Attachment_J.15_Business_Proposal_Template.xlsx

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Quality Innovation Network (QIN) Quality Improvement Organizations (QIOs)
Solicitation number
HHSM-500-2014-RFP-QIN-QIO
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Attachment J.15 Business Proposal Template

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F718 BP SUM

1. Name and Address of QIO Organization 3. RFP Number

4: Proposed Contract Period

2. QIO Service Area: From:

To:

Medicare5. Total Proposed6. CMS Recommended7. $8. %
ContractCostsCostsDifferenceDIfference

Direct Cost

a. LABOR:
1. Professional$0$0$0ERROR:#DIV/0!
2. Information Systems$0$0$0ERROR:#DIV/0!
3. Corporate Management$0$0$0ERROR:#DIV/0!
4. Support Staff$0$0$0ERROR:#DIV/0!

SUBTOTAL - Direct Labor $0 $0 $0 ERROR:#DIV/0!

b. Leave$0$0$0ERROR:#DIV/0!
c. Fringe Benefits$0$0$0ERROR:#DIV/0!

SUBTOTAL - Leave/Fringe $0 $0 $0 ERROR:#DIV/0!

d. Subcontractors
1. Physician Reviewers/ Phys.Advisors$0$0$0ERROR:#DIV/0!
1. Other Consultants$0$0$0ERROR:#DIV/0!
2. Other Subcontracts$0$0$0ERROR:#DIV/0!

SUBTOTAL - Subcontractors $0 $0 $0 ERROR:#DIV/0!

e. Travel$0$0$0ERROR:#DIV/0!
f. Other Direct Costs$0$0$0ERROR:#DIV/0!

SUBTOTAL - DIRECT $0 $0 $0 ERROR:#DIV/0!

g. Indirect Costs$0$0$0ERROR:#DIV/0!
h. Pass-thru Costs$0$0$0ERROR:#DIV/0!

TOTAL COSTS $0 $0 $0 ERROR:#DIV/0!

h. Fee $0 $0 $0 ERROR:#DIV/0!

TOTAL COST WITH FEE $0 $0 $0 ERROR:#DIV/0!

9.
10. Signature of Authorized Official:CMS USE ONLY
Fringe Rate
14. Proposal Receipt Date:
Indirect Rate11. Type or Print Name and Title:

Other Rate 15. Review By:

Indirect Leave Rate
12. DATE:13. Telephone #
16. Signature/Title:

&"Arial,Bold"QUALITY IMPROVEMENT ORGANIZATION 10th SOW BUSINESS PROPOSAL SUMMARY &"Arial,Regular"CENTERS FOR MEDICARE and MEDICAID SERVICES &G

Form 718 BP &9Prepared on:

QIO F719

1. RFP Number:2. Name and Address of QIO Organization:
00
0
0
4. Contract Period
3. QIO Service Area:From:12/31/99
0To:12/31/99
Group 1Group 2Group 2Group 2Group 2Group 2Group 3Group 4Group 4Group 4Group 5Group 6
Quality Improvement NetworksInformation ServicesTitle3Title4Title5Title6Title7Title8Title9Title10Title11Title12TOTAL

MEDICARE COSTS

HOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTSHOURSCOSTS
a. LABOR:
1. Professional0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
2. Information Systems0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
3. Corporate Management0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
4. Support Staff0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
SUBTOTAL - Direct Labor0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
b. Leave0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
c. Fringe Benefits$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - Leave / Fringe0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.00.00.0$ - 0
d. Subcontracts:
1. Physician Reviewers / Phys. Advisors0.0$00.0$ - 0
1. Other Consultants0.0$00.0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
2. Other Subcontractors0.0$00.0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - Subcontracts0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$ - 0
e. Travel$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
f. Other Direct Costs$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0
SUBTOTAL - DIRECT0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0

g. Indirect Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

h. Pass-thru Costs $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

TOTAL COSTS0.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$00.0$0
h. Fee$0$0$0$0$0$0$0$0$0$0$0$0$0$0$ - 0

TOTAL COSTS WITH FEE $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $ - 0

&11Quality Improvement Organization 10th SOW Business Proposal&10 Centers for Medicare and Medicaid Services &G

&11Form 719 BP Page &P Prepared on:

QIO F720

FRINGE BENEFIT PROPOSAL
QIN QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP Number
00
0
04: Proposed Contract Period

