The file's text, extracted by GovTribe without its formatting.
TAB 1 - Self Funded Proposals
Schedule O - Claims Pricing Worksheet
| STATE OF MICHIGAN |
| Request For Proposal No. 250000000637 |
| Vision Insurance Administration Services for Michigan Public School Employees’ Retirement System (MPSERS) |
| Instructions |
| 1. If Bidder is providing a Self-funded proposal, Bidder must complete TAB 1. If Bidder is providing a Fully insured proposal, Bidder must complete TAB 2. If Bidder is providing a Self-funded and Fully insured proposal, Bidder must complete TAB 1 and TAB 2. Bidders must complete only areas shaded in yellow and must not alter data or formulas in cells that are not shaded yellow. |
| 2. Column A and B – Current benefit offered to members. With the exception of Section 3.C -Lens Options, these benefits cannot change (see Schedule A Section 1.1.2 ) and costs should be provided based on the listed benefit design. |
| 3. Column C and D - Section 3C: Use Column C to select either copay or discount. Enter the applicable value in Column D. In this section only, Bidder may match the existing benefit design or enter customized offerings. The listed copays/discounts for lens options will remain in effect for the duration of the contract. If Bidders fail to enter customized offerings, Bidder agrees to match the existing plan design as stated in this document. |
| 4. Column E – Total Cost Per Claim (prior to any member cost share): Enter the average self-funded book of business cost per each claim in dollars. The amount is the starting point before determining any member cost share or any vendor discounts, sometimes referred to as the “allowed” amount. For example, if on average a self-funded book of business retail in-network eye exam is $50 then the member would pay a $10 copay and the plan would pay $40. In this example, $50 would be entered in Column E. Another example is for frames, if on average for the self-funded book of business frames are $300 before any discounts, allowances, copays then $300 would be entered into Column E. |
| 5. Column L – Plan Cost – Allowance Offset: If Bidder provides an additional savings that would be used to offset the plan cost allowance, please enter in Column J. This only applies to the in-network benefits that have a member allowance which are, Progressive – Premium Tier IV lenses, Frames, Conventional Contact Lenses and Contact Lens exams. This amount should be based on the vendor self-funded book of business average and should be entered as a negative dollar amount. If Bidder does not offer this, please enter 0 in the applicable spaces. |
| 6. The annual estimated member out-of-pocket cost will be calculated in O64. Enter this value in the applicable spaces in Schedule B Pricing. |
| 7. The annual estimated claims cost to the plan will be calculated in P64. Enter this amount in the applicable spaces in Schedule B Pricing. |
| | Bidder Copays/Discounts | | | Member Cost | | | | Plan Cost | | | | | | |
| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P |
| | | | | Minimum (Copay or Total Cost per Claim) | [E]*[Discount Percent] | [Total Cost per Claim]-[Allowance] | [F]+[G]+[H] | [E]-[F] | [Allowance] | | [J]+[K]+[L] | | [I]*[N] | [M]*[N] |
| Benefit Line Item | Member Benefit | Cost Sharing Type | Amount | Total Cost per Claim (prior to any member cost share) | Member Cost - Copay | Member Cost - Vendor Discount | Member Cost - Above Allowance | Total Member Cost per Claim | Plan Cost - Amount After Copay | Plan Cost - Benefit Allowance | Plan Cost - Allowance Offset | Total Plan Cost per Claim | Number of Claims | Annual Member Cost | Annual Plan Cost |
| 1. Exams | | | | | | | | | | | | | | | |
| Retail (In-Network) | $10 Copay | | | | $10.00 | | | $10.00 | -$10.00 | | | -$10.00 | 17,331 | $173,310 | -$173,310 |
