J-20 Price Evaluation Template_Amend 0001.xlsx

XLSX spreadsheet 34 KB Posted

Attached to
TRICARE Dental Program 6 (TDP6) Request for Proposal (RFP) Federal contract opportunity
Solicitation number
HT9402-22-R-0001
Issued by
Defense Health Agency

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HT940222R0001_Amend0003.pdf PDF
HT940222R0001_Conformed_Amend 0002.pdf PDF
J-20 Price Evaluation Template_Amend 0002.xlsx XLSX spreadsheet
HT940222R0001_Amend 0002.pdf PDF
Industry QA_Amend 0002.pdf PDF
HT940222R0001_Conformed_Amend 0001.pdf PDF
Industry QA_Amend 0001.pdf PDF
HT940222R0001_Amend 0001.pdf PDF
HT940222R0001.pdf PDF
TDP6 J Attachments.zip ZIP file
TDP6 CDRLs.zip ZIP file
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Healthcare Cost & Discount

Solicitation Number: HT9402-20-R-0005
Service: Managed Care Support Contract (MCSC) T-5 West Region
Offeror:
Price Evaluation Template
CLIN X001 Underwritten Healthcare Costs
Health Care Cost Discount
CLIN:10012001300140015001600170018001
RowOption 1Option 2Option 3Option 4Option 5Option 6Option 7Option 8Total
Government's Estimate of Underwritten Healthcare Costs (HCC) Before Any DiscountsA$6,157,528,658$6,415,177,516$6,703,860,504$7,005,534,227$7,320,783,267$7,650,218,514$7,994,478,347$8,354,229,873$57,601,810,906

Projected Allowed Amount for Underwritten HCC Delivered by Network Providers on Non-OHI Claims B $ 5,428,183,236 $ 5,655,314,166 $ 5,909,803,304 $ 6,175,744,452 $ 6,453,652,953 $ 6,744,067,336 $ 7,047,550,366 $ 7,364,690,132 $ 50,779,005,945

Offeror's Proposed Percentage Discount Guarantee (insert offeror's proposed percentage discount guarantee) C 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

Offeror's Proposed Discount Amount: B x C = DD$ 271,409,162$ 282,765,708$ 295,490,165$ 308,787,223$ 322,682,648$ 337,203,367$ 352,377,518$ 368,234,507$ 2,538,950,297
Offeror's Proposed Underwritten Healthcare Costs:
Government HCC Estimate LESS Offeror's Proposed Discount Amount: A - D = EE$ 5,886,119,496$ 6,132,411,808$ 6,408,370,339$ 6,696,747,004$ 6,998,100,619$ 7,313,015,147$ 7,642,100,829$ 7,985,995,366$ 55,062,860,609

Offeror's Proposed Underwritten Healthcare Costs Equals Row E (Link to Section B and Total Proposed Prices worksheets, CLINs X001) F $ 5,886,119,496 $ 6,132,411,808 $ 6,408,370,339 $ 6,696,747,004 $ 6,998,100,619 $ 7,313,015,147 $ 7,642,100,829 $ 7,985,995,366 $ 55,062,860,609

Underwritten Fixed Fee Amount (Link to Section B and Total Proposed Prices worksheets, CLINs X008) G $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0 $ - 0

Total Underwritten Healthcare Cost Inclusive of Fixed FeeH$ 5,886,119,496$ 6,132,411,808$ 6,408,370,339$ 6,696,747,004$ 6,998,100,619$ 7,313,015,147$ 7,642,100,829$ 7,985,995,366$ 55,062,860,609
Comments:
1. Row A: The Government's Estimate of Underwritten Healthcare Costs (HCC) is for the West Region.
2. Row B: The Projected Allowed Amount for Underwritten HCC Delivered by Network Providers on Non-OHI Claims is for the West Region.
3. Row C: The Offeror's proposed discount shall be expressed as a percentage figure.
In Row C, the Government has inputted 5% as a hypothetical, illustrative example. It should be replaced with the Offeror’s proposed percentage discount guarantee.
4. Row D: The Offeror's percentage discount shall be applied to the Projected Allowed Amount for Underwritten Healthcare Delivered by Network Providers on Non-Other Health Insurance (OHI).
5. Rows E and F: The Government's estimate of the underwritten healthcare costs less the Offeror's proposed discount dollar amount equals the Offeror's proposed underwritten healthcare costs.
6. Row F: Link the Offeror's proposed healthcare costs in Row F to "Section B" and "Total Proposed Prices" worksheets, CLIN X001.
7. In Row G, the Offeror shall enter its proposed Underwritten Fixed Fee Dollar Amount for each year of heathcare delivery, which will be linked the Underwritten Fixed Fee in "Section B" and "Total Proposed Prices" worksheets for CLINs X008.
8. Row H will represent the sum of Row F and Row G.

