Form CMS-10142 Worksheets: Medicare Advantage Bid Pricing Tool

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

Note: See bid instructions for ESRD and hospice exclusions.
MA-2021.1
OMB Approved # 0938-0944 (Expires: 1/31/2022)

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

2021

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

II. Base Period Background Information

N/A

14. SNP Type:

N/A

15. VBID-C:
16. VBID-H:

N
N

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

Incurred from:
Incurred to:
Paid through:

01/01/2019
12/31/2019

III. Base Period Data (at Plan's Risk Factor) for 1/1/2019-12/31/2019
(b)
(c)
(d)
(e)
Net
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/Diabetes
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)
Suppl. Ben. Chpt 4 (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

t.

Subtotal Medicare-covered service categories

0.00
$0.00

0

DE#
0
0.0000

5. Bids In Base

Contr-Plan-Seg ID Member Months

Contr-Plan-Seg ID Member Months

4. Completion Factor

(f)

Cost
Sharing

Non-DE#

2. Member Months
3. Risk Score

1. Time Period Definition

Service Category

13. Region Name:
N/A

(g)

Util
Type

Annualized
Util/1000

(h)
Total Benefits
Avg Cost
per Unit

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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. Projection Assumptions
(j)
(k)

(i)
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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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. Base Period Summary for 1/1/2019-12/31/2019 (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

$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.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0944. The time required to complete this information collection is estimated to average 30
hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
CMS - 10142

Medicaid Revenue
Medicaid Cost
Benefit expenses
Non-benefit expenses

$0

PMPM

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:
2021

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

II. Projected Allowed Costs

N
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. VBID-C:
16. VBID-H:

(e)
Util
Type

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/Diabetes
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)
Suppl. Ben. Chpt 4 (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

t.

Subtotal Medicare-covered service categories

(f)

(g)
(h)
Projected Experience Rate
Annual
Avg Cost
Allowed
Util/1000
per Unit
PMPM
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

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

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

(i)
Annual
Util/1000

(j)
Manual Rate
Avg Cost
per Unit

1. Projected member months
2. Projected risk factor
(m)
(n)

(k)

(l)

Allowed
PMPM

Credibility

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

Annual
Util/1000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

$0.00
$0.00

Avg Cost
per Unit
$0.00
0.00
0.00
0.00
0.00
0.00
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
0
0.0000

Non-DE#
0
0.0000
(p)

DE#
0
0.0000
(q)

(o)
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:

2021

5.
6.
7.
8.

Org 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. VBID-C:
16. VBID-H:

N
N

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

1. In Network

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.

s.
t.
u.

Description

Measurement
Unit
Code

NO

2. Out of Network

(f)

(g)

In-Network
Effective
Deductible
PMPM*

In-Network
Util/1000
or PMPM

(h)

NO

(i)

3. Combined NO

(j)

In-Network Cost Sharing After Deductible
Description of Cost
Effective
Sharing / Add'l Days /
Copay / Coin
Benefit Limits****
Before OOP Max

**Effective
Copay / Coin
After OOP Max

Inpatient Facility
Acute
Inpatient Facility
Mental Health
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Diabetes DME
DME/Prosthetics/Diabetes Prosthetics/Diabetes
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
Suppl. Ben. Chpt 4 (Non-Covered)
Other Non-Covered

Total

(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

Actual combined plan deductible:

(k)

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 in-network plan deductible:

***Actual OON plan deductible:

** 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

5
6
7a
7b
7c
7d
7e
7f
7g
7h
7i
7j
7k
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
16a
16b
17a
17b
18a
18b
V/T
19a
19b
19c

a1
a2
b
h5
f
f
f
h3, h5
c
i1
i2, i6
i4
i2, i5, i6
i3
i2, i6
i2, i6
i3
i4
i1
i2
h1
h2
h5, g
g
h5
h5, k
d
l
e1
e2
e2
h4
q
q
q
q
q
k, i1, i2, i6
i1, i2, i6
p
i1, i2, i6
i1, i2, i6
j
m
m
n1
n2
o1
o2

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:

2021

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. VBID-C:
16. VBID-H:

N
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)

(e)
Allowed
PMPM

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

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Diabetes
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)
Suppl. Ben. Chpt 4 (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/Diabetes
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)
Suppl. Ben. Chpt 4 (Non-Covered)
Other Non-Covered
COB/Subrg. (outside claim system)
Total Medical Expenses

(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

(h)
Plan
Reimb

(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

(l)
Plan cost sh.
for Medicarecovered svcs.

