CMS-10142 MA BPT Screen Shots

WORKSHEET 1 - MA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:
2008

MA-2008.1
OMB Approved # 0938-0944
5. Organization Name
6. Plan Name:
7. Plan Type:
8. MA-PD:

9. Enrollee Type:
10. MA Region:
11. Act. Swap/Equiv Apply:
12. SNP:

13. Region Name:

N/A

N/A
14. % of CY Enrollees that are Dually-Eligible:

II. Base Period Background Information
1. Time Period Definition
2. Member Months (excl ESRD)
Incurred from:
3. Non-ESRD Risk Score
Incurred to:
4. Completion Factor
Paid through:
6. Describe the source of the base period experience data (1000 character limit)

III. Base Period Data (at Plan's non-ESRD Risk Factor)
(c)
(f)

Service Category
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Supplies
OP Facility - Emergency
OP Facility - Surgery
OP Facility - Other
Professional
Part B Rx
Other Medicare Part B
Transportation (Non-Covered)
Dental (Non-Covered)
Vision (Non-Covered)
Hearing (Non-Covered)
POS
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

u.

Subtotal Medicare-covered services

Util
Type

(g)
Annualized
Util/1000

(h)
Total Benefits
Avg Cost

5. Plans In Base

(i)
Allowed
PMPM

IV. Projection Assumptions
(j)
(k)
(l)
Util. Adjustments to Contract Period
Util/1000
Benefit Plan Population
Trend
Change
Change

Contract-Plan ID
a.
b.
c.
d.

(m)
Other
Factor

(n)
Unit Cost/
Intensity
Trend

% of MMs

(o)

(p)
Additive
Adjustments
Util/1000
PMPM

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00
$0.00

V. Description of Other Utilization Factor and Additive Values (1000 character limit)

CMS - 10142 (03/31/2009)

CY2008 MA BPT.xls

5/16/2007

WORKSHEET 2 - MA PROJECTED ALLOWED COSTS PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
2008
Contract Year:

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
MA-PD:

9. Enrollee Type:
10. MA Region:
N/A
11. Act. Swap/Equiv Apply
12. SNP:

13. Region Name:

N/A

14. % of CY Enrollees that are Dually-Eligible:

0.0%

II. Projected Allowed Costs
Contract Year Allowed Costs at Plan's non-ESRD Risk Factor:
(c)

Service Category

(e)
Util
Type

(f)
(g)
(h)
Projected Experience Rate
Annual
Allowed
Util/1000
Avg Cost
PMPM
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

Annual
Util/1000

(j)
Manual Rate
Avg Cost

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Supplies
OP Facility - Emergency
OP Facility - Surgery
OP Facility - Other
Professional
Part B Rx
Other Medicare Part B
Transportation (Non-Covered)
Dental (Non-Covered)
Vision (Non-Covered)
Hearing (Non-Covered)
POS
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

u.

Subtotal Medicare-covered services

v.

Briefly describe the source for the manual rate, including what trend assumptions were used, if applicable (1000 character limit)

CY2008 MA BPT.xls

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

(i)

(k)
Allowed
PMPM

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

(l)
Exper.
Cred.
%

(m)

(n)
(o)
Contract Year Rate
Annual
Allowed
Util/1000
Avg Cost
PMPM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

(p)
% of svcs
provided
OON

$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00

$0.00

5/16/2007

WORKSHEET 3 - MA PROJECTED COST SHARING PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
Contract Year:

2008

II. Maximum Cost Sharing Per Member Per Year
1. In Network

5.
6.
7.
8.

Organization N
Plan Name:
Plan Type:
MA-PD:

9. Enrollee Type:
10. MA Region:
11. Act. Swap/Equiv Apply:
12. SNP:

13. Region Name:

N/A

N/A
14. % of CY Enrollees that are Dually-Eligible:

2. Out of Network

0.0%

3. Combined

4. Briefly explain the methodology for reflecting the impact of maximum cost sharing in Section III (1000 character limit):

III. Development of Contract Year Cost Sharing PMPM (Plan's non-ESRD Risk Factor)
(c)
(d)
(e)
(f)
Effective
Measurement
In-Network
Description/
Unit
Plan-Level
Service Category
Note
Code
Deductible PMPM*
a.1.
a.2.
b.
c.
d.
e.1.
e.2.
f.
g.
h.1.
h.2.
h.3.
h.4.
h.5.
i.1.
i.2.
i.3.
i.4.
i.5.
i.6.
j.
k.
l.
m.
n.1.
n.2.
o.1.
o.2.
p.
q.
r.