2. QIO Service Area: 0 From: 12/31/99

To: 12/31/99

6. Prior Year7. Projected8. Prior Year9. Projected
DETAIL COSTSTotalTotal 5-YRTotalTotal 5-YR
Organization CostsOrganization CostsMedicare CostsMedicare Costs
Fringe Benefits
a. Employer's FICA Expense$0$0
b. Federal Unemployment Insurance$0$0
c. State Unemployment Insurance$0$0
d. Disability Insurance$0$0
e. Pension Expense$0$0
f. Workers Compensation$0$0
g. Group Health Insurance$0$0
h. Group Life Insurance$0$0
i. Empl. Relations & Welfare$0$0
j. Leave$0$0
k. Other - see attached$0$0
l. Total Fringe Benefits$0$0
m. Fringe Benefit Rate0.00%0.00%0.00%0.00%

&G

Form 720 BP &D

QIO F721 a

INDIRECT AND OTHER DIRECT COST
QIN QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP Number
00
0
04: Proposed Contract Period

2. QIO Service Area: 0 From: 12/31/99

To: 12/31/99

5. Prior Year6. Projected7. Prior Year8. Projected9. Prior Year10. Projected
DETAIL COSTSTotalTotal 5yr.MedicareMedicare 5yrMedicareMedicare 5yr
Indirect CostsIndirect CostsIndirect CostsIndirect CostsOther Direct.Other Direct.
a. Indirect Labor$0$0
b. Indirect Leave$0$0
c. Indirect Fringe$0$0
d. Rent$0$0$0$0
e. Storage$0$0$0$0
f. Utilities$0$0$0$0
g. Maintenance & Repairs$0$0$0$0
h. Depreciation$0$0$0$0
i. Data Processing$0$0$0$0
j. Equipment Leasing & Rental$0$0$0$0
k. Office Supplies$0$0$0$0
l. Reproduction & Printing$0$0$0$0
m. Telephone$0$0$0$0
n. Postage & Express Mail$0$0$0$0
o. Consultants$0$0
p. Meeting & Conferences$0$0$0$0
q. Travel$0$0
r. Training$0$0$0$0
s. Garage & Parking Spaces$0$0$0$0
t. Dues & Subscriptions$0$0$0$0
u. Recruiting$0$0$0$0
v. Temporary Help$0$0$0$0
w. Continuing Education$0$0$0$0
x. Legal Fees$0$0$0$0
y. Accounting/Audit Fees$0$0$0$0
z. Board of Directors Fees$0$0$0$0
aa. Insurance$0$0$0$0
bb. Bank Charges$0$0$0$0
cc. Other - see attached$0$0$0$0

dd. ** TOTAL $0 $0 $0 $0

ee. Indirect Cost Rate 0.00% 0.00%

&G

Form 721 BP &D

QIO F721 b

INDIRECT AND OTHER DIRECT COST
QIN QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP Number
00
0
04: Proposed Contract Period

2. QIO Service Area: 0 From: 12/31/99

To: 12/31/99

5. Prior Year6. Projected7. Prior Year8. Projected9. Prior Year10. Projected
DETAIL COSTSTotalTotal 5yr.MedicareMedicare 5yrMedicareMedicare 5yr
Indirect CostsIndirect CostsIndirect CostsIndirect CostsOther Direct.Other Direct.
a. Indirect Labor$0$0
b. Indirect Leave$0$0
c. Indirect Fringe$0$0
d. Rent$0$0
e. Storage$0$0
f. Utilities$0$0
g. Maintenance & Repairs$0$0
h. Depreciation$0$0
i. Data Processing$0$0
j. Equipment Leasing & Rental$0$0
k. Office Supplies$0$0
l. Reproduction & Printing$0$0
m. Telephone$0$0
n. Postage & Express Mail$0$0
o. Consultants$0$0
p. Meeting & Conferences$0$0
q. Travel$0$0
r. Training$0$0
s. Garage & Parking Spaces$0$0
t. Dues & Subscriptions$0$0
u. Recruiting$0$0
v. Temporary Help$0$0
w. Continuing Education$0$0
x. Legal Fees$0$0
y. Accounting/Audit Fees$0$0
z. Board of Directors Fees$0$0
aa. Insurance$0$0
bb. Bank Charges$0$0
cc. Other - see attached$0$0

dd. ** TOTAL $0 $0

ee. Indirect Cost Rate 0.00% 0.00%

&D

QIO F721 c

INDIRECT AND OTHER DIRECT COST
QIN QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP Number
00
0
04: Proposed Contract Period

