4001 41st Street NW
Rochester, Minnesota 55901-8901
gbs.mayoclinic.org
Mayo Clinic Health Solutions
Information Needed for Self-Funded Quote
1. Benefit plan summary and/or plan document (e.g. summary plan description) for each plan. Please note any plan changes during time period of claims experience provided in # 3 below and any proposed changes.
2. Census for ALL eligible employees
- If possible, please e-mail census information (or provide on CD-Rom) using Microsoft Excel or similar spreadsheet program
- Census should include the following for ALL covered and non-covered eligible employees (a) date of birth, (b) sex, (c) coverage type—i.e. none, single, family, etc., (d) status—i.e. active, retiree, COBRA, (e) home zip code, (f) indicate which plan employee is covered under if you have more than one plan, and (g) indicate work location if you have more than one location
- For participants on COBRA continuation, please indicate (a) continuation start date, and (b) qualifying event—i.e. termination, death, divorce or other
- Monthly claims experience for the current and previous two plan years for each plan
- Monthly employee count by coverage type (i.e. single, family, etc.) for the current and previous two plan years for each plan
- Employee (participant) contribution amounts by coverage type (e.g. single, family, etc.) for each plan
- Large claim information (claims exceeding $25,000 per individual or, if self-funded, 50% of specific deductible level) for the current and previous two plan years for each plan
- Large claim information should include (a) whether individual is an employee, dependent or retiree, (b) age or date of birth, (c) whether actively at work, on medical leave or disabled, (d) diagnosis, (e) amounts of claims and dates incurred, (f) last hospitalization dates, (g) prognosis, (h) current and proposed course of treatment, (I) whether future claims expected to increase, decrease or remain level, (j) which plan paid the claims if you have more than one plan, and (k) whether individual is still covered under the plan.
- Information on disabled participants for each plan
- Information should include (a) whether individual is an employee, dependent or retiree, (b) nature of disability, (c) date of disability, (d) amounts of claims and dates incurred, (e) prognosis, (f) which plan the individual is covered under if you have more than one plan, and (g) indicate if individual is on COBRA.
- Broker Commission/ fee request
- Indicate fixed fee or add to stop-loss quote (a) net commissions; (b) up to 15% of stop-loss premium
- For self-insured plans— (a) stop-loss premium rates (specific and aggregate) for the current and previous two plan years; (b) stop loss claims experience for the current and previous two plan years; (c) copy of your stop loss policy; and (d) copy of administrative services agreement
- For fully-insured plans—(a) premium rates and (b) monthly premiums paid for the current and previous two plan years for each plan
RFP\RFP Supporting Materials-TPA\Sales Managers