eutf.hawaii.goveutf.hawaii.gov/wp-content/uploads/2017/12/rfp-no.-18... · web viewplan comparison...

PLAN COMPARISON SUMMARIES & FEE PROPOSAL FORMS

PROPOSED BENEFITS

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. The EUTF seeks to maintain the current level of benefits. Unless noted, it will be assumed that proposed benefits match the requested benefits exactly.

THE “WORD” FILE THAT IS AVAILABLE WITH THIS RFP MUST INCLUDE YOUR PROPOSED FEES AND RATES. YOU ARE TO INPUT YOUR PROPOSAL INTO THE “WORD” FILE AND PRINT OUT A COPY FOR YOUR ORIGINAL HARD COPY SUBMISSION.

[NOTE: For all of the following Sections, please read the instructions to OFFERORS concerning the disclosure of “trade secret” or “confidential” information and mark your responses in this RFP accordingly. Failure of the OFFEROR to appropriately identify the responses as such may result in the disclosure of any such information]. Please refer to the instructions for the submission of a redacted copy of your proposal in Section 1.11, Submission of Proposals.

Notes Applicable to Insured/Risk Sharing Proposed Rates

1. All proposals must include fees and taxes, and exclude fees mandated under ACA which are to be listed separately. ACA fees will be excluded from the rates should they no longer be mandated by the law.

2. All proposals should guarantee a fixed administration fee, inclusive of retention and profit, per employee/retiree per month. This guarantee must be separately stated for the initial contract term and the optional contract extensions.

3. You must separately list the guaranteed administration/retention fee on your proposal sheet for the fully insured options.

4. For the fully insured plans with risk sharing, if the total benefit paid, excluding ACA fees, at the end of the runout period is less than the total premiums collected, excluding ACA fees, the excess amount will be refunded to the EUTF. Each plan must be separately accounted although surpluses from one plan may be applied to offset deficits of another plan, but the active employee contract may not be merged with the retiree plan contract to offset deficits or surpluses. The two contracts must be accounted for independently. See example below.

Initial Reconciliation

The Contractor agrees to an initial reconciliation with six months of benefits run-out following the end of the contract period and a final reconciliation that shall occur with twelve months of benefits run-out following the end of the contract period. Both reconciliations will be done within 45 days after the respective run-out periods.

The initial reconciliation shall be calculated as follows: Paid premiums (excluding ACA PCORI and insurer fees), minus paid benefits, minus administration/retention fees, and minus reserves for incurred but not reported benefits. Administration/retention fees shall be calculated by multiplying the fixed dollar amounts (per employee/retiree per month rates) by the number of employees/retirees in each month of the contract period. Any surplus shall be returned to the EUTF within 30 days of

the initial reconciliation (Example 1). Any deficit shall be the responsibility of the Contractor (Example 2).

Example #1: Surplus returned to the EUTF

$1,000,000 paid premiums-$750,000 minus paid benefits-$60,000* minus administration/retention fees-$100,000 minus reserves for incurred but not reported benefits$90,000 surplus paid to EUTF*$4.00 per subscriber per month ($4.00 is an example only) x 15,000 (sum of enrolled employees/retirees in each month of the contract period) = $60,000

Example #2: Deficit is the responsibility of the Contractor

$1,000,000 paid premiums-$850,000 minus paid benefits-$68,000* minus administration/retention fees-$100,000 minus reserves for incurred but not reported benefits-$18,000 Contractor may not invoice EUTF*$4.00 per subscriber per month ($4.00 is an example only) x 17,000 (sum of enrolled employees/retirees in each month of the contract period) = $68,000

Final Reconciliation

The final reconciliation shall be calculated as follows: Paid premiums (excluding ACA PCORI and insurer fees), minus paid benefits, minus administration/retention fees, and minus reserves for incurred but not reported benefits (which will be calculated based upon the previous plan year run-out of claim experience for months 13-24 but not more than .20% of plan year benefits). Administration/retention fees shall be calculated by multiplying the fixed dollar amounts (per employee/retiree per month rates) by the number of employees/retirees in each month of the contract period.

