University of Missouri · 2019. 8. 24. · benefits for both same-sex and opposite-sex domestic...

Personal Information Full Name:

Title:

Location Address:

Phone Number:

Email Address:


Title:

Location Address:

Phone Number:

Email Address:

Number of Years with

your Organization:

Number of Years in

Current Position:

Number of Years

Experience in Industry

Professional InformationTotal Number of Current

Clients:

Maximum Number of

Clients this Account

Manager may support: Average Size of Clients

(e.g., 0-1,000 ; 1,000-

4,999 ; 5,000-10,000

lives): Percent of Acct.

Managers Time

Available for our Client

on an ongoing basis:


Title:

Location:

Number of Years with

your Organization:

Number of Years in

Current Position

Number of Years

Experience in Industry:

Professional Information

Average Size of Clients

(e.g., 0-1,000 ; 1,000-

4,999 ; 5,000-10,000

lives):

Percent of

Implementation

Manager's Time

Available for our Client's

Implementation:

Do the Proposed Rates include requested

commission levels?Not Included

Comments on proposed rates Not Included

University of Missouri

General Information >> Implementation Manager

General Information >> Proposed Rates

Questionnaire: US Sales Contact Questionnaire

General Information >> Sales Executive

General Information >> Account Manager / National Account Executive

Dental RFP 2018 TO BE COMPLETED ON AON ONLINE RFP TOOL 1

Please provide the following information for the

person to contact regarding this proposal.a) Contact Name

b) Title

c) Street Address

d) City, State, ZIP

e) Internet/e-mail

address

f) Phone Number

g) Fax Number


Account Executive assigned to the client account.a) Contact Name

b) How many accounts

does this person

handle?

c) Briefly describe this

person's scope of

responsibility.


Account Manager (day to day) assigned to the

client account.

a) Contact Name

b) Title

c) Street Address

d) City, State, ZIP

e) Internet/e-mail

address

f) Phone Number

g) Fax Number

h) Length of service with

your organization

i) How long has this

individual held this

position?

j) How many accounts

does this person

handle?

k) Percent of time

dedicated to the client

during implementation

l) Percent of time

dedicated to the client

on an ongoing basis

m) Briefly describe this

person's scope of

responsibility

Are there any locations where you are not able to

administer the dental plan designs as specified?

Please describe the plan design differences and

provide location[s].

Yes

No

Please attach a description of any and all

standard benefit exclusions.

In general, how are treatments initiated prior to

the effective date handled? Please describe your

transition of care procedures in detail.

Are any services outsourced or administered

offshore? If so, provide name and location of

company and which function is outsourced.

Yes

No

Questionnaire: Large Market Questionnaire

Product Type: Dental (U.S.)

Product Group: Dental (U.S.)


General >> General Information







List proposed services you intend to

contract/subcontract to a third party. Include the

contractor name(s), contractor location(s),

contracting arrangements, and other special

considerations that may be important to client's

evaluation.

a) If you will be using

contractors, please

confirm your

organization will be the

sole contracting agent

with respect to any

service agreement with

the client and that your

organization will be fully

accountable for any and

all contracted services.

Yes

No

Not applicable

b) Do you have any

leased networks? If yes,

list location[s].

Yes

No

In general, how are treatments in progress prior

to the effective date continued under the

network?

a) Please describe your

transition of care

procedures in detail.

Please confirm that a detailed implementation

timetable that ensures a smooth

implementation/transition has been attached.

Yes

No

How many other implementations with this client's

effective date could be assigned to the same

implementation coordinator assigned to this

client?

Address your willingness to participate in the

enrollment meetings at no cost if needed at

various sites during the open enrollment period.

Confirm your organization will allow the client to

self bill?

Yes

No

For self-funded plans, do you require use of a

specific bank? If so, please provide information.

Yes

No

Are you willing to fund a pre-implementation audit

up to $25,000?

Yes

No

If so, can you have your

claims system coded by

30 days prior to the

effective date?

