ITN for Third Party Administrator (TPA) Services Attachment FR 1: Instructions

Transcription

1 Attachment FR1: Instructions Instructions: Review and prepare a Financial Reply for each proposed Network Alternative. Each Network Alternative and proposed ASO fees may include one broad network or a combination of networks but must include and encompass all eligible Participants. Vendor shall provide a name for each proposed Network Alternative using the appropriate cells in Attachments A8, A9, B2, B3 and B4. Administrative fees must be provided both on a yearbyyear basis and as one fixed fee for the Contract term. If multiple Network Alternatives are proposed, please prepare and provide Technical Reply Attachments TR8, TR9 and a separate Financial Reply for each. Each Financial Reply consists of: Attachment FR1: Instructions Attachment FR2: Claims and Administration Attachment FR3: Network s Attachment FR4: Financial Reply Assumptions Financial Replies shall assume that the Vendor agrees to all terms and conditions of the ITN. If the Negotiation Team accepts an alternate term or condition, the Vendor will be provided an opportunity to revise the Financial Reply. When structuring the Financial Reply, the Vendor may not include additional or enhanced benefits, less restrictive benefit limitations, or benefits that eliminate or reduce exclusions contained in the attached benefit design. The following data has been provided for completion of the Financial Reply: File of subscribers containing ZIP code, gender, date of birth, plan option (standard or health investor) and coverage type (active, COBRA and Medicare) Claim file of eligible charges by provider type for 2012 with ZIP code Monthly net paid claims for each PPO plan design and Subscriber type, separated into the following categories: Inpatient hospital Outpatient hospital Professional Primary Care Professional Specialist Ancillary Services Monthly Subscribers for each PPO plan design and Subscriber type by Metropolitan Statistical Areas (MSA) and in total Monthly Participants for each PPO plan design and Subscriber type by MSA and in total Summary of high cost claimant information for each PPO plan design by MSA and in total FR2: Claims and Administration I. Administrative Fees The Vendor shall propose an administrative fee(s), on a Per Subscriber Per Month (PEPM) basis, which the Vendor guarantees for the initial Contract term. The Vendor must propose the administrative fee(s) in two ways: (i) a fixed dollar amount constant for the entire initial Contract term and (ii) a fixed dollar amount for each Plan Year for the entire initial Contract term. The Vendor shall also propose the maximum administrative fee(s) for the renewal term and for RunOut Claims. II. Projected and Target Claims Cost Vendor shall provide a Projected and Target Claims Cost as part of the Financial Proposal for Plan Year The Projected and Target Claims Cost must be provided based on the following Subscriber types: Active, Early Retirees (Pre65 Medicare), Medicare (post 65), and COBRA. The Projected and Target Claims Cost shall include innetwork and outofnetwork claims and shall exclude prescription drugs (except for those included in medical claims). The Projected Target and Claims Cost shall not include savings attributable to disease management and lifestyle programs. The Vendor shall identify (in Attachment FR4: Financial Reply Assumptions) all assumptions used to develop Projected and Target Claims Cost for 2015, including expected trend and adjustments from the incumbent Service Provider's network to the proposed Network Alternative (if applicable) except for the following assumptions, which must be used: Constant enrollment from the most recent data period No migration among PPO plans No plan design changes for 2014 or 2015 The Projected and Target Claims Cost must be provided for Plan Year For each subsequent Plan Year, the Projected and Target Claims Cost will be based on the actual total paid claims incurred in the prior Plan Year plus the Paid Claims Expected Trend. DMS 12/13047 TPA Services FR1 Instructions Page 1 of 7

