Med Adv_Pricing 5718.xlsx

XLSX spreadsheet 84 KB Posted Jun 11, 2018

Attached to: T3093 - SHBP and SEHBP Medicare Advantage Plans
Solicitation number: 19DPP00265
Issued by: Mercer County, New Jersey

About this file

Written by GovTribe AI · Apr 3, 2024

This document is a bid solicitation from the New Jersey Department of the Treasury for Medicare Advantage (MA) Plans under the State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP). The bid solicitation seeks proposals from vendors for MA PPO and HMO plans to cover over 200,000 members, with multiple award scenarios being considered. The contract term is for 2 years, with potential extension years.

The bid solicitation outlines specific pricing, budget, and gain sharing requirements for the vendors. Vendors must provide guaranteed premium rates for 2019 and 2020, and are required to submit detailed rate development workbooks and budgets under the various award scenarios. Gain sharing agreements are also required from the vendors. The solicitation provides incumbent enrollment details and notes that prescription drug coverage will remain as a carve-out.

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Other files

File	Type	Posted
T3093 Amend 1.docx	DOCX document	Jun 11, 2018
Attachment 2 PPO CMS ACCESS Match.xlsx	XLSX spreadsheet	Jun 11, 2018
T3093 Amend 2 QA Final.docx	DOCX document	Jun 11, 2018
T3093 SHBP RFP 6-8-18~1.docx	DOCX document	Jun 11, 2018
T3093 Offer and Acceptance Page 060818~1.pdf	PDF	Jun 11, 2018
T3093 Bid Solicitation Checklist 060818.docx	DOCX document	Jun 11, 2018
Attachment 3 Service Area Match.xlsx	XLSX spreadsheet	Jun 11, 2018
Attachment 4 Statement of Assurances.docx	DOCX document	Jun 11, 2018
Attachment 1 CMS STAR rating.xlsx	XLSX spreadsheet	Jun 11, 2018
T3093 SHBP RFP 6-19-18.docx	DOCX document	Jun 11, 2018
T3093 SHBP RFP 6-29-18.docx	DOCX document	Jun 11, 2018

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Instructions

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Price Sheet/Schedule Instructions

Vendor's {Bidder's} Name

Instructions: Complete each tab of this workbook by following the instructions in each tab. Note that the Scenario descriptions outlined in Section 1.1.1 of the Bid Solicitation apply and are listed here for reference. The possible award outcomes should be considered by Vendors {Bidders} when setting premium rates, budgets, and other financial information.

The possible Blanket P.O. Award scenarios are as follows:

(1) Award Scenario 1 (One Medicare Advantage (MA) Vendor {Contractor}): All current MA PPO and HMO plans are awarded to one Vendor {Contractor}

Scenario 1A:

i. All current MA PPO and HMO Members (82,000 Members) are awarded effective 1/1/2019

Scenario 1B:

i. All current MA PPO and HMO Members (82,000 Members) are awarded effective 1/1/2019

ii. All Education Medicare Members currently enrolled in $10/$15 Horizon Medicare Supplement PPO plans (117,000 Members) are awarded effective 1/1/2019

Scenario 1C:

i. All current MA PPO and HMO Members (82,000 Members) are awarded effective 1/1/2019

ii. All Education Medicare Members currently enrolled in $10/$15 Horizon Medicare Supplement PPO plans (117,000 Members) are awarded effective 1/1/2020

(2) Award Scenario 2 (Two MA Vendors {Contractors}): Vendor {Contractor} A is awarded current MA PPO plans and Vendor {Contractor} B is awarded current MA HMO plans

Scenario 2A:

i. Vendor {Contractor} A is awarded all current MA PPO Members (66,000 PPO Members) effective 1/1/2019

ii. Vendor {Contractor} B is awarded all current HMO Members (16,000 HMO Members) effective 1/1/2019

Scenario 2B:

i. Vendor {Contractor} A is awarded all current MA PPO Members (66,000 PPO Members) effective 1/1/2019 and all Education Medicare Members currently enrolled in $10/$15 Horizon Medicare Supplement PPO plans (117,000 Members) effective 1/1/2019

ii. Vendor {Contractor} B is awarded all current HMO Members (16,000 HMO Members) effective 1/1/2019

Scenario 2C:

ii. Vendor {Contractor} B is awarded all current HMO Members (16,000 HMO Members) effective 1/1/2019

(3) Award Scenario 3 (Two MA Vendors{Contractors}): Vendor {Contractor} A is awarded current Horizon membership and Vendor {Contractor} B is awarded current Aetna membership.