(g)
(h)
(i)
(j)
In-Network Cost Sharing After Deductible is Satisfied (incl. OOP max**)
In-Network
In-Network
In-Network
Util/1000
Cost Sharing
Effective Copay/
In-Network
or PMPM
Description
Coinsurance
PMPM

Inpatient Facility
Acute
Inpatient Facility
Mental Health
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Supplies
DME
DME/Prosthetics/Supplies
Prosthetics/Supplies
OP Facility - Emergency
OP Facility - Surgery
OP Facility - Other
Lab
OP Facility - Other
Radiology
OP Facility - Other
Observation
OP Facility - Other
Renal Dialysis
OP Facility - Other
Other
Professional
PCP
Professional
Specialist excl. MH
Professional
Mental Health (MH)
Professional
Therapy (PT/OT/ST)
Professional
Radiology
Professional
Other
Part B Rx
Other Medicare Part B
Transportation (Non-Covered)
Dental (Non-Covered)
Vision (Non-Covered)
Professional
Vision (Non-Covered)
Hardware
Hearing (Non-Covered)
Professional
Hearing (Non-Covered)
Hardware
POS
Health & Education (Non-Covered)
Other Non-Covered

Total

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00
*The actual in-network plan level deductible is:
** PMPM impact of in-network OOP max is:

CY2008 MA BPT.xls

(k)
Total
In-Network
Cost Sharing
PMPM

(l)
Out-of-Network
Cost Sharing
Description

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00
***Actual OON plan level deductible is:
***PMPM impact of OON OOP max is:

(m)
Out-of-Network
Cost Sharing
PMPM***
(formerly 3B col N)

$0.00

(n)
Grand Total
Cost Sharing
PMPM
(INN+OON)
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

5/16/2007

WORKSHEET 4 - MA PROJECTED REVENUE REQUIREMENT PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
Contract Year:

2008

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
MA-PD:

9. Enrollee Type:
10. MA Region:
N/A
11. Act. Swap/Equiv Apply:
12. SNP:

II. Development of Projected Revenue Requirement

Service Category
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
1.
2.
3.
4.
5.
x.
y.
z.
1.
2.
3.

(e)
Allowed
PMPM

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Supplies
OP Facility - Emergency
OP Facility - Surgery
OP Facility - Other
Professional
Part B Rx
Other Medicare Part B
Transportation (Non-Covered)
Dental (Non-Covered)
Vision (Non-Covered)
Hearing (Non-Covered)
POS
Health & Education (Non-Covered)
Other Non-Covered
ESRD (Section IV)
Additional Benefits (employer bids only)
COB/Subrg. (outside claim system)
Total Medical Expenses
Non-Benefit Expense:
Marketing & Sales
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Total Non-Benefit Expense
Gain/(Loss) Margin
Total Revenue Requirement

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

(f)
Total Benefits
Cost
Sharing
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

(g)
Net
PMPM
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

14. % of CY Enrollees that are Dually-Eligible:

(h)
(i)
% for Cov. Svcs
Cost
Allowed Sharing

0.0%
0.0%
0.0%
0.0%

0.0%
0.0%
0.0%
0.0%

0.0%
0.0%
0.0%
0.0%

0.0%
0.0%
0.0%
0.0%
0.0%

(j)
FFS Medicare
Actl. Equiv.
cost sharing

(k)
Plan cost shr
for Medicarecovered svcs.

0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

(l)
(m)
(n)
Medicare Covered (w/AE cost shr)
Allowed
FFS AE
Net
PMPM
Cost Sharing
PMPM
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00

0.0%
0.0%
0.0%

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00
$0.00
Yes

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

0.00
0.00
0.00

$0.00
0.00
0.00
0.00
$0.00
$0.00
$0.00

0.0%
0.0%
0.0%

IV. Development of Projected Contract Year ESRD "subsidy"

0.0%
0.0%
0.0%

V. For Employer Bid Use Only ("800-series")
0

Basic benefits (user entries should be reported as "per ESRD member per month")
CY Revenue
- CMS capitation
CY Medical Expenses for Basic Services
CY Non-Benefit Expenses for Basic Services
CY Margin Requirement for Basic Services
CY Gain/(Loss) Margin for Basic Services

$0.00
$0.00

Cost for CY basic benefits allocated to all plan members

$0.00

1. PMPM for additional/ unspecified MS benefits
(see instructions for additional information)
Supplemental Benefits
Non-ESRD CY cost sharing reductions
Non-ESRD CY additional benefits

