2CY 2010 Bid Pricing Tool (BPT) for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDP)-CMS-10142

WORKSHEET 1 - MA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:
2010

MA-2010.1
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

II. Base Period Background Information
Total

Non-Dual Elig Dual Eligible
0 5. Plans In Base
0.0000

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.

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)
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

t.

Subtotal Medicare-covered services

Util
Type

(g)
Annualized
Util/1000

(h)
Total Benefits
Avg Cost

(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

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

CMS - 10142 (03/2011)

CY2010_PD_BPT-PRA.xls

12/17/2008

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

General Information
Contract Number:
Plan ID:
Segment ID:
2010
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

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

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

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)
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

(e)
Util
Type

(f)
(g)
(h)
Projected Experience 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

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

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

(i)
Annual
Util/1000

(j)
Manual Rate
Avg Cost

(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

(l)
Exper.
Cred.
%

1. Projected member months
2. Projected risk factor
(m)
(n)
Annual
Util/1000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Avg Cost
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

$0.00

Total Non-Dual Elig
Dual Eligible
0
0
0
0.0000
0.0000
0.0000
(o)
(p)
(q)
Contract Year Rate
Total Allowed
Non-Dual Elig
Dual Eligible
PMPM
Allowed PMPM 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

$0.00

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

$0.00

$0.00

$0.00

(r)
% of svcs
provided
OON

0% CMS Guideline Credibility
t.

Subtotal Medicare-covered services

u.

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

CY2010_PD_BPT-PRA.xls

$0.00

$0.00

12/17/2008

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

General Information
Contract No:
Plan ID:
Segment ID:
Contract Year:

2010

5.
6.
7.
8.

Org Name:
Plan Name
Plan Type:
MA-PD:

II. Maximum Cost Sharing Per Member Per Year
Is there a plan-level OOP maximum? (Yes/No, then enter amount)

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

1. In Network

13. Region Name:

2. Out of Network

N/A

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)
MeasureIn-Network
ment
Effective
Description/
Unit
Plan-Level
Service Category
Note
Code
Deduct 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.

(g)
In-Network
Util/1000
or PMPM

(h)
(i)
(j)
In-Network Cost Sharing After Plan-Level Deductible
Description of Cost
Effective
**Effective
Sharing / Add'l Days /
Copay / Coin
Copay / Coin
Benefit Limits
Before OOP Max
After OOP Max

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
Health & Education (Non-Covered)
Other Non-Covered

Total

In-Network
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
0.00
0.00
$0.00

$0.00
*Actual in-network plan level deductible:
** PMPM impact of in-network OOP max:

CY2010_PD_BPT-PRA.xls

(k)

(l)
Total
In-Network
Cost Share
PMPM

(m)
Out-of-Network
Description of
Cost Sharing / . . .

Benefit Limits

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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:
***PMPM impact of OON OOP max:

Out-of-Network
Cost Sharing
PMPM***

(n)

(o)
Grand Total
Cost Share
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

12/17/2008

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

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

2010

5.
6.
7.
8.

Organization Name:
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

II. Development of Projected Revenue Requirement
A: Non-Dual Eligible Beneficiaries
Cost and Required Revenue PMPM at Plan's non-ESRD Risk Factor:
(c)

(e)
Allowed
PMPM

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

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)
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

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

0.0000
(f)
(g)
Total Benefits
Plan Cost
Sharing

(h)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

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

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

(e)
Reimb +
Actual Cost Sh.

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)
Health & Education (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

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

(e)

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

1.
2.
3.
4.
5.
w.
x.
y.
1.
2.
3.

(h)
Plan
Reimb

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)
Plan cost sh.
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%
$0.00

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

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

(m)
(n)
(o)
Medicare Covered (w/AE cost sh.)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

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

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

(k)
(l)
State Medicaid Actual cost sh.
Level of Bene. for Medicarecost sharing covered svcs.

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

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

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

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

(m)
(n)
(o)
Medicare Covered (w/Medicaid cost sh.)
Allowed
Medicaid
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

(h)

(i)

(j)

(k)

(l)

(m)

Net
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)
Health & Education (Non-Covered)
Other Non-Covered
ESRD
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
0.00
0.00
0.00
0.00
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)
Medicare Covered

(o)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00
$0.00
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

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)
(q)
(r)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)
(q)
(r)
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

0.00
0.00
0.00

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$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%

III. Development of Projected Contract Year ESRD

0.0%
0.0%
0.0%

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

Non-ESRD CY member months
ESRD CY member months

0

Basic benefits (user entries must 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

Incremental CY cost of cost sharing reductions
Incremental CY cost of additional benefits