Section B

Solicitation Number: HT9402-22-R0001
Service: TRICARE Dental Plan 6
Offeror:
Price Evaluation Template
Section B - Proposed Prices

Comments:

1. The SF 33/completed Section B of Volume I represents the offeror's proposed price, its offer, not those on the Template.
2. The proposed unit prices shall be carried out to two decimal places ($xx.xx).
3. The offeror's total price shall be calculated as follows: proposed unit price multiplied by the CLIN quantity.
4. The resulting proposed total prices shall be linked to the "Total Proposed Prices" worksheet.
5. The unit and total prices on the Section B worksheet shall match those on the offeror's Completed Section B in Volume I.
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
0001Transition-InFFPLO1$ - 0
0002Reports, Contract Data Requirements List (DD Form 1423)NSP
Total Base Period Price$ - 0
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
1001Single Enrollment PremiumFFPEA2,250,000.00$ - 0
100101Junior Enlisted (E1-E4)FFPEA
100102E5 and above ranksFFPEA
1002Family Enrollment PremiumFFPEA5,592,000.00$ - 0
100201Junior Enlisted (E1-E4)FFPEA
100202E5 and above ranksFFPEA
1003Survivor Benefit-Single Enrollment PremiumFFPEA44,100.00$ - 0
1004Survivor Benefit-Family Enrollment PremiumFFPEA46,620.00$ - 0
1005Reimbursement for Cost in Excess of Allowable Charges for OCONUS ClaimsCRLO1$ 694,140.00$ 694,140.00
1006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 3,564,988.00$ 3,564,988.00
1007NIST and Physical & Personnel SecurityFFPMO12$ - 0
1008IncentivesLO1$ 1,775,000.00$ 1,775,000.00
1009Reports, Contract Data Requirements List (DD Form 1423)NSP
1010Transition-outFFPLO1$ - 0
Total Ordering Period 1 Price$ 6,034,128.00
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
2001Single Enrollment PremiumFFPEA2,272,500.00$ - 0
200101Junior Enlisted (E1-E4)FFPEA
200102E5 and above ranksFFPEA
2002Family Enrollment PremiumFFPEA5,647,920.00$ - 0
200201Junior Enlisted (E1-E4)FFPEA
200202E5 and above ranksFFPEA
2003Survivor Benefit-Single Enrollment PremiumFFPEA44,541.00$ - 0
2004Survivor Benefit-Family Enrollment PremiumFFPEA47,086.20$ - 0
2005Reimbursement for Cost in Excess of Allowable Charges for OCONUS ClaimsCRLO1$ 701,081.40$ 701,081.40
2006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 3,600,637.88$ 3,600,637.88
2007NIST and Physical & Personnel SecurityFFPMO12$ - 0
2008IncentivesLO1$ 1,775,000.00$ 1,775,000.00
2009Reports, Contract Data Requirements List (DD Form 1423)NSP
2010Transition-outFFPLO1$ - 0
Total Ordering Period 2 Price$ 6,076,719.28
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
3001Single Enrollment PremiumFFPEA2,295,225.00$ - 0
300101Junior Enlisted (E1-E4)FFPEA
300102E5 and above ranksFFPEA
3002Family Enrollment PremiumFFPEA5,704,399.20$ - 0
300201Junior Enlisted (E1-E4)FFPEA
300202E5 and above ranksFFPEA
3003Survivor Benefit-Single Enrollment PremiumFFPEA44,986.41$ - 0
3004Survivor Benefit-Family Enrollment PremiumFFPEA47,557.06$ - 0
3005Reimbursement for Cost in Excess of Allowable Charges for OCUNUS ClaimsCRLO1$ 708,092.21$ 708,092.21
3006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 3,636,644.26$ 3,636,644.26
3007NIST and Physical & Personnel SecurityFFPMO12$ - 0
3008IncentivesLO1$ 1,775,000.00$ 1,775,000.00
3009Reports, Contract Data Requirements List (DD Form 1423)NSP
3010Transition-outFFPLO1$ - 0
Total Ordering Period 3 Price$ 6,119,736.47
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
4001Single Enrollment PremiumFFPEA2,318,177.25$ - 0
400101Junior Enlisted (E1-E4)FFPEA
