Form CMS-10142 MA-BPT

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

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

2013

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

II. Base Period Background Information

III. Base Period Data (at Plan's Risk Factor) for 1/1/2011-12/31/2011
(b)
(c)
(d)

Service Category

Utilizers

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 service categories

Net
PMPM

0.00
$0.00

N/A
14. SNP Type:

Note: DE# refers to Dual Eligible Beneficiaries without full Medicare cost sharing liability
Total
Non-DE#
DE#
2. Member Months
0
0
3. Risk Score
0.0000
4. Completion Factor

1. Time Period Definition
Incurred from:
Incurred to:
Paid through:
6. Describe the source of the base period experience data

13. Region Name:

01/01/2011
12/31/2011

(e)

(f)

(g)

Cost
Sharing

Util
Type

Annualized
Util/1000

(h)
Total Benefits
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
$0.00

(i)
Allowed
PMPM

Note: See bid instructions for ESRD and hospice exclusions.
MA-2013.1
OMB Approved # 0938-0944
N/A

5. Plans In Base

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

(m)
Other
Factor

N/A

15. EGWP: N

Contract-Plan ID Member Months

(n)
(o)
Unit Cost Adjustment
Provider Payment
Other
Change
Factor

Contract-Plan ID Member Months

(p)

(q)
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 Adjustment Factor, Other Unit Cost Adjustment Factor, and Additive Adjustments

VI. Base Period Summary for 1/1/2011-12/31/2011 (excludes Optional Supplemental)
ESRD
Hospice
All Other
1. CMS Revenue
2. Premium Revenue
3. Total Revenue
$0
$0
$0
4. Net Medical Expenses

$0
$0
$0
$0

5. Member Months
PMPMs:
6a. Revenue PMPM
6b. Net Medical PMPM
6c. Non-Benefit PMPM
6d. Gain/(Loss) Margin PMPM

Total

0

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

0

Non-Benefit Expenses:
7a. Sales & Marketing
7b. Direct Administration
7c. Indirect Administration
7d. Net Cost of Private Reinsurance
7e. Quality Initiatives
7f. Taxes and Fees
7g. Total Non-Benefit Expenses

8. Gain/(Loss) Margin

$0

Percentage of Revenue:
9a. Net Medical Expenses
9b. Non-Benefit Expenses
9c. Gain/(Loss) Margin

0.0%
0.0%
0.0%

$0

$0.00
$0.00
$0.00
$0.00

CMS - 10142 (3/31/2012)

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

General Information
Contract Number:
Plan ID:
Segment ID:
2013
Contract Year:

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

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. SNP Type:

N/A

II. Projected Allowed Costs
Contract Year Allowed Costs at Plan's 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

Annual
Util/1000

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 service categories

u.

Briefly describe the source for the manual rate, including what trend assumptions were used, if applicable

Attachment D-1, CY2013_MA_BPT.xlsm

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

(i)

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

(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.
%

Note: DE# refers to Dual Eligible Beneficiaries without full Medicare cost sharing liability
Total
Non-DE#
DE#
1. Projected member months
0
0
0
2. Projected risk factor
0.0000
0.0000
0.0000
(m)
(n)
(o)
(p)
(q)
(r)
Blended Rate
% of svcs
Annual
Total Allowed
Non-DE#
DE#
provided
Util/1000
Avg Cost
PMPM
Allowed PMPM Allowed PMPM
OON
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

$0.00
$0.00

15. EGWP: N

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

0%
0% CMS Guideline Credibility
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

12/14/2011

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

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

2013

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

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)

1. In Network

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

NO

2. Out of Network

13. Region Name:

N/A

14. SNP Type:

N/A

NO

15. EGWP: N

3. Combined NO

4. Briefly explain the methodology for reflecting the impact of maximum cost sharing in Section III

III. Development of Contract Year Cost Sharing PMPM (Plan's Risk Factor)
(c)
(d)
(e)
(f)
MeasureIn-Network
ment
Effective
Unit
Plan-Level
Service Category
Description
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)

(h)
(i)
(j)
In-Network Cost Sharing After Plan-Level Deductible
In-Network
Description of Cost
Effective
**Effective
Util/1000
Sharing / Add'l Days /
Copay / Coin
Copay / Coin
or PMPM
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
Mental Health
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

$0.00
Actual combined plan level deductible:
Does combined ded apply to Pt B only?

