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:

2014

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 1/1/2012-12/31/2012
(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

01/01/2012
12/31/2012

(e)
Cost
Sharing

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:

(f)

(g)

Util
Type

(h)
Total Benefits

Annualized
Util/1000

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-2014.beta
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 1/1/2012-12/31/2012 (excludes Optional Supplemental)
ESRD
Hospice
All Other
1. CMS Revenue
2. Premium Revenue
3. Total Revenue
$0
$0
$0
4. Net Medical Expenses

Total
$0
$0
$0
$0

5. Member Months

0

Non-Benefit Expenses:
7a. Sales & Marketing
7b. Direct Administration
7c. Indirect Administration
7d. Net Cost of Private Reinsurance

CMS - 10142 (4/30/2013)

CY2014_MA_BPT.xlsm

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0

0.0%
0.0%
0.0%

0
7e. Total Non-Benefit Expenses

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

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

$0.00
$0.00
$0.00
$0.00

$0
10a. NBE Quality Initiatives
10b. Taxes and Fees
10c. Insurer Fees (subset of Taxes & Fees)
11a. Medicaid Revenue
11b. Medicaid Cost
11b1. Benefit expenses
11b2. Non-benefit expenses
11c. Adjusted GLM

$0

$0

12/06/2012

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

General Information
Contract Number:
Plan ID:
Segment ID:
2014
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

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

CY2014_MA_BPT.xlsm

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
$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.
%

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

12/06/2012

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

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

2014

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)
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
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:

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

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
i2, 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, 13e, 13f
q
13g, 13h
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
* new line 4c

****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.

CY2014_MA_BPT.xlsm

12/06/2012

f

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

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

2014

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.

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)
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

(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

CY2014_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)
(l)
FFS Medicare Plan cost sh.
Actl. Equiv.
for Medicarecost sharing covered 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

(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

12/06/2012

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

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

2014

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

(h)

(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.
1.
2.
3.
4.

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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.
w.
x.
y1.
y2.
y3.

Total Non-Benefit Expense
Gain/(Loss) Margin
Total Revenue Requirement
Net Medical Expense % of Revenue
Non-Benefit % of Revenue
Gain/(Loss) Margin % of Revenue

$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

z1. NBE Quality Initiatives
z2. Taxes and Fees
z3. Insurer Fees (subset of Taxes & Fees)

z4. Overall Gain/(Loss) Margin Level
$0.00
0.0%
0.0%
0.0%

(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

CONTRACT

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
0.0%
0.0%
0.0%

$0.00
0.00
0.00
0.00

0.00
0.00
0.00

0.00
0.00
0.00

III. Development of Projected Contract Year ESRD "Subsidy"

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)

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 plan members

$0.00

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

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" =

CY2014_MA_BPT.xlsm

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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. Projected Medicaid Data
Entries must be reported as "Per Member Per Month" (PMPM).
1. Medicaid Projected Revenue
2. Medicaid Projected Cost (not in bid)
2a. Benefit expenses
2b. Non-benefit expenses
3. Adjusted GLM

$0.00

$0.00

$0.00

12/06/2012

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

General Information
Contract Number:
Plan ID:
Segment ID:
Contract Year: 2014

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
73.2%
26.8%
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:

CY2014_MA_BPT.xlsm

0

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

Not Applicable
50.0%

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
51.077%

48.923%

(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

12/06/2012

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

5.
6.
7.
8.

2014

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

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

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=$104.90)
$104.90 2. Part B Rebate Allocation, rounded to one decimal (see instructions)

Medicarecovered
$0.00
$0.00
0.00
$0.00
$0.00
$0.00
0.0000
0.0000

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

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

$0.00

Rebate PMPM Allocation
Non-Benefit
Gain / (Loss)
n/a
n/a
$0.00
0.00
n/a
n/a
n/a
$0.00

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.

$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
$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
104.90 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

CY2014_MA_BPT.xlsm

12/06/2012

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

2014

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

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

CY2014_MA_BPT.xlsm

5.
6.
7.
8.

(d)

Benefit category or
pricing component

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)
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

12/06/2012

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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:

2014

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

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

CY2014_MA_BPT.xlsm

5.
6.
7.
8.