Yes

No

Not applicable

How much of an implementation credit is your

organization offering?

General >> Specifications






General >> General InformationThe client may wish to have its logo on various

printed materials. The designated vendor must

agree to this at no additional cost and must

ensure that logo placement and color

requirements are met.

Yes

No

Confirm that if selected as a finalist the vendor

must provide at least three references from

clients similar in size, complexity, and

demographic makeup of the client.

Yes

No

Please confirm that you are able to administer

benefits for both same-sex and opposite-sex

domestic partners. If no, please explain.

Yes

No

Your organization must be able to accept

eligibility information from the client's selected

third-party administrator.

Yes

No

Describe your organization's disabled dependent

verification process.

Your organization agrees to allow for 90 calendar

days for retroactive adjustments to coverage and

recalculation of premiums for new hires,

terminations, and status changes.

Yes

No

The client will be granted online access to all

eligibility and claims information, including edit

access for eligibility.

Yes

No

Is your organization compliant with the HIPAA

Privacy Rule, Unsecured Protected Health

Information Breach Notification Rule, and Security

Rule issued by the U.S. Department of Health

and Human Services?

Yes

No

Pursuant to the U.S. Department of Health and

Human Services Standards for Privacy of

Individually Identifiable Health Information (the

'HIPAA Privacy Rule'), will your organization

require an individual's authorization before using

or disclosing his/her protected health information

for purposes other than treatment, payment, or

health care operations, or as otherwise permitted

or required by the HIPAA Privacy Rule?

Yes

No

If your organization uses an authorization form,

would your organization be willing to use a

standard authorization form developed

by University of Missouri for this purpose?

Yes

No

Is your organization subject to state laws that, in

your organization's opinion, require more stringent

privacy policies and procedures for individually

identifiable health information than those outlined

in the HIPAA Privacy Rule issued by the U.S.

Department of Health and Human Services?

Yes

No

a) If 'yes', then is your

organization compliant

with such state law(s)

not preempted by

HIPAA?

Yes

No

General >> Eligibility

Administration >> HIPAA






General >> General InformationWith respect to self-insured plan options, will your

organization enter into a business associate

contract and/or agreement with University of

Missouri, as plan sponsor, to comply with the

HIPAA Privacy Rule, Unsecured Protected Health

Information Breach Notification Rule, Security

Rule, and the applicable requirements of the

HIPAA Electronic Transaction and Code Set

Standards?

Yes

No

To the extent that your organization conducts all

or part of an electronic HIPAA transaction

covered by the HIPAA Electronic Transaction and

Code Set Standards, does your organization

conduct such transaction(s) in a manner that

complies with applicable HHS standards,

requirements and operating rules?

Yes

No

a) With respect to self-

insured options, if your

organization uses

subcontractors who

conduct all or part of an

electronic HIPAA

transaction covered by

the HIPAA Electronic

Transaction and Code

Set Standards, does

your organization require

that such subcontractor

conduct such

transaction(s) in a

manner that complies

with applicable HHS

standards, requirements,

and operating rules?

Yes

No

With respect to self-insured options, will your

organization notify University of Missouri, as plan

sponsor, in the event of a breach of unsecured

protected health information as required by the

Unsecured Protected Health Information Breach

Notification Rule?

Yes

No

With respect to self-insured options, if your

organization uses subcontractors who create,

receive, transmit, or maintain protected health

information on your behalf, will your organization

obtain satisfactory assurances in accordance with

the HIPAA Privacy and Security Rules that the

subcontractor will appropriately safeguard the

protected health information?

Yes

No






General >> General InformationIs your organization compliant with the HIPAA

omnibus final rule (effective date of March 26,

2013; compliance date of September 23, 2013)

that includes final modifications to the HIPAA

Privacy Rule and Security Rule to implement the

privacy and security provisions of the HITECH

Act, a final Unsecured Protected Health

Information Breach Notification Rule, and, with

respect to self-insured options, modifications to

the HIPAA Privacy Rule and Security Rule that

impact the HIPAA compliance obligations of

business associates?

