CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
CHESAPEAKE
PUBLIC SCHOOLS
GROUP HEALTH
INSURANCE
Request for Proposals
Part 6
Cost Proposals/
Vendor Response
(MS Word)
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
1
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.1
MEDICAL BENEFITS – COST PROPOSALS
All carriers should price their benefits by line of coverage. If you are selected for two or more coverage
lines you will need to be able to offer a blended rate. You must also use our enrollment assumptions.
In quoting the reinsurance, use the following assumptions:
A.

Specific stop loss - $300,000 – quote based on a 12/15 and a Paid contract.

No aggregate stop loss
Cost Proposals – Administrative Services Only (ASO)
COST PROPOSALS
ADMINISTRATIVE SERVICES ONLY (ASO)
PPO
12/15 SSL
No. of
Employe
es
(1)
Administratio
n Network
Pre-Cert Cost
(2)
Specific
Stop
Loss
+ $300,000
12/15
(3)
+
Expecte
d
Claim
Liability
=
Expecte
d
Rate
Total
Monthly Cost
=
(1x5)
(2+3+4)
(5)
(4)
Medical:
Employee
Employee/Child(ren)
Employee + Spouse
Employee/ Family
GRAND TOTAL $
COST PROPOSALS
ADMINISTRATIVE SERVICES ONLY (ASO)
HMO (POS)
12/15 SSL
No. of
Employe
es
(1)
Administratio
n Network
Pre-Cert Cost
+
(2)
Specific
Stop
Loss
$300,000
12/15
(3)
+
Expecte
d
Claim
Liability
(4)
=
Expecte
d
Rate
Total
Monthly Cost
=
(1 x 5)
(2+3+4)
(5)
Medical:
Employee
Employee/Child(ren)
Employee + Spouse
Employee/ Family
GRAND TOTAL $
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
2
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
COST PROPOSALS
ADMINISTRATIVE SERVICES ONLY (ASO)
PPO
PAID SSL
No. of
Employees
Administration
Network
Pre-Cert Cost
+
(1)
Specific
Stop Loss
$300,000
PAID
(2)
Expected
Claim
Liability
+
Expected
Rate
=
(4)
(3)
(2+3+4)
(5)
Total
Monthly Cost
=
(1x5)
Medical
Employee
Employee/Child(ren)
Employee + Spouse
Employee/ Family
GRAND TOTAL $
COST PROPOSALS
ADMINISTRATIVE SERVICES ONLY (ASO)
HMO (POS)
PAID SSL
No. of
Employees
Administration
Network
Pre-Cert Cost
+
(1)
(2)
Specific
Stop
Loss
$300,000
PAID
(3)
Expected
Claim
Liability
+
(4)
Expected
Rate
=
(2+3+4)
Total
Monthly Cost
=
(1 x 5)
(5)
Medical
Employee
Employee/Child(ren)
Employee + Spouse
Employee/ Family
GRAND TOTAL $
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
3
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.2
MEDICAL BENEFITS – RESPONSE
A.
GENERAL INFORMATION
1. Have you followed specifications as requested?
deviations.
If not, specifically outline your
2. Where is your servicing office that will be responsible for this account?
3. What management reports will be provided and how often are these available?
Please include examples of these reports. Can these be quarterly? Can your reports
be provided on disk, and if so, is there an additional cost?
4. Can you administer COBRA and HIPAA? What is the cost?
B.
MANAGED CARE – PPO and HMO (POS)
(Please be specific on PPO and HMO (POS) on all of the following questions.)
1. Are you quoting PPO and HMO (POS)?
2. How long has your network been organized in Hampton Roads? Approximately how
many employees are covered in South Hampton Roads:
Years
Number Covered
PPO
HMO (POS)
3. Are your HMO (POS) physician contracts fee schedules, discounts or capitation? If
on a fee schedule, what is the percentage savings over UCR for Primary Care
Physicians? For Specialists? If the reimbursement is on a straight discount, what
percentage?
______________Inpatient
______________Outpatient
4. What percentage savings do your hospital contracts generate?
5. Are all savings passed on to the plan? If not, explain.
6. What quality standard and credentialing is required of your providers?
7. What percent of your physicians are not accepting new patients?
8. Are you using your own network? If not, what network(s) are you using?
9. Are network directories available on-line?
10. What is your NCQA status? (HMO [POS])
11. Did you include Disease Management? In which plans? Which diseases?
12. Please complete the following tables with your current average reimbursement
associated with each diagnosis code for each of the following hospitals.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