(k)

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

*Actual in-network plan level deductible:
Does in-network ded apply to Pt B only?
** PMPM impact of in-network OOP max:

(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:
Does OON ded apply to Pt B only?
***PMPM impact of OON OOP max:

(n)
Out-of-Network
Cost Sharing
PMPM***

(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

IV. Mapping of PBP service
categories to BPT
PBP line BPT category
1a
a1
1b
a2
2
b
3
h5
4a
f
4b
f
5
h5
6
c
7a
i1, i5
7b
i6
7c
i4
7d
i6
7e
i3
7f
i6
7g
i6
7h
i3
7i
i4
8a
h1
8b
h2
9a
h5, g
9b
g
9c
h5
9d
k
10a
d
10b
l
11a
e1
11b
e2
11c
e2
12
h4
13a
q
13b
q
13c
q
13d
q
13e
q
14a
i1
14b
i1
14c
p
14d
i6
14e
i6
15
j
16a
m
16b
m
17a
n1
17b
n2
18a
o1
18b
o2

****NOTE: Cells H25:H64 and cells M25:M64 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.

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

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

2013

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

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

14. SNP Type:

N/A

N/A
15. EGWP: N

II. Development of Projected Revenue Requirement
A. Non-DE# (Non-Dual Eligible Beneficiaries AND Dual Eligible Beneficiaries with full Medicare cost sharing liability)
Cost and Required Revenue PMPM at Plan's Risk Factor:
0.0000
(c)

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

(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)
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

(f)
(g)
Total Benefits
Plan 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

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

Attachment D-1, CY2013_MA_BPT.xlsm

(e)
Reimb +
Actual Cost Sh.
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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%

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

(k)
FFS Medicare
Actl. Equiv.
cost 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%
0.0%
$0.00

(l)
Plan cost sh.
for Medicarecovered 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

(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

(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

0.0000

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

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

B. DE# (Dual Eligible Beneficiaries without full Medicare cost sharing liability)
Cost and Required Revenue PMPM at Plan's Risk Factor:
(c)

(h)

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)
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

(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.
Required 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

(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

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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

12/14/2011

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

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

2013

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

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

14. SNP Type:

N/A

N/A
15. EGWP: N

II. Development of Projected Revenue Requirement
C. All Beneficiaries
Cost and Required Revenue PMPM at Plan's Risk Factor:
(c)

0.0000
(e)

(f)
(g)
Total Benefits

1.
2.
3.
4.
5.
6.
7.
w.
x.
y1.
y2.
y3.

(i)

(j)

(k)

(l)

(m)

Net
PMPM

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

(h)

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:
Sales & Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Quality Initiatives
Taxes and Fees
Total Non-Benefit Expense
Gain/(Loss) Margin
Total Revenue Requirement
Net Medical Expense % of Revenue
Non-Benefit % of Revenue
Gain/(Loss) Margin % of Revenue

(n)
Medicare Covered

(o)

(p)

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

z1. Describe what's included in Quality Initiatives

$0.00
z2. Overall Gain/(Loss) Margin Level
$0.00
0.0%
0.0%
0.0%

y4. Adjusted MLR*
0.0%
* Adjusted MLR based on bid projection, Numerator includes
Quality Initiatives and denominator excludes Taxes and Fees.

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

(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

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

CY member months entered by county
0
CY ESRD member months
0
CY Out-of-Area (OOA) member months
0
Basic benefits (user entries must be reported as "per ESRD member per month")
CY Revenue
- CMS capitation

1. PMPM for additional/ unspecified MS benefits
(see instructions for additional information)

$0.00
$0.00

Cost for CY basic benefits allocated to plan members

$0.00

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 DE#
Entries must be reported as "Per DE# Member Per Month."
1. Medicaid Projected Revenue
2. Medicaid Projected Cost* (not in bid)
*Cost includes benefit expenses and non-benefit expenses.