Yes

No

Will your organization send out-of-pocket data to

the client's FSA administrator?

Yes

Noa) If yes, is there an

additional fee to do so?

Please include the

additional fee in the

comments box.

Yes

No

You will provide weekly data extracts to the

client's FSA/HRA administrator to substantiate

debit card transactions, and you will be compliant

with the client data layout requirements, which will

be shared at a later date.

Yes

No

The client expects that your organization will

maintain adequate levels of corporate/general

liability insurance. Please confirm and provide

details on the levels of coverage your

organization maintains.

Please confirm that you carry a fiduciary bond as

required by ERISA for any arrangements where

you serve as a fiduciary.

Yes

No

If you are unwilling to serve as fiduciary, please

describe why you would be unwilling to make this

representation.

If the plan is fully insured, we assume your

organization will act as fiduciary. If this is not

correct, please explain who will have fiduciary

responsibility.

Are you willing to be designated as the claims and

appeals fiduciary for the clients' plans?

Specifically, you will handle both the benefit

determination (a.k.a., ERISA claim) and any

mandatory benefit determination on review

(a.k.a., ERISA appeals). ERISA reg. section

2560.503-1 (h)(3) requires that an adverse benefit

determination be made by a named fiduciary of

the plan and that will require your organization to

take such a role. If not, please describe why you

would be unwilling to agree to this request.

Yes

No

Administration >> FSA Coordination

Administration >> Legal Concerns






General >> General InformationWhile this RFP does not specify all of the

requirements of ERISA Section 503 and related

regulations, the client expects that you will be in

compliance on all matters including, but not

limited to, timing of response and content of

response to plan participants.

Yes

No

To the extent that a benefit package option is not

"grandfathered" under the Patient Protection and

Affordable Care Act and the Health Care and

Education Reconciliation Act of 2010 (collectively,

the "Affordable Care Act") and is not otherwise

exempt from complying as a "limited, excepted

benefit" as defined in ERISA reg. section

2590.732(c)(3), the client expects that your

organization will comply with the new internal

claims and appeals and external review

processes for group health plans and group

health insurance issuers.

Yes

No

The client reserves the right to audit (or designate

an independent third-party to audit) the selected

health plan at any time during and up to three

years following termination of the

Contract/Administrative Agreement (with prior

written notification).

Yes

No

Which of the following are performed/reviewed as

part of your standards for provider

credentialing/recredentialing?

a) State licenseYes

No

b) Malpractice coverageYes

No

c) Detailed malpractice

history

Yes

No

d) History of

litigations/disciplinary

action

Yes

No

e) Fraud/felony

convictions

Yes

No

f) Membership in

professional organization

Yes

No

g) Regularly scheduled

hours at least four days

per week

Yes

No

h) Availability of chair

hours

Yes

No

i) Service complaintsYes

No

j) Quality of care

complaints

Yes

No

k) Member grievancesYes

No

l) Member surveysYes

No

m) Chart reviewYes

No

n) On-site visitsYes

No

o) Emergency training

(CPR)

Yes

No

p) Other (specify)

Describe your provider credentialing process.

Administration >> Quality Assurance






General >> General InformationWho conducts initial and subsequent

credentialing?

How often are network providers recredentialed?

Annually

Every two years

Other (specify)

How frequently are providers given formal reports

of their performance?

What are your procedures for resolving patient

grievances concerning care and treatment? Can

members appeal to a third party? Please give the

name of this third party.

How frequently are patient satisfaction surveys

sent out?

Monthly

Quarterly

Semiannually

Annually

Biannually

None

Can patient satisfaction results be reported on a

client-specific basis?

Yes

No

What percentage of all network participants are

typically surveyed each year?

What were your most recent patient satisfaction

survey results? Please attach a copy of your most

recent results.

a) Very Satisfied

b) Satisfied

c) Somewhat Satisfied

d) Other

Are network providers surveyed for their

satisfaction levels with network administration?