(d)

Benefit category or
pricing component

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)
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

12/06/2012

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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:

2014

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)
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

III. Comments

IV. Base Period Summary for 1/1/2012-12/31/2012 (Note: This section must be reported at the contract level.)
Net Medical
Expenses
1. Total $: for all OSB packages combined
2. PMPM (based on OSB membership)

CY2014_MA_BPT.xlsm

$0.00

Non-Benefit Gain/(Loss)
Expenses
Margin
$0
$0.00
$0.00

Premium

Member
Months

$0.00

12/06/2012

WORKSHEET 1 - MSA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:
2014

Note: See bid instructions for ESRD and hospice exclusions.
MSA-2014.beta
OMB Approved # 0938-0944

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:

A/B

MSA

II. Base Period Background Information
1. Time Period Definition
Incurred from:
01/01/2012
Incurred to:
12/31/2012
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

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

(f)
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

5. Plans In Base

(g)

(h)
Total Benefits
Annualized
Util/1000
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

V. Description of Other Utilization Factor and Additive Values

CMS - 10142 (4/30/2013)

CY2014_MSA_BPT.xlsm

12/06/2012

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

General Information
Contract Number:
Plan ID:
Segment ID:
2014
Contract Year:

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
MSA
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

(j)
Manual Rate

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

CY2014_MSA_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

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

12/06/2012

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

General Information
Contract Number:
Plan ID:
Segment ID:
2014
Contract Year:

5.
6.
7.
8.

Note: See bid instructions for ESRD and hospice exclusions.

Organization Name:
Plan Name:
Plan Type:
MSA
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:

CY2014_MSA_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

12/06/2012

WORKSHEET 4 - MSA 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:
2014
Contract Year:

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
MSA
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. 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. NBE Quality Initiatives
k. Taxes and Fees
l. Insurer Fees (subset of Taxes and Fees)
CY2014_MSA_BPT.xlsm

12/06/2012

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

2014

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

CY2014_MSA_BPT.xlsm

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

Note: See bid instructions for ESRD and hospice exclusions.

9. Enrollee Type:

A/B

MSA

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

(h)

(i)

PMPM

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

12/06/2012

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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 - MSA OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:

2014

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

CY2014_MSA_BPT.xlsm

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

Note: See bid instructions for ESRD and hospice exclusions.

9. Enrollee Type:

A/B

MSA

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

(h)

(i)

PMPM

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

12/06/2012

n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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 - MSA OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Number:
2. Plan ID:
3. Segment ID:
4. Contract Year:

2014

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.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

(e)
Util.
type

Note: See bid instructions for ESRD and hospice exclusions.

9. Enrollee Type:

A/B

MSA

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

(h)

(i)

PMPM

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
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)

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

(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

$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

IV. Base Period Summary for 1/1/2012-12/31/2012 (Note: This section must be reported at the contract level.)
Net Medical
Expenses
1 Total $: for all OSB packages combined
2 PMPM (based on OSB membership)

CY2014_MSA_BPT.xlsm

$0.00

Non-Benefit Gain/(Loss)
Expenses
Margin
$0
$0.00
$0.00

Premium

Member
Months

$0.00

12/06/2012

WORKSHEET 1

ESRD-2014.beta

III. ESRD MSP Adjustment Factors for CY (from April Rate Announcement)

ESRD Plan Bid Submission
Enrollment and PMPM Revenue Projection

OMB Approved # 0938-0944
CMS - 10142 (4/30/2013)

1. Functioning Graft (i.e., postgraft) "F"
2. Dialysis / transplant ("D" / "T")

I. General Information

6. Contract #:

IV. Summary Data

7. Plan ID:
8. Segment ID:

1. Part C Mandatory Monthly Enrollee Premium
2. Part C Monthly Plan Revenue
3. Part D Premium (basic + supplemental) net of MA "rebates"
4. Plan intention for target Part D basic Premium
5. Quality Bonus Rating (per CMS)
6. New/low indicator (per CMS)

1.
2.
3.
4.
5.