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

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

(i)

(j)
% for Cov. Svcs
Cost
Allowed
Sharing

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

(k)
State Medicaid
Required Bene.
cost sharing

(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

(l)
Actual 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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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

(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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
$0.00

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

$0.00

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

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
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
Service Category

(i)

0.0000

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)

(i)

(j)

(k)

(l)

(m)

(n)

(o)

Medicare Covered
Net
PMPM

Net
PMPM

(p)

(q)

(r)

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

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:

2021

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. VBID-C:
16. VBID-H:

N
N

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

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Diabetes
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
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

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

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

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

COB/Subrg. (outside claim system)
Total Medical Expenses
Non-Benefit Expense:
Sales & Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Insurer Fees

0.00
$0.00

0.00
$0.00

0.00
$0.00

0.00
$0.00

0.00
$0.00

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

Other Medicare Part B
Transportation (Non-Covered)
Dental (Non-Covered)
Vision (Non-Covered)
Hearing (Non-Covered)
Suppl. Ben. Chpt 4 (Non-Covered)
Other Non-Covered
ESRD

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

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

$0.00
0.00
0.00
0.00
0.00

z4. Is this bid part of a valid product pairing?
z5. Bids in Product Pairing

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

$0.00
0.0%
0.0%
0.0%

$0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0.00
0.00
0.00

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

III. Development of Projected Contract Year ESRD "Subsidy"
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
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

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

IV. 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:

2021

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:
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

N/A

15. VBID-C:
16. VBID-H:

N
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
62.6%
37.4%
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
43.310%

56.690%

(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.

2021

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. VBID-C: N
16. VBID-H: N

II. Other Information
A. Part B Information

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

B. Rebate Allocation for Part B Premium
1. PMPM Rebate Allocation for Part B premium (maximum value=$144.60)
$144.60 2. Part B Rebate Allocation, rounded to one decimal (see instructions)

C. Rebate Allocations
$0.00

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

$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

5. Standardized A/B Benchmark $0.00
6. Plan A/B Benchmark
$0.00
7. Risk Factor
0.0000
8. Conversion Factor
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 Actuarial 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
144.60 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 Part D 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:

5.
6.
7.
8.

2021

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

Description

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

(d)
Allowed
Medical Expense
PMPM

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

(e)
Enrollee
Cost Sharing
PMPM

(f)
Net
PMPM
value

13. Region Name:

N/A

14. SNP Type:

N/A

N/A

(g)
NonBenefit
Expense

(h)
Gain/
(Loss)
Margin

15. VBID-C:
16. VBID-H:

(i)

(j)
Projected
Member
Months

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

$0.00

0

III. Base Period Summary for 1/1/2019-12/31/2019 (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

Member
Months

Premium
$0
$0.00

N
N

$0.00

WORKSHEET 1 - MSA BASE PERIOD EXPERIENCE AND PROJECTION ASSUMPTIONS

Note: See bid instructions for ESRD and hospice exclusions.
MSA-2021.1
OMB Approved # 0938-0944 (Expires: 1/31/2022)

I. General Information

1.
2.
3.
4.

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

2021

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:

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

5. Bids In Base

2. Member Months
3. Risk Score

01/01/2019
12/31/2019

4. Completion Factor

Utilizers

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

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Diabetes
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

% of MMs

(n)

(o)

IV. Projection Assumptions

(f)

(g)

(h)

(i)

Total Benefits
Service Category

Contr-Plan-Seg ID
a.
b.
c.
d.

Util
Type

Annualized
Util/1000

(j)

(k)

(l)

(m)

Util. Adjustments to Contract Period

Avg Cost
per Unit

Allowed
PMPM

Util/1000
Trend

Benefit Plan
Change

Population
Change

Unit Cost/
Other
Factor

Intensity
Trend

(p)
Additive

Adjustments
Util/1000

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-0944. The time required to complete this information collection is estimated to average 30
hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
CMS - 10142

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:
2021
Contract Year:

5.
6.
7.
8.

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

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

Inpatient Facility
Skilled Nursing Facility
Home Health
Ambulance
DME/Prosthetics/Diabetes
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

(e)
Util
Type

(f)

(g)

(h)

Projected Experience Rate
Annual
Avg Cost
Allowed
Util/1000
per Unit
PMPM
0
0
0
0
0
0
0
0
0
0
0

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

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

(i)

(j)

Manual Rate
Annual
Avg Cost
Util/1000
per Unit

(k)

(l)

Allowed
PMPM

Exper.
Cred.
%

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

(m)

(n)

Contract Year Rate
Annual
Avg Cost
Util/1000
per Unit

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)

(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:
2021
Contract Year:

5.
6.
7.
8.

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

9. Enrollee Type:

A/B

MSA

II. Contact Information

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 Actuarial 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.