Yes

No

Please describe any other of your organization's

cost management strategies.

The preference of the client is to have dedicated

units. Please confirm your organization will agree

to a dedicated claims processing and customer

service staff for the client account.

Yes

No

Provide your organization's definition of

"dedicated" for claims processing and customer

service on a percent of time basis.

For the customer service team proposed to serve

the client, provide the following information for the

claim.

a) Ratio of staff to

members

b) Average years of

service

For the claims processing team proposed to

serve the client, provide the following information

for the claim adjudicators.

a) Ratio of staff to

members

b) Average years of

service

Provide the following statistics for the claim office

that will handle the account for the client. We are

requesting actual results for a designated claim

office.

a) Claim payment

accuracy (number of

correct payments

divided by number or

payments)

Administration >> Claims Administration/Member Services






General >> General Information b) Claim processing

accuracy (number of

claims processed with

100% accuracy divided

by number of claims)c) Financial accuracy

(dollars paid correctly

divided by total dollars

paid)d) Average turnaround

time (x% in x business

days)

e) Average customer

service telephone

response time (seconds)

f) Call abandonment rate

(%)

g) Percentage of

incoming calls that are

recorded

h) Length of hold time

i) First call resolution

percentage

j) Percentage of

incoming calls that are

logged

k) Average number of

days claims are pended

Do the same representatives perform both

customer service and claim processing functions,

or are they specialized?

Please indicate whether customer service

representatives may reprocess claims.

Yes

No

How long is claim history maintained online?

Provide national performance goals for the

following indicators. [SPECIFICS WILL BE

NEGOTIATED WITH FINALISTS]

a) Claim payment

accuracy (Number of

correct payments

divided by total number

of payments

[percentage]).b) Claim processing

accuracy (Number of

claims processed with

100% accuracy divided

by the total number of

claims processed

[percentage]).c) Financial accuracy

(Dollars paid correctly

divided by the total

dollars paid

[percentage]).d) Average claim

turnaround time (Claim

office receipt of a claim

until the transaction is

completely processed

with check and/or EOB

issued).






General >> General Information e) Average claim

turnaround time:

Percentage in 10

working daysf) Average claim

turnaround time:

Percentage in 15

working daysg) Average claim

turnaround: Percentage

in 14 calendar days

h) Average claim

turnaround: Percentage

in 21 calendar days

How are member inquiries logged and tracked?

How many grievances have you had regarding

the network in the prior calendar year per 1,000

members?

Confirm the following are maintained or tracked

by the processing system.

a) Various copayment

levels

b) Scheduled benefit

amounts (by ADA

procedure). Dental - In-

network; out-of-network.

c) Days/visits or other

treatment maximums per

plan design

d) Accumulators

(dollars)

e) Individual deductible

f) Annual maximum

g) Orthodontia lifetime

maximum

h) Potential COB

opportunities

i) Tooth chart (flags

potentially duplicate

treatment)

j) Other

What percentage of claims are audited on a

predisbursement basis?

What percentage of claims are audited on a

postdisbursement basis?

Will the client have designated customer service

representatives (CSRs)?

Yes

No

a) Total number of full-

time equivalent (FTE)

customer service

representatives

The client may acquire companies throughout the

year. Please confirm your organization's ability to

accommodate being responsive and flexible in

having the ability to use the acquired employee's

EOB from prior company vendor to apply to their

clients' plan's YTD deductible, OOP max, etc.

What percentage of claims are auto-adjudicated?






General >> General Information Are there any provisions that cannot be auto-

adjudicated by your system? If so, what

provisions?

Yes

No

Do customer service representatives have

access to claims information?

Yes

No

Do customer service representatives have online

access to benefit plans?

Yes

No

What additional training is provided for new client

accounts?

What are the telephone hours for your customer

service unit servicing the client?

How are after-hour phone calls handled?

Please respond to the following regarding ID

cards:

a) What is your normal

process and method for

ID card distribution?

b) Can cards be

customized for the

client?