ESRD CY cost sharing reductions
ESRD CY additional benefits

Total CY ESRD "subsidy" =

Attachment D-1, CY2013_MA_BPT.xlsm

$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

III. Development of Projected Contract Year ESRD "Subsidy"

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

$0.00
$0.00

$0.00

12/14/2011

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

General Information
Contract Number:
Plan ID:
Segment ID:
2013
Contract Year:

Note: See bid instructions for ESRD and hospice exclusions.

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

II. Benchmark and Bid Development
1. Member Months (Section VI)
2. Standardized A/B Benchmark (@ 1.000)
3. Medicare Secondary Payer Adjustment
4. Weighted Avg Risk Factor
5. Conversion 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 Apply:
12. SNP:

Total
0
$0.00

Non-DE#

DE#
0

13. Region Name:

N/A

14. SNP Type:

N/A

15. EGWP:

N

Note: DE# refers to Dual Eligible Beneficiaries without full Medicare cost sharing liability
IV. Standardized A/B Benchmark - Regional Plans Only

0
0
$0.00
$0.00
$0.00

0

Weighting
74.0%
26.0%
100.0%

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

VIII. Projected CY Member Months
1. Member months entered by county (Sect. VI)
2. ESRD member months
3. Hospice member months
4. Out-of-Area (OOA) member months
5. Total member months

N/A

0

0

* 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.
1.
2.
3.

VI: County Level Detail and Service Area Summary
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:

Attachment D-1, CY2013_MA_BPT.xlsm

0

Quality Rating
Quality Bonus Rating (per CMS)
New org/low enrollment indicator (per CMS)
Rebate %

58.3%

VII: Other Medicare Information
(g)
Plan Provided
ISAR factors
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
52.532%

47.468%

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

0.0%

0.0%

n/a

n/a

n/a

(t)
(u)
Metropolitan Statistical Area
MM
MSA name
0 n/a
0% predominant MSA

12/14/2011

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

5.
6.
7.
8.

2013

II. Other Information
A. Part B Information
1. Maximum Pt B premium buydown amt., per CMS

III. Plan A/B Bid Summary
A. Overview

1. Net medical cost

Standardized A/B Benchmark
Plan A/B Benchmark
Risk Factor
Conversion Factor

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 Part B Premium
1. PMPM rebate allocation for Part B premium (maximum value=$99.90)
$99.90 2. Part B Rebate Allocation, rounded to one decimal (see instructions)

$0.00

Medicarecovered
$0.00
$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
Non-Benefit
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.

13. Region Name:

N/A

14. SNP Type:

N/A

N/A

B. MA Rebate Allocation

2. Non-benefit expense
3. Gain / loss margin
4. Total revenue requirement
5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Total
$0.00
$0.00
0.00
0.00
0.00
0.00
$0.00
$0.00

15. EGWP: N

C. Rebate Allocations
1. Reduce A/B Cost Sharing (max. value=$0.00)
2. Other A/B Mand Suppl Benefits (max. value=$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
99.90 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

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

2013

II. Optional Supplemental Packages
(b)
(c)
Package
ID
Description
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Service
category

5.
6.
7.
8.

(d)

Benefit category or
pricing component

1
Package Total
Description
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

Package Total

Attachment D-1, CY2013_MA_BPT.xlsm

Note: See bid instructions for ESRD and hospice exclusions.

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

(i)
Measurment
unit code

13. Region Name:

N/A

14. SNP Type:

N/A

N/A

(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

15. EGWP:N

(n)

(o)
Gain/
(Loss)
Margin

NonBenefit
Expense
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

12/14/2011

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

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

2013

II. Optional Supplemental Packages
(b)
(c)
Package
ID
Description
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

Service
category

5.
6.
7.
8.

(d)

Benefit category or
pricing component

3
Package Total
Description
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

Package Total

Attachment D-1, CY2013_MA_BPT.xlsm

Note: See bid instructions for ESRD and hospice exclusions.

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

(i)
Measurment
unit code

13. Region Name:

N/A

14. SNP Type:

N/A

N/A

(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

15. EGWP:N

(n)

(o)
Gain/
(Loss)
Margin

NonBenefit
Expense
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

12/14/2011

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

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

2013

II. Optional Supplemental Packages
(b)
(c)
Package
ID
Description
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5

Service
category

5.
6.
7.
8.