4
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
CHESAPEAKE REGIONAL MEDICAL CENTER
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
Cost Proposal/Vendor Response (MS Word)
PER
DIEM
5
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
CHILDRENS HOSPITAL OF THE KING’S DAUGHTERS
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
Cost Proposal/Vendor Response (MS Word)
PER
DIEM
6
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
BON SECOURS MARYVIEW MEDICAL CENTER
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
PER
DIEM
Cost Proposal/Vendor Response (MS Word)
7
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
SENTARA VIRGINIA BEACH GENERAL HOSPITAL
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
Cost Proposal/Vendor Response (MS Word)
PER
DIEM
8
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
SENTARA LEIGH HOSPITAL
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
PER
DIEM
Cost Proposal/Vendor Response (MS Word)
9
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
SENTARA NORFOLK GENERAL HOSPITAL
HMO (POS)
ICD 9 CODE
CASE
RATE
PPO
PER
DIEM
AVERAGE
LENGTH
OF STAY
ICD 9 CODE
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
1 41401 - Cor As- Native
Vessel
2 78650 - Chest Pain Nos
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
3 V3001 - Sngl Lb, Hosp,
Del by Cd
4 585 - Chronic Renal
Failure
5 650 - Normal Delivery
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
6 78900 - Abdominal
Pain-Site Nos
7 72210 - Lumbar Disc
Displacement
8 2860 - Cong Factor
Viii Diord
9 430 - Subarachnoid
Hemorrhage
10 7242 - Lumbago
11 7070 - Decubitus Ulcer
11 7070 - Decubitus Ulcer
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
12 99661 - Infect D/T Hrt
Device
13 V202 - Routine Child
Health Exam
14 V3000 - Sin LivebnHosp-No C-Sec
15 7220 - Cerv Disc
Displacement
16 2765 - Hypovolemia
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
17 78039 - Oth
Convulsions
18 1749 - Malign Neopl
Breast Nos
19 7840 - Headache
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
20 78659 - Chest Pain
Neck
21 V581 - Chemotherapy
Encounter
22 41071 - Subend InfarctInitial
23 7231 - Cervicalgia
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
24 V723 - Gynecologic
Examination
25 57410 - Gb Calculus W
Chol Nec
RFP 15-1213 Group Health Insurance
- Addendum 001 -
CASE
RATE
Cost Proposal/Vendor Response (MS Word)
PER
DIEM
10
AVERAGE
LENGTH
OF STAY
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
C.
Allowable Charges
1. For the Hampton Roads area, please indicate the current negotiated fee or allowable
charge under your PPO and HMO (POS) plans for the following procedures:
Medical Procedure
Adult Physical
Appendectomy
Bilateral Myringotomy
Biopsy of Skin
Cataract Extra Cap W/
Insert lens
Cesarean Section
Cholecystectomy
Colonoscopy
D&C
Destruction lesion, face
Emergency Room Visit
Four Artery Bypass
Fragmenting of Kidney
Stones
Hysterectomy
Knee Arthroscopy
Laparoscopic
Cholecystectomy
Radical Mastectomy
Repair of tendons
Tonsillectomy &
Adenoidectomy
Triple Bypass
TURP
Vaginal Hysterectomy
Vasectomy
Well Baby Visit
Automated multi-channel
19 + tests
CAT Scan, Brain
Complete Blood Count
Echogram, pelvic
Hospital Care
Hospital Care
Hospital Care
Lt Hear Catherization
MRI
MRI, Head
MRI, Head
MRI-Lumbar Spine
RFP 15-1213 Group Health Insurance
CPT Code
Negotiated Fee
PPO
POS
UCR
99385
44950
69420
11100
66984
59510
47500
45378
58120
17100
99385
33513
50590
58150
29881
56341
19240
23410
42820
33512
52601
58260
55250
99391
80019
70460
85022
76856
99222
99232
99251
93510
73721-26
70551
70553
72148
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
11
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
Medical Procedure
OB CARE
Office visit
Office visit
Pap Smear; screening by
tech
Pathology Level IV
Physical Ed-Therapeutic
Psychotherapy
Routine Urinalysis
Thyroid Stimulating
Hormone
X-Ray Finger(s) 3 or more
views
X-Ray Chest 2 Views
2.
3.
Negotiated Fee
PPO
POS
CPT Code
UCR
59400
99212
99213
88150
88305
97110
90844
81000
84443
73140
71020
Please list any centers of excellence used by the plan, and for what services they