Yes

No

c) What is your process

for providing timely

replacement cards or

cards to new hires?

d) Confirm the ID cards

have a non social

security number

identifier and anyone

with dependent

coverage will be

provided with 2 cards.

Yes

No

Are all of your internal systems integrated? (e.g.,

claims payment, eligibility, and customer service)

Yes

No

What is the time lag between the eligibility and

claims systems? Are all systems updated in real

time?

What procedures are not subject to R&C by your

organization?

How often are the R&C profiles updated?

Describe in detail your current methodology for

developing your Reasonable and Customary

(R&C) database.

a) How often is this

information updated?

b) To which procedures

would R&C limits apply?

The client requires 100% of calls (incoming and

outgoing) to be recorded.

a) Can your organization

comply with this

requirement?

Yes

No






General >> General InformationDoes your system have the capability to record

the computer screens accessed by customer

service representatives during calls?

Yes

No

Please provide the following information about

your national networks.a) Location

b) Initial date of network

operation

c) Is network owned by

your organization or

subcontracted through a

third party? If network is

subcontracted, list

network.d) Number of employer

groups served by

network as of the

effective date of the prior

year.e) Total members

(employees and

dependents) as of the

effective date of the prior

year.f) Total members

(employees and

dependents) as of the

effective date of the

current year.

g) What percentage of

general providers are

accepting new patients?

h) What is the annual

rate of network providers

turnover for the prior

year?

i) What is the annual

rate of network providers

turnover for the current

year (projected)?

Would you be willing to expand to any locations of

the client where you do not currently have a

network? Please describe any current expansion

plans.

Yes

No

What is the nature of the relationship between

your organization and your providers? Are

providers:

Employees of your

organization

Subsidiary company

Exclusive affiliation

Non-exclusive affiliation

What is the provider credentialing, selection, and

monitoring process? How do you maintain quality

in your providers and the services they offer?

How often are network providers visited by your

quality assurance department?

What are the average office hours of providers in

the network?

Administration >> Network Management






General >> General InformationWhat percentage of network providers have

weekend or evening hours?

What percentage of your providers are

reimbursed in the following ways? (These

numbers must total 100%).

a) Discount off charges

b) Fee Schedule

c) Capitation

d) Other (specify)

Does your reimbursement system for providers

include the following?a) Withholds

Yes

No

b) BonusesYes

No

If bonuses are paid, which factors determine the

amount of incentive compensation?a) Cost results

Yes

No

b) Utilization resultsYes

No

c) Member satisfactionYes

No

d) Other (please specify)Yes

No

What network management services will be

delivered by a subcontractor or other outside

organization? (Include any leased network

arrangements)

Confirm your organization will proactively provide

material network changes to the client, including

identification of the affected membership.

Yes

No

Please detail the process, timing, frequency, and

other important information about this notification

process.

How will you notify members of material network

changes?

Under what terms may providers withdraw from

your network?

How much advance notice must providers give

before voluntarily leaving the network?

Must an enrollee select a primary care dentist

within your program?

Yes

No

How often are participants allowed to change

primary care providers?

Can family members use different providers?Yes

No

What procedures or practices must be

preauthorized (e.g., when is a treatment plan

requested)? What is the dollar threshold?

How many network providers were added each

year for the past three years?a) Year 1

b) Year 2

c) Year 3

Can providers be nominated? If so, how?Yes

No






General >> General InformationIf any part of your network is leased, please state

the percentage, identify the owner of the network

and geographic service area.

Yes

No

If you use leased networks to service this

account, are the leased discounts loaded into

your claims system?

Yes

No

Does your organization offer the capability to pay

providers quickly and easily, directly from the

member website?

Yes

No

a) If not, do you have

any plans to do so in the

future? When?

b) If yes, when did you

include this?

Does your organization's member website allow

users to run reports to analyze their health care

spending, so they can understand their

healthcare expenses, and make informed plan

selection decisions?

Yes

No

a) If not, do you have

any plans to do so in the

future? When?

b) If yes, when did you

include this?