(d)

Benefit category or
pricing component

Package Total

Note: See bid instructions for ESRD and hospice exclusions.

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

(i)
Measurment
unit code

13. Region Name:

N/A

14. SNP Type:

N/A

N/A

(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

15. EGWP:N

(n)

(o)
Gain/
(Loss)
Margin

NonBenefit
Expense
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

WORKSHEET 1 - MSA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:
2013

Note: See bid instructions for ESRD and hospice exclusions.
MSA-2013.1
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
Incurred from:
01/01/2011
Incurred to:
12/31/2011
Paid through:
6. Describe the source of the base period experience data

III. Base Period Data (at Plan's Risk Factor)
(c)
(e)

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

Utilizers

(f)
Util
Type

2. Member Months
3. Risk Score
4. Completion Factor

5. Plans In Base

(h)
Total Benefits
Annualized
Util/1000
Avg Cost

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

(g)

(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

CMS - 10142 (3/31/2012)

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

General Information
Contract Number:
Plan ID:
Segment ID:
2013
Contract Year:

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

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

9. Enrollee Type:

A/B

II. Projected Allowed Costs
Contract Year Allowed Costs at Plan's 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

Annual
Util/1000

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

n.

Briefly describe the source for the manual rate, including what trend assumptions were used, if applicable

Attachment D-1, CY2013_MA_BPT.xlsm

0
0
0
0
0
0
0
0
0
0
0

(i)

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

(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

0%
0% CMS Guideline Credibility

(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

12/14/2011

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

General Information
Contract Number:
Plan ID:
Segment ID:
2013
Contract Year:

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:

II. Contact Information

A/B

IV. Quality Bonus Rating
1. Quality Bonus Rating

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
(b)
State/County
Code

(c)
State

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

Attachment D-1, CY2013_MA_BPT.xlsm

(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

12/14/2011

WORKSHEET 4 - ENROLLEE DEPOSIT AND PLAN PAYMENT PMPM
Note: See bid instructions for ESRD and hospice exclusions.
I.
1.
2.
3.
4.

General Information
Contract Number:
Plan ID:
Segment ID:
2013
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 Risk Factor and Exclude Services Covered Within the Deductible)
(c)
(d)
(e)
(f)
(g)
Annual
Annual
Percentage
Projected
Average
of Member Months
Gross
Gross Claims
Claim
Claim
(Only Use Highest
Claims
Over Deductible
Interval
Amount
Claim Interval)
(PMPM)
(PMPM)
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

III. Development of Summary Information (Plan's Risk Factor)
a. Plan Medical Expenses
b. Non-Benefit Expense:
1. Sales & Marketing
2. Direct Administration
3. Indirect Administration
4. Net cost of private reinsurance
5. Quality Initiatives
6. Taxes and Fees
7. 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

$0.00

$0.00

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

i. Adjusted MLR*
0.00%
* Adjusted MLR based on bid projection, Numerator includes
Quality Initiatives and denominator excludes Taxes and Fees.
j. Describe what's included in Quality Initiatives

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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

2013

II. Optional Supplemental Packages
(b)
(c)
(d)
Benefit category
Package
Service
or pricing
ID
category
component
Description
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Package Total
Description
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

Package Total

Attachment D-1, CY2013_MA_BPT.xlsm

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

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

9. Enrollee Type:

(h)

(i)

PMPM

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

A/B

(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

12/14/2011

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

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

2013

II. Optional Supplemental Packages
(b)
(c)
(d)
Benefit category
Package
Service
or pricing
ID
category
component
Description
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Package Total
Description
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4

Package Total

Attachment D-1, CY2013_MA_BPT.xlsm

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

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

9. Enrollee Type:

(h)

(i)

PMPM

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

A/B

(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
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n/a
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n/a

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

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

12/14/2011

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

2013

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

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

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

9. Enrollee Type:

(h)

(i)

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

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

A/B

(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
$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

(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

Attachment D-1, CY2013_MA_BPT.xlsm

12/14/2011

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