are used? Describe the financial arrangement
a. Is a self-care program provided to all members? ______Yes _______No
b. If yes, does the program include: (check all that apply)
Yes
No
An instructional manual
Newsletter
RN advice line
Other
D.
Program Management
1. For the Hampton Roads area, what is your overall PPO rate of physician turnover
for the past five (5) years?
2008
2009
2010
2011
2012
Physician Initiated
Plan Initiated
Involuntary (move, death, etc.)
2. For the Hampton Roads area, what is your overall HMO (POS) rate of physician
turnover for the past five years?
2008
2009
2010
2011
2012
Physician Initiated
Plan Initiated
Involuntary (move, death, etc.)
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
12
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
3. For the Hampton Roads area, what has been the enrollment (number of members) in
your plans for the last three years?
2010
2011
2012 YTD
HMO (POS)
PPO
E.
PRESCRIPTION DRUG CARD
1. Please confirm that your organization is willing and able to have the pharmacy’s
Usual and Customary (U&C) price field serve as the reimbursement formula for all
claims transmitted at the Chesapeake Public Schools pharmacies.
2. Please confirm that your organization is willing and able to allow 90-day fills at the
Chesapeake Public Schools pharmacies.
3. Please confirm that your organization is willing to administer the prescription benefit
as it pertains to quantity limits, prior authorizations, step therapy and DUR edits
identically to other providers.
4. Speak to your firm’s ability to allow certain maintenance medications to be
administered differently at the employee pharmacies.
5. Please confirm that your organization will provide a detailed claims level report to the
client or their consultant on a monthly basis with the following data fields:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Name of Drug
Date of Fill
Metric Quantity
Days Supply
AWP
Ingredient Cost
Dispensing Fee
Plan Pay
Member Pay
Brand/Generic Indicator
Pharmacy Identifier (NCPDP/NABP)
11 digit NDC
6. Please include in your submittal the required paperwork necessary to join your
pharmacy network. Additionally, describe the timeline in adding pharmacies to your
network, with special circumstances such as these.
7. Is your organization able to suppress billing for those claims processed at the
employee pharmacies – no bill no remit?
8. Please identify the clinical/pharmacy liaison that your firm would assign for the
Division and their experience and capabilities as it pertains to this unique situation.
9. Does your firm have any other clients for whom you provide this type of business
model? Please identify those that would be willing to be used as a reference. (Note:
The Division will not contact unless your firm is selected as a finalist.)
10. Confirm that no additional fees or charges will be required to provide the services as
outlined in this proposal.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
13
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
F.
CLAIMS ADMINISTRATION
1.
What office will be responsible for medical claim payments?
2.
What is your turnaround time for “clean” claims?
3.
Will the Division have a dedicated claims processing unit.
4.
Can you provide on-line access to claim details, enrollment/changes on “real
time” basis.
5.
Can you accept eligibility by tape or other means of electronic transfer? Please
describe in detail any format by which you can accept eligibility.
6.
Please confirm that you agree to accept fiduciary responsibility for final claim
determination, and indicate the cost for this service separately in the financial
section.
7.
Briefly outline your appeals process, as though you are the fiduciary for final
claim determinations.
8.
The Division is interested in collecting claim and utilization data on each of its
plans. Please confirm that you are able to provide the following minimum data
electronically, separated by plan type and by active, retiree and COBRA.
Paid claims by month
Covered employees/members by month
Incurred claims by month
Utilization data