Which of the following services are provided via

the internet? If the response is no, include the

plan and timing of when this may become

available.

a) General plan

coverage information

Yes

No

b) Provider directoriesYes

No

c) Access to content

information on

preventive care and

health

Yes

No

d) Members can request

additional or

replacement ID cards

Yes

No

e) Members can print ID

cards from the site

Yes

No

f) Members can email

member services

Yes

No

g) Do you include

providers that are not

accepting the new

patients?

Yes

No

h) Provider selection

where users enter

search criteria

Yes

No

i) Provider cost

information

Yes

No

Administration >> Technology Capabilities







j) Provider quality

information

Yes

No

k) Cost

estimation/budgeting

tools

Yes

No

l) Deductible, out of

pocket, and maximum

tracking

Yes

No

m) Claim lookup statusYes

No

n) Appointment

reminders

Yes

No

o) Members can

download and print claim

forms

Yes

No

Describe smartphone capabilities.

Describe the health content information available

online.

COBRA participation percent above which you

reserve the right to change rates/fees?

Are retirees covered?Yes

No

Minimum employer contribution, if applicable

Is your proposal a replacement or an option?

Confirm the out of network percentile being

proposed.

Provide the percent of retained savings, if

applicable.

Confirm that your ASO fee is on a mature basis.Yes

No

Confirm the number of years your rates/ASO fees

are being held unchanged.

Will you provide hard copy network directories at

no cost for employees and retirees who do not

have internet access?

Yes

No

Will you agree to absorb postage costs?Yes

No

How often do you update the hard copy provider

directory?

How often are provider directories updated

online?

Daily

Monthly

Quarterly

Annually

Plan Information >> Summary Plan Documents (SPDs)

Administration >> Underwriting Assumptions

Plan Information >> Provider Directories






General >> General InformationWill you provide reasonable assistance to the

Plan and its designated agents in preparation of

summary plan descriptions (SPDs) in compliance

with the Department of Labor SPD content

requirements set forth in ERISA reg. section

2520.102-3?

Yes

No

Provide sample EOB with an explanation for each

section.

Yes

No

Plan Information >> Explanation of Benefits (EOB)


Requested

Commission

Frequency Monthly

Commission Type Percentage

Type of Fee / Commission

Initial Commission 0.00%

Commission Expectation $0.00

Ongoing Commission 0.00%

Paid To Aon

Comments

University of MissouriProduct Group: Dental (U.S.)