$0.00
$0.00

ESRD CY cost sharing reductions
ESRD CY additional benefits
Incremental CY cost of cost sharing reductions
Incremental CY cost of additional benefits
Total CY ESRD "subsidy" =

CY2008 MA BPT.xls

0.0%

(o)
(p)
(q)
A/B Mand Suppl (MS) Benefits
Net PMPM for
Reduction of
Add'l Svcs.
A/B Cost Sh.
Total

$0.00
0.00
0.00
0.00
$0.00
$0.00
$0.00

$0.00

Percent of Revenue (excluding ESRD)
Net Medical Expense
Non-Benefit
Gain/(Loss) Margin

Non-ESRD CY member months
ESRD CY member months

N/A

III. Comparison of cost sharing for covered services with FFS Medicare
1. Standardized FFS cost sharing Medicare-covered services
2. Standardized plan cost sharing for covered services
3. Is covered cost share within FFS Medicare limit?

Cost and Required Revenue PMPM at Plan's non-ESRD Risk Factor:
(c)

13. Region Name:

$0.00
$0.00

$0.00

5/16/2007

WORKSHEET 5 - MA BENCHMARK PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
2008
Contract Year:

II.
1.
2.
3.
4.
5.
6.
7.

Benchmark and Bid Development
Standardized A/B Benchmark (@ 1.000)
Medicare Secondary Payer Adjustment
Weighted Avg Factor (excl ESRD)
Conversion Factor
Plan A/B Benchmark
Plan A/B Bid
Standardized A/B Bid (@ 1.000)

5. Organization Name:
6. Plan Name:
7. Plan Type:
8. MA-PD:

9. Enrollee Type:
10. MA Region:
N/A
11. Act. Swap/Equiv App
12. SNP:

13. Region Name: N/A

14. % of CY Enrollees that are Dually-Eligible:

$0.00

IV. Standardized A/B Benchmark - Regional Plans Only

0
0
$0.00
$0.00
$0.00

1. Statutory Component - Region N/A
2. Plan Bid Component (from CMS)*
3. Standardized A/B Benchmark

Weighting
82.9%
17.1%
100.0%

0.0%

N/A

* See instructions - if Line 2 is not filled in, then Line 7 of Section II will be used
III. Savings/Basic Member Premium Development
1. Savings
2. Rebate
3. Basic Member Premium

$0.00
$0.00
$0.00

V: County Level Detail and Service Area Summary (excl ESRD)
1. Use of plan-provided ISAR factors? (Regional Plans only - enter Yes or No)
(b)
(c)
(d)
(e)
(f)
State/County
Projected Member Projected Risk
Code
State
County Name
Months
Factors
2. Total or Weighted Average for Service Area:
3. County Level Detail:

CY2008 MA BPT.xls

0

0

VI: Other Medicare Information
(g)
Plan Provided ISAR
factors for risk rates
0.00

(h)
MA Risk Ratebook
Unadjusted

(i)
MA Risk Ratebook
Risk-Adjusted

$0.00

$0.00

(j)
ISAR
scale

(k)
ISAR-Adjusted
Bid
0

$0.00

(l)
(m)
Risk Payment Rate
A only
B only
51.800%

48.200%

(n)
(o)
(p)
(q)
(r)
(s)
(t)
(u)
Original Medicare cost sharing (c.s.) FFS costs to weight Medicare c.s. FFS equiv cost sharing
Inpatient
SNF
Pt B (excl HH) Inpatient
SNF
Pt B (excl HH) Part A
Part B
0.0%

0.0%

0.0%

n/a

n/a

n/a

$0.00

$0.00

(v)
(w)
Metropolitan Statistical Area
MM
MSA name
0 n/a
0% predominant MSA

5/16/2007

WORKSHEET 6 - MA BID SUMMARY
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:

5.
6.
7.
8.

2008

Organization Name:
Plan Name:
Plan Type:
MA-PD:

II. Other Information
A. Part B Information
1. CMS Estimate of CY Part B Premium
2. Part B % of USPCC (risk)

$96.40
48.20%

III. Plan A/B Bid Summary
A. Overview

1. Allowed medical cost
2. Less cost sharing
3. Net medical cost

Medicarecovered
$0.00
0.00
$0.00

4. Non-benefit expense
5. Gain / loss margin
6. Total revenue requirement
7. Standardized A/B Benchmark
8. Plan A/B Benchmark
9. Non-ESRD Risk Factor
10. Conversion Factor