If the final reconciliation surplus is greater than the initial reconciliation surplus, then the surplus from the final reconciliation less any surplus paid to the EUTF for the initial reconciliation shall be returned to the EUTF within 30 days of the final reconciliation (see example 1a). If the final reconciliation surplus is less than the initial reconciliation surplus, the Contractor may invoice the EUTF for the difference (see example 1b). If the initial reconciliation resulted in a surplus and the final reconciliation resulted in a deficit, the Contractor may invoice the EUTF the amount of the initial reconciliation surplus (see example 1c).

Example #1a: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$840,000 minus paid benefits-$60,000 minus administration/retention fees-$1,092 minus incurred but not reported benefits (for active employees, the calculation is $840,000 x 0.0013)*$98,908 final reconciliation surplus-$90,000 minus initial reconciliation surplus paid to EUTF$8,908 additional surplus to be refunded to EUTF

Example #1b: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$900,000 minus paid benefits

-$60,000 minus administration/retention fees-$1,170 minus incurred but not reported benefits (for active employees, the calculation is $900,000 x 0.0013)*$38,830 final reconciliation surplus

The Contractor may invoice the EUTF for $51,170, which represents the difference between the initial reconciliation refund and the final reconciliation surplus ($90,000 - $38,830 = $51,170).

Example #1c: (Contractor paid EUTF $90,000 refund at initial reconciliation):

$1,000,000 paid premiums-$1,000,000 minus paid benefits-$60,000 minus administration/retention fees-$1,300 minus incurred but not reported benefits (for active employees, the calculation is $1,000,000 x 0.0013)*-$61,300 final reconciliation deficit

The Contractor may invoice the EUTF for the $90,000 initial reconciliation surplus.

If the initial reconciliation resulted in a deficit, and the final reconciliation also results in a deficit, the Contractor shall not invoice the EUTF (see example 2a). If the initial reconciliation resulted in a deficit, and the final reconciliation results in a surplus, the surplus from the final reconciliation shall be returned to the EUTF (see example 2b).

Example #2a: (Contractor had an $18,000 deficit at initial reconciliation):

$1,000,000 paid premiums-$960,000 minus paid benefits-$68,000 minus administration/retention fees-$1,248 minus incurred but not reported benefits (for active employees, the calculation is $960,000 x 0.0013)*-$29,248 final reconciliation deficit

The Contractor may not invoice the EUTF for the final reconciliation deficit.

Example #2b: (Contractor had an $18,000 deficit at initial reconciliation):

$1,000,000 paid premiums-$850,000 minus paid benefits-$68,000 minus administration/retention fees-$1,105 minus incurred but not reported benefits (for active employees, the calculation is $850,000 x 0.0013)*$80,895 final reconciliation surplus to be refunded to EUTF

*Amount is for example purposes only

5. Deficits may not be carried forward to subsequent contract periods to be recovered from any future surplus. Each contract period must be separately accounted and surpluses must be returned 15 months after the conclusion of each contract period.

6. The financial experience of each plan must be independent of the financial experience of any other plan that may be awarded to a Contractor. Gains or losses from one plan may be applied to the gains or losses of another plan, but active plans must be rated separately from retiree plans. For example, the active EUTF Dental plan must be accounted for separately from the HSTA VB Dental plan. Likewise, the HSTA VB Supplemental Dental plan must be accounted for separately from any other plan, although on final reconciliation, the surplus or deficit from one plan may be used to offset a

deficit in another, provided only within the same contract that is active contract versus retiree contract.

7. The EUTF reserves the right to offer multiple carrier options.

8. No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

9. Rates must be quoted on a three tiered basis (self, two-party, and family). If this is not possible due to federal filing requirements, please note that exception clearly on each rate table that you are completing, but you must guarantee your administration/retention fee for the entire contract period and successive periods.

10. All underwriting rules/restrictions that apply to rates quoted must be listed as an attachment to the rate exhibit.

11. All rates quoted must exclude any commissions or payments to any third party.

12. Please list any rating method which uses a credibility factor less than 100% in your underwriting assumptions.

13. Rates shown must be valid for the contract periods contained in Section 1.4, Contract Period.

14. Rates must be filled out in the proposal sheets provided.

15. All rates must be guaranteed for the term of the contract, including any extensions.

16. If your proposal is accepted by the EUTF, the following additional rates will be required for various self-pay categories: Tiered Cobra Rates.

