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Part 5 - Cost Proposal The Offeror’s total cost for the Work must include all one-time and ongoing costs and be represented as the unit of measure specified.
Contractor will be paid according to the fee structure within the Cost Proposal Form.
The Offeror must ensure its cost proposal is submitted separately from the technical proposal as indicated in the Proposal Submittal paragraph of Section 4, Requirements for Proposals. Cost information must not be included in the technical proposal.
The Offeror may not modify or reformat the Cost Proposal Form. The Offeror must complete the required portions of the Cost Proposal Form. Additionally, all portions of the Cost Proposal Form must be completed in the exact format provided. The Offeror must not include exceptions, additional terms and conditions, or assumptions in the submitted Cost Proposal Form. The State may reject any Proposal with a modified or reformatted Cost Proposal Form; a Cost Proposal Form that is not separately submitted; or a Cost Proposal Form that includes exceptions, additional terms and conditions, or assumptions.
The State will not be liable for any costs the Offeror does not identify in its cost proposal. There will be no additional reimbursement for travel or other related expenses.
*The Offeror must specify below the region(s) for which this Cost Proposal Form applies. This Cost Proposal Form may be reproduced for each region which an Offeror is submitting a Proposal in the event the Administrative Only Fees differ by region.
*REGION(S) __________
Per Enrolled Employee Per Month (PEPM) Estimates by Region
| Region |
| *Estimated Monthly Enrolled Employees |
| *Estimated Annual Enrolled Employees |
| Cleveland-Akron |
| 5,848 |
| 70,176 |
| Dayton-Springfield |
| 3,180 |
| 38,160 |
This Cost Proposal Form, as fully negotiated and mutually agreed upon between the parties, is incorporated into this Contract by reference as if fully rewritten herein.
*Indicates an update to the Cost Proposal Form instructions, per amendment 1, effective 10/20/26.
| CORE SERVICES |
| UNIT OF MEASURE (UOM) |
| ESTIMATED |
ANNUAL
USAGE
COST PER UOM
| Administrative services only fee, for healthcare services |
| PEPM |
| See chart above |
| Implementation and set up fee. The Contractor may invoice this one-time fee upon successful completion and approval by the Agency of all implementation activities. |
| Per implementation completion |
| once |
| File feeds |
| Per setup |
| seven |
| Single-sign on |
| Per connection |
| seven |
| Communications |
| Per year |
| once |
| ID card maintenance (for new employees and up to one replacement card per Member per year) |
| PEPM |
| See chart above |
| ID card full reissue – one time cost |
| One time implementation |
| once |
Disease Management The estimated annual usage shown is for all regions. For purposes of evaluating costs on a per region basis, the State will divide the estimated annual usage shown by seven.
| CORE SERVICES |
| UNIT OF MEASURE (UOM) |
| ESTIMATED |
ANNUAL
USAGE
COST PER UOM
| Asthma |
| Per Member participant per month |
| 2,100 |
| Chronic obstructive pulmonary disease |
| Per Member participant per month |
| 350 |
| Coronary artery disease |
| Per Member participant per month |
| 825 |
| Congestive heart failure |
| Per Member participant per month |
| 175 |
| Diabetes-diabetics and pre-diabetics who participate in the diabetes management program are eligible to receive diabetic supplies at $0 copay. |
| Per Member participant per month |
| 4,100 |
| Kidney disease |
| Per Member participant per month |
| 75 |
| Obesity/weight management |
| Per Member participant per month |
| 6.000 |
| Hypertension |
| Per Member participant per month |
| 1,000 |
| Tobacco cessation |
| Per Member participant per month |
| 15 |
| Maternity |
| Per Member participant per month |
| 200 |
| Musculoskeletal |
| Per Member participant per month |
| 1,800 |
| Renal |
| Per Member participant per month |
| 75 |
| Women’s Health |
| Per Member participant per month |
| 400 |
Nurse Line The estimated annual usage shown is for all regions. For purposes of evaluating costs on a per region basis, the State will divide the estimated annual usage shown by seven.
| CORE SERVICES |
| UNIT OF MEASURE (UOM) |
| ESTIMATED |
ANNUAL
USAGE
COST PER UOM
| Nurse line |
| Per Member participant per month |
| 500 calls |
THE LINE ITEMS BELOW ARE OPTIONAL. THEY ARE NOT INCLUDED IN THE COST EVALUATION
| ADDITIONAL SERVICES |
| UNIT OF MEASURE (UOM) |
| ESTIMATED ANNUAL USAGE |
| COST PER UOM |
ID card cost maintenance - Cost to print and mail ID cards over one replacement card per Member per year at no additional cost.
Healthcare navigation services
Healthcare navigator TPA integration (Add on fees if a healthcare navigator TPA (separate entity from the Contractor) is chosen by the Agency)
| Additional communications |
| Per hour |
Additional innovation or value-added services (add rows as needed)
Offeror best practices (add rows as needed)
*The Offeror must fill out the table below to denote any discounts that would be available if the Offeror is awarded any of the defined total estimated enrolled employee thresholds. The discount will apply to all fees contained in this Cost Proposal Form unless specified otherwise.
The discounts in this table will not be considered for evaluation.
| Estimated Enrolled Employees per Month Awarded |
| Discount off ASO Fee |
All costs must be in U.S. Dollars.
The State will not be responsible for any costs not identified.
There will be no additional reimbursement for travel or other related expenses.
*Indicates the addition of the ASO discount chart to the Cost Proposal Form, per amendment 1, effective 10/20/26.
State of Ohio, Department of Administrative Services Medical Plan Third-Party Administrator – RFP #SRC0000038100 On behalf of the Department of Administrative Services