2021

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

9. Enrollee Type:

A/B

MSA

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)

$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

(f)

(g)

Gross
Claims
(PMPM)

Gross Claims
Over Deductible
(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
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%

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:

2021

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

$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

$0.00

0

III. Base Period Summary for 1/1/2019-12/31/2019 (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-2021.1
OMB Approved # 0938-0944
(Expires: 1/31/2022)

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

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 reductions
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:

2021

ESRD SNP

II. Service Area Summary
(a)

State/County
Code

(b)

State

(c)

County Name
(Func Graft)

1. Total or Weighted Average for Service Area:

(d)
ESRD

Status
D/T/F

(e)

Projected
Member Months
Jan.- Dec. 2021
-

0.173
0.215

$0.00
$0.00
$0.00
0
Not applicable

(f)

(g)

(h)

(i)

Proj. Risk
Score

CY 2021
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 Revenue Requirement PMPM
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

2021
0_000_00
0
0
ESRD SNP

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

0

Section II Projection of Revenue Requirement PMPM

Service
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 / Diabetes
Part B Rx: Medicare-covered
Other Part B services
Coordination of benefits
Sub-total: Medicare-covered services

Allowed
cost

$0.00

Enrollee
cost
sharing

$0.00

Other: Part B premium reduction
Other: Part D Basic premium reduction
Other: Part D Supp premium reduction
Additional services
Sub-total: premium reductions + add'l services net PMPM

Net
PMPM
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
0.00
0.00
0.00
0.00
$0.00

Total benefit cost

$0.00

Non-benefit Expenses (NBE) and Gain Loss Margin (GLM)
Sales & Marketing
Direct Administration
Indirect Administration

Mandatory Supplemental Benefits
Medicare
AE
cost sharing
Cost sharing
value
enhancements
6.2%
$0.00
$0.00
19.8%
0.00
0.00
0.0%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
19.8%
0.00
0.00
0.00
Sub-total cost sharing
$0.00
$0.00
Medicare
AE
cost sharing
proportion

Other: Part B premium reduction
Other: Part D Basic premium reduction
Other: Part D Supp premium reduction
Additional services
Sub-total: prem reduct + add'l srvs net PMPM
Total benefit cost - mand. supplemental

0.00
0.00
0.00
0.00
$0.00
$0.00

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

Net Cost of Private Reinsurance
Insurer Fees

Net Medical % of Revenue

Sub-total non-benefit expenses

$0.00 Non-Benefit Expense % of Revenue

Gain / loss margin
Total NBE + GLM
Total Revenue Requirement
CMS capitation
Part C mandatory enrollee premium
Summary of Total Revenue Requirement
Benefit Cost
Medicare-covered benefits
$0.00
Cost sharing enhancements
$0.00
Additional services
$0.00
Part B premium reduction
$0.00
Part D Basic premium reduction
$0.00
Part D Supp premium reduction
$0.00
Mandatory supplemental benefits
$0.00
Medicare covered and mand. supplemental benefits
$0.00

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

Section III Development of Estimated Plan Premium

Gain/ loss margin % of Revenue
$0.00 NBE + GLM % of Revenue
$0.00
$0.00
$0.00
Total
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00

"Excess Funds"
Funds for Part B & Part D premium reductions
Part B Premium Reduction
1. PMPM reduction for Part B premium
2. Part B Premium Reduction, rounded to one decimal (see instructions)

$0.00
$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.

$0.00

0.0%
0.0%
0.0%
0.0%

WORKSHEET 3
ESRD Plan Bid Submission
Program Experience for Calendar Year 2019
I. General Information
1. Contract Year:
2. Contract-Plan-Segment:
3. Organization Name:
4. Service Area:
5. Plan type:

2021
0_000_00
0
0
ESRD SNP

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

Section III

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

0

ESRD-SNP Certifying Actuary:
Name, Creden.
Phone Number
Email Address
Date Prepared
Revenues
CY2019
Enrollment
PMPM

Member months
CMS payments
Enrollee premium

n/a

Total revenue

Section IV

n/a
n/a
n/a

$0.00

Components of Revenue (PMPM)
CY2019

Service
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 / Diabetes
Part B Rx: Medicare-covered
Other Part B services
Coordination of benefits
Sub-total: Medicare-covered
Additional services
Sub-total: additional services

Total benefit costs
Non-benefit Expenses (NBE) and Gain Loss Margin (GLM)
Sales & Marketing
Direct Administration
Indirect Administration
Net Cost of Private Reinsurance
Insurer Fee
Sub-total non-benefit exp.
Gain / loss margin
Total NBE+GLM
Total Revenue

Claims
incurred
in period
paid thru

Claim
reserve
as of

$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

$0.00
$0.00
$0.00

Utilizers

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

6. Contract #:

0

1. Contract Year:

2021

7. Plan ID:

2. Contract-Plan-Segment:

0_000_00

8. Segment ID:

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

$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. Base Period Summary for 1/1/2019-12/31/2019 (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