Note that Retirees have the option to switch plans once per year and may choose to move between the two Vendors {Contractors};

but current MA membership will be automatically transferred to Vendor {Contractor} A and Vendor {Contractor} B as described.

Scenario 3A:

i. Vendor {Contractor} A is awarded all current Horizon MA PPO Members (58,000 PPO Members) effective 1/1/2019

ii. Vendor {Contractor} B is awarded all current Aetna MA PPO and HMO Members (8,000 PPO Members and 16,000 HMO Members) effective 1/1/2019

Scenario 3B:

i. Vendor {Contractor} A is awarded all current Horizon MA PPO Members (58,000 PPO Members) and all Education Medicare Members currently enrolled in $10/$15 Horizon Medicare Supplement PPO plans (117,000 Members) effective 1/1/2019

ii. Vendor {Contractor} B is awarded all current Aetna MA PPO and HMO Members (8,000 PPO Members and 16,000 HMO Members) effective 1/1/2019

Scenario 3C:

i. Vendor {Contractor} A is awarded all current Horizon MA PPO Members (58,000 PPO Members) effective 1/1/2019 and awarded all Education Medicare Members currently enrolled in $10/$15 Horizon Medicare Supplement PPO plans (117,000 Members) effective 1/1/2020

ii. Vendor {Contractor} B is awarded all current Aetna MA PPO and HMO Members (8,000 PPO Members and 16,000 HMO Members) effective 1/1/2019

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MA Premium

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Medicare Advantage (MA) Premiums

Vendor's {Bidder's} Name

Instructions:

- Complete the Per Member Per Month (PMPM) Premiums below under the scenarios described in Section 1.1.1 of the RFP.

- Vendors {Bidders} are required to provide guaranteed premium rates for Plan Year 2019 and Plan Year 2020.

- Per current regulatory guidance, Vendors {Bidders} must assume there will be no Health Insurer Fee in 2019 and must assume that the Health Insurer Fee will be re-instated in 2020.

- Use the comment box below to supplement your premium rates.

- For Plan Year 2021 and Plan Year 2022, Vendors {Bidders} are required to provide an overview of their rate renewal methodology in the box below. Vendors {Bidders} must differentiate if the methodology varies between the different scenarios. If providing an attachment, please label it.

- For scenarios 2 and 3, Vendors {Bidders} must provide rates assuming they are awarded the Vendor {Contractor} A population and a separate set of rates assuming they are awarded the Vendor {Contractor} B population, as described on the Instructions tab.

Note the following fee requirements:

- Quotes should include medical coverage only - prescription drug will remain as a carve-out with a Pharmacy Benefits Manager (PBM).

- Premiums are mature and assume that no premiums or fees would be charged to the Plan at termination. The Vendor {Contractor} would be required to administer the Plan for a minimum of 12 months at plan termination and as required by State and federal rules and continue to process all claims incurred before Plan termination.

- Premium rates must be all-inclusive; the Vendor {Contractor} may not charge the State separately for administration of any program requirements outlined in the Bid Solicitation.

Group	Average Membership from January through December 2017
		Horizon		Aetna
	Total - All Plans	$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382	15,795	22,853	469	1,025	7,220	19
Local Government	25,578	15,821	3,895	3,102	446	2,241	73
Local Education Current MA	9,156	n/a	n/a	2,326	186	6,620	25
Local Education Current Medicare Supplement	117,500	107,000	10,500	n/a	n/a	n/a	n/a
Total	199,616	138,616	37,247	5,896	1,658	16,081	118

Scenario 1A - One Vendor {Contractor}, Current MA Population Only
Group	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA Only)	9,156
Group	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA Only)	9,156

Scenario 1B - One Vendor {Contractor}, Additional 117,000 Education Medicare Supplement Members Move to MA in 2019
Group	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA + Current Med Supp)	126,656
Group	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA + Current Med Supp)	126,656
Scenario 1C - One Vendor {Contractor}, Additional 117,000 Education Medicare Supplement Members Move to MA in 2020
Group	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA Only)	9,156
Group	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
		$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	47,382
Local Government	25,578
Local Education (Current MA + Current Med Supp)	126,656

