RFP 25-1371 Appendix B Excel Forms.xlsx
XLSX spreadsheet 408 KB Posted
- Solicitation number
- RFP_No._25-1371
- Issued by
- Texas
About this file
This document is an Excel-based Request for Proposal (RFP) 25-1371 Appendix B form for the City, focusing on medical and dental carrier benefits proposal submissions. The RFP requires medical carriers to provide two plan options (PPO, HSA, and HMO) that mirror or enhance current plans, with detailed specifications for benefits including deductibles, out-of-pocket maximums, coinsurance, emergency room coverage, preventive care, and prescription networks. Similarly, dental carriers are asked to propose base and buy-up plan designs with comprehensive details on preventive, basic, and major services, including orthodontia coverage.
The form includes extensive financial and network submission requirements, with carriers expected to provide enrollment financials, monthly and annual premiums, percentage changes from current plans, and network geographic access metrics. Specific allowance requests are outlined, including $25,000 for wellness and $5,000 for communication. Carriers must demonstrate network coverage, with requirements for provider access (2 PCPs within 10 miles, 2 specialists within 10 miles, 1 hospital within 10 miles) and provider record match percentages. The document emphasizes that the proposed benefits should closely replicate the existing plan structures, with carriers invited to enhance current offerings while maintaining similar overall benefits.
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Other files
| File | Type | Posted |
|---|---|---|
| RFP 25-1371 Health and Wellness Medical_Rx Dental Ins Svcs.pdf |
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Text version
Medical
| Carriers can enter their proposed Medical plan designs on this form. Reminder, the City would like two options that mirror or enhance the current plans as close as possible. | ||||||
| MEDICAL BENEFITS | Carrier Name | |||||
| PPO Plan | HSA Plan | HMO Plan | ||||
| Proposed | Proposed | Proposed | ||||
| Deductible | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Out Of Pocket Max | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Coinsurance | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Lifetime Max | ||||||
| Emergency Room | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Maternity | ||||||
| Physician Office Visit | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Specialist Office Visit | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Preventive Care | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Urgent Care | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Diagnostic Lab & X-Ray | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| In-Patient Hospital | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Out-Patient | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Mental Health / Substance Abuse | ||||||
| In-Network | ||||||
| Non-Network | ||||||
| Prescriptions | ||||||
| Network Retail Pharmacy | ||||||
| Mail Order | ENROLLMENT | |||||
| FINANCIALS | PPO | HSA | HMO | |||
| Employee Only | ||||||
| Employee + Spouse | ||||||
| Employee + Children | ||||||
| Employee + Family |
| Monthly Cost |
| Annual Cost |
| Total Premium |
| Credit |
| Combined Annual Cost (Not Including Credits) |
| Combined $ Change from Current |
| Combined % Change from Current |
| AM's Best Rating |
| Network |
| GEO Access (2 PCP's within 10 miles) |
| Notes |
| The benefits above are based upon duplication of the current plan of benefits. |
Signature
Dental
| Carriers can enter their proposed Dental plan designs on this form. Reminder, the City would like the option that mirror or enhance the current plans as close as possible. | ||||
| DENTAL BENEFITS | Carrier Name | Carrier Name | ||
| Base Plan | Buy Up Plan | |||
| Type I – Preventive Services | ||||
| Waiting Period | ||||
| Oral Examinations | ||||
| X-rays | ||||
| - Bite Wings Frequency | ||||
| - Full Mouth Frequency | ||||
| Cleanings | ||||
| Topical Fluoride Treatment | ||||
| Space Maintainers | ||||
| Sealants | ||||
| Type II – Basic Services | ||||
| Waiting Period | ||||
| Fillings | ||||
| - Amalgam | ||||
| - Composite | ||||
| Root Canal Treatment | ||||
| Root Planning | ||||
| Periodontic Maintenance | ||||
| Periodontal Surgery | ||||
| Extractions | ||||
| General Anesthesia | ||||
| Palliative Treatment (Relief of Pain) | ||||
| Deep IV Sedation | ||||
| Type III – Major Services | ||||
| Waiting Period | ||||
| Crowns | ||||
| Inlays and Onlays | ||||
| Removable / Fixed Bridge-Work | ||||
| Partial or Complete Dentures | ||||
| Denture Relines / Rebases | ||||
| Implants | ||||
| Type IV - Orthodontia | ||||
| Waiting Period | ||||
| Orthodontia Lifetime Maximum | ||||
| Orthodontia Eligibility | ||||
| Calendar Year Deductible | ||||
| Individual | ||||
| Family | ||||
| Dental Annual Maximum | ||||
| Maximum Rollover | ||||
| Preventive Max Waiver | ||||
| Waiting Period Applies to: | ||||
| UCR Out of Network Percentile | ENROLLMENT | |||
| FINANCIALS | Base | Buy Up | Base Plan | Buy Up Plan |
| Employee Only | ||||
| Employee & Spouse | ||||
| Employee & Child(ren) | ||||
| Employee & Family | ||||
| Monthly Premium | ||||
| Annual Premium | ||||
| $ Change from Current | ||||
| % Change from Current |
| Participation Requirements |
| Employer Contribution Requirements |
| Effective Date |
| Rate Guarantee |
| Provider Disruption |
| GEO Access Results |
| Network Website |
| Network Name |
| Note: This is a brief summary and not intended to be a contract. |
| The benefits above are based upon duplication of the current plan of benefits. |
MedicalRx Network SF
MEDICAL NETWORK
SUBMISSION FORM
| The tables below outline the data requested from each proposer. | |
| MEDICAL NETWORK - GEO ACCESS | (Network Name) |
| GeoAccess (2 PCPs within 10 miles) | % coverage |
| GeoAccess (2 Specialists within 10 miles) | % coverage |
| GeoAccess (1 Hospital within 10 miles) | % coverage |
| MEDICAL NETWORK - DISRUPTION | |
| Provider Record Match | % coverage |
| Pharmacy Disruption |
| ALLOWANCE REQUESTS | Asked: | Provided: |
| Wellness | $25,000 | |
| Communication | $5,000 |
Dental Network SF
DENTAL NETWORK
SUBMISSION FORM
| DENTAL NETWORK - GEO | (PPO Network Name) |
| GeoAccess (2 GPs within 10 miles) | % coverage |
| GeoAccess (2 Specialists within 10 miles) | % coverage |
| DENTAL NETWORK DISRUPTION | (PPO Network Name) |
| Provider Record Match | % coverage |
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