Form CMS-10142 Medicare Advantage Bid Pricing Tool

WORKSHEET 1 - MA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS

Note: See bid instructions for ESRD and hospice exclusions.
MA-2016.1
OMB Approved # 0938-0944

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

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

2016

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

II. Base Period Background Information

Note: DE# refers to Dual Eligible Beneficiaries without full Medicare cost sharing liability

1. Time Period Definition

2. Member Months
3. Risk Score

Total
Incurred from:
Incurred to:
Paid through:
6. Describe the source of the base period experience data

01/01/2014
12/31/2014

III. Base Period Data (at Plan's Risk Factor) for 1/1/2014-12/31/2014
(b)
(c)
(d)

(e)

Non-DE#
0

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

(f)

Cost
Sharing

0.00
$0.00

N/A

14. SNP Type:

N/A

15. EGWP:

N

DE#
0
0.0000

5. Plans In Base

Contract-Plan ID Member Months

Contract-Plan ID Member Months

4. Completion Factor

(g)

(h)

IV. Projection Assumptions
(j)
(k)

(i)

Total Benefits
Service Category

13. Region Name:
N/A

Util
Type

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

Allowed
PMPM

(l)

(m)

Util. Adjustments to Contract Period
Util/1000
Benefit Plan
Population
Trend
Change
Change

Other
Factor

(n)

(o)

(p)

Unit Cost Adjustment
Provider Payment
Other
Change
Factor

(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 1/1/2014-12/31/2014 (excludes Optional Supplemental)
ESRD

1. CMS Revenue
2. Premium Revenue
3. Total Revenue

Hospice

All Other

Total
$0
$0

$0

$0

$0

4. Net Medical Expenses

$0
$0

0

5. Member Months

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

CMS - 10142 (2/28/2015)

$0.00
$0.00

$0.00
$0.00

$0.00
$0.00

$0

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

0.0%
0.0%
0.0%

0
7f. 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

$0.00
$0.00
$0.00
$0.00

$0
10a.
10b.
10b1.
10b2.
10c.

Medicaid Revenue
Medicaid Cost
Benefit expenses
Non-benefit expenses
Adjusted GLM

$0

$0

WORKSHEET 2 - MA PROJECTED ALLOWED COSTS PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:
2016

5.
6.
7.
8.

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

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

13. Region Name:

N/A

14. SNP Type:

N/A

II. Projected Allowed Costs

N

Note: DE# refers to Dual Eligible Beneficiaries without full Medicare cost sharing liability

Contract Year Allowed Costs at Plan's Risk Factor:
(c)

Service Category

15. EGWP:

(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

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

t.

Subtotal Medicare-covered service categories

u.

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

$0.00

(i)
Annual
Util/1000

(j)
Manual Rate
Avg Cost

(k)
Allowed
PMPM

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

(l)
Exper.
Cred.
%

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

$0.00
$0.00

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%
0% CMS Guideline Credibility
0%

Total
Non-DE#
DE#
0
0
0
0.0000
0.0000
0.0000
(o)
(p)
(q)
Blended Rate
Total Allowed
Non-DE#
DE#
PMPM
Allowed PMPM Allowed PMPM
$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

(r)
% of svcs
provided
OON

WORKSHEET 3 - MA PROJECTED COST SHARING PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract No:
Plan ID:
Segment ID:
Contract Year:

2016

5.
6.
7.
8.

Org 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

15. EGWP:

N

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

1. In Network

NO

2. Out of Network

NO

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)

Service Category
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.
r1.
r2.
r3.
r4.
r5.
r6.
r7.
r8.
r9.
r10.
s.
t.
u.
v.

Description

Measurement
Unit
Code

(f)

(g)

In-Network
Effective
Plan-Level
Deduct PMPM*

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)

(l)

(m)
Out-of-Network
Description of

In-Network
PMPM

Total
In-Network
Cost Share
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

Cost Sharing / . . .

Benefit Limits****

*Actual in-network plan level deductible:
Does in-network ded apply to Pt B only?

***Actual OON plan level deductible:
Does OON ded apply to Pt B only?

** PMPM impact of in-network OOP max:

***PMPM impact of OON OOP max:

****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.

(n)

(o)

Out-of-Network
Cost Sharing
PMPM***

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
1b

2
3
4a
4b
4c

a1
a2
b
h5

16a
16b
17a
17b
18a

f
f
f
h5
c
i1, i5
i6
i4
i2, i6
i3
i6
i6
i3
i4
h1
h2
h5, g
g
h5
k
d
l
e1
e2
e2
h4
q
q
q
q
q
i1
i1
p
i6
i6
j
m
m
n1
n2
o1

18b

o2

5
6
7a
7b
7c
7d
7e
7f
7g
7h
7i
8a
8b
9a
9b
9c
9d
10a
10b
11a
11b
11c

12
13a
13b
13c
13d, 13e, 13f
13g, 13h
14a
14b
14c
14d
14e

15

WORKSHEET 4 - MA PROJECTED REVENUE REQUIREMENT PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

2016

5.
6.
7.
8.