Scenario 2A - Two MA Vendors {Contractors} - Vendor {Contractor} A is awarded current MA PPO plans and Vendor {Contractor} B is awarded current MA HMO plans
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA Only)	2,512	6,645
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA Only)	2,512	6,645
Scenario 2B - Two MA Contractors - Contractor A is awarded current MA PPO plans (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2019) and Vendor {Contractor} B is awarded current MA HMO plans
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA + Current Med Supp)	120,012	6,645
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA + Current Med Supp)	120,012	6,645

Scenario 2C - Two MA Vendors {Contractors} - Vendor {Contractor} A is awarded current MA PPO plans (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2020) and Vendor {Contractor} B is awarded current MA HMO plans
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA Only)	2,512	6,645
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. PPO Member Count	Approx. HMO Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	40,142	7,239
Local Government	23,264	2,314
Local Education (Current MA + Current Med Supp)	120,012	6,645

Scenario 3A - Two MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership and Vendor {Contractor} B is awarded current Aetna membership
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA Only)	0	9,156
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA Only)	0	9,156
Scenario 3B - Two MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2019) and Vendor {Contractor} B is awarded current Aetna membership
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA + Current Med Supp)	117,500	9,156
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA + Current Med Supp)	117,500	9,156

Scenario 3C - Two MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2020) and Vendor {Contractor} B is awarded current Aetna membership
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2019		PMPM Premium - Plan Year 2019
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA Only)	0	9,156
Group	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A Rates		Vendor {Contractor} B Rates
	Approx. Member Count	Approx. Member Count	PMPM Premium - Plan Year 2020		PMPM Premium - Plan Year 2020
			$10 PPO	$15 PPO	$10 PPO	$15 PPO	Legacy HMO	Legacy HMO 15/25
State	38,648	8,734
Local Government	19,716	5,862
Local Education (Current MA + Current Med Supp)	117,500	9,156
Provide your rate renewal methodology for Plan Year 2021 and Plan Year 2022, if the State pursues the Blanket P.O. extension years:

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MA Budgets

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Medicare Advantage Proposed Budgets

Vendor's {Bidder's} Name

Instructions:

- Vendors {Bidders} are required to complete the gold shaded cells below and provide the minimum budgets listed below to the State under the scenarios described in Section 1.1.1 of the RFP.

- Vendors {Bidders} are encouraged to provide larger budgets in the various categories below for the State as part of the Quote.

- Please note that if a Vendor {Bidder} does not fill in a budget in any of the gold shaded cells below, the Budget amounts listed in the table titled “Minimum Budget Requirements” shall apply.

- If a Vendor {Bidder} proposes budget amounts that are less than those listed in the table titled “Minimum Budget Requirements”, the budget amounts in the "Minimum Budget Requirements" table shall prevail.

- Vendors {Bidders} must provide a description of each budget and what it will be used for as a separate attachment.

- For Scenarios 2 and 3, Vendors {Bidders} must provide Budgets assuming they are awarded the Vendor {Contractor} A population and a separate set of Budgets assuming they are awarded the Vendor {Contractor} B population, as described on the Instructions tab.

Definition of Budgets

- Implementation budget must cover, but is not limited to, file fees from current vendors, retiree implementation meetings, implementation communications to retirees, and pre-implementation audits.

- Audit budget includes, but is not limited to, claims audits, operational audits and clinical audits, occuring post-implementation.

Note that the audit budget must be able to be carrier forward and applied to future years of the contract.

- Communication budget includes, but is not limited to, member mailings, attendance at State events, and annual retiree meetings.

Minimum Annual Budget Requirements
	Scenario #1A - Minimum Required Annual Budget	Scenario #1B/C - Minimum Required Annual Budget	Scenario #2A/3A - Minimum Required Annual Budget	Scenario #2B/2C - Minimum Required Annual Budget	Scenario #2B/2C - Minimum Required Annual Budget	Scenario #3B/3C - Minimum Required Annual Budget	Scenario #3B/C - Minimum Required Annual Budget
	One Vendor {Contractor}	One Vendor {Contractor}	Both Vendors {Contractors}	Vendor {Contractor} A	Vendor {Contractor} B	Vendor {Contractor} A	Vendor {Contractor} B
Implementation Budget	$1,000,000	$1,500,000	$500,000	$1,000,000	$500,000	$1,000,000	$500,000
Audit Budget	$150,000	$150,000	$75,000	$150,000	$75,000	$150,000	$75,000
Communication Budget	$300,000	$450,000	$150,000	$300,000	$150,000	$300,000	$150,000
Scenario 1A - One Vendor {Contractor}, Current MA Population Only
	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0
Total Approx. Member Count for Reference	82,116	82,116