Top diagnoses

Top hospitals

Average length of stay

Average cost per day, MDCs, etc.
G.
YES



NO











UTILIZATION MANAGEMENT PROGRAM
1.
Are you using your own Utilization Management Program or are you subcontracting this to another party? If so, please show the name of the
subcontractor.
2.
Do you have a High Risk Pregnancy Screening? Did you include a brochure
outlining this plan?
3.
What triggers Large Case Management? How does Large Case Management
function?
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
14
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
H.
FUNDING AND FINANCIAL CONSIDERATION
1.
2.
I.
Administrative Services Only (ASO)
a.
What banking arrangement is required under your ASO arrangement?
b.
Who is the Stop Loss carrier?
c.
Is the Specific Stop Loss $300,000?
d.
Did you quote Stop Loss coverage at 12/15 and Paid basis?
e.
Explain the mechanics of cash transfers for claim payment.
f.
Are you willing to provide 240 days advance notice for renewal rate
increases?
If not, what is your normal notification period?
What factor will you use to mature the first year claims?
MISCELLANEOUS
1.
Provide your fees you are willing to place at risk for the following proposed
performance guarantees in the structure below:
Description
Performance Standard
% of Fees or Dollar
Amount at Risk
Average speed of answer of all incoming
calls answered in 30 seconds or less
Phone Access
Abandon Rate
Eligibility Data
Mailing ID Cards
Implementation
Claims turnaround time
Claims accuracy
Member Satisfaction Survey
Less than 5% of all calls abandoned
Data and corrections updated within 3
days of receipt
100% mailed within 7 calendar days from
the time eligibility goes into the system
Satisfactory completion of key activities of
implementation work plan
90% within 14 days
98% financial
96% incidence
97% total processing
To be performed annually, plan wide and
results shared with the Division
2.
Will each of these standards be measured with the Division specific data or
otherwise?
Please indicate for each standard.
3.
How will each of these performance standards be measured? How often will it be
measured?
4.
Provide us with the references of at least five (5) current customers of similar
size and occupation, for which the Vendor has provided applicable services
during the past five (5) years. Please provide firm’s name, contact person,
address, phone number/e-mail address, number of years Vendor has served the
firm, and a brief summary of scope and services provided to the firm.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
15
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
5.
Provide us with the names and phone numbers of at least two (2) former
customers of similar size and occupation for which the Vendor provided
applicable services during the last five (5) years. Please provide firm’s name,
contact person, address, phone number/e-mail address, number of years Vendor
served the firm, and a brief summary of scope and services provided to the firm.
6.
Please perform one GeoAcess study for ALL eligible employees in the census
data (please see RFP Section 1.1 - Introduction). The study must consider only
open physician practices in your PPO and HMO (POS) networks and must
comply with the following parameters:
a.
Percentage of employees with two (2) adult primary care physicians
(internal medicine, family practice) within ten (10) miles of an employee’s
zip code.
b.
Percentage of employees with two (2) pediatricians within ten (10) miles
of an employee’s zip code.
c.
Percentage of employees with two (2) OB/GYNs within ten (10) miles of
an employee’s zip code.
d.
Percentage of employees with one (1) hospital within 20 miles of an
employee’s zip code.
7.
Please describe your normal implementation service and support that will be made
available to the Division.
8.
The Leapfrog Group has identified three initial hospital safety measures as the focus
of consumer education, health care provider performance comparisons, and hospital
recognition and reward. Based on independent scientific evidence, the initial set of
safety measures includes: computer physician order entry; evidence-based hospital
referral; and intensive care unit (ICU) staffing by physicians trained in critical care
medicine.

Computer Physician Order Entry (CPOE) – With CPOE systems,
physicians enter medication orders via computer linked to prescribing
error prevention software. CPOE has been shown to reduce serious
prescribing errors in hospitals by more than 50%.

Evidence-Based Hospital Referral – By referring patients needing certain
complex medical procedures to hospitals offering the best survival odds
based on scientifically valid criteria – such as the number of times a hospital
performs these procedures each year – research indicates that a patient’s
risk of dying could be reduced by more than 30%.