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

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

13. Region Name:

N/A

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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 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

(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.

(e)
Reimb +
Actual Cost Sh.

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Supplies
OP Facility - Emergency
OP Facility - Surgery
OP Facility - Other
Professional
Part B Rx

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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 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

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

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

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

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

C. All Beneficiaries
Cost and Required Revenue PMPM at Plan's Risk Factor:
(c)

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)

(h)
Plan
Reimb

(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
$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

(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
(e)

(f)

(g)

(h)

Total Benefits

(i)

(j)

(k)

(l)

(m)

(n)

(o)

Medicare Covered
Net

Net

(p)

(q)

(r)

A/B Mand Suppl (MS) Benefits
Net PMPM for
Reduction of

WORKSHEET 4 - MA PROJECTED REVENUE REQUIREMENT PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

2016

5.
6.
7.
8.

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

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

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

6.
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

14. SNP Type:

N/A

15. EGWP: N

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

Other Medicare Part B

1.
2.
3.
4.
5.

N/A

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
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
Insurer Fees

13. Region Name:
N/A

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

Add'l Svcs.

A/B 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
0.00
$0.00

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
z1. Corporate Margin Requirement % of Rev.
z2. Corporate Margin Basis
z3. Overall Gain/(Loss) Margin Level

$0.00

NON-MEDICARE
CONTRACT

$0.00
0.0%
0.0%
0.0%

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00

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

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

Supplemental Benefits
Non-ESRD CY cost sharing reductions
Non-ESRD CY additional benefits

$0.00
$0.00

1. Medicaid Projected Revenue
2. Medicaid Projected Cost (not in bid)
2a. Benefit expenses
2b. Non-benefit expenses

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" =

$0.00

V. Projected Medicaid Data
Entries must be reported as "Per Member Per Month" (PMPM).

$0.00
$0.00

$0.00

WORKSHEET 5 - MA BENCHMARK PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:
2016

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)

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

Total

Non-DE#

DE#

0
$0.00

0

0

5. Conversion Factor
6. Plan A/B Benchmark
7. Plan A/B Bid

0
0
$0.00
$0.00

8. Standardized A/B Bid (@ 1.000)

$0.00

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

VIII. Projected CY Member Months

3. Medicare Secondary Payer Adjustment

4. Weighted Avg Risk Factor

Weighting
69.7%
30.3%
100.0%

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

3. Standardized A/B Benchmark

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
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

$0.00

V. Quality Rating

2. Rebate
3. Basic Member Premium

$0.00
$0.00

1. Quality Bonus Rating (per CMS)

2. New org/low enrollment indicator (per CMS)
3. Rebate %

Not applicable
50.0%

VI: County Level Detail and Service Area Summary

VII: Other Medicare Information

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:
Out of Area

0

(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
46.368%

53.632%

(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

WORKSHEET 6 - MA BID SUMMARY

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

5.
6.
7.
8.

2016

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. Other Information
A. Part B Information

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)

1. Max. Pt B premium buydown amt., per CMS

$0.00

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

III. Plan A/B Bid Summary
A. Overview

1. Net medical cost

B. MA Rebate Allocation

Medicarecovered
$0.00

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

A/B Mandatory 1. MA Rebate
Supplemental
$0.00 2. Reduce A/B Cost Sharing

3. Other A/B Mand Suppl Benefits
2. Non-benefit expense
3. Gain / loss margin
4. Total revenue requirement
5. Standardized A/B Benchmark
6. Plan A/B Benchmark

7. Risk Factor
8. Conversion Factor

$0.00
0.00
$0.00

$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

$0.00
0.00
0.00
0.00
0.00
$0.00

$0.00
$0.00
0.0000
0.0000

$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

MA Plan Bid Contact:
Name, Position
Phone Number

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.

MA Certifying Actuary:
Name, Credentials
Phone Number
Email Address

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

$0.00
0.00
0.00
0.00
0.00
$0.00
$0.00

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)

IV. Contact Information

Email Address

Total
$0.00

C. Development of Estimated Plan Premium
Maximum
Value
1. A/B Mandatory Supplemental revenue requirements

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
9. Total estimated plan premium*
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.

$0.00
$0.00
$0.00

WORKSHEET 7 - OPTIONAL SUPPLEMENTAL BENEFITS

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information
1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:
2016

5.
6.
7.
8.