400102E5 and above ranksFFPEA
4002Family Enrollment PremiumFFPEA5,761,443.19$ - 0
400201Junior Enlisted (E1-E4)FFPEA
400202E5 and above ranksFFPEA
4003Survivor Benefit-Single Enrollment PremiumFFPEA45,436.27$ - 0
4004Survivor Benefit-Family Enrollment PremiumFFPEA48,032.63$ - 0
4005Reimbursement for Cost in Excess of Allowable Charges for OCONUS ClaimsCRLO1$ 715,173.14$ 715,173.14
4006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 3,673,010.70$ 3,673,010.70
4007NIST and Physical & Personnel SecurityFFPMO12$ - 0
4008IncentivesLO1$ 1,775,000.00$ 1,775,000.00
4009Reports, Contract Data Requirements List (DD Form 1423)NSP
4010Transition-outFFPLO1$ - 0
Total Ordering Period 4 Price$ 6,163,183.84
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
5001Single Enrollment PremiumFFPEA2,341,359.02$ - 0
500101Junior Enlisted (E1-E4)FFPEA
500102E5 and above ranksFFPEA
5002Family Enrollment PremiumFFPEA5,819,057.62$ - 0
500201Junior Enlisted (E1-E4)FFPEA
500202E5 and above ranksFFPEA
5003Survivor Benefit-Single Enrollment PremiumFFPEA45,890.64$ - 0
5004Survivor Benefit-Family Enrollment PremiumFFPEA48,512.96$ - 0
5005Reimbursement for Cost in Excess of Allowable Charges for OCONUS ClaimsCRLO1$ 722,324.87$ 722,324.87
5006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 3,709,740.81$ 3,709,740.81
5007NIST and Physical & Personnel SecurityFFPMO12$ - 0
5008IncentivesLO1$ 1,775,000.00$ 1,775,000.00
5009Reports, Contract Data Requirements List (DD Form 1423)NSP
5010Transition-outFFPLO1$ - 0
Total Ordering Period 5 Price$ 6,207,065.68
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
6001Single Enrollment PremiumFFPEA1,182,386.31$ - 0
600101Junior Enlisted (E1-E4)FFPEA
600102E5 and above ranksFFPEA
6002Family Enrollment PremiumFFPEA2,938,624.10$ - 0
600201Junior Enlisted (E1-E4)FFPEA
600202E5 and above ranksFFPEA
6003Survivor Benefit-Single Enrollment PremiumFFPEA23,174.77$ - 0
6004Survivor Benefit-Family Enrollment PremiumFFPEA24,499.04$ - 0
6005Reimbursement for Cost in Excess of Allowable Charges for OCONUS ClaimsCRLO1$ 364,774.06$ 364,774.06
6006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS ClaimsCRLO1$ 1,873,419.11$ 1,873,419.11
6007NIST and Physical & Personnel SecurityFFPMO6$ - 0
6008IncentivesLO1$ 887,500.00$ 887,500.00
6009Reports, Contract Data Requirements List (DD Form 1423)NSP
6010Transition-outFFPLO1$ - 0
Total FAR 52.217-8, Option to Extend Services 6 months Price$ 3,125,693.17
Phase-Out CLINs - The Government intends to only exercise one phase out CLIN in the performance of this contract.
CLIN/SLINDescriptionContract TypeU/MQTYUnit PriceTotal Price
7001Residual Services Phase-Out - Ordering Period 1FFPLO1$ - 0
7002Residual Services Phase-Out - Ordering Period 2FFPLO1$ - 0
7003Residual Services Phase-Out - Ordering Period 3FFPLO1$ - 0
7004Residual Services Phase-Out - Ordering Period 4FFPLO1$ - 0
7005Residual Services Phase-Out - Ordering Period 5FFPLO1$ - 0
Total Phase-Out$ - 0
Summary
Total Price
Total Base Period Price$ - 0
Total Ordering Period 1 Price$ 6,034,128.00
Total Ordering Period 2 Price$ 6,076,719.28
Total Ordering Period 3 Price$ 6,119,736.47
Total Ordering Period 4 Price$ 6,163,183.84
Total Ordering Period 5 Price$ 6,207,065.68
Total Contract, without Transition-Out and Residual Phase-Out$ 30,600,833.27
Transition-Out and Residual Phase-Out$ - 0
Total Contract, with Transition-Out and Residual Phase-Out$ 30,600,833.27
6-month Extension - 50% of Ordering Period 5, not including Transition-Out$ 3,125,693.17
Total Evaluated Price (TEP)$ 33,726,526.43