| Independent (In-Network) | $10 Copay | | | | $10.00 | | | $10.00 | -$10.00 | | | -$10.00 | 37,943 | $379,430 | -$379,430 |
| Out-of-Network | $40 Allowance | | | | | | -$40.00 | -$40.00 | | $40.00 | | $40.00 | 1,913 | -$76,520 | $76,520 |
| Total Exam | | | | $0.00 | $9.67 | | -$1.34 | $8.33 | -$9.67 | $1.34 | $0.00 | -$8.33 | 57,187 | $476,220 | -$476,220 |
| 2. Refractions (In-Network) | | | | | | | | | | | | |
| Retail | Included in Exam Copay | | $0.00 | | $0.00 | $0.00 | | | $0.00 | 14,829 | $0 | $0 |
| Independent | Included in Exam Copay | | $0.00 | | $0.00 | $0.00 | | | $0.00 | 39,743 | $0 | $0 |
| Total Refractions | | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | 54,572 | $0 | $0 |
| 3. Glasses (In-Network) | | | | | | | | | | | | | |
| A. Lenses | | | | | | | | | | | | | |
| Single Vision | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 8,726 | $218,150 | -$218,150 |
| Bifocal | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 8,771 | $219,275 | -$219,275 |
| Trifocal | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 1,885 | $47,125 | -$47,125 |
| Progressive - Standard | $80 Copay | | $80.00 | | | $80.00 | -$80.00 | | | -$80.00 | 2,635 | $210,800 | -$210,800 |
| Progressive - Premium Tier I | $110 Copay | | $110.00 | | | $110.00 | -$110.00 | | | -$110.00 | 1,216 | $133,760 | -$133,760 |
| Progressive - Premium Tier II | $120 Copay | | $120.00 | | | $120.00 | -$120.00 | | | -$120.00 | 4,735 | $568,200 | -$568,200 |
| Progressive - Premium Tier III | $135 Copay | | $135.00 | | | $135.00 | -$135.00 | | | -$135.00 | 17,143 | $2,314,305 | -$2,314,305 |
| Progressive - Premium Tier IV | $120 allowance, $90 copay, 20% discount after copay/allowance | | $90.00 | $0.00 | -$120.00 | -$30.00 | -$90.00 | $120.00 | | $30.00 | 11,954 | -$358,620 | $358,620 |
| Average Lenses | | $0.00 | $83.90 | $0.00 | -$25.14 | $58.76 | -$83.90 | $25.14 | $0.00 | -$58.76 | 57,065 | $3,352,995 | -$3,352,995 |
B. Frame (In-Network) $120 Allowance -$120.00 -$120.00 $120.00 $120.00 49,276 -$5,913,120 $5,913,120
| C. Lens Options (In-Network) | | | | | | | | | | | | | |
| UV protection/coating | $15 Copay | | | | | $0.00 | | | | $0.00 | 26,397 | $0 | $0 |
| Tint (solid and gradient) | $15 Copay | | | | | $0.00 | | | | $0.00 | 1,977 | $0 | $0 |
| Standard scratch resistant | $15 Copay | | | | | $0.00 | | | | $0.00 | 2,204 | $0 | $0 |
| Standard Polycarbonate | $40 Copay | | | | | $0.00 | | | | $0.00 | 35,531 | $0 | $0 |
| Standard anti-reflective coating | $45 Copay | | | | | $0.00 | | | | $0.00 | 6,627 | $0 | $0 |
| Premium anti-reflective coating tier 1 | $57 Copay | | | | | $0.00 | | | | $0.00 | 3,878 | $0 | $0 |
| Premium anti-reflective coating tier 2 | $68 Copay | | | | | $0.00 | | | | $0.00 | 9,166 | $0 | $0 |
| Premium anti-reflective coating tier 3 | 20% Discount | | | | | $0.00 | | | | $0.00 | 22,435 | $0 | $0 |
| Polarized | 20% Discount | | | | | $0.00 | | | | $0.00 | 2,897 | $0 | $0 |
| Other add-ons and services | 20% Discount | | | | | $0.00 | | | | $0.00 | 4,748 | $0 | $0 |
| Average Lens Options | | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | 115,860 | $0 | $0 |
| 4. Contact Lenses (In-Network) | | | | | | | | | | | | | |
| Conventionals | $120 allowance, $25 copay, 15% discount after copay/allowance | | $25.00 | $0.00 | -$120.00 | -$95.00 | -$25.00 | $120.00 | | $95.00 | 5,660 | -$537,700 | $537,700 |
| Contact lens exam | $55 allowance,10% discount after allowance | | | $0.00 | -$55.00 | -$55.00 | | $55.00 | | $55.00 | 3,765 | -$207,075 | $207,075 |
| Average Contact Lens | | $0.00 | $15.01 | $0.00 | -$94.03 | -$79.02 | -$15.01 | $94.03 | $0.00 | $79.02 | 9,425 | -$744,775 | $744,775 |
Estimated Annual Costs -$2,828,680 $2,828,680
| Plan Year 1 Claims Contracts | 168,923 | 168,923 |
| Estimated Annual Claims Costs Per Contract Per Month | -$1.40 | $1.40 |
