Cost Template Part One

ADMINISTRATIVE EXPENSES TO BE PAID MONTHLY FROM
THE CONCLUSION OF PHASE THREE OF THE TRANSITION PERIOD
UNTIL THE END OF THE CONTRACT PERIOD
Include in each item 1.a., 1.b., 2 and 3the total cost of labor, education and training, supplies, office space, and contracted / subcontracted / consulting staff.
1. / Call Center Operations
  1. Information & Referral
/ Fee-for-Service / Managed Care
Item 1.a. TOTAL PER MONTH / Click here to enter amount. / Click here to enter amount. /
  1. Level of Care Screening & Eligibility Determination
/ Fee-for-Service / Managed Care
Item 1.b. TOTAL PER MONTH / Click here to enter amount. / Click here to enter amount. /
2. / Appeals / Fee-for-Service / Managed Care
Item 2 TOTAL PER MONTH / Click here to enter amount. / Click here to enter amount. /
3. / Quality Management / Fee-for-Service / Managed Care
Item 3TOTAL PER MONTH / Click here to enter amount. / Click here to enter amount. /
For Item 4 include in this total cost of labor, education and training, supplies, office space, and contracted / subcontracted / consulting staff not included in categories above, and IT infrastructure.
4. / GENERAL ADMINISTRATIVE EXPENSES NOT INCLUDED IN CATEGORIES ABOVE / Fee-for-Service / Managed Care
Item 4TOTAL PER MONTH / Click here to enter amount. / Click here to enter amount. /
5. / TOTAL ADMINISTRATIVE COST PER MONTH / Fee-for-Service
Click here to enter amount. / Managed Care
Click here to enter amount.
For each item above (1.a., 1.b., 2, 3 and 4) enter narrative
in Part Two of this appendix specifying details of the
estimated Administrative Costs shown above and how you determined these costs.
EXPENSES TO BE PAID BY VOLUME FOR THE ENTIRE CONTRACT PERIOD
Unit Cost Proposal / Fee-for-Service / Managed Care
6. / Price per Face-to-Face Assessment / Click here to enter amount. / Click here to enter amount. /
7. / Price per Plan of Care / Click here to enter amount. /
8. / Per Participant Cost of Case monitoring, inclusive of:
  1. Monthly Phone call
  2. Quarterly Home visit
/ Click here to enter amount. /
Fee-for-Service / Cost / *Monthly Volume / = Monthly Total
Total Administrative cost per month (from line 5) / Click here to enter amount. / Click here to enter amount. /
Price per Face-to-Face Assessment (from line 6) / Click here to enter amount. / 1,500 / Click here to enter amount. /
Price per Care Plan (from line 7) / Click here to enter amount. / 1,050 / Click here to enter amount. /
Price per participant cost of case monitoring (from line 8) / Click here to enter amount. / 8,250 / Click here to enter amount. /
9. / Total Cost for Fee-for-Service Proposal / Click here to enter amount. /
Managed Care / Cost / *Monthly Volume / = Monthly Total
Total Administrative cost per month (from line 5) / Click here to enter amount. / Click here to enter amount. /
Price perFace-to-Face Assessment (from line 6) / Click here to enter amount. / 2,050 / Click here to enter amount. /
10. / Total Cost for Managed Care Proposal / Click here to enter amount. /

Appendix G320 PUR-DHHRFP-ACCESS-FY16-OAAS1/3

Cost Template Part Two

Narrative for each item should be in sufficient detail for reviewers to determine the reasonableness of the assumptions underlying the estimated cost. At a minimum, provide line itemization for salaries & labor, education & training, supplies , office space, contracts, and consulting.

Call Center Operations Information and Referral Administrative Functions
Cost Estimate Narrative (Item 1.a.):
Click here to enter specific details of the estimated costs shown in Item 1.a. above and how you determined these costs.
Call Center Operations Level of Care Screening & Eligibility Determination Administrative Functions
Cost Estimate Narrative (Item 1.b.):
Click here to enter specific details of the estimated costs shown in Item 1.b. above and how you determined these costs.
Appeals Functions Administrative Cost Estimate Narrative (Item 2):
Click here to enter specific details of the estimated costs shown in 2 above and how you determined these costs.
Quality Management FunctionsAdministrative Cost Estimate Narrative (Item 3):
Click here to enter specific details of the estimated costs shown in 3 above and how you determined these costs.
General Administrative Expenses Not Included in Categories 1 – 3 on page 1, including IT Infrastructure (Item 4):
Click here to enter specific details of the estimated costs shown in 4 above and how you determined these costs.

Appendix G320 PUR-DHHRFP-ACCESS-FY16-OAAS1/3