ICU Physician Staffing - Staffing ICUs with physicians who have
credentials in critical care medicine has been shown to reduce the risk of
patients dying in the ICU by more than 10%.
Please comment on your plan’s facilities’ current capabilities in these areas, and
their future plans for their initiatives.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
16
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.3
DENTAL BENEFITS - COST PROPOSALS
COST PROPOSALS
ADMINISTRATIVE SERVICES ONLY
PLAN 1 – CURRENT BENEFITS
Mature
Cost
No. of
Employees
Administrative
Costs
+
Expected Claim
=
Monthly
Contract Cost
Per Employee
Total
Monthly Cost
Employee
Employee /
Family
Contract should be 12-12. However, you must disclose how much you have discounted your fees
and expected claims reflecting the immature nature of this contract if Chesapeake Public School
Board changes carrier.
Discounts
________% Fees
________% Expected Claims
6.4
DENTAL BENEFITS - RESPONSE
A.
DENTAL COVERAGE
1.
Have you followed specifications and quoted these coverages, as requested? If
not, specifically outline your deviations.
2.
What Usual and Customary Fee Schedule do you use?
_________________________
What percentile? ___________________
How often is it updated? ________________
Can the Division choose the percentile? ___________________________
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
17
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
3. What is your allowable charge for Dental Usual and Customary charges for the
following procedures in the Hampton Roads area?
Code
Description
01110 Adult Prophylaxis
$
$
03330 Root Canal, Molar
$
$
02752 Porcelain Semiprecious Crown
$
$
00120 Period Oral Exam
$
$
02150 Amalgam, 2 Surface permanent
$
$
04341 Root Planning/Quadrant
$
$
04260 Osseous Surgery/per Qt.
$
$
00274 4-bite Wing Films
$
$
02330 Resin, 1 Surface Anterior
$
$
07110 Simple Extraction
$
$
06752 Crown Porcelain to Semi-Precious Metal $
$
05214 Chrome Cobalt Partial Lower
$
$
01351 Sealant
$
$
00230 Additional Films
$
$
07240 Impaction (Completely Bony)
$
$
Annual Frequency
Per 1,000
members
4.
Are Dental expenses required to be pre-authorized prior to treatment? Explain.
5.
a.
Do you have a PPO Dental program?
participating dentists.
b.
B.
Fee for Service
Allowance
PPO
Usual Customary
Charge
If yes, include a directory of
Explain how claims are adjudicated if the insured uses a non-par dentist?
CLAIMS ADMINISTRATION
1.
Where are dental claims paid?
2.
What is your turnaround time for “clean” claims? If not “clean” claims, what
follow-up do you have?
3.
Is there a toll-free customer service line for use by insureds and providers? What
are the hours of operation?
4.
Will the Division have a dedicated claims processing unit?
5.
Can you provide on-line access to claim details, enrollment/changes on “real
time” basis?
6.
Can you accept eligibility by tape or other means of electronic transfer? Please
describe in detail any format by which you can accept eligibility.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
18
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
7. Can you accept claims directly from providers? Electronically from providers?
C.
MISCELLANEOUS
1.
Provide us with the references of at least five (5) current customers of similar
size and occupation, for which the Vendor has provided applicable services
during the past five (5) years. Please provide firm’s name, contact person,
address, phone number/e-mail address, number of years Vendor has served the
firm, and a brief summary of scope and services provided to the firm.
2.
Please perform a GeoAccess study using all eligible employees on the census
(please see RFP Section 1.1 - Introduction). The access parameters should be:


3.
Number of employees with access to two (2) dentists within 20 miles
One dentist within 10 miles
Please complete this table regarding the provider networks for your dental PPO
product proposed for the Hampton Roads area. Indicate reporting date of
provider information.
PPO
Network Providers
Number
Percentage of
Market
As of
Reporting
Date:
Hampton Roads Area
 Board Certified: Number &
Percent
4.