Associated Designs: Dental - PPOCommission: Commission


Effective Date

Expiration Date

Currency

Allow Deviation Designs

Allow Proposed Designs

Design Type

Design Comment

Current Design

Common Provisions

R&C Percentile

In-Network

90th

Out-of-Network

90th

Annual deductible

In-Network

Individual deductible $100

Family deductible $300

Out-of-Network



Deductible applies to

In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes

Annual maximum

In-Network

Annual maximum ($) $1,500

Comments Comments

Out-of-Network


Comments Comments

Services accruing towards annual

maximum

In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes

Dependent children to age 26

Coinsurance



Design: Dental - PPO

1/1/2018

12/31/2018

United States Dollar (USD) -$

Required

Plan Design >> General

Plan Design >> Services


Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Required

Plan Design >> General In-Network

Preventive & Diagnostic 100%

Basic 80%

Major 50%

Out-of-Network


Basic 80%

Major 50%

Classification of services

In-Network

Examination Preventive & Diagnostic

Fluoride - Children Preventive & Diagnostic

X-rays Preventive & Diagnostic

Routine cleaning Preventive & Diagnostic

Sealants (permanent molars) Preventive & Diagnostic

Emergency palliative treatment Preventive & Diagnostic

Simple restorations (fillings) Basic

Endodontics Basic

Surgical Periodontics Basic

Routine extractions Basic

Endodontics (RCT- molars) Basic

Non-Surgical Periodontics Basic

Inlays/onlays Major

Dentures Basic

Implants Not Covered

Soft tissue impaction Not Specified

Partial/full bony impaction Not Specified

Crown & Bridge Basic

Oral surgery Basic

Extraction- erupted tooth Basic

Anesthesia Basic

Out-of-Network







Simple restorations (fillings) Preventive & Diagnostic

Endodontics Basic




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Required

Plan Design >> General Endodontics (RCT- molars) Basic


Inlays/onlays Major

Dentures Basic

Implants Basic




Oral surgery Basic


Anesthesia Basic

Frequency of services Not Included

Comments

Orthodontia Covered by Plan No

Plan Design >> Orthodontia


Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions

R&C Percentile

In-Network

90th

Out-of-Network

90th

Annual deductible

In-Network



Out-of-Network




In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes

Annual maximum

In-Network


Comments Comments

Out-of-Network


Comments Comments


maximum

In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes


Coinsurance



Design: Dental - Option 1 - PPO

1/1/2018

12/31/2018


Alternate




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Basic 80%

Major 50%

Out-of-Network


Basic 80%

Major 50%


In-Network








Endodontics Basic





Inlays/onlays Major

Dentures Basic





Oral surgery Basic


Anesthesia Basic

Out-of-Network








Endodontics Basic




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Inlays/onlays Major

Dentures Basic

Implants Basic




Oral surgery Basic


Anesthesia Basic


Comments

Orthodontia Covered by Plan Yes

Orthodontia coinsurance

In-Network

50%

Out-of-Network

50%

Orthodontia deductible $1,500

Coverage available for child? Adult?

In-Network

Child only

Comments Comments

Out-of-Network

Child only

Comments Comments

Coverage for children to age 19

Lifetime maximum--orthodontia

In-Network

Lifetime maximum -

orthodontia$1,500

Out-of-Network

Lifetime maximum -

orthodontia$1,500



Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions

R&C Percentile

In-Network

90th

Out-of-Network

90th

Annual deductible

In-Network



Out-of-Network




In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes

Annual maximum

In-Network


Comments Comments

Out-of-Network


Comments Comments


maximum

In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes


Coinsurance



Design: Dental - Option 2 - Base Plan - PPO

1/1/2018

12/31/2018


Alternate




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Basic 80%

Major 50%

Out-of-Network


Basic 80%

Major 50%


In-Network








Endodontics Basic





Inlays/onlays Major

Dentures Basic





Oral surgery Basic


Anesthesia Basic

Out-of-Network








Endodontics Basic




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Inlays/onlays Major

Dentures Basic

Implants Basic




Oral surgery Basic


Anesthesia Basic


Comments

Orthodontia Covered by Plan No



Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions

R&C Percentile

In-Network

90th

Out-of-Network

90th

Annual deductible

In-Network



Out-of-Network




In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes

Annual maximum

In-Network


Comments Comments

Out-of-Network


Comments Comments


maximum

In-Network

Prev. & Diag. No

Basic Yes

Major Yes

Out-of-Network

Prev. & Diag. No

Basic Yes

Major Yes


Coinsurance



Design: Dental - Option 2 - Buy Up Plan

1/1/2018

12/31/2018


Alternate




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Basic 80%

Major 50%

Out-of-Network


Basic 80%

Major 50%


In-Network








Endodontics Basic





Inlays/onlays Major

Dentures Basic





Oral surgery Basic


Anesthesia Basic

Out-of-Network








Endodontics Basic




Effective Date

Expiration Date

Currency



Design Type

Design Comment

Current Design

Common Provisions




1/1/2018

12/31/2018


Alternate



Inlays/onlays Major

Dentures Basic

Implants Basic




Oral surgery Basic


Anesthesia Basic


Comments

Orthodontia Covered by Plan Yes

Orthodontia coinsurance

In-Network

50%

Out-of-Network

50%

Orthodontia deductible $1,500

Coverage available for child? Adult?