V. Projected Medicaid Data for Dual Eligible Beneficiaries
Entries must be reported as "Per Dual-Eligible Member Per Month."
1. Medicaid Projected Revenue
2. Medicaid Projected Benefits (not in bid)

ESRD CY cost sharing reductions
ESRD CY additional benefits

Total CY ESRD "subsidy" =

CY2010_PD_BPT-PRA.xls

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)
(q)
(r)
A/B Mand Suppl (MS) Benefits
Net PMPM for
Reduction of
Add'l Svcs.
A/B Cost Sh.
Total

0.0000
(f)
(g)
Total Benefits

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

0.00%
0.00%
0.00%
0.00%
0.00%
0.00%

(k)
FFS Medicare
Actl. Equiv.
cost sharing

0.0000
(f)
(g)
Total Benefits
Plan Cost
Actual Cost
Sharing
Sharing

C: All Beneficiaries (Non-Dual + Dual Eligible)
Cost and Required Revenue PMPM at Plan's non-ESRD Risk Factor:
(c)

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

$0.00
$0.00

$0.00
$0.00

$0.00

12/17/2008

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

General Information
Contract Number:
Plan ID:
Segment ID:
2010
Contract Year:

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

II. Benchmark and Bid Development
1. Projected Member Months
2. Standardized A/B Benchmark (@ 1.000)
3. Medicare Secondary Payer Adjustment
4. Weighted Avg Risk Factor (excl ESRD)
5. Post-MSP Risk Factor
6. Plan A/B Benchmark
7. Plan A/B Bid
8. Standardized A/B Bid (@ 1.000)

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

Total
0
$0.00

Non-Dual Elig

13. Region Name:

N/A

Dual Eligible
0
IV. Standardized A/B Benchmark - Regional Plans Only

0
0
$0.00
$0.00
$0.00

0

Weighting
79.2%
20.8%
100.0%

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

N/A

* See instructions - if Line 2 is not filled in, then Line 8 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
Proj Member
Proj Risk
Code
State
County Name
Months
Factors
2. Total or Weighted Average for Service Area:
3. County Level Detail:

CY2010_PD_BPT-PRA.xls

0

VI: Other Medicare Information
(g)
Plan Provided ISAR
factors for risk rates
0

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
53.300%

46.700%

(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
Pt B (excl HH) Inpatient
SNF
Pt B (excl HH)
Part A
Part B
Inpatient
SNF
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

12/17/2008

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

5.
6.
7.
8.

2010

II. Other Information
A. Part B Information

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

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

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

1. CMS Estimate of CY Part B Premium

13. Region Name:

N/A

N/A

$0.00
No reduction

#NAME?
III. Plan A/B Bid Summary
A. Overview

1. Net medical cost

B. MA Rebate Allocation

Medicarecovered
$0.00

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

$0.00
0.00
$0.00
$0.00
$0.00
0.0000
0.0000

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

MA Certifying Actuary:
Name, Credentials
Phone Number
Email Address

MA Additional BPT Contact:
Name, Position
Phone Number
Email Address

A/B Mandatory 1. MA Rebate
Supplemental
$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

Rebate PMPM Allocation
Medical
Admin
Gain / (Loss)
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
$0.00

$0.00
0.00
n/a
n/a
n/a
$0.00
Unalloc. rebate

V. Working Model Text Box
This section can be used at the discretion of the Plan sponsor.
The contents are NOT uploaded in the bid submission, and will
be deleted during finalization. See instructions for details.

Total
$0.00

0.00
0.00
0.00
$0.00
$0.00

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 target PD basic premium
* The premiums shown in lines 7 and 9 are estimates. Actual plan premiums will be
calculated by CMS when the Part D National Average is determined by CMS. The premiums
shown in lines 7 and 9 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.

Date Prepared

CY2010_PD_BPT-PRA.xls

12/17/2008

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

2010

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

Service
category

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Package Total

Package Total

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

Package Total

4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

Package Total

5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5

(d)

Benefit category or
pricing component

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

(e)
Util.
type

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

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

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

5.
6.
7.
8.