Number with closed practices

Annual Turnover Rate (%)
Please describe your normal implementation service and support that will be
made available to the Division.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
19
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
D.
PERFORMANCE GUARANTEES
1.
Provide your proposed performance guarantees in the structure below for your
Dental PPO:
Description
Performance Standard
Phone Access
Average speed of answer of all
incoming calls answered in 30 seconds
or less
Abandon Rate
Less than 5% of all calls abandoned
Eligibility Data
Data and corrections updated within 3
days of receipt
Mailing ID Cards
100% mailed within 7 calendar days
from the time eligibility goes into the
system
Implementation
Satisfactory completion of key activities
of implementation work plan
Claims turnaround time
90% within 14 days
Claims accuracy
98% financial
96% incidence
97% total processing
Member Satisfaction
Survey
To be performed annually, plan-wide
and results shared with the Division
% of Fees or Dollar
Amount at Risk
2.
Will each of these standards be measured with the Division’s’ specific data or
otherwise? Please indicate for each standard.
3.
How will each of these performance standards be measured? How often will it be
measured?
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
20
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.5
PHARMACY BENEFITS MANAGEMENT – COST PROPOSALS
Cost Proposals
Pharmacy Benefits Management
Mail Order
Jan. 1 – Dec. 31, 2011
Jan. 1 – Nov. 30, 2012
Jan. 1 – Dec. 31, 2011
Jan. 1 – Nov. 30, 2012
1. Brand Discount % off AWP
2. Brand Dispensing Fee per Rx
3. MAC* Pricing (Yes or No)
4. MAC Generic Discount % off AWP
5. % Generic Rxs with MAC price
6. Non-MAC Generic Discount % off AWP
7. Generic Dispensing Fee per Rx
8. Postage-Paid Return Envelopes (Yes/No)
Administrative Fees
1. Network Electronic Claims Processing
2. Out of Network and Paper Processing Charge
3. Mail Order Claims Processing
* MAC - Maximum Allowable Charges
Trend Rates: (If different for your PPO from your HMO (POS), please provide both responses
separately.)
2011
2012
Network
Due to the increase in utilization
%
%
Due to the increase in unit price
%
%
Due to the increase in utilization
%
%
Due to the increase in unit price
%
%
Non-Network
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
21
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.6
PHARMACY BENEFITS MANAGEMENT - RESPONSE
A.
MAC Pricing
1. For each MAC list that you maintain, disclose the following as of 1/1/2013. If different
for your PPO from your HMO (POS), please provide both responses separately.
Name of MAC List
Check () the MAC list
proposed for CPS
Number of GCNs on
the MAC list
Estimated % of retail
generic* Rxs that will
be MAC’d
Estimated % of retail
generic* AWP that will
be MAC’d
For those drugs on the
MAC list, what is the
average or effective
discount off the generic
AWP (weighted by
dollars)
Does the MAC list
include any multisource
brand drugs?
If yes, provide a list:
* Defined as generic drugs + multi-source brand drugs on the MAC list
2.
Provide the following information regarding the AWP source and pricing:
a.
Source document or service providing AWP
b.
Frequency of updates to AWP file
c.
Use of manufacturer’s full 11-digit NDC code to determine AWP
d.
Package size basis for typical book of business AWP formula
e.
Use of acquisition package size AWP in pricing determination
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
22
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
B.
Formulary Charges
1.
Complete the following table. If different for your PPO and your POS, provide
both responses:
Proposal
Is this an Estimate (E) or a
Guarantee (G)?
Length of Guarantee
(Years)
Minimum Rebate Guarantee –
Retail
Minimum Rebate Guarantee – Mail
Order
Formulary Rebate Pass-thru %
2.
a.
If the rebate guarantee is based upon formulary list brand Rxs, or
rebatable Rxs, estimate the percentage of retail Rxs and mail Rxs that
will have a rebate. Describe any guarantees you are willing to offer
related to the minimum number of Rxs applicable to the minimum rebate
guarantee and indicate the amount at risk if the guarantee is not
satisfied.
b.
Describe the frequency and measurement of formulary rebates. Provide
a sample report used to reconcile formulary rebate accrual and
demonstrate satisfaction of the guarantee. If you do not provide a report
showing rebates accrued by manufacturer, clearly explain why this
cannot or will not be done.
c.
Are shipping costs included in the mail order dispensing fee? If not,
define the additional cost. Indicate whether the proposed mail order
dispensing fees are subject to increases in postal/shipping rates during
the contract term.
d.
Indicate whether pre-addressed, postage-paid prescription mail order
envelopes are included in your cost quotation. Explain any issues
related to this service such as impact
on mail order turnaround time.
Describe any additional costs if this service is requested.
Describe any additional cost to the Division due to taxes and address the
following points:
a.
Type of tax
Sales
Usage
Service
b.
List of states with taxes
c.
Level of taxes
d.
Applicability of taxes (e.g., state of prescribing, dispensing, or shipment)
e.
Estimate of annual tax
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
23
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
C.
D.
E.
Administration
1.
Please confirm that you agree to accept fiduciary responsibility for final claim
determination, and indicate the cost for this service separately in the financial
section.
2.
Briefly outline your appeals process, assuming you are the fiduciary for final
claim determinations.
Plan Design
1.
Under an open formulary program, describe the level of formulary intervention to
which the Division must agree in order to qualify for the proposed formulary
rebates.
2.
In the Division’s plan design, do you have any recommendations to better
manage costs and/or improve outcomes with minimal employee disruption?
3.
Indicate the dispensing facility you propose for this account’s mail order drug
benefit and briefly explain the reasons for this recommendation (if multiple
facilities available) or the advantages of this location (if a single facility).
Implementation
1.
Describe available options for transitioning mail order prescriptions from the
current Vendors. Which option do you recommend?
2.