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

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

Description

(d)
Allowed
Medical Expense
PMPM

13. Region Name: N/A

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

(e)
Enrollee
Cost Sharing
PMPM

(f)
Net
PMPM
value

14. SNP Type:

(g)
NonBenefit
Expense

(h)
Gain/
(Loss)
Margin

15. EGWP:

N/A

(i)
Premium

1

$0.00

$0.00

2

$0.00

$0.00

3

$0.00

$0.00

4

$0.00

$0.00

5

$0.00

$0.00

Weighted Avg.
Total

$0.00

$0.00

$0.00

$0.00

$0.00

(j)
Projected
Member
Months

$0.00

0

III. Comments

IV. Base Period Summary for 1/1/2014-12/31/2014 (Note: This section must be reported at the contract level.)
Net Medical
Expenses

Non-Benefit
Expenses

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

$0.00

$0.00

Gain/(Loss)
Margin
$0
$0.00

Premium
$0.00

N

Member
Months

WORKSHEET 1 - MSA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS

Note: See bid instructions for ESRD and hospice exclusions.
MSA-2016.1
OMB Approved # 0938-0944

I. General Information

1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

2016

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:
Incurred to:
Paid through:

5. Plans In Base

2. Member Months
3. Risk Score

01/01/2014
12/31/2014

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

4. Completion Factor

6. Describe the source of the base period experience data

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

IV. Projection Assumptions

(f)

(g)

(h)

(i)

Total Benefits
Service Category

Utilizers

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

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)

m.

Total Medicare Covered Medical Expenses

Util
Type

V. Description of Other Utilization Factor and Additive Values

CMS - 10142 (2/28/2015)

% of MMs

Annualized
Util/1000

(j)

(k)

(l)

(m)

Util. Adjustments to Contract Period

Avg Cost

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

Util/1000
Trend

Benefit Plan
Change

Population
Change

(n)
Unit Cost/

Other
Factor

Intensity
Trend

(o)

(p)
Additive

Adjustments
Util/1000

PMPM

WORKSHEET 2 - MSA TOTAL PROJECTED ALLOWED COSTS PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information

1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
2016
Contract Year:

5.
6.
7.
8.

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

9. Enrollee Type:

A/B

MSA

II. Projected Allowed Costs
Contract Year Allowed Costs at Plan's Risk Factor:

(c)

(e)

(f)

(g)

(h)

(i)

Projected Experience Rate
Service Category

Util
Type

Annual
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

Allowed
PMPM

Annual
Util/1000

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

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)

m.

Total Medicare Covered Medical Expenses

n.

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

0
0
0
0
0
0
0
0
0
0
0

(j)

(k)

(l)

Allowed
PMPM

Exper.
Cred.
%

Manual Rate

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

(m)

(n)

Annual
Util/1000

Avg Cost

Allowed
PMPM

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

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

0%
0% CMS Guideline Credibility

$0.00

0
0
0
0
0
0
0
0
0
0
0
$0.00

(o)

Contract Year Rate

(p)
% of svcs
provided
OON

WORKSHEET 3 - MSA BENCHMARK PMPM

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information

1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
2016
Contract Year:

5.
6.
7.
8.

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

2. New/low indicator (per CMS)

MSA Plan Contact Person:

Not applicable

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

(d)
County Name

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

(g)
MA Risk Ratebook
Unadjusted

(h)
MA Risk Ratebook
Risk-Adjusted
Plan

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

0

0

$0.00

$0.00 Benchmark

WORKSHEET 4 - MSA ENROLLEE DEPOSIT AND PLAN PAYMENT PMPM
Note: See bid instructions for ESRD and hospice exclusions.
I. General Information

1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

5.
6.
7.
8.

2016

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)
Annual
Projected
Claim
Interval

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

(d)
Annual
Average
Claim
Amount

(e)
Percentage
of Member Months
(Only Use Highest
Claim Interval)

(f)

(g)

Gross
Claims
(PMPM)

Gross Claims
Over Deductible
(PMPM)

$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

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

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. Insurer Fees

$0.00

6. 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

$0.00

h. Standardized Plan Benchmark

$0.00

i. Corporate Margin Requirement % of Rev.
j. Corporate Margin Basis
k. Overall Gain/(Loss) Margin Level

$0.00
$0.00
$0.00

Part A

Part B

$0.00

$0.00

$0.00

$0.00

0.0%
0.0%
0.0%

NON-MEDICARE
CONTRACT

WORKSHEET 5 - MSA OPTIONAL SUPPLEMENTAL BENEFITS

Note: See bid instructions for ESRD and hospice exclusions.

I. General Information

1.
2.
3.
4.

Contract Number:
Plan ID:
Segment ID:
Contract Year:

2016

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

Description

5.
6.
7.
8.