Scenario 1B - One Vendor {Contractor}, Additional 117,000 Education Medicare Supplement Members Move to MA in 2019
	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0
Total Approx. Member Count for Reference	199,616	199,616

Scenario 1C - One Vendor {Contractor}, Additional 117,000 Education Medicare Supplement Members Move to MA in 2020
	Plan Year 2019	Plan Year 2020
Implementation Budget
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0
Total Approx. Member Count for Reference	82,116	199,616
Note: Implementation budget is requested in 2020 for Scenario 1C due to addition of Education membership.
Scenario 2A - Two (2) MA Vendors {Contractors}- Vendor {Contractor} A is awarded current MA PPO plans and Vendor {Contractor} B is awarded current MA HMO plans
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	65,917	65,917	16,198	16,198

Scenario 2B - Two (2) MA Vendors {Contractors} - Vendor {Contractor} A is awarded current MA PPO plans (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2019) and Contractor B is awarded current MA HMO plans
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	183,417	183,417	16,198	16,198

Scenario 2C - Two (2) MA Vendors {Contractors} - Vendor {Contractor} A is awarded current MA PPO plans (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2020) and Vendor {Contractor} B is awarded current MA HMO plans
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget				n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	65,917	183,417	16,198	16,198
Note: Implementation budget is requested in 2020 for Scenario 2C for Contractor A is due to addition of Education membership in 2020.
Scenario 3A - Two (2) MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership and Vendor {Contractor} B is awarded current Aetna membership
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	58,364	58,364	23,752	23,752

Scenario 3B - Two (2) MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2019) and Vendor {Contractor} B is awarded current Aetna membership
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget		n/a		n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	175,864	175,864	23,752	23,752

Scenario 3C - Two (2) MA Vendors {Contractors} - Vendor {Contractor} A is awarded current Horizon membership (with additional 117,000 Education Medicare Supplement Members moving to MA PPO in 2020) and Vendor {Contractor} B is awarded current Aetna membership
	Vendor {Contractor} A		Vendor {Contractor} B
	Plan Year 2019	Plan Year 2020	Plan Year 2019	Plan Year 2020
Implementation Budget				n/a
Audit Budget
Communication Budget
Total Annual Budget Allowance	$0	$0	$0	$0
Total Approx. Member Count for Reference	58,364	175,864	23,752	23,752
Note: Implementation budget is requested in 2020 for Scenario 3C for Vendor {Contractor} A due to the addition of Education membership in 2020.

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MA Gain Sharing

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Medicare Advantage Gain Sharing

Vendor's {Bidder's} Name

Instructions: As specified in Section 5.14.6 of the RFP, Vendors {Bidders} shall provide the State with details related to their proposed Gain Sharing Agreement (GSA) for PY 2019 and PY 2020. If providing an attachment, please label it.

- For Scenario 1 [1 or 2 GSAs], Vendors {Bidders} must provide either a separate or combined MA PPO and MA HMO GSA - whichever is most advantageous for the State.

- For Scenario 2 [2 GSAs], Vendors {Bidders} must provide separate GSAs assuming award of either the Vendor {Contractor} A PPO population or the Vendor {Contractor} B HMO population.

- For Scenario 3 [Vendor {Contractor} A: 1 GSA,Vendor {Contractor} B: 1 or 2 GSAs], Vendor {Bidders} must provide separate GSAs assuming they are awarded either the Vendor {Contractor} A (current Horizon) population or the Vendor {Contractor} B (current Aetna) population. For the Vendor {Contractor} B population, the Vendor {Bidder} must provide either a separate or combined MA PPO and MA HMO GSA - whichever is most advantageous for the State.