Include a copy of your standard enrollment kit including ID card.
3.
Please describe your normal implementation service and support that will be
made available to the Division.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
24
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
F.
Service Performance Standards
1.
Define the guaranteed terms of the service performance standards outlined
below.
Service Performance Standards
1. Pharmacy Network Access (for each proposed network)
a. Percent available pharmacies in network nationwide
b. Percent available pharmacies in network within member zip
codes
c. Percent participants with urban area zip code within one (1) mile
of network pharmacy
d. Percent participants with suburban area zip code within three (3)
miles of network pharmacy
2. Network Pharmacy Management
a. Percent of network pharmacies audited on-site each year
b. Percent of total Rxs processed that will be in network
3. Retail Paper Claims Processing Time
a. Percent of Rxs reimbursed or responded to within five (5)
business days
b. Percent of Rxs reimbursed or responded to within ten (10)
business days
c. Number of business days for 100% reimbursement or response
4. Mail Order Claims Processing Time
a. Average turnaround time for Rxs requiring NO intervention in
business days measured from date mail order received to date
mail order shipped
b. Average turnaround time for Rxs requiring administrative or
clinical intervention in business days measured from date mail
order received to date mail order shipped
c. Average turnaround time for Rxs received via phone or fax in
business days measured from date mail order received to date
mail order shipped
d. Average turnaround time for Rxs received via mail in business
days measured from date mail order received to date mail order
shipped
Guarantee
_____%
_____%
_____%
_____%
_____%
_____%
_____%
_____%
_____ days
_____ business days
_____ business days
_____ business days
_____ business days
5. Retail Claims Processing Accuracy
a. Percent of all claims paid with NO errors
b. Maximum percent error in total paid amount
_____%
_____%
6. Mail Order Claims Processing Accuracy
a. Overall dispensing accuracy rate
_____%
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
25
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
Service Performance Standards
7.
Customer Service
a. Percent of calls that will be answered within
- 15 seconds
- 20 seconds
- 30 seconds
b. Average time in seconds to answer customer service calls
c.
d.
e.
f.
Percent of calls abandoned
Percent of calls blocked
Percent of written inquiries responded to within 5 business days
Percent of written inquiries responded to within 10 business days
Guarantee
_____%
___ sec.
_____%
_____%
_____%
_____%
8. Participant Satisfaction Survey
a. Percent of participants satisfied with retail program per survey
results (Describe type and date of survey)
b. Percent of participants satisfied with mail order program per
survey results (Describe type and date of survey)
9. Account Service
a. Percent of calls returned by account service representative within
12-24 hours of receipt
b. Percent of calls resolved within 24 hours of receipt
c. Number of days for a response to a written inquiry
10. Implementation
_____%
_____%
_____%
_____%
_____ days
a. Terms of guarantee to ensure that all services are implemented
as proposed within specified timeframe
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
26
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
G.
Service Performance Penalties
Define the penalty to be assessed for each service performance guarantee if the
proposed standard is not achieved. Define the penalty as a percent of administration
fees and estimate the total dollar value equivalent of the penalty. State your willingness
to permit this organization to redistribute the total penalty and explain any conditions.
Penalty Amount
(dollars or % of
administration fees)
Service Performance Guarantee
1.
Pharmacy Network Access
2.
Network Pharmacy Management
3.
Retail Paper Claims Processing Time
4.
Mail Order Claims Processing Time
5.
Retail Claims Processing Accuracy
6.
Mail Order Claims Processing Accuracy
(based on overall accuracy)
7.
Customer Service
8.
Participation Satisfaction Survey
9.
Account Service
(based on overall accuracy)
•
•
•
•
•
Penalty Description
Explanation of Conditions
Basis for Measurements of Standard
Frequency of Standard Measurement
Frequency of Penalty Reconciliation
Subject to Aggregate Limit
10. Implementation
11. Indicate limit for all penalties in aggregate
H.
Provide a listing of the major chain pharmacies participating and not participating in the
Hampton Roads area.
I.
References
Provide us with the references of at least five (5) current customers of similar size and
occupation, for which the Vendor has provided applicable services during the past five (5)
years. Please provide firm’s name, contact person, address, phone number/e-mail
address, number of years Vendor has served the firm, and a brief summary of scope and
services provided to the firm.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
27
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
J.
Financial Questionnaire
1.
For your pharmacy program, please provide the following information for 2011, 2012
and 2013 projections. If the information is different for your PPO and HMO (POS),
please provide both responses separately.
Book of Business
Description
2011
a.
Average rebate per prescription
b.
Average co-pay per brand name prescription
c.
Average co-pay per generic prescription
d.
Generic substitution rate (%)
e.
Formulary compliance:
Projected
2013
2012
i. % of total scripts in formulary
ii. % of total dollars in formulary
iii. Number of drugs in formulary
2.
Please provide the following projections:
Retail
1. Number of Pharmacies
Jan. 1 – Dec. 31, 2013
Jan. 1 – Dec. 31, 2014
2. Brand Discount % off AWP
3. Brand Dispensing Fee per Rx
4. MAC Generic Effective Discount
5. % Generic Rxs on MAC
6. % Generic Dollars on MAC
7. Non-MAC Generic Discount % off AWP
8. Generic Dispensing Fee per Rx
9. Lower of UCR Pricing - % Effect and
basis
10. Effective Discount Rate
3.
The Division is interested in collecting claim and utilization data on each of its
plans. Please confirm that you are able to provide the following minimum data
electronically, separated by plan type and by active, retiree and COBRA.
YES
NO
Covered employee/member per month


