click here
Click here
Click here
Frederick County
Click here
Click here
Click here
Click here
Click here
Click here
Garrett County
Click here
Click here
Click here
Click here
Click here
Click here
Washington County
Click here
Click here
Click here
Click here
Click here
Click here

Totals per Practice

E. For the states and locations shown below, list the total number of participating providers by specialty.

State
Participating Physicians including Family Practice, General Internal Medicine
Pediatricians
OB/GYN
Hospitals
Alabama
Click here
Click here
Click here
Click here
Alaska
Click here
Click here
Click here
Click here
Arizona
Click here
Click here
Click here
Click here
Arkansas
Click here
Click here
Click here
Click here
California
Click here
Click here
Click here
Click here
Colorado
Click here
Click here
Click here
Click here
Connecticut
Click here
Click here
Click here
Click here
Delaware
Click here
Click here
Click here
Click here
District of Columbia
Click here
Click here
Click here
Click here
Florida
Click here
Click here
Click here
Click here
Georgia
Click here
Click here
Click here
Click here
Hawaii
Click here
Click here
Click here
Click here
Idaho
Click here
Click here
Click here
Click here
Illinois
Click here
Click here
Click here
Click here
Indiana
Click here
Click here
Click here
Click here
Iowa
Click here
Click here
Click here
Click here
Kansas
Click here
Click here
Click here
Click here
Kentucky
Click here
Click here
Click here
Click here
Louisiana
Click here
Click here
Click here
Click here
Maine
Click here
Click here
Click here
Click here
Massachusetts
Click here
Click here
Click here
Click here
Michigan
Click here
Click here
Click here
Click here
Minnesota
Click here
Click here
Click here
Click here
Mississippi
Click here
Click here
Click here
Click here
Missouri
Click here
Click here
Click here
Click here
Montana
Click here
Click here
Click here
Click here
Nebraska
Click here
Click here
Click here
Click here
Nevada
Click here
Click here
Click here
Click here
New Hampshire
Click here
Click here
Click here
Click here
New Jersey
Click here
Click here
Click here
Click here
New Mexico
Click here
Click here
Click here
Click here
New York
Click here
Click here
Click here
Click here
North Carolina
Click here
Click here
Click here
Click here
North Dakota
Click here
Click here
Click here
Click here
Ohio
Click here
Click here
Click here
Click here
Oklahoma
Click here
Click here
Click here
Click here
Oregon
Click here
Click here
Click here
Click here
Pennsylvania
Click here
Click here
Click here
Click here
Rhode Island
Click here
Click here
Click here
Click here

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