| Plan Year 1 Claims Members | 261,586 | 261,586 |
| Estimated Annual Claims Costs Per Member Per Month | -$0.90 | $0.90 |
TAB 2 - Fully Insured Proposals
Schedule O - Claims Pricing Worksheet
| STATE OF MICHIGAN |
| Request For Proposal No. 250000000637 |
| Vision Insurance Administration Services for Michigan Public School Employees’ Retirement System (MPSERS) |
| Instructions |
| 1. If Bidder is providing a Self-funded proposal, Bidder must complete TAB 1. If Bidder is providing a Fully insured proposal, Bidder must complete TAB 2. If Bidder is providing a Self-funded and Fully insured proposal, Bidder must complete TAB 1 and TAB 2. Bidders must complete only areas shaded in yellow and must not alter data or formulas in cells that are not shaded yellow. |
| 2. Column A and B – Current benefit offered to members. With the exception of Section 3.C -Lens Options, these benefits cannot change (see Schedule A Section 1.2.2 ) and costs should be provided based on the listed benefit design. |
| 3. Column C and D - Section 3C: Use Column C to select either copay or discount. Enter the applicable value in Column D. In this section only, Bidder may match the existing benefit design or enter customized offerings. The listed copays/discounts for lens options will remain in effect for the duration of the contract. |
| 4. Column E – Total Cost Per Claim (prior to any member cost share): Enter the average self-funded book of business cost per each claim in dollars. The amount is the starting point before determining any member cost share or any vendor discounts, sometimes referred to as the “allowed” amount. For example, if on average a self-funded book of business retail in-network eye exam is $50 then the member would pay a $10 copay and the plan would pay $40. In this example, $50 would be entered in Column E. Another example is for frames, if on average for the self-funded book of business frames are $300 before any discounts, allowances, copays then $300 would be entered into Column E. |
| 5. Column L – Plan Cost – Allowance Offset: If Bidder provides an additional savings that would be used to offset the plan cost allowance, please enter in Column J. This only applies to the in-network benefits that have a member allowance which are, Progressive – Premium Tier IV lenses, Frames, Conventional Contact Lenses and Contact Lens exams. This amount should be based on the vendor self-funded book of business average and should be entered as a negative dollar amount. If Bidder does not offer this, please enter 0 in the applicable spaces. |
| 6. The annual estimated member out-of-pocket cost will be calculated in O64. Enter this value in the applicable spaces in Schedule B Pricing. |
| | Bidder Copays/Discounts | | | Member Cost | | | | Plan Cost | | | | | | |
| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P |
| | | | | Minimum (Copay or Total Cost per Claim) | [E]*[Discount Percent] | [Total Cost per Claim]-[Allowance] | [F]+[G]+[H] | [E]-[F] | [Allowance] | | [J]+[K]+[L] | | [I]*[N] | [M]*[N] |
| Benefit Line Item | Member Benefit | Cost Sharing Type | Amount | Total Cost per Claim (prior to any member cost share) | Member Cost - Copay | Member Cost - Vendor Discount | Member Cost - Above Allowance | Total Member Cost per Claim | Plan Cost - Amount After Copay | Plan Cost - Benefit Allowance | Plan Cost - Allowance Offset | Total Plan Cost per Claim | Number of Claims | Annual Member Cost | Annual Plan Cost |
| 1. Exams | | | | | | | | | | | | | | | |
| Retail (In-Network) | $10 Copay | | | | $10.00 | | | $10.00 | -$10.00 | | | -$10.00 | 17,331 | $173,310 | -$173,310 |
| Independent (In-Network) | $10 Copay | | | | $10.00 | | | $10.00 | -$10.00 | | | -$10.00 | 37,943 | $379,430 | -$379,430 |