2 III. Allowable Adjustment Factors Allowable Adjustment Factors will be used to develop mutually agreed upon annual adjustments to the Paid Claims Expected Trend for each subsequent Plan Year based on changes in enrollment, demographics and plan changes which may impact total paid claims. When submitting a Reply to this ITN the Allowable Adjustment Factors should remain 1.0. The Vendor shall provide explicit assumptions regarding Your development of material changes in these factors in Attachment FR4: Financial Reply Assumptions. The Allowed Adjustment Factors will be discussed during the Negotiation Phase and incorporated into the Contract to define adjustments to the Paid Claims Expected Trend for Plan Years 2016 through IV. Paid Claims Expected Trend The Vendor shall provide a Paid Claims Expected Trend used to calculate Projected and Target Claims Cost for years 24 of the Contract term. The Vendor shall guarantee the Paid Claims Expected Trend (annually adjusted as noted above) for the Contract term. Respondent's Paid Claims Expected Trend must guarantee the maximum trend factor that will be used in developing the Projected and Target Claims Cost for years 24. V. Guaranteed Savings Attributable to Disease Management and Wellness Initiatives Vendor shall also provide a Guaranteed Savings Attributable to Disease Management and Wellness Initiatives. Vendor shall provide specific assumptions regarding the expected savings to the program after implementation of any quoted disease management or wellness initiatives in Attachment FR4: Financial Reply Assumptions. VI. Aggregate Projected Claims Cost Net Savings Attributable to Disease Management and Wellness Initiatives Respondent's Projected and Target Claims Cost will be combined with the Paid Claims Expected Trend and Guaranteed Savings Attributable to Disease Management and Wellness Initiatives to form an Aggregate Projected Claims Cost net of savings attributable to disease management and wellness initiatives. The Aggregate Projected Claims Cost plus the lowest cost of the two administrative fee structures will be considered to be the Total Contract Price in the evaluation phase. VII. Claims Target Guarantee (PEPM) The Aggregate Projected Claims Cost shall be divided by the average actual enrollment for each Plan Year to calculate the Claims Target Guarantee on a per Subscriber (PEPM) basis. The Claims Target Guarantee will be compared to the actual paid claims (PEPM) and enrollment on an annual (Plan Year) basis. Medicare Subscribers shall not be included in the Claims Target Guarantee. For this ITN, a sample projected enrollment is included to calculate the Claims Target Guarantee. The Claims Target Guarantee shall establish a risk corridor of 105% of the Projected and Target Claims Cost for the eligible populations. The State of Florida shall be responsible to pay medical claims up to the 105% corridor. The Vendor shall be responsible for 100% of actual paid claims above the 105% corridor, capped at 100% of the total administrative fee(s) for the Plan Year. If actual claims exceed the 105% corridor by more than 100% of the total administrative fee(s), the Vendor shall be responsible for 50% of actual paid claims in excess of the 105% corridor plus 100% of total administrative fee(s) for the Plan Year. The risk corridor will be based on the aggregate Claims Target Guarantee (PEPM). The Claims Target Guarantee will be assessed annually based on the receipt of the Annual Claims Target Guarantee Report specified in the Technical Reply TR4 (AR77(af)). If the claims incurred during the Plan Year, divided by average actual enrollment for the same time period, exceed the aggregate Claims Target Guarantee (PEPM) risk corridor, the Vendor shall remit the appropriate amount to the Department no more than 15 Calendar Days after the receipt of the annual report. FR3: Network s Vendor shall define the top ten (10) Metropolitan Statistical Areas (MSA) based on inpatient facility allowed charges. For each of the MSAs, as well as for the service area not encompassed by the MSAs and in total, the Vendor shall provide assumptions for the eligible charges and current average network discounts of their proposed Network Alternative. Current average network discounts shall be provided in each of the primary categories; inpatient facility, outpatient facility, professional specialist, professional primary care, and ancillary services. Please identify any expected improvements in discounts over the Contract term using Attachment FR4: Financial Reply Assumptions. Submitted average discounts will also be compared to the NetPic database to assess reasonability of expected discounts and resulting total expected claims cost incorporated in the proposal. Submitted average discounts will be used as a minimum and are expected to be maintained or improved over the contract period. Total Network reflected in Attachment FR3: Network s will establish the guaranteed minimum network discount amount related to PG22 of Attachment TR10 Performance Guarantees. FR4: Assumptions Service Provider shall provide the assumptions, methodology or logic applicable to each of the items requested above. DMS 12/13047 TPA Services FR1 Instructions Page 2 of 7