Organization Name:
Plan Name:
Plan Type:
Deductible Amount

9. Enrollee Type:

A/B

MSA

(d)

(e)

(f)

(g)

(h)

Allowed
Medical Expense
PMPM

Enrollee
Cost Sharing
PMPM

Net
PMPM
value

NonBenefit
Expense

Gain/
(Loss)
Margin

(i)

(j)

Premium

Projected
Member
Months

1

$0.00

$0.00

2
3
4
5

$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00
$0.00

Weighted Avg.
Total

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

0

III. Comments

IV. Base Period Summary for 1/1/2014-12/31/2014 (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)

$0.00

Non-Benefit
Expenses
$0.00

Gain/(Loss)
Margin
$0
$0.00

Premium
$0.00

Member
Months

WORKSHEET 1
ESRD Plan Bid Submission
Enrollment and PMPM Revenue Projection

ESRD-2016.1
OMB Approved # 0938-0944
CMS - 10142 (2/28/2015)

III. ESRD MSP Adjustment Factors for CY (from April Rate Announcement)
1. Functioning Graft (i.e., postgraft) "F"
2. Dialysis / transplant ("D" / "T")

I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

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

IV. Summary Data

2016
__

ESRD SNP

II. Service Area Summary
(a)

State/County
Code

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

(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. 2016
-

0.173
0.215

$0.00
$0.00
$0.00
0
Not applicable

(f)

(g)

(h)

(i)

Proj. Risk
Score

CY 2016
State or
County Rate

Percentage
of MSP
Mem. Months

Projected
CMS Monthly
Capitation

-

$0.00

-

n/a

$0.00

WORKSHEET 2
ESRD Plan Bid Submission
Projection of benefit cost, non-benefit expenses, and gain/loss margin PMPM
I. General Information
6. Contract #:
0
1. Contract Year:
2016
7. Plan ID:
0
2. Contract-Plan-Segment:
0_0_0
8. Segment ID:
0
3. Organization Name:
0
4. Service Area:
0
5. Plan type:
ESRD SNP
Section II

Projection of Plan Costs

Benefit
category

Allowed
cost

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

Enrollee
cost
sharing

$0.00

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

$0.00

Medicare
AE
cost sharing
proportion
6.2%
21.0%
0.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%
20.0%

Supplemental Benefits
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

Corporate Margin Requirement % of Rev.
Corporate Margin Basis
Overall Gain/(Loss) Margin Level

Net Cost of Private Reinsurance
Insurer Fees
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
$0.00
Total Cost
$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)

Section III Development of Estimated Plan Premium
Part B Premium Reduction
1. PMPM reduction for Part B premium
2. Part B Premium Reduction, 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 reductions (rounded value from Rx BPT)
5b. Part D Basic Premium reduction
5c. Part D Basic Premium reduction (rounded)
5d. Part D Basic Premium*

$0.00
$0.00

6. Part D Supplemental Premium
6a. Prior to reductions (rounded value from Rx BPT)
6b. Part D Suppl Premium reduction
6c. Part D Suppl Premium reduction (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.

NON-MEDICARE
CONTRACT

WORKSHEET 3
ESRD Plan Bid Submission
Program Experience for Calendar Year 2014
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

Section III

2016
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
Date Prepared
Revenues
Enrollment

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

Section IV

CY 2014
PMPM
n/a

n/a
n/a
n/a

$0.00

Medical Benefits (PMPM) 2/
CY 2014

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
03/31/2015

Claim
reserve
as of
03/31/2015

$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

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

Gain / loss margin
Total NBE+GLM
Total plan cost

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 2014 are to include an estimate of final risk adjustment settlement to be received in mid-2015.
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

$0.00
$0.00

Utilizers

WORKSHEET 4
ESRD Plan Bid Submission
OPTIONAL SUPPLEMENTAL BENEFITS
I. General Information

6. Contract #:

0

1. Contract Year:

2016

7. Plan ID:

0

2. Contract-Plan-Segment:

__

8. Segment ID:

0

3. Organization Name:

0

4. Service Area:

0

5. Plan type:

ESRD SNP

II. Optional Supplemental Packages
(b)
(c)
(d)
Allowed
Medical Expense
Package
Description
PMPM
ID

(e)
Enrollee
Cost Sharing
PMPM

(f)
Net
PMPM
value

(g)
NonBenefit
Expense

(h)
Gain/
(Loss)
Margin

(i)
Premium

1

$0.00

$0.00

2
3
4
5

$0.00
$0.00
$0.00
$0.00

$0.00
$0.00
$0.00
$0.00

Weighted Avg.
Total

$0.00

$0.00

$0.00

$0.00

$0.00

(j)
Projected
Member
Months

$0.00

0

III. Comments

IV. Base Period Summary for 1/1/2014-12/31/2014 (Note: This section must be reported at the contract level.)
Net Medical
Expenses

Non-Benefit
Expenses

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

$0.00

$0.00

Gain/(Loss)
Margin
$0
$0.00

Premium
$0.00

Member
Months