PPO_Attachment D - Cost.xlsx
XLSX spreadsheet 165 KB Posted
- Attached to
- TPA Services for PPO
- Solicitation number
- ITN-02203
- Issued by
- Leon County, Florida
About this file
This document is an attachment related to a solicitation for Third Party Administrative (TPA) Services for Preferred Provider Organization (PPO) coverage issued by the State of Florida, Department of Management Services' Division of State Group Insurance (Department). The solicitation requires respondents to provide pricing for an initial three-year contract period from 2024 to 2026, with up to three optional one-year renewals through 2029. Respondents are to provide fixed core administrative fees per member per month (PEPM) for claims adjudication, customer service, network access/management, and care management. The solicitation covers the administration of two current PPO plan options - Standard and High Deductible Health Plan (HDHP).
The document outlines the required pricing structure, with respondents needing to provide PEPM fees for each contract year. Respondents must also note any key assumptions in the provided explanation column, limited to 400 characters. This solicitation is for the State of Florida, with the primary jurisdictions being Leon County and the City of Tallahassee.
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Other files
| File | Type | Posted |
|---|---|---|
| PPO_Attachment A - Administrative Requirements_07.27.2022.xlsx | XLSX spreadsheet | |
| PPO_Attachment C - Network.xlsx | XLSX spreadsheet | |
| Revised Attachment A - Administrative Requirements_10.4.22.xlsx | XLSX spreadsheet | |
| DMS-2223-073_Addendum No. 1_PPO_10.4.22.pdf | ||
| PPO Addendum No. 2.pdf | ||
| PPO_Attachment B - Technical.xlsx | XLSX spreadsheet | |
| PPO_Attachment G - Benefit Document_2023.pdf | ||
| PPO_Attachment H - Data Use Agreement.pdf | ||
| QA DMS-2223-073_PPO_10.4.2022.pdf | ||
| Revised Attachment B - Technical_10.4.22.xlsx | XLSX spreadsheet | |
| Addendum No. 3.pdf | ||
| DMS-2223-073 PPO ITN.pdf | ||
| PPO_Attachment E -Draft Contract.pdf | ||
| Revised Attachment E - Draft Contract_10.4.22.pdf | ||
| Addendum No. 4.pdf | ||
| PPO_Attachment F - BAA.pdf |
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Text version
ASO PPO
| Invitation to Negotiate (ITN) for the State of Florida, Florida Department of Management Services ("Department") |
| PPO Medical Self-Insured |
| Medical Pricing |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Proposed Program Fees |
| ■ Fees must be provided for an initial three year contract (entirety of 2024 - 2026) plus up to three optional one year renewals (occurring in 2027, 2028 and 2029). |
| ■ Self-Insured (Administrative Services Only (ASO)) fees should be input in this tab. Below fees should assume pharmacy benefit is carved-out to a separate PBM and NO commissions are paid to any broker or consultant. Finally, note any key assumptions in "Explanation" column. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated. |
made a small edit
■ Base fees assuming administration of current two plan options - Standard and HDHP PPOs. See Attachment A - Administrative Requirements, Read Me First tab for additional information on how to access detailed plan designs.
Fixed Core Administrative Fees (PEPM)
Please note, yellow shaded cells below are formula driven. When adding rows for additional services, please follow instructions on where to add additional rows so costs are captured in calculations.
| In the event the Respondent doesn’t properly add necessary information in the rows as instructed, such provided information may be considered in calculating the total fixed core administration fees. | Plan Year 1/1/2024 through 12/31/2024 |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2025 through 12/31/2025 |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2026 through 12/31/2026 |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2027 through 12/31/2027 |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2028 through 12/31/2028 |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2029 through 12/31/2029 |
(Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract)
| Core Administration Fee - Includes Claims Adjudication + Customer Service + Network Access/ Management + Care Management | ||||||
| <15,000 Subscribers | ||||||
| 15,000 - 49,999 Subscribers | ||||||
| 50,000+ Subscribers | ||||||
| Standard Reports | ||||||
| Nurse Line | ||||||
| Telemedicine Service Fee for any available services from external vendor (PCP, Behavioral Health, Dermatology) | ||||||
| Any Other Administrative or Carve-Out Vendor Fees (For example, radiology precertification, etc.) (Define in Explanation column) Add additional rows as necessary below this row. | ||||||
| Any Other Service/Program Included in Core Administration Fee above (Add rows as necessary above this row) | ||||||
| Total of All Fixed Core Administration Fees | ||||||
| <15,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 15,000 - 49,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 50,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Claims Per Subscriber Per Month | ||||||
| Capitation Claim Amounts (if applicable). | ||||||
| To what services do these amounts pertain? | ||||||
| Do these amounts vary by any counties in FL, GA or AL? If so, describe how. | ||||||
| Case Management and Utilization Management |
Confirm each of the below services are included in the core fee provided above.