3 Attachment FR2: Claims and Administration Instructions: Respondents shall populate the cells in yellow below. Network Name: I. Administrative Fees The Vendor shall propose an administrative fee(s), on a Per Subscriber Per Month (PEPM) basis, which will be guaranteed for the initial Contract term, renewal term(s), and RunOut Period. Vendor must propose the administrative fee(s) in two ways, using the tables below to identify the fee components. The Department may choose which proposed administrative fee structure to include in the final Contract. The lowest cost of the two structures will be included in the evaluation phase based on a fouryear term and the projected enrollment below. However, the Negotiation Team is not prohibited from consideration of alternate fee structures. Table 1: A fixed dollar amount, constant for the entire initial Contract term. Table 2: A fixed dollar amount for each Plan Year for the entire initial term of the Contract. Table 1 Table 2 Member Communication Materials Customer Service Medical Claims Administration Utilization Review Care/Case Management Disease Management Reporting Corporate and Other Overhead Expenses Network Management Appeals Taxes Profit Network Access Fees Other (Please Specify) Total ASO (PEPM) $ $ $ $ $ $ $ $ x Projected Enrollment $ $ $ $ $ $ $ $ Total Projected Contract ASO $ $ Runout ASO (PEPM) DMS 12/13047 TPA Services FR2 Claims and Administration Page 3 of 7

4 Renewal ASO (PEPM) II. Projected and Target Claims Cost Active $ $ $ PreMedicare & Dependents $ $ $ Medicare & Dependents $ $ $ COBRA $ $ $ Total Cost by Year $ $ $ $ Total Contract Cost $ III. Allowable Adjustment Factors for the Projected Target Claims Cost x Average Member per Subscriber Adjustment x Age/Sex Adjustment x Geographic Adjustment x Participant Migration x Plan Changes Adjustment to Paid Claims Expected Trend IV. Paid Claims Expected Trend V. Guaranteed Savings Attributable to Disease Management and Wellness Initiatives Active PreMedicare & Dependents Medicare & Dependents COBRA Total Savings by Year $ $ $ $ Total Contract Savings $ VI. Aggregate Projected Claims Cost Net Savings Attributable to Disease Management and Wellness Initiatives Active $ $ $ $ PreMedicare & Dependents $ $ $ $ Medicare & Dependents $ $ $ $ COBRA $ $ $ $ Total Cost by Year $ $ $ $ Total Contract Cost $ DMS 12/13047 TPA Services FR2 Claims and Administration Page 4 of 7

5 Projected Enrollment (Illustory) Active 55,000 55,000 55,000 55,000 PreMedicare & Dependents 4,200 4,200 4,200 4,200 Medicare & Dependents 24,100 24,100 24,100 24,100 COBRA Total 83,800 83,800 83,800 83,800 VII. Claims Target Guarantee (PEPM) (Illustory) Active $ $ $ $ PreMedicare & Dependents $ $ $ $ COBRA $ $ $ $ Claim Target Guarantee (aggregate) $ $ $ $ Claim Target Guarantee (PEPM) $ $ $ $ 105% Corridor (aggregate) $ $ $ $ Total Contract Price (Administrative Fees + Aggregate Projected Claims) $ DMS 12/13047 TPA Services FR2 Claims and Administration Page 5 of 7

6 Attachment FR3: Network s Instructions: Respondents shall populate the cells in yellow below. Network Name: Inpatient Facility Outpatient Facility Professional Service Primary Care Professional Service Specialist MSA 1 MSA 2 MSA 3 MSA 4 MSA 5 MSA 6 MSA 7 MSA 8 MSA 9 MSA 10 Remaining Network (excluding MSAs) Total Network $0 $0 $0 $0 $0 Ancillary Services DMS 12/13047 TPA Services FR3 Network s Page 6 of 7

7 Attachment FR4: Financial Reply Assumptions Instructions: Respondents must use this tab to provide their assumptions and methodology for calculation of items required in the Financial Reply. Network Name: I. Identify all assumptions used to develop Projected and Target Claims Cost for 2015, including expected trend. II. Identify all assumptions regarding Your development of material changes in Allowable Adjustment Factors. III. Identify all assumptions regarding the expected savings to the program after implementation of any quoted disease management or wellness initiatives. IV. Identify all assumptions regarding any expected improvements in discounts over the Contract term. DMS 12/13047 TPA Services FR4 Reply Assumptions Page 7 of 7