Paid claims by month by brand, generic; retail and mail utilization data



Average number scripts per employee/member



Average cost per script for brand, generic



% generic, top prescription by dollar and by number, etc.


RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
28
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.7
LIFE, ACCIDENTAL DEATH & DISMEMBERMENT – COST PROPOSAL
COSTS PROPOSED
LIFE INSURANCE, ACCIDENTAL DEATH & DISMEMBERMENT
FULLY INSURED
Volume
Monthly Unit Rate
Monthly Cost
Employee Life Insurance per $1,000
Basic AD&D per $1,000
6.8
LIFE, ACCIDENTAL DEATH AND DISMEMBERMENT - RESPONSE
A.
GENERAL INFORMATION
1.
Have you followed specifications as requested?
outline your deviations.
2.
Where is your servicing office that will be responsible for this account?
3.
What assistance will you give in installing this account and employee
enrollment?
4.
B.
C.
If not, specifically
Will you offer a refunding contract?
LIFE INSURANCE AND AD&D
1.
Does your company charge for conversion of Life Insurance? If so, what
amount?
2.
Explain your claim charge procedure for Waiver of Premium claims.
3.
Where is the servicing office located?
4.
Where is the claims office located?
MISCELLANEOUS
1.
RFP 15-1213 Group Health Insurance
Provide us with the references of at least five (5) current customers of
similar size and occupation, for which the Vendor has provided
applicable services during the past five (5) years. Please provide firm’s
name, contact person, address, phone number/e-mail address, number
of years Vendor has served the firm, and a brief summary of scope and
services provided to the firm.
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
29
CHESAPEAKE PUBLIC SCHOOLS
Purchasing Department
School Administration Building
312 Cedar Road
Chesapeake, Virginia 23322
6.9
HIGH LIMIT ACCIDENTAL DEATH & DISMEMBERMENT – COST PROPOSAL
COSTS PROPOSAL
HIGH LIMIT ACCIDENTAL DEATH & DISMEMBERMENT
FULLY INSURED
Volume
Monthly Unit Rate
Total Monthly
Costs
$50,000
Employee Only Per $1,000
Family Rate per $1,000
$100,000
Employee Only Per $1,000
Family Rate per $1,000
$150,000
Employee Only Per $1,000
Family Rate per $1,000
$200,000
Employee Only Per $1,000
Family Rate per $1,000
$250,000
Employee Only Per $1,000
Family Rate per $1,000
6.10
HIGH LIMIT ACCIDENTAL DEATH & DISMEMBERMENT – RESPONSE
A.
B.
GENERAL INFORMATION
1.
Have you followed specifications as requested? If not, specifically outline your
deviations.
2.
Where is your servicing office that will be responsible for this account?
3.
What assistance will you give in installing this account and employee enrollment?
HIGH LIMIT ACCIDENTAL DEATH & DISMEMBERMENT
1.
C.
Where is the claims office located?
2.
Do you provide the required information to complete the Summary Plan
Description requirements?
3.
Are you willing to provide 180 days advance notice for renewal rate increases? If
not, what is your normal notification period?
MISCELLANEOUS
1.
Provide us with the references of at least five (5) current customers of similar
size and occupation, for which the Vendor has provided applicable services
during the past five (5) years. Please provide firm’s name, contact person,
address, phone number/e-mail address, number of years Vendor has served the
firm, and a brief summary of scope and services provided to the firm.
RFP 15-1213 Group Health Insurance
- Addendum 001 -
Cost Proposal/Vendor Response (MS Word)
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