Total Proposed Prices

Solicitation Number: HT9402-22-R0001
Service: TRICARE Dental Plan 6
Offeror:
Price Evaluation Template
Total Proposed Prices
BaseOrdering Period 1Ordering Period 2Ordering Period 3Ordering Period 4Ordering Period 5Option to Extend ServicesGrand
CLINDescriptionTotal PriceTotal PriceTotal PriceTotal PriceTotal PriceTotal PriceTotal PriceTotal Price
0001Transition-In$ - 0$ - 0
0002Reports, Contract Data Requirements List (DD Form 1423)NSP
x001Single Enrollment Premium$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
x002Family Enrollment Premium$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
x003Survivor Benefit-Single Enrollment Premium$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
x004Survivor Benefit-Family Enrollment Premium$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
x005Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims$ 694,140$ 701,081$ 708,092$ 715,173$ 722,325$ 364,774$ 3,905,586
x006Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims$ 3,564,988$ 3,600,638$ 3,636,644$ 3,673,011$ 3,709,741$ 1,873,419$ 20,058,441
x007NIST and Physical & Personnel Security$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
x008Incentives$ 1,775,000$ 1,775,000$ 1,775,000$ 1,775,000$ 1,775,000$ 887,500$ 9,762,500
x009Reports, Contract Data Requirements List (DD Form 1423)NSPNSPNSPNSPNSPNSP
x0010Transition-out$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
Total Option/Contract, without Transition-Out$ - 0$ 6,034,128.00$ 6,076,719.28$ 6,119,736.47$ 6,163,183.84$ 6,207,065.68$ 3,125,693.17$ 30,600,833

Transition-Out $ - 0

Total Contract, with Transition-Out $ 30,600,833

6-month Extension - 50% of Ordering Period 5, not including Transition-Out$ 3,125,693
Total Evaluated Price (TEP)$ 33,726,526
NOTE:
1. The CLIN/SLIN total prices for the above worksheet are derived from/linked to the worksheets in the "Section B" tab.
2. CDRLS are not separately priced (NSP). However, the offeror shall provide an estimated price for each CDRL in its proposal for Government budgetary purposes. See CDRL worksheet tab.

CDRLs

Solicitation Number: HT9402-22-R0001
Service: TRICARE Dental Plan 6
Offeror:
Price Evaluation Template
Contract Data Requirements List (CDRLs)
Estimated Prices for each CDRL
Comments:
1. In accordance with DFARS 215.470, Estimated Data Prices, DoD requires estimates of the prices of data in order
to evaluate the cost to the Government in terms of their management, product, or engineering value.
2. The CDRLs are Not Separately Priced (NSP) in the Section B worksheet or the Completed Section B of Volume I.
3. The Offeror shall provide price/cost estimates for each CDRL for Government budgetary use.
Transition-InOrdering Period 1Ordering Period 2Ordering Period 3Ordering Period 4Ordering Period 5Option to Extend Services
CDRL NumberCDRL TitlePricePricePricePricePricePricePrice
A010Proposed FOIA Releasable Contract$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
A020Risk Assessment Letter of Assurance$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
A030Disaster Recovery Test Results Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
A040Fraud Detection and Prevention Strategy and Int Procedures$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
AP010Beneficiary and Provider Education Plan$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
AP020Continuity of Ops Plan$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
AP030QCP Plan$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
AP040Continuation of Essential Contractor Services Plan$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
AP050System Security Plan and Associated Plans of Action for a Contractor's Internal Unclassified Information System$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M010Management Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M020Provider Network Access Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M030OCONUS Payment Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M040HIPAA Privacy Complaint Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M050Worldwide Incurred-Paid Claims Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M060MDR Data Claims and Provider Files$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M070Enrollment and Fee Reconciliation Analysis Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M080Employee Access to DOD IS Networks Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
M090Transition-Out and Residual Services Status Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
Q010QCP Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
Q020Fraud and Abuse Summary Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
Q030Enrollment Activity Summary Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R010Breach Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R020Identification of Systems of Record Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R030Transition-In IMP and IMS$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R040Transition-Out and Residual Services Plan$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R050National Disaster Action Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R060Threats Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R070DSMO Summary Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R080Ad Hoc Management Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R090Standard Operating Procedures (Desk Procedures)$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R100Consolidated TDP Historical Data File$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R110MOU with DHA Communications$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R120Appeals Processing Guidelines, Desk Instructions and Reference Materials$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R130Declaration of Transfer and Destruction of Records$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R140Random Sample Audit Worksheet$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R150Fraud Abuse Patient Harm - Intl Notice Checklist$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R160DHA MTF Fraud and Abuse Referral Cover Sheet$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R170B2B Gateway Questionnaire$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
R180CLIN Price Structure$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
S010Utilization Report by Uniformed Services AD Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
S020Utilization Report by Uniformed Services NGR Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
S030Utilization CONUS OCONUS Frequency Dollar Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
S040Utilization CONUS OCONUS Denied Services Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
S050Survivor Covered Lives and Utilization Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
W010Transition-In Status Report$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0

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