Audits of Prescription Drug Benefit/ Audit Infrastructure

Medicare Advantage, Prescription Drug, Employer/Union Sponsored Group Health Plan, PACE and Cost Based Program Audits and Compliance Infrastructure Development THIS IS NOT A FORMAL REQUEST FOR PROPOSAL (RFP) AND DOES NOT COMMIT THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) TO AWARD A CONTRACT NOW OR IN THE FUTURE This is a SOURCES SOUGHT NOTICE to determine the availability of potential small businesses on the GSA MOBIS Schedule (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that can provide assistance in the development of audit and compliance tools and policy for the Medicare Advantage (MA), Prescription Drug, Employer/Union Sponsored Group Health Plan, Program of All Inclusive Care for the Elderly (PACE) and Cost Based Programs as well as performing both routine and focused program compliance audits of these organizations. History: In December 2003, the President signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). MMA expanded the role of private plans in providing benefits to Medicare beneficiaries. The law added a new section to the Social Security Act (SSA); 1860D (Part D) that offered prescription benefits beginning in 2006 through Prescription Drug Plans (PDPs). Secondly, the statute allowed for payments to MA - local plans (formerly Medicare Plus Choice (M+C) plans) and created a new type of private plan, - regional MA plans (RPPOs). PACE became a permanent program under the Balanced Budget Act of 1999 (PubLNo 105-33) and a state option for the Medicaid program. PACE was created to help community-based organizations provide health and long-term care services on a capitated basis to frail elderly persons at risk of being institutionalized. CMS has statutory authority to waive or modify requirements that hinder the design of, the offering of, or the enrollment in, employer/union sponsored MA plans and standalone PDPs. The statutory authority, set forth in Section 1857(i) of the SSA applies to MA plans. The statutory authority set forth in Section 1860D-22(b) of the Social Security Act applies to PDPs. Under this specific statutory authority, in order to facilitate the offering of MA plans and PDPs to employer/union group health plan sponsors, CMS may grant waivers and/or modifications to MA Organizations (MAOs) and PDP Sponsors. Under Section 1876 and 1833(a)(1)(A) of the SSA, a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) is allowed to participate in the Medicare program by receiving - reasonable cost reimbursement for furnishing coverer services to enrolled beneficiaries. 1833 Cost Plans [or Heath Care Prepayment Plans (HCPP)] must either be union or employer sponsored or must not provide inpatient hospital services for its enrollees. Payments are made to these plans on a per capita basis each month and adjusted up or down to the level of incurred costs during the contract year. Both 1876 and 1833 (HCPP) need to undergo monitoring audits to determine compliance with applicable laws and regulations. Oversight of Medicare Health & Drug Plan Organizations CMS is responsible for providing oversight of the types of organizations listed above. CMS's oversight of plans and drug sponsors is a monitoring control designed to ensure they are in compliance with regulations established within applicable Medicare law, and therefore eligible to participate in the Medicare program. CMS has ten Regional Offices, as well as an existing audit contractor that performs the program compliance audits. Upon the completion of the audit, CMS is required to communicate noncompliances identified to the organizations, which are then required to submit corrective action plans. CMS Management is required to evaluate the corrective action plans in order to make a final determination of each plan's eligibility. CMS has the responsibility to: - build and maintain an auditing and oversight infrastructure to properly oversee these programs - ensure program compliance audit findings, corrective action plans (CAPS), and acceptance of the provider's corrective action plans are provided, reviewed, and released within the proposed time frames - ensure that relevant data are updated timely in order to provide the information necessary for adequate management oversight. Oversight System The Health Plan Management System (HPMS) is used by CMS to monitor the execution and status of plan/sponsor oversight, and to serve as a repository to the various audit elements utilized during this review process. This system lies at the core of CMS's management process for MAOs. The Monitoring Review Module in HPMS enables management to monitor the MAOs by tracking the progress of the program compliance audits. Results are updated, including exceptions, corrective action plans, and CMS's acceptance of CAPS from MAO's. Purpose: The purpose of this potential action is to support CMS through: ? statute and regulatory analysis and review of CMS sub-regulatory guidance; ? audit guide, standard operating procedures and worksheet development and training; ? program manual development; and, ? plan enforcement activity support. When necessary, the contractor will also perform oversight and auditing activities of Prescription Drug Plans (PDPs), Medicare Advantage Organizations (MAOs), Medicare Advantage Prescription Drug Plans (MA-PDs), Employer/Union-Only Group Waiver Plans (EGWPs) and Programs of the All-Inclusive Care for the Elderly (PACE) plans, in addition to Medicare Cost-based plans together labeled - plans for the Medicare programs. In addition, the Contractor will provide technical assistance to CMS Regional Offices, Health Plans and Sponsors. CMS currently contracts with approximately 800 plans and plan sponsors and will provide the contractor with an audit schedule. Performance on this potential action for Part C, Cost Plan and PACE audits may require some on-site visits to plans. However, CMS will attempt to limit the need for on-site visits as much as possible. CMS estimates the contractor will audit at least 40 different organizations during the period of performance Task Descriptions: The tasks under this potential action will focus on the development, management, performance and quality of the compliance audit and oversight program performed by CMS. Given the timeframe of the work to be accomplished, these tasks will need to be carried out simultaneously. In addition, tasks may require that policy guides and audits be conducted concurrently. The multiple tasks being performed simultaneously will require a contractor to have several groups of staff available at the same time. CMS intends for the tasks to be done in a collaborative effort between CMS and the contractor. A close working relationship between the contractor and CMS throughout all aspects of this potential action is expected. CMS anticipates the contractor will audit at least 20 different contracted organizations within one year, as well as develop a fully up-to-date audit protocol within a 90-day period. The contractor will have to ensure the audits are performed timely and according to CMS Standard Operating Procedures and Audit Guides. The tasks will include the following: 1. Perform policy and regulatory analysis to further develop auditing tools and elements. 