Package Total

(i)
Measurment
unit code

13. Region Name:

N/A

N/A

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

(l)

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

(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

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

$0.00

$0.00

$0.00

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

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

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

$0.00

$0.00

$0.00

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

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

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

(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

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

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

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

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

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

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

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

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

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

$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

$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

$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

$0.00

III. Comments

CY2010_PD_BPT-PRA.xls

12/17/2008

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

Contract Yr:
Experience Year:
(f)

(g)

(h)

Original Projection [1]
Individual
EGWP
Total
1. Revenue
a. CMS Revenue
b. Premium
c. 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
EGWP

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

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

2010
2008

LB-2010.1
OMB Approved # 0938-0944
(n)
(o)
(p)
Actual/Projected
Individual
EGWP
Total

$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

$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
EGWP
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
EGWP
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

Individual

Claim Reserves
EGWP

$0.00

$0.00

Total
$0.00
$0.00
$0.00
$0.00

CMS - 10142 (03/2011)

CY2010_PD_BPT-PRA.xls

12/17/2008

WORKSHEET 1 - MSA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:
2010

MSA-2010.1
OMB Approved # 0938-0944
5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:

A/B

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.

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
COB/Subrg. (outside claim system)
Total Medicare Covered Medical Expenses

Util
Type

(g)

(h)
Total Benefits
Annualized
Util/1000
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

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

CMS - 10142 (03/2011)

CY2010_PD_BPT-PRA.xls

12/17/2008

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

General Information
Contract Number:
Plan ID:
Segment ID:
2010
Contract Year:

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount:

9. Enrollee Type:

A/B

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

Service Category
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

(e)
Util
Type

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
COB/Subrg. (outside claim system)
Total Medicare Covered Medical Expenses

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

(i)
Annual
Util/1000

(j)
Manual Rate
Avg Cost

(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

(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

$0.00
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% CMS Guideline Credibility

n.

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

CY2010_PD_BPT-PRA.xls

12/17/2008

WORKSHEET 3 - MSA BENCHMARK PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
2010
Contract Year:

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:

A/B

II. Contact Information
MSA Plan Contact Person:
Name, Position
Phone Number
Email Address
MSA Certifying Actuary:
Name, Credentials
Phone Number
Email Address
MSA Additional BPT Contact:
Name, Position
Phone Number
Email Address
Date Prepared (MM/DD/YYYY)
III: County Level Detail and Service Area Summary (excl ESRD)
(b)
State/County
Code

(c)
State

1. Total or Weighted Average for Service Area:
2. County Level Detail:

CY2010_PD_BPT-PRA.xls

(d)
County Name

(e)
(f)
Projected Member Projected Risk
Months
Factors
0

0

(g)
MA Risk Ratebook
Unadjusted
$0.00

(h)
MA Risk Ratebook
Risk-Adjusted
Plan
$0.00 Benchmark

12/17/2008

WORKSHEET 4 - ENROLLEE DEPOSIT AND PLAN PAYMENT PMPM
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
2010
Contract Year:

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:A/B

II. Development of Claim Information Intervals (Plan's non-ESRD Risk Factor and Exclude Services Covered Within the Deductible)
(c)
(d)
(e)
(f)
(g)
Annual
Annual
Percentage
of Member Months
Gross
Gross Claims
Projected
Average
Claim
Claim
(Only Use Highest
Claims
Over Deductible
Interval
Claim Interval)
(PMPM)
(PMPM)
Amount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

$0-$250
$251-$2,000
$2001-$4,000
$4001-$6,000
$6001-$8,000
$8001-$10,000
$10,001-$12,000
$12,001-$15,000
$15,001-$20,000
$20,001-$30,000
$30,001-$50,000
$50,001-$70,000
over $70,000
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

Services Covered Within the Deductible
Cost Sharing Offset Over Deductible
III. Development of Summary Information (Plan's non-ESRD Risk Factor)
Total
a. Plan Medical Expenses
b. Non-Benefit Expense:
1. Marketing & Sales
2. Direct Administration
3. Indirect Administration
4. Net cost of private reinsurance
5. Total Non-Benefit Expense
c. Gain/(Loss) Margin
d. Total Plan Revenue Requirement
e. Projected Plan Benchmark
f. Projected Monthly Enrollee Deposit
g. Percent of Plan Revenue
1. Medical Expenses
2. Non-Benefit Expense
3. Gain/(Loss) Margin
h. Standardized Plan Benchmark

CY2010_PD_BPT-PRA.xls

Part A

Part B

$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

12/17/2008

WORKSHEET 5 - OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:

2010

II. Optional Supplemental Packages
(b)
(c)
(d)
Benefit category
Package
Service
or pricing
ID
category
component
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Package Total

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

Package Total

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

Package Total

4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

Package Total

5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5

Package Total

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

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

(h)

(i)

PMPM

Measurment
unit code

9. Enrollee Type:

A/B

(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

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

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

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

$0.00

$0.00

$0.00

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

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

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

$0.00

$0.00

$0.00

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

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

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

(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

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

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

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

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

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

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

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

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

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

$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

$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

$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

$0.00

III. Comments

CY2010_PD_BPT-PRA.xls

12/17/2008