IV. Contact Information
Plan Contact Person:
Name, Position
Phone Number
Email Address

Certifying Actuary:
Name, Credentials
Phone Number
Email Address
Date Prepared

$0.00
0.00
$0.00
$0.00
$0.00
0.0000
0.0000

9. Enrollee Type:
10. MA Region:
11. Act. Swap/Equiv Apply:
12. SNP:

3. Maximum for Part A Package on 'Part B Only' Members
a. Required Revenue for Part A Services
b. Average benchmark rate for Part A
c. CMS Part A Charge
d. Mandatory Suppl. Prem for Part A Package

B. MA Rebate Allocation
A/B Mandatory
Supplemental
n/a 1. MA Rebate
n/a
$0.00 2. Reduce A/B Cost Sharing
3. Other A/B Mand Suppl Benefits
$0.00 4. Pt B Premium Buydown
0.00 5. Pt D Premium Buydown Basic
$0.00 6. Pt D Premium Buydown Suppl
7. Total

Medical
n/a
$0.00
0.00
0.00
0.00
0.00
$0.00

13. Region Name:

14. % of CY Enrollees that are Dually-Eligible:

n/a
n/a
n/a

Rebate PMPM Allocation
Admin
Gain / (Loss)
n/a
n/a
$0.00
0.00
n/a
n/a
n/a
$0.00

N/A

N/A

$0.00
0.00
n/a
n/a
n/a
$0.00
Unallocated rebate

0.0%

B. Rebate Allocation for Contract Year Part B Premium
1. PMPM rebate allocation for Part B premium (max value=$96.40)
2. Part B Rebate Allocation - rounded (see instructions)
Maximum 3. Does plan intend to reduce the entire standard Part B premium using rebates?
$0.00
Enter Yes/No. (See instructions for further info).

Total
$0.00

0.00
0.00
0.00
$0.00
$0.00

$0.00
No reduction

C. Development of Estimated Plan Premium
Maximum
Value
1. A/B Mandatory Supplemental revenue requirements
2. Less rebate allocations:
2a. Reduce A/B Cost Sharing
$0.00
2b. Other A/B Mand Supplemental Benefits
0.00
96.40 3. A/B Mandatory Supplemental premium
0.00
0.00 4. Basic MA premium
5. Total MA Enrollee Premium (excl. Opt. Suppl.)
6. Rounded MA Premium (excl. Opt. Suppl.)

$0.00
0.00
0.00
0.00
0.00
0.00
$0.00

7. Part D Basic Premium
7a. Prior to rebates (rounded value from Rx BPT)
7b. A/B rebates allocated to Part D Basic Premium
7c. A/B rebates for Part D Basic Premium (rounded)
7d. Part D Basic Premium*

$0.00
$0.00

8. Part D Supplemental Premium
8a. Prior to rebates (rounded value from Rx BPT)
8b. A/B rebates allocated to Part D Suppl Premium
8c. A/B rebates for Part D Suppl Premium (rounded)
8d. Part D Supplemental Premium

$0.00
$0.00

9. Total estimated plan premium*

$0.00

10. Plan Intention for Part D target premium
* The premium shown here is an estimate. The actual plan premium will be calculated by CMS
when the Part D National Average is determined by CMS. The premium shown here may
not be final.
Note: Premiums are rounded to one decimal (i.e., to the nearest dime) to comply with
premium withhold system requirements. See instructions for more information.

CY2008 MA BPT.xls

5/16/2007

WORKSHEET 7 - OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:

2008

II. Optional Supplemental Packages
(b)
(c)
Package
ID

Service
category

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Package Total

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Package Total

CY2008 MA BPT.xls

5.
6.
7.
8.

(d)

Benefit category or
pricing component

9. Enrollee Type:
10. MA Region:
11. Act. Swap/Equiv Apply:
12. SNP:

Organization Name
Plan Name:
Plan Type:
MA-PD:

(e)
Util.
type

(f)
(g)
(h)
Allowed medical expense
Annual
Average
Util / 1000
cost
PMPM

(i)
Measurment
unit code

13. Region Name:

N/A

N/A

(j)
(k)
Enrollee cost sharing
Util/1000 or
Average
PMPM
cost shr

14. % of CY Enrollees that are Dually-Eligible:

(l)

PMPM

(m)
Net
PMPM
value

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

$0.00

$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

$0.00

$0.00

(n)
NonBenefit
Expense

0.0%

(o)
Gain/
(Loss)
Margin
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

(p)

(q)
Projected
Member
Months

Premium
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

$0.00
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
$0.00

5/16/2007

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

(b)

(c)

Package
ID

Service
category

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Package Total

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Package Total

CY2008 MA BPT.xls

(d)
Benefit category or
pricing component

(e)
Util.
type

(f)
(g)
(h)
Allowed medical expense
Annual
Average
Util / 1000
cost
PMPM

(i)
Measurment
unit code

(j)
(k)
Enrollee cost sharing
Util/1000 or
Average
PMPM
cost shr

(l)