17. Amounts shall be in U.S. dollars unless a specific percent is requested.

18. All active rates must be rounded to even cents.

Important Self Insured Proposal Instructions and Information

1. The EUTF reserves the right to offer multiple carrier options.

2. All proposals must include all fees and taxes, and exclude fees mandated under ACA which are to be listed separately.

3. No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

4. All services to be provided for the quoted fee should be listed including quantities and frequencies.

5. All fees quoted must exclude any commissions or payments to any third party.

6. Fees must be filled out in the proposal sheets provided.

7. Individual fee components will be assumed to be self-supporting standalone services.

8. Your fees must include any fee for PPO Leasing/Network Access for a national network to cover all 50 states, and the District of Columbia.

9. All rates must be guaranteed for the term of the contract, including any extensions.

10.List services/supplies not covered under the fees quoted above (i.e., custom reports, printing, etc.).

11.Fees quoted are to cover services for claims incurred on or after the contract effective date. All fees for the payment of run-out claims must be included in the monthly fees charged during the contract period.

12.Amounts shall be in U.S. dollars unless a specific percent is requested.

ACTIVE EUTF - DENTAL PLAN

TABLE AND PROPOSAL SHEETS #1

ACTIVEEUTF - DENTAL PLANTABLE AND PROPOSAL SHEETS #1

Detailed benefits information is provided in Exhibit E. Please note any deviation in proposed benefits in the charts below. Unless noted it will be assumed that proposed benefits match the requested benefits exactly. You must agree to a "no loss, no gain" provision with the current benefit plan.

TABLE - ACTIVE

Plan Design Hawaii Dental Service (HDS)NOTE ALL DEVIATIONS IN

YOUR COMPANY’S PROPOSED BENEFITS

Plan Maximum per person per plan year $2,000 Deductible per plan year (does not apply to benefits covered at 100%)

$50/person

Plan Covers Diagnostic 100% Examinations - twice per calendar year Bitewing X-rays - twice per calendar year through age 14; once per calendar year thereafter

Other X-rays (full mouth X-rays limited to once every 5 years)

Preventive Cleanings – twice per calendar year 100%

-Diabetic Patients – four cleanings or *periodontal maintenance

-Expectant Mothers – three cleanings or *periodontal maintenance

*Periodontal maintenance benefit level *80% Fluoride (twice per calendar year through age 19) 100%

-Fluoride - high risk - once per calendar year Space maintainers (through age 17) 100% Sealants (through age 18) – one treatment application, once per lifetime only to permanent molars with no cavities and no occlusal restorations, regardless of the number of surfaces sealed.

100%

Restorative Amalgam (silver-colored) fillings 80% Composite (white-colored) fillings – limited to the anterior (front) teeth

80%

Crowns and gold restorations (once every 5 years when teeth cannot be restored with amalgam or composite fillings. Covered after wait period of 12 months of continuous enrollment in plan.)

60%

Note: Composite (white) and porcelain (white)

restorations on posterior (back) teeth will be processed as the alternate benefit of the metallic equivalent – the patient is responsible for the cost difference up to the amount charged by the dentist.

Endodontics 80% Pulpal therapy / Root canal treatment, retreatment, apexification, apicoectomy

Periodontics 80% Periodontal scaling and root planing – once every two years

Gingivectomy, flap curettage and osseous surgery –

TABLE - ACTIVE



once every three yearsPeriodontal Maintenance – twice per calendar year after qualifying periodontal treatment

Prosthodontics (Covered after a wait period of 12 months of continuous enrollment in plan)

60%

Fixed bridges (once every 5 years; ages 16 and older)

Dentures (complete and partial – once every 5 years; ages 16 and older)

Implant services: Surgical placement of endosteal implant and abutment supported crowns. Once per tooth every five years (ages 19 and older).

Oral Surgery 80% Adjunctive General Services 80% Palliative treatment (for relief of pain but not to cure) 100% Orthodontics 50% Maximum amount payable by HDS for an eligible patient shall be $1,000 lifetime per case paid in eight quarterly payments of $125.

Orthodontic services are not covered:

*If services were started prior to the date the patient became eligible under this employer’s plan.

*If a patient’s eligibility ends prior to the completion of the orthodontic treatment, payments will not continue.