| Asthma case management | |||||||||
| Back case management/discounts | |||||||||
| Cancer case management | |||||||||
| Chronic condition case management | |||||||||
| Congestive heart failure case management | |||||||||
| Diabetes case management | |||||||||
| Depression and anxiety case management | |||||||||
| Family planning case management | |||||||||
| Heart disease case management. | |||||||||
| Hypertension case management. | |||||||||
| Low back pain/injury case management. | |||||||||
| Lung conditions (except asthma) case management. | |||||||||
| Muscle or joint problems case management. | |||||||||
| Neonatal intensive case management | |||||||||
| Patient management | |||||||||
| Prenatal case management | |||||||||
| Rheumatoid arthritis case management | |||||||||
| Complex Comorbidities case management | |||||||||
| Catastrophic injury case management | |||||||||
| Hospice case management | |||||||||
| Behavioral health case management | |||||||||
| Pre-admission verification/authorization | |||||||||
| Pre-admission outreach | |||||||||
| Inpatient admission/concurrent review | |||||||||
| Discharge planning | |||||||||
| Post discharge outreach | |||||||||
| Retrospective review | |||||||||
| Outpatient surgical review/prior authorization | |||||||||
| Outpatient imaging review/prior authorization | |||||||||
| Home health care (include scope of services covered in Explanation) | |||||||||
| Durable medical equipment review | |||||||||
| Physical therapy review | |||||||||
| Occupational therapy review | |||||||||
| Speech therapy review | |||||||||
| Predictive technology | |||||||||
| High-risk outreach | |||||||||
| Episodic case management | |||||||||
| Complex case management | |||||||||
| Demand management/nurse triage | |||||||||
| Offset to Administrative Fees | PY 2024 | PY 2025 | PY 2026 | PY 2027 | PY 2028 | PY 2029 | |||
| If Respondent chooses to reply to both PPO administrative and carve-out PBM services and is awarded both medical and pharmacy benefits, is there an offset to the above administrative fees? If so, detail (as a PEPM offset) otherwise input "N/A". | |||||||||
| Provider Networks | Reply | Explanation | |||||||
| Confirm the provider network that you are proposing and basing your above quoted fees represents your broadest provider network? | |||||||||
| If so, what would impact be on above proposed fees should State of Florida choose to offer a broad network? | |||||||||
| If so, what would impact be on above proposed fees should State of Florida choose to offer a narrow network? | |||||||||
| If so, what approximate impact on claims under this alternative network should State of Florida expect, for the counties in which you are proposing to be offered? | |||||||||
| Any Additional Programs Available not Identified Above | |||||||||
| Include Fees and Any ROI Guarantees | Reply | Explanation | |||||||
| Insert here and describe in "Explanation" column. | |||||||||
| Insert here and describe in "Explanation" column. | |||||||||
| Add Rows as Needed | |||||||||
| Broker Commissions | Reply | Explanation | |||||||
| Confirm proposed fees are net of commissions (no commissions) |
| Service Area |
| Confirm the service areas to which your above proposed PPO fixed core administrative fees apply. |
| Administratively Operational and Available? | Acceptable Provider Network/ Care Coverage? | Explanation - note any issues, limitations, etc. | |
| International | |||
| United States | |||
| All of Florida | |||
| Are there any counties in Florida for which your service does not meet the Access requirements from a provider network perspective? Access Requirements: for urban and suburban areas, 98% of Subscribers will have access to at least two (2) providers within 8 miles of their home zip code. For rural areas, 98% of subscribers will have access to at least one (1) provider within 15 miles of their home zip code. If so, list such counties in "Explanation" column. (Alternatively, list those counties in FL for which your plan is operational, but be sure to note what your list represents.) |
| Cost Questions | Reply | Explanation | ||
| Please enter your reply in the "Reply" column and any explanation in the "Explanation" column. Responses beyond 400 characters will not be evaluated. | ||||
| 1 | Confirm that administrative fees will be paid monthly and that the administrative cost will be assessed on a per-employee-per-month (PEPM) basis based on DMS' enrollment counts (self-bill), with no subsequent accounting or year-end reconciliation. The PEPM fee can differ by plan type but not by enrollment tier (e.g. single/family). | |||
| 2 | Have you identified the costs for any services beyond those specified that you recommend Department consider that are not included in your quoted fees in the Additional Programs section in the chart above? Please outline a description of any service, the charge of said service and your best estimate of the annual cost in the Explanation column. | |||
| 3 | Confirm that the pricing submitted within this Reply (as well as provider network disruption and stats exhibits provided in Attachment C- Network) is based on your broadest provider networks, both in FL and the US. | |||
| a. | What is the name of this network? | |||
| Self-Insured Plan - Ongoing Services, Renewals | Reply | Explanation | ||