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(A) MA Premium Develop

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Medicare Advantage - Premium Development Workbook - (A)

Vendor's {Bidder's} Name

Instructions: Vendors {Bidders} should complete the entire sheet for the Scenario listed in line 13 below.

o Fields requiring input are shaded in gold. Vendors {Bidders} shall not change any other aspects of this sheet (formulas, non-gold cells, etc.).

o Provide a forecast for 2018 along with a development of the 2019 and 2020 guaranteed insured premium quotes.

Note: Workbooks are requested for the following plan designs/groups. Vendors {Bidders} do not need to complete this workbook for any of the other group/plan/enrollment distribution options.

(A) State Group, PPO ($10 PPO + $15PPO) in Scenario 1A (40,142 Members)

(B) Government Group, PPO ($10 PPO + $15PPO) in Scenario 1A (23,264 Members)

(D) Education Group, HMO (Legacy HMO + Legacy HMO 15/25) in Scenario 1A (6,645 Members)

(E) Education Group, PPO ($10 PPO + $15PPO) in Scenario 1B (120,012 Members)

(F) Vendor {Contractor} A: State Group, PPO ($10 PPO + $15PPO) in Scenario 2A (40,142 Members)

(G) Vendor {Contractor} B: State Group, HMO (Legacy HMO + Legacy HMO 15/25) in Scenario 2A (7,239 Members)

(H) Vendor {Contractor} A: Education Group, PPO ($10 PPO + $15PPO) in Scenario 2B (120,012 Members)

(I) Vendor {Contractor} A: State Group, PPO ($10 PPO + $15PPO) in Scenario 3A (38,648 Members)

(J) Vendor {Contractor} B: State Group, HMO (Legacy HMO + Legacy HMO 15/25) in Scenario 3A (7,239 Members)

(K) Vendor {Contractor} A: Education Group, PPO ($10 PPO + $15PPO) in Scenario 3B (117,500 Members)

THIS WORKBOOK IS FOR: (A) State Group, PPO ($10 PPO + $15PPO) in Scenario 1A (40,142 Members)

Rating Development		2018 - Forecast	2019 Pricing	2020 Pricing	Comments
1	Incurred From Date:	1/1/18	1/1/19	1/1/20
2	Incurred Through Date:	12/31/18	12/31/19	12/31/20
3	Projected Member Months

Healthcare Cost Projection - PMPM		2018 - Forecast	2019 Pricing	2020 Pricing	Comments
4	Base Period	CY2018	CY2019	CY2020
5	Base Period Healthcare Cost PMPM:
6	Months of Trend	12	12	12
7	Annualized Trend
8	Claims Trend Factor	1.000	1.000	1.000
9	Projected Claims Rating Period - Current Design	$ - 0	$ - 0	$ - 0
10	x Adjustment for Benefit Changes
11	x Adjustment for Provider Contracting
12	x Adjustment for Medical Management
13	x Adjustment for Other (Specify)
14	x Adjustment for Other (Specify)
15	x Adjustment for Other (Specify)
16	Experienced Rated -- Projected Claims PMPM	$ - 0	$ - 0	$ - 0
17	Manual Rated -- Projected Claims PMPM
18	Experience Credibility Percentage

19 Projected Healthcare Costs $0.00 $0.00 $0.00

CMS Revenue Projection - PMPM		2018 - Forecast	2019 Pricing	2020 Pricing	Comments
20	Projected Risk Score
21	Base Period CMS Revenue
22	Baseline CMS Trend Factor
23	x Revenue Adjustment for Other (Specify)
24	x Revenue Adjustment for Other (Specify)
25	x Revenue Adjustment for Other (Specify)
26	x Revenue Adjustment for Other (Specify)
27	CMS Revenue -- Net Trend Factor	- 0	- 0	- 0
28	Projected CMS Revenue	$ - 0	$ - 0	$ - 0

Retention - PMPM		2018 - Forecast	2019 Pricing	2020 Pricing	Comments
29	Target Margin
30	Administrative Costs
31	State Premium Taxes
32	ACA Insurer Fee
33	Other
34	Total Retention Charges	$0.00	$0.00	$0.00

Average PMPM Group Rate $0.00 $0.00 $0.00

&A Page &P of &N

(B) MA Premium Develop

T3093 - State Health Benefits Program and School Employees Health Benefits Program Plans – Medicare Advantage Plans

Bid Solicitation 19DPP00265

Medicare Advantage - Premium Development Workbook - (B)