*If your employer elects to remove the orthodontic

benefit, coverage will end on the last day of the month that the change occurred.

INSURED, RISK SHARINGProposal Sheet 1A

Dental Plan - EUTF Active onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)

Complete the following table on a monthly, per capita tiered basis ONLY

The Dental Benefit Cost and Retention components must stand on their own. If the total benefit paid at the end of the runout period is less than the proposed benefit cost, the excess amount will be refunded to the EUTF.

Dental Plan Period 1 7/1/19-6/30/20

Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental

Monthly Benefit Cost: Single Two-Party Family

Maximum Benefit Cost Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Monthly Administration and Retention:

Single Two-Party Family

Total Dental Premium (Including Administration and Retention): Single Two-Party Family

Monthly ACA Fees to be Added to the Above Total Dental Premium

Insurer Fee: Single Two-Party Family

NOTES:(1) The EUTF reserves the right to offer multiple carrier options.(2) No adjustments to the proposed rates based on actual initial enrollment or subsequent enrollment changes are acceptable.

Authorized Signature

Title

Name of Company

DateSELF-INSURED

Proposal Sheet 1BDental Plan - EUTF Active only

Target Claims, Retention and Fees Tables (Self-Insured ASO)Complete the following table on a monthly, composite and/or per capita tiered basis

Dental Plan Period 17/1/19 – 6/30/20

Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental

Monthly Dental ASO Fees (PEPM): Composite

Monthly Dental ASO Fees by Tier: Single Two-Party Family

Maximum Dental ASO Percent Increase from Prior Contract Period: N/A ______% ______% ______%

Estimated Monthly Dental Claims Cost:




Title

Name of Company

Date

ACTIVE HSTA VB - DENTAL PLAN


ACTIVEHSTA VB - DENTAL PLANTABLE AND PROPOSAL SHEETS #2


TABLE - ACTIVE



Plan Maximum per person per plan year $2,000 Deductible per plan year (does not apply to benefits covered at 100%)

$50/person

Plan Covers Diagnostic 100% Examinations - twice per calendar year Bitewing X-rays - twice per calendar year through age 14; once per calendar year thereafter





*Periodontal maintenance benefit level *80% Fluoride (once per calendar year through age 19) 100%


100%


80%

Crowns and gold restorations (once every 5 years when teeth cannot be restored with amalgam or composite fillings. Covered after a wait period of 12 months of continuous enrollment in plan.)

60%





Gingivectomy, flap curettage and osseous surgery –

TABLE - ACTIVE



once every three yearsPeriodontal Maintenance – twice per calendar year after qualifying periodontal treatment

Prosthodontics (Covered after a wait period of 12 months of continuous enrollment in plan)

60%

Fixed bridges (once every 5 years; ages 16 and older)


Implant services (covered as an alternate benefit) when one tooth is missing between two natural teeth. Once per tooth every 5 years (ages 16 and older).

Oral Surgery 80% Adjunctive General Services 80% Palliative treatment (for relief of pain but not to cure) 100% Orthodontics 50% Maximum amount payable by HDS for an eligible patient shall be $1,000 lifetime per case paid in eight quarterly payments of $125.




*If your employer elects to remove the orthodontic

benefit, coverage will end on the last day of the month that the change occurred.


Dental Plan - HSTA VB Active onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)




Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental










Title

Name of Company

DateSELF-INSURED

Proposal Sheet 2BDental Plan - HSTA VB Active only



Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental








Title

Name of Company

Date

ACTIVE HSTA VB – SUPPLEMENTAL DENTAL PLAN


ACTIVEHSTA VB – SUPPLEMENTAL DENTAL PLANTABLE AND PROPOSAL SHEETS #3


TABLE - ACTIVE



Plan Maximum per person per plan year $750 Plan Covers

Diagnostic 50% Examinations - twice per calendar year Bitewing X-rays - twice per calendar year through age 14; once per calendar year thereafter





*Periodontal maintenance benefit level *45% Fluoride (once per calendar year through age 19) 50%


50%


45%

Crowns and gold restorations (once every 5 years when teeth cannot be restored with amalgam or composite fillings)

45%





Gingivectomy, flap curettage and osseous surgery – once every three years

Periodontal Maintenance – twice per calendar year

TABLE - ACTIVE



after qualifying periodontal treatmentProsthodontics Fixed bridges (once every 5 years; ages 16 and older)

45%


45%

Implant services (covered as an alternate benefit) when one tooth is missing between two natural teeth. Once per tooth every 5 years (ages 16 and older).