2. QIO Service Area: 0 From: 12/31/99

To: 12/31/99

5. Prior Year6. Projected7. Prior Year8. Projected9. Prior Year10. Projected
DETAIL COSTSTotalTotal 5yr.MedicareMedicare 5yrMedicareMedicare 5yr
Indirect CostsIndirect CostsIndirect CostsIndirect CostsOther Direct.Other Direct.
a. Indirect Labor$0$0
b. Indirect Leave$0$0
c. Indirect Fringe$0$0
d. Rent$0$0
e. Storage$0$0
f. Utilities$0$0
g. Maintenance & Repairs$0$0
h. Depreciation$0$0
i. Data Processing$0$0
j. Equipment Leasing & Rental$0$0
k. Office Supplies$0$0
l. Reproduction & Printing$0$0
m. Telephone$0$0
n. Postage & Express Mail$0$0
o. Consultants$0$0
p. Meeting & Conferences$0$0
q. Travel$0$0
r. Training$0$0
s. Garage & Parking Spaces$0$0
t. Dues & Subscriptions$0$0
u. Recruiting$0$0
v. Temporary Help$0$0
w. Continuing Education$0$0
x. Legal Fees$0$0
y. Accounting/Audit Fees$0$0
z. Board of Directors Fees$0$0
aa. Insurance$0$0
bb. Bank Charges$0$0
cc. Other - see attached$0$0

dd. ** TOTAL $0 $0

ee. Indirect Cost Rate 0.00% 0.00%

&D

QIO F721 d

INDIRECT AND OTHER DIRECT COST
QIN QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL
CENTERS FOR MEDICARE & MEDICAID SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
1. Name and Address of QIO Organization3. RFP Number
00
0
04: Proposed Contract Period

2. QIO Service Area: 0 From: 12/31/99

To: 12/31/99

5. Prior Year6. Projected7. Prior Year8. Projected9. Prior Year10. Projected
DETAIL COSTSTotalTotal 5yr.MedicareMedicare 5yrMedicareMedicare 5yr
Indirect CostsIndirect CostsIndirect CostsIndirect CostsOther Direct.Other Direct.
a. Indirect Labor$0$0
b. Indirect Leave$0$0
c. Indirect Fringe$0$0
d. Rent$0$0
e. Storage$0$0
f. Utilities$0$0
g. Maintenance & Repairs$0$0
h. Depreciation$0$0
i. Data Processing$0$0
j. Equipment Leasing & Rental$0$0
k. Office Supplies$0$0
l. Reproduction & Printing$0$0
m. Telephone$0$0
n. Postage & Express Mail$0$0
o. Consultants$0$0
p. Meeting & Conferences$0$0
q. Travel$0$0
r. Training$0$0
s. Garage & Parking Spaces$0$0
t. Dues & Subscriptions$0$0
u. Recruiting$0$0
v. Temporary Help$0$0
w. Continuing Education$0$0
x. Legal Fees$0$0
y. Accounting/Audit Fees$0$0
z. Board of Directors Fees$0$0
aa. Insurance$0$0
bb. Bank Charges$0$0
cc. Other - see attached$0$0

dd. ** TOTAL $0 $0

ee. Indirect Cost Rate 0.00% 0.00%

&D

QIO STAFFING

Quality Improvement NetworksQuality Improvement NetworksQuality Improvement NetworksQuality Improvement NetworksQuality Improvement NetworksQuality Improvement NetworksQuality Improvement NetworksQuality Improvement Networks17. Average
4a current4b current4c current4d current5. Proposed5aProposedYr 15bPropYr15c Prop Yr 15d Prop Yr 17. Proposed7aProposedYr7bPropYr27c Prop Yr 27d Prop Yr 29. Proposed9aProposedYr 39bPropYr39c Prop Yr 39d Prop Yr 311. Proposed11aProposedYr 311bPropYr311c Prop Yr 311d Prop Yr 313. Poposed13aProposedYr 313bPropYr313c Prop Yr 313d Prop Yr 315. AverageProf. HoursIS hrsCorp AdminSupport16. Total 5yrProf. LaborIS laborCorp AdminSupportInformation Services
1. Staff2. Position3. Labor4. CurrenthourlyhourlyhourlyhourlyYear 1hourlyhourlyhourlyhourly6. PercentYear 2hourlyhourlyhourlyhourly8. PercentYear 3hourlyhourlyhourlyhourly10. PercentYear 4hourlyhourlyhourlyhourly12. PercentYear 5hourlyhourlyhourlyhourly14. PercentQuality Improvement Networksper yearper yearhours per yrStaff Hrs perQuality Improvement Networkscosts/yr$$ per yearLabor $ per yrStaff Hrs per
NameTitleCategoryHourly RateprofessionalISCorp Adminsupport staffHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHourly RateprofessionalISCorp Adminsupport staffChangeHours Per Yearavgavgavgyr, avgLabor CostsavgavgavgLabor $$yr, avgHours Per Year
1$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
2$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
3$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
4$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
5$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
6$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
7$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
8$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
9$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
10$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!$0.00$0.00$0.00$0.00ERROR:#DIV/0!0000$0$ - 0$ - 0$ - 0$ - 0
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