Contract Year:
Contract-Plan-Segment:
Organization Name:
Service Area:
Plan type:

2014
__

ESRD SNP

II. Service Area Summary
(a)

State/County
Code

(b)

State

1. Total or Weighted Average for Service Area:

(c)

County Name
(Func Graft)

(d)
ESRD

Status
D/T/F

(e)

Projected
Member Months
Jan.- Dec. 2014
-

0.173
0.189

$0.00
$0.00
$0.00
0

(f)

(g)

(h)

(i)

Proj. Risk
Score

CY 2014
State or
County Rate

Percentage
of MSP
Mem. Months

Projected
CMS Monthly
Capitation

-

$0.00

n/a

$0.00

-

CY2014_ESRD_SNP_BPT.xlsm

12/06/2012

WORKSHEET 2
ESRD Plan Bid Submission
Projection of benefit cost, non-benefit expenses, and gain/loss margin PMPM
I. General Information
6. Contract #:
1. Contract Year:
2014
7. Plan ID:
2. Contract-Plan-Segment:
0_0_0
8. Segment ID:
3. Organization Name:
0
4. Service Area:
0
5. Plan type:
ESRD SNP

0
0
0

Projection of Plan Costs

Benefit
category
Inpatient hospital
Skilled nursing facility
Home health
Outpatient hospital / ASC
Emergency Room
Dialysis
Primary care physician
Nephrologist
Physician specialist (o/t nephrologist)
Other professional
Radiology / pathology
Ambulance / transportation
DME / supplies
Part B Rx: Medicare-covered
Other Part B services
Coordination of benefits 1/
Sub-total: Medicare-covered

Allowed
cost

$0.00

Enrollee
cost
sharing

$0.00

Supplemental Benefits
Medicare
AE
cost sharing
proportion

Net
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

6.2%
18.7%
0.0%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%
19.9%

Medicare
AE
cost sharing
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

n/a

$0.00

Total
cost sharing
enhancements
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

Other: Part B premium reduction
Other: Part D Basic premium reduction
Other: Part D Supp premium reduction
Additional services 2/
Sub-total: additional services

0.00
0.00
0.00
0.00
$0.00

0.00
0.00
0.00
0.00
$0.00

Total benefit cost

$0.00

$0.00

Non-benefit components
Sales & Marketing
Direct Administration
Indirect Administration

Adjusted MLR*
0.00%
* Adjusted MLR based on bid projection, Numerator includes
Quality Initiatives and denominator excludes Taxes and Fees.

Net Cost of Private Reinsurance

Gain / loss margin
Total NBE+GLM
Total plan cost
CMS capitation
Part C mandatory enrollee premium
Medicare-covered benefits
Cost sharing enhancements
Additional services
Part B premium reduction
Part D Basic premium reduction
Part D Supp premium reduction
Total Supplemental benefits
Total

Benefit Cost
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

NBE+GLM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00 NBE Quality Initiatives
$0.00 Taxes and Fees
Total Cost
Insurer Fees (subset of Taxes and Fees)
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

1/ Coordination of benefits and reinsurance recoveries are to be entered as negative figures
2/ Additional services includes preventative services that are not covered by Medicare and covered benefits that exceed Medicare
limits (such as inpatient coverage beyond lifetime reserve days)

CY2014_ESRD_SNP_BPT.xlsm

12/06/2012

WORKSHEET 2
ESRD Plan Bid Submission
Projection of benefit cost, non-benefit expenses, and gain/loss margin PMPM
I. General Information
6. Contract #:
1. Contract Year:
2014
7. Plan ID:
2. Contract-Plan-Segment:
0_0_0
8. Segment ID:
3. Organization Name:
0
4. Service Area:
0
5. Plan type:
ESRD SNP

0
0
0

Development of "Rebate" Allocations and Estimated Plan Premium
Rebate Allocation for Part B Premium
1. PMPM rebate allocation for Part B premium
2. Part B Rebate Allocation, rounded to one decimal (see instructions)

$0.00

3. Total MA Enrollee Premium (excl. Opt. Suppl.)
4. Rounded MA Premium (excl. Opt. Suppl.)

0.00
$0.00

5. Part D Basic Premium
5a. Prior to rebates (rounded value from Rx BPT)
5b. A/B rebates allocated to Part D Basic Premium
5c. A/B rebates for Part D Basic Premium (rounded)
5d. Part D Basic Premium*

$0.00
$0.00

6. Part D Supplemental Premium
6a. Prior to rebates (rounded value from Rx BPT)
6b. A/B rebates allocated to Part D Suppl Premium
6c. A/B rebates for Part D Suppl Premium (rounded)
6d. Part D Supplemental Premium

$0.00
$0.00

7. Total estimated plan premium*

$0.00

8. Plan Intention for target PD basic premium
* The premiums shown in lines 5 and 7 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 5 and 7 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.