| Out-of-Network | $40 Allowance | | | | | | -$40.00 | -$40.00 | | $40.00 | | $40.00 | 1,913 | -$76,520 | $76,520 |
| Total Exam | | | | $0.00 | $9.67 | | -$1.34 | $8.33 | -$9.67 | $1.34 | $0.00 | -$8.33 | 57,187 | $476,220 | -$476,220 |
| 2. Refractions (In-Network) | | | | | | | | | | | | |
| Retail | Included in Exam Copay | | $0.00 | | $0.00 | $0.00 | | | $0.00 | 14,829 | $0 | $0 |
| Independent | Included in Exam Copay | | $0.00 | | $0.00 | $0.00 | | | $0.00 | 39,743 | $0 | $0 |
| Total Refractions | | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | 54,572 | $0 | $0 |
| 3. Glasses (In-Network) | | | | | | | | | | | | | |
| A. Lenses | | | | | | | | | | | | | |
| Single Vision | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 8,726 | $218,150 | -$218,150 |
| Bifocal | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 8,771 | $219,275 | -$219,275 |
| Trifocal | $25 Copay | | $25.00 | | | $25.00 | -$25.00 | | | -$25.00 | 1,885 | $47,125 | -$47,125 |
| Progressive - Standard | $80 Copay | | $80.00 | | | $80.00 | -$80.00 | | | -$80.00 | 2,635 | $210,800 | -$210,800 |
| Progressive - Premium Tier I | $110 Copay | | $110.00 | | | $110.00 | -$110.00 | | | -$110.00 | 1,216 | $133,760 | -$133,760 |
| Progressive - Premium Tier II | $120 Copay | | $120.00 | | | $120.00 | -$120.00 | | | -$120.00 | 4,735 | $568,200 | -$568,200 |
| Progressive - Premium Tier III | $135 Copay | | $135.00 | | | $135.00 | -$135.00 | | | -$135.00 | 17,143 | $2,314,305 | -$2,314,305 |
| Progressive - Premium Tier IV | $120 allowance, $90 copay, 20% discount after copay/allowance | | $90.00 | $0.00 | -$120.00 | -$30.00 | -$90.00 | $120.00 | | $30.00 | 11,954 | -$358,620 | $358,620 |
| Average Lenses | | $0.00 | $83.90 | $0.00 | -$25.14 | $58.76 | -$83.90 | $25.14 | $0.00 | -$58.76 | 57,065 | $3,352,995 | -$3,352,995 |
B. Frame (In-Network) $120 Allowance -$120.00 -$120.00 $120.00 $120.00 49,276 -$5,913,120 $5,913,120
| C. Lens Options (In-Network) | | | | | | | | | | | | | |
| UV protection/coating | $15 Copay | | | | | $0.00 | | | | $0.00 | 26,397 | $0 | $0 |
| Tint (solid and gradient) | $15 Copay | | | | | $0.00 | | | | $0.00 | 1,977 | $0 | $0 |
| Standard scratch resistant | $15 Copay | | | | | $0.00 | | | | $0.00 | 2,204 | $0 | $0 |
| Standard Polycarbonate | $40 Copay | | | | | $0.00 | | | | $0.00 | 35,531 | $0 | $0 |
| Standard anti-reflective coating | $45 Copay | | | | | $0.00 | | | | $0.00 | 6,627 | $0 | $0 |
| Premium anti-reflective coating tier 1 | $57 Copay | | | | | $0.00 | | | | $0.00 | 3,878 | $0 | $0 |
| Premium anti-reflective coating tier 2 | $68 Copay | | | | | $0.00 | | | | $0.00 | 9,166 | $0 | $0 |
| Premium anti-reflective coating tier 3 | 20% Discount | | | | | $0.00 | | | | $0.00 | 22,435 | $0 | $0 |
| Polarized | 20% Discount | | | | | $0.00 | | | | $0.00 | 2,897 | $0 | $0 |
| Other add-ons and services | 20% Discount | | | | | $0.00 | | | | $0.00 | 4,748 | $0 | $0 |
| Average Lens Options | | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | 115,860 | $0 | $0 |
| 4. Contact Lenses (In-Network) | | | | | | | | | | | | | |
| Conventionals | $120 allowance, $25 copay, 15% discount after copay/allowance | | $25.00 | $0.00 | -$120.00 | -$95.00 | -$25.00 | $120.00 | | $95.00 | 5,660 | -$537,700 | $537,700 |
| Contact lens exam | $55 allowance,10% discount after allowance | | | $0.00 | -$55.00 | -$55.00 | | $55.00 | | $55.00 | 3,765 | -$207,075 | $207,075 |
| Average Contact Lens | | $0.00 | $15.01 | $0.00 | -$94.03 | -$79.02 | -$15.01 | $94.03 | $0.00 | $79.02 | 9,425 | -$744,775 | $744,775 |
Estimated Annual Costs -$2,828,680 $2,828,680
| Plan Year 1 Claims Contracts | 168,923 | 168,923 |
| Estimated Annual Claims Costs Per Contract Per Month | -$1.40 | $1.40 |
| Plan Year 1 Claims Members | 261,586 | 261,586 |
| Estimated Annual Claims Costs Per Member Per Month | -$0.90 | $0.90 |
Sheet1