| 4 | Respondent will provide a definition of all terms and an itemization of all assumptions used including projected claims, trend factors and the formula involved, plus a complete explanation of the logic inherent in the final renewal rate/fee package. | |||
| 5 | Respondent will provide annual actuarial services including estimated or actual identification of expenses, including the change in IBNR, claim administration expenses, other expenses (such as, number of transactions/EOBs), and a detailed allocation of administrative cost projections. | |||
| Self-Insured Plan - Guaranteed Claim Discounts | Reply | Explanation | ||
| 6 | Is Respondent willing to guarantee medical claim discounts off normal charges? If so, indicate below for what types of services and in the "Explanation" column describe how these guarantees will be measured - you can expand on your description in the additional Cost Explanation section below. | |||
| a. | Hospital Inpatient Discount | |||
| b. | Hospital Outpatient Discount | |||
| c. | Physician Discount | |||
| d. | Out of Network Discount | |||
| e. | Other Services Discount - please describe | |||
| Self-Insured Plan - Guaranteed Claim Trend Rates | Reply | Explanation | ||
| 7 | Is Respondent willing to guarantee PEPM medical trend? | |||
| a. | If so, what is Respondent's PEPM medical trend guarantee for PPO Medical Only? | |||
| What will Respondent's trend guarantee be if Respondent is awarded both PPO and PBM services? | ||||
| 8 | Provide the percentage of ASO fees the Respondent would put at risk for the guaranteed discount/medical trend guarantee. |
Wellness ASO PPO
| Invitation to Negotiate (ITN) for the State of Florida, Florida Department of Management Services ("Department") |
| PPO Medical Self-Insured |
| Wellness Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Proposed Program Fees |
| Confirm the wellness or care management programs that are available via your proposed self-insured PPO Plan |
| Health Improvement Program - Please review the below programs. Please add rows for additional programs, as necessary. | Year 1 | ||
| (Effective January 1, 2024) | Year 2 | ||
| (Effective January 1, 2025) | Year 3 | ||
| (Effective January 1, 2026) | Year 4 | ||
| (Effective January 1, 2027) | Year 5 | ||
| (Effective January 1, 2028) | Year 6 |
(Effective January 1, 2029)
| Wellness Services |
| Online Health Risk Questionnaire |
| Onsite Biometric Screenings - Includes: |
| Total Cholesterol (LDL & HDL) |
| Glucose |
| Blood Pressure |
| Waist Measurement |
| BMI |
| Other (Add Rows as Necessary) |
| Health Coaching |
| Telephonic-based coaching - Includes: |
| Weight Management |
| Nutrition |
| Smoking Cessation |
| Exercise |
| Healthy Pregnancy |
| Back Pain |
| Stress Management |
| Other (Add Rows as Necessary) |
| Tobacco Cessation Services |
| Tobacco Cessation Program with: |
| Specialized Tobacco Cessation Coaching |
| Nicotine Replacement Therapy |
| Prescription Medications |
| Other (Add Rows as Necessary) |
| Immunizations |
| Organize and sponsor onsite flu shots |
| Physical Activity |
| Conduct team-based corporate challenges |
| Weight loss discount programs |
| Fitness club membership reimbursement |
| Other (Add Rows as Necessary) |
| Online Wellness Tools |
| Personalized Portal with: |
| Health scores |
| Screening results |
| Program recommendations |
| Health library |
| Other (Add Rows as Necessary) |
| Online behavior change modules addressing: |
| Physical activity |
| Tobacco cessation |
| Nutrition |
| Weight management |
| Stress/energy |
| Sleep |
| Living with a condition |
| Other (Add Rows as Necessary) |
| Online tracking tools for: |
| Physical activity |
| Healthy eating and living well |
| Living well |
| Other (Add Rows as Necessary) |
| Telephonic-based Disease Management - Includes: |
| Asthma - Adult and Pediatric |
| Diabetes |
| CAD |
| COPD |
| Heart Failure |
| Chronic Low Back Pain |
| Osteoarthritis |
| Cerebrovascular/Peripheral Artery Disease |
| Behavioral |
| Low Back Pain |
| Other (Add Rows as Necessary) |
| Other |
| Insert Here (Add Rows as Necessary) |
Medical Repricing
| Invitation to Negotiate (ITN) for the State of Florida, Florida Department of Management Services ("Department") |
| PPO Medical Self-Insured |
| Medical Repricing |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Please complete the below charts using the data from the State repricing file obtained by contacting the Procurement Officer. Data file represents the Statewide / National PPO plan. Provide an electronic copy of actual Excel workbook with your firm's repricing data with the response. Name the file: Respondent's Name_ Medical Repricing_PPO. |
Proposed Network Name: Insert Here
| Claim Types | Network Charges | Network Discount (%) | Network Discount ($) | Network Allowed |
| Inpatient | ||||
| Outpatient | ||||
| Professional | ||||
| Repriced Subtotal | $0 | 0% | $0 | $0 |
| Unmatched Claims | $0 | $0 | ||
| Grand Total | $0 | 0% | $0 | $0 |
Proposed Network Name: Insert Here
| Claim Types | Network Charges | Network Discount (%) | Network Discount ($) | Network Allowed |
| Inpatient | ||||
| Outpatient | ||||
| Professional | ||||
| Repriced Subtotal | $0 | 0% | $0 | $0 |
| Data Issues | $0 | $0 | ||
| Grand Total | $0 | 0% | $0 | $0 |
Out of Network (OON) Charges image1.png
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