Premium Credit Rebate Program Services

REV 4/4/2023 Page 1 of 3 PROCUREMENT JUSTIFICATION FORM (PJF) This form must accompany all contract requests and sole source requisitions (RQS) over $5,000 submitted to the Division of Procurement Services. INSTRUCTIONS: Please provide the requested information in the white spaces below. All responses (except signatures) must be typed; no hand-written forms will be accepted. See the guidance document posted with this form on the Division of Procurement Services intranet site (Forms page) for additional instructions. PART I: OVERVIEW Department Office/Division/Program: DPFR / Insurance Department Contract Administrator or Grant Coordinator: Vanessa J. Sullivan 207-624-8452 (If applicable) Department Reference #: Amount: (Contract/Amendment/Grant) $ 525,000 Advantage CT / RQS #: 20220201 1789 CONTRACT Proposed Start Date: Proposed End Date: AMENDMENT Original Start Date: 11/1/2021 Effective Date: Previous End Date: 7/31/2023 New End Date: 7/31/2023 GRANT Project Start Date: Grant Start

Date: Project End Date: Grant End Date: Vendor/Provider/Grantee Name, City, State: Anthem Health Plans of Maine, Inc. 2 Gannett Drive South Portland, ME 04106-6911 Brief Description of Goods/Services/Grant: Premium Credit Rebate Program Services PART II: JUSTIFICATION FOR VENDOR SELECTION Check the box below for the justification(s) that applies to this request. (Check all that apply.) A. Competitive Process G. Grant B. Amendment H. State Statute/Agency Directed C. Single Source/Unique Vendor I. Federal Agency Directed D. Proprietary/Copyright/Patents J. Willing and Qualified E. Emergency K. Client Choice F. University Cooperative Project L. Other Authorization DEPARTMENT OF ADMINISTRATIVE AND FINANCIAL SERVICES ()) DIVISION OF PROCUREMENT SERVICES STATE OF MAINE Procurement Justification Form (PJF) REV 4/4/2023 Page 2 of 3 Please respond to ALL of the questions in the following sections. PART III: SUPPLEMENTAL INFORMATION 1. Provide a more detailed description and explain the need for the goods, services or grant to supplement the response in Part I. These disbursement services shall be made in accordance with Maine P.L. 2021, c 483, Part C, legislative change completed in PL2023, c.3, to implement the Small Business Health Insurance Premium Support Program and any rules promulgated by the MBOI. The participating Provider shall make available premium credits to eligible Maine employers, pursuant to MJRP parameters during the period. The reimbursement period is scheduled to end on July 30, 2023. This amendment is necessary to receive reallocated federal funds from another contract in order to process premium rebate invoices in a timely manner. 2. Provide a brief justification for the selected vendor to supplement the response in Part II. Reference the RFP number, if applicable. The intent of Maine P.L. 2021, c 483, Part C, legislative change completed in PL2023, c.3, is to reimbursement health insurance companies for providing premium credits to small group employers that provide health insurance to their employees. 3. Explain how the negotiated costs or rates are fair and reasonable; or how the funding was allocated to grantee. This is a reimbursement agreement. Each participating health insurance company will receive an ongoing $1 PMPM administrative expense reimbursement. 4. Describe the plan for future competition for the goods or services. None contemplated. PART IV: AMERICAN RESCUE PLAN ACT (ARPA) / MAINE JOBS & RECOVERY PLAN (MJRP) Does this request utilize ARPA/MJRP funds? Yes If Yes, please attach the approved Business Case(s). No If No, proceed to Part V. PART V: APPROVALS The signatures below indicate approval of this procurement request. Signature of requesting Departments Commissioner (or designee): Typed Name: Anne L. Head Date: 08/ /2023 Signature of DAFS Procurement Official: Typed Name: Date: 10 8/28/2023Kathy Paquette DocuSigned by: 41C2BA36FAF44CD... Procurement Justification Form (PJF) REV 4/4/2023 Page 3 of 3 2023-08-28T12:19:35-0700 Digitally verifiable PDF exported from www.docusign.com