PMPM

(m)
Net
PMPM
value

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

$0.00

$0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

$0.00

$0.00

(n)
NonBenefit
Expense

(o)
Gain/
(Loss)
Margin
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

(p)

(q)
Projected
Member
Months

Premium
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

$0.00
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
$0.00

5/16/2007

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

(b)

(c)

Package
ID

Service
category

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Package Total

(d)
Benefit category or
pricing component

(e)
Util.
type

(f)
(g)
(h)
Allowed medical expense
Annual
Average
Util / 1000
cost
PMPM

(i)
Measurment
unit code

(j)
(k)
Enrollee cost sharing
Util/1000 or
Average
PMPM
cost shr

(l)

PMPM

(m)
Net
PMPM
value

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

$0.00

$0.00

(n)
NonBenefit
Expense

(o)
Gain/
(Loss)
Margin
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

(p)

(q)
Projected
Member
Months

Premium
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
$0.00

III. Comments

CY2008 MA BPT.xls

5/16/2007

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a

TWO-YEAR LOOK-BACK WORKSHEET
Actual to Projected Comparison for Medicare Advantage Costs PMPM
(Excludes optional supplemental, Part D, and "extra" negotiated group benefits/revenue)
Contract Number:
Organization Name:

Contract Yr:
Experience Year:
(f)

(g)

(h)

Original Projection [1]
Individual
EGHP
Total
1. Revenue
a1. CMS Revenue (excl. bonuses)
a2. Regional PPO Bonus Payments
b. Member Premium - Basic
c. Member Premium - A/B Mandatory Supplemental
d. MA Rebate applied to Part D
e. Total
2. Net Medical Expenses [2]
a. Covered Benefits (excl. risk share)
b. A/B Mandatory Supplemental Benefits
c. Regional PPO Risk Share Paid/(Rec'd)
d. Total

$0.00

$0.00

(l)

Individual

Actual Incurred
EGHP

Total

$0.00

$0.00

$0.00
0.00
0.00
$0.00

$0.00
0.00
0.00
$0.00

$0.00

$0.00

4. Profit/(Loss) Bef Taxes and Investment Income

$0.00

$0.00

$0.00

n/a
n/a
n/a

(k)

$0.00

$0.00
0.00
0.00
0.00
$0.00

5. Key Statistics
a. Member Months (excl ESRD)
b. Non-ESRD risk factor
c. Loss Ratio
d. Non-Benefit Ratio
e. Profit Margin

(j)

$0.00
0.00
0.00
0.00
0.00
$0.00

3. Non-Benefit Expense
a. Marketing & Sales
b. Direct Administration
c. Indirect Administration
d. Net Cost of Private Reinsurance [3]
e. Total

n/a
n/a
n/a

0
n/a
n/a
n/a
n/a

2008
2006

LB-2008.1
OMB Approved # 0938-0944
(n)
(o)
(p)
Actual/Projected
Individual
EGHP
Total

$0.00

$0.00
0.00
0.00
0.00
0.00
$0.00

n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a
n/a

$0.00
0.00
0.00
$0.00

$0.00
0.00
0.00
$0.00

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a

0.00
$0.00

0.00
$0.00

$0.00
0.00
0.00
0.00
$0.00

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

$0.00

$0.00

$0.00

n/a

n/a

n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a
n/a
n/a

n/a
n/a
n/a

n/a
n/a
n/a

[1] Provided by CMS using bid filings two years prior (than the contract year), re-weighted by actual member months.
[2] Enter the net medical expenses below:
Incurred in Experience Year
and Pd thru:
Net Medical Expenses
Individual
EGHP
a. Covered Benefits (excl. risk share)
b. A/B Mandatory Supplemental Benefits
c. Regional PPO Risk Share Paid/(Rec'd)
d. Total
$0.00
$0.00
[3] Actual Incurred components of Net Reinsurance are:
Individual
EGHP
Total
a. Private Reinsurance Premium
$0.00
b. Private Reinsurance Recoveries
$0.00
c. Net Reinsurance Cost
$0.00
$0.00
$0.00

0
n/a
n/a
n/a
n/a

Total
$0.00
$0.00
$0.00
$0.00

Claim Reserves
Individual
EGHP

$0.00

$0.00

Total
$0.00
$0.00
$0.00
$0.00

CMS - 10142 (03/31/2009)

CY2008 MA 2YrLB.xls

5/16/2007