50%

Oral Surgery 50% Adjunctive General Services 45% Palliative treatment (for relief of pain but not to cure)

50%

Orthodontics 100% Maximum amount payable by HDS for an eligible patient shall be $750 lifetime per case paid in eight quarterly payments of $93.75.




*If your employer elects to remove the

orthodontic benefit, coverage will end on the last day of the month that the change occurred.


Supplemental Dental Plan - HSTA VB Active onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)




Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental










Title

Name of Company

DateSELF-INSURED

Proposal Sheet 3BSupplemental Dental Plan - HSTA VB Active only



Period 27/1/20 – 6/30/21

Period 37/1/21 – 6/30/22

Period 47/1/22 – 6/30/23

Dental








Title

Name of Company

Date

RETIREE EUTF – DENTAL PLAN


RETIREEEUTF - DENTAL PLANTABLE AND PROPOSAL SHEETS #4


TABLE - RETIREE



Plan Maximum per person per plan year $2,000 Plan Covers Diagnostic 100% Examinations - twice per calendar year Bitewing X-rays - twice per calendar year through age 14; once per calendar year thereafter






-Fluoride - high risk - once per calendar year Space maintainers (through age 17) 100% Sealants (through age 18) – one treatment application, once per lifetime only to permanent molars with no occlusal restorations, regardless of the number of surfaces sealed.

100%


60%


60%




Periodontics 60% Periodontal scaling and root planing (once every two years)

Gingivectomy, flap curettage and osseous surgery (once every three years)

Periodontal Maintenance – twice per calendar year after qualifying periodontal treatment

TABLE - RETIREE



Prosthodontics 60% Fixed bridges (once every 5 years; ages 16 and older)


Implant services: Surgical placement of endosteal implant and implant abutment supported crowns. Once per tooth every five years (ages 16 and older).

Oral Surgery 60% Adjunctive General Services 60% Palliative treatment (for relief of pain but not to cure) 100%


Dental Plan - EUTF Retirees onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)



Dental Plan Period 11/1/19-12/31/19

Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Dental










Title

Name of Company

DateSELF-INSURED

Proposal Sheet 4BDental Plan - EUTF Retirees only



Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Dental

Monthly Dental ASO Fees (PRPM): Composite







Title

Name of Company

Date

RETIREE HSTA VB - DENTAL PLAN


RETIREEHSTA VB - DENTAL PLANTABLE AND PROPOSAL SHEETS #5


TABLE - RETIREE



Plan Maximum per person per plan year $2,000 Plan Covers Diagnostic 100% Examinations - twice per calendar year Bitewing X-rays - twice per calendar year through age 14; once per calendar year thereafter






-Fluoride - high risk - once per calendar year Space maintainers (through age 17) 100% Sealants (through age 18) – one treatment application, once per lifetime only to permanent molars with no occlusal restorations, regardless of the number of surfaces sealed.

100%


60%


60%




Periodontics 60% Periodontal scaling and root planing (once every two years)

Gingivectomy, flap curettage and osseous surgery (once every three years)

Periodontal Maintenance – twice per calendar year after qualifying periodontal treatment

TABLE - RETIREE



Prosthodontics 60% Fixed bridges (once every 5 years; ages 16 and older)


Implant services: Surgical placement of endosteal implant and implant abutment supported crowns. Once per tooth every five years (ages 16 and older).

Oral Surgery 60% Adjunctive General Services 60% Palliative treatment (for relief of pain but not to cure) 100%


Dental Plan - HSTA VB Retirees onlyPremium Rate Table (Insured With Risk Sharing-Surplus Refund)




Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Dental










Title

Name of Company

DateSELF-INSURED

Proposal Sheet 5BDental Plan - HSTA VB Retirees only



Period 21/1/20-12/31/20

Period 31/1/21-12/31/21

Period 41/1/22-12/31/22

Dental

Monthly Dental ASO Fees (PRPM): Composite







Title

Name of Company

Date

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