In-Network

Child and Adult

Out-of-Network

Child and Adult

Coverage for children to age 19

Lifetime maximum--orthodontia

In-Network

Lifetime maximum -

orthodontia$1,500

Out-of-Network

Lifetime maximum -

orthodontia$1,500



Frequency

Total Employees Enrolled

Total Members CoveredFee Year 1 Mature Year 2 Mature Year 3 Mature Year 4 Mature Year 5 Mature

Base Fee

Claims Fiduciary

Claims Processing

Network Access

Utilization Management

Other

Total Fees

Fee Assumptions Year 1 Mature Year 2 Mature Year 3 Mature Year 4 Mature Year 5 Mature

Enrollment

Estimated Paid Claims per Employee

Estimated Network Penetration

Percentage

Estimated Number of Transactions

Are these rates guaranteed for term of

agreement?

Do the mature rates include run-out

claims for 12 months after end of

contract?

Fee: ASO Fee

Monthly (PEPM)

23503

Fee Assumptions

Additional Fee Information >> Self Insured Fee Questions

Associated Design's: Dental - PPO, Dental - Option 1 - PPO, Dental - Option 2 - Base Plan - PPO, Dental -





Commission Basis:

Rates are net

of

Commissions

ContributionTotal (100%

Employer Paid)

Frequency Monthly

Per Unit Flat Rate

EE EE + Spouse EE + Children EE + Family

Basic Rate

Lives (Required) 11,511 5,264 2,522 4,206

Annual Total Cost

Comment

Rate Guarantee End Date

Participation Requirements

Multi-line Discount

Rate Caveats

Fully-insured funding arrangement.

To what date are your rates/fees

guaranteed (for fixed rate guarantees)?

If applicable, please describe how your

rate/fee increases are capped in future

years beyond your fixed rate guarantee.

Is your dental plan willing to provide

rate guarantees beyond three years?

Rates conform to all applicable state

mandates? Attach list of mandates by

state.

Provide all rates on a coverage tier per

month basis (i.e. Employee Only,

Employee + Spouse, Employee +

Child(ren), Family)

All actively-at-work will be waived for

employees and dependents to be

covered on the effective date and at all

other times while the contract is in force

(i.e., employees on disability, etc.).

Rates Description:




Rates: Proposed Dental - PPO

All Employees

Rate Information

Additional Rate Information >> Fully Insured Rate Questions


Provide trend factors for the following

periods:

All dental program rates should be

guaranteed for a minimum of three

years.

Please describe underlying rate

assumptions.

Are there minimum participation

requirements? If so, please describe.

Will your organization accept

assignment of benefits directly to out-of-

network providers, upon request?

Are HIPAA certificates included? If no,

include the additional charge as a line

item in your financial proposal.


Commission Basis:

Rates are net

of

Commissions


Employer Paid)

Frequency Monthly

Per Unit Flat Rate


Basic Rate

Lives (Required) 11,511 5,264 2,522 4,206

Annual Total Cost

Comment



Multi-line Discount

Rate Caveats











state.




Child(ren), Family)







periods:

Rates: Proposed Dental - Option 1

Rates Description:

All Employees

Rate Information









years.


assumptions.










Commission Basis:

Rates are net

of

Commissions


Employer Paid)

Frequency Monthly

Per Unit Flat Rate


Basic Rate

Lives (Required) 5,756 2,632 1,261 2,103

Annual Total Cost

Comment



Multi-line Discount

Rate Caveats











state.




Child(ren), Family)







periods:

Rates: Proposed Dental - Option 2 Base

Rates Description:

All Employees

Rate Information









years.


assumptions.










Commission Basis:

Rates are net

of

Commissions


Employer Paid)

Frequency Monthly

Per Unit Flat Rate


Basic Rate

Lives (Required) 5,755 2,632 1,261 2,103

Annual Total Cost

Comment



Multi-line Discount

Rate Caveats











state.




Child(ren), Family)







periods:

Rates: Proposed Dental - Option 2 Buy Up

Rates Description:

All Employees

Rate Information









years.


assumptions.










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