CY2014_ESRD_SNP_BPT.xlsm

12/06/2012

WORKSHEET 3
ESRD Plan Bid Submission
Program Experience for Calendar Year 2012
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

2014
0_0_0
0
0
ESRD SNP

II. Contact Information
ESRD-SNP Plan Contact Person:
Name, Position
Phone Number
Email Address

6. Contract #:
0
7. Plan ID:
0
8. Segment ID: 0

ESRD-SNP Certifying Actuary:
Name, Creden.
Phone Number
Email Address

Revenues
Enrollment
Member months
CMS payments 1/
Enrollee premium 1/
Total revenue

n/a
n/a
n/a

CY 2012
PMPM
n/a

$0.00

Medical Benefits (PMPM) 2/
CY 2012

Benefit
category
Inpatient hospital
Skilled nursing facility
Home health
Outpatient hospital / ASC
Emergency Room
Dialysis
Primary care physician
Nephrologist
Physician specialist (o/t nephrologist)
Other professional
Radiology / pathology
Ambulance / transportation
DME / supplies
Part B Rx: Medicare-covered
Other Part B services
Coordination of benefits 3/
Sub-total: Medicare-covered
Additional services
Sub-total: additional services

Total benefit costs

Claims
incurred
in period
paid thru
03/31/2013

Claim
reserve
as of
03/31/2013

$0.00

$0.00

$0.00

$0.00

Incurred
claims
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00
0.00
$0.00

$0.00

$0.00

$0.00

Utilizers

Non-benefit components
Sales & Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance

Gain / loss margin
Total NBE+GLM
Total plan cost

$0.00
$0.00

1/ CMS payments and enrollee premium are to be reported in period in which they are due, not period of collection.
CMS payments for CY 2012 are to include an estimate of final risk adjustment settlement to be received in mid-2013.
2/ Medical benefits are to be reported net of enrollee cost-sharing.
3/ Coordination of benefits and reinsurance recoveries are to be entered as negative figures

CY2014_ESRD_SNP_BPT.xlsm

12/06/2012

WORKSHEET 4
ESRD Plan Bid Submission
OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

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

CY2014_ESRD_SNP_BPT.xlsm

6. Contract #:
7. Plan ID:
8. Segment ID:

2014
__
0
0
ESRD SNP

(e)
Util.
type

0
0
0

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

(h)

(i)

PMPM

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)

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

(q)
Projected
Member
Months
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

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

12/06/2012

WORKSHEET 4
ESRD Plan Bid Submission
OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

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

CY2014_ESRD_SNP_BPT.xlsm

6. Contract #:
7. Plan ID:
8. Segment ID:

2014
__
0
0
ESRD SNP

(e)
Util.
type

0
0
0

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

(h)

(i)

PMPM

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)

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

(q)
Projected
Member
Months
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

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

12/06/2012

WORKSHEET 4
ESRD Plan Bid Submission
OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

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

6. Contract #:
7. Plan ID:
8. Segment ID:

2014
__
0
0
ESRD SNP

Package Total

(e)
Util.
type

0
0
0

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

(h)

(i)

PMPM

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)

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

(q)
Projected
Member
Months
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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

IV. Base Period Summary for 1/1/2012-12/31/2012 (Note: This section must be reported at the contract level.)

1 Total $: for all OSB packages combined
2 PMPM (based on OSB membership)

CY2014_ESRD_SNP_BPT.xlsm

Net Medical Non-Benefit Gain/(Loss)
Expenses
Expenses
Margin
Premium
$0
$0.00
$0.00
$0.00
$0.00

Member
Months

12/06/2012