2. Assist CMS in the development, revision, testing, and training of all audit elements and worksheets, standard operating procedures, detailed business processes, and data-driven performance assessment tools for all programs including but not limited to: Part C, Part D, PACE, MSA, EGWP, and Cost Plans. 3. Perform data analysis and reporting of audit findings stored in CMS internal systems, and based on such analysis, develop plan risk assessments utilizing a data driven approach. 4. Perform Routine, Focused, and Ad-Hoc Plan Audits as well as Validation Surveys and - look-behind reviews utilizing appropriate staff with the required experience (e.g.: pharmacists, managed care specialists, nurses) according to CMS audit strategy or on an as needed basis. 5. Ensure that existing policies and procedures for the monitoring of organizations within the Medicare program are consistently applied and that audits performed are documented in accordance with appropriate standards and guidelines. 6. Meet with CMS to review the results and progress of all tasks and provide detailed reports that summarize accomplishments to date. Contractor Requirements: In order to respond to this notice, contractors must be able to indicate experience and/or the ability to provide all of the bulleted points below. Please provide enough detail so your response clearly indicates that you can provide the following: 1. Specified knowledge and experience/ability working with and understanding the Medicare Prescription Drug Improvement Act of 2003. 2. Specified knowledge and experience/ability working with and understanding the Medicare Advantage and PACE programs 3. Specified knowledge and experience/ability working with and understanding 1876 and 1833 Cost Plans 4. Specified knowledge and experience/ability working with and understanding Employer/Union-Only Group Waiver Plains (EGWPs) 5. Ability to evaluate an organization's performance of Medicare requirements using data analysis 6. The ability to conduct large scale projects requiring Medicare regulation and policy analysis to develop operational protocols and/or oversight tools within prompt time periods (please provide at least one example) 7. Current knowledge and experience working with the Health Plan Management System (HPMS) and those modules related to the Program compliance audits, complaints tracking, and marketing. If prior experience of the HPMS is not possessed, then the contractor shall possess experience using large benefit data bases to examine and manipulate data and issue reports to management. 8. Experience/ability in preparing and giving technical presentations before small and large internal and external audiences on compliance and oversight related topics and the Medicare Modernization Act of 2003. 9. Staff with applicable experience to requirements 1 through 5 above, and if so, at what educational level and experience. 10. Provide references for all demonstrated requirements. It is essential that the offeror be free of all perceived, potential or actual conflicts. Specifically, the offeror must not have any relationships or arrangements through its business operations or its employees that could be considered as possibly lessening the company's objectivity concerning any aspect of this action. If such relationships or arrangements exist, offerors would be required, during the potential procurement process, to identify potential conflicts of interest and discuss how the conflicts will be addressed and mitigated. Capability Submission: Capability statements shall also include the following business information: a. DUNS b. Company Name c. Company Address d. Company Point of Contact, phone number and email address e. Type of company under NACIS: 541618 - Other Management Consulting Services (Size Standard: $6.5 million), as validated via the Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp. f. Current GSA Schedules appropriate to this Sources Sought g. Point of Contact, phone number and email address of individuals who can verify the demonstrated capabilities identified in the responses. Teaming Arrangements: All teaming arrangements should also include the above-cited information and certifications for each entity on the proposed team. Teaming arrangements are encouraged. The synopsis is for information and planning purposes and is not to be construed as a commitment by the Government. This is not a solicitation announcement for proposals and no contract will be awarded from this announcement. No reimbursement will be made for any costs associated with providing information in response to this announcement and any follow-up information requests. Respondents will not be notified of the results of the evaluation. All information submitted in response to this announcement must arrive on or before the closing date. All capability statements can be submitted via e-mail, facsimile, or regular mail to the point of contact listed below. Responses must be submitted not later than May 29, 2008. Responses shall be limited to 15 pages. Resumes of key people and references are limited to 2 pages and may be submitted as attachments, which will not count towards the page limit. Documentation should be sent to: Centers for Medicare & Medicaid Services Attn: Kevin Pope, Contract Specialist Office of Acquisitions and Grants Management Acquisitions and Grants Group Division of Beneficiary Support Contracts Mailstop: C2-21-15 7500 Security Boulevard Baltimore, MD 21244 Please refer any questions to: Point of Contact Name: Kevin Pope, Contract Specialist Phone: 410-786-5794 Fax: 410-786-9088 Email: kevin.pope@cms.hhs.gov