MEDICAL LOSS RATIO AUDITING AND EXAMINATION SERVICES

This is a SMALL BUSINESS SOURCES SOUGHT NOTICE. This is NOT a solicitation for proposals, proposal abstracts, or quotations. The purpose of this notice is to obtain information regarding the availability and capability of qualified small businesses (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 the Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), medical loss ratio auditing and examination services of national and regional health insurance issuers data and operations. The information from this market research will assist the Government in determining the appropriate acquisition method, including whether a set-aside is possible. An organization that is not considered small business under the applicable NAICS code should not submit a response to this notice. BACKGROUND The Patient Protection and Affordable Care Act (Affordable Care Act), Pub. L. 111-148, was enacted on March 23, 2010; the Health Care and Education Reconciliation Act, Pub. L. 111-152, was enacted on March 30, 2010. Section 2718 of the Public Health Service Act (PHS Act), as added by section 1001 of the Affordable Care Act, established medical loss ratio (MLR) requirements for health insurance issuers. Section 2718 of the PHS Act includes two provisions designed to achieve the objective of "bringing down the cost of health care coverage." The first is the establishment of greater transparency and accountability around the expenditures made by health insurance issuers. The law requires that issuers publicly report on major categories of spending of policyholder premium dollars, such as clinical services provided to enrollees and activities that will improve health care quality. The second provision is the establishment of minimum Medical Loss Ratio (MLR) standards for issuers, which are intended to help ensure policyholders receive value for their premium dollars. Issuers will provide rebates to enrollees when their spending for the benefit of policyholders on reimbursement for clinical services and quality improving activities, in relation to the premiums charged, is less than the MLR standards established by the statute. The rebate provisions of section 2718 are designed not just to provide value to policyholders, but also to create incentives for issuers to become more efficient in their operations. Section 2718 also contains provisions which allow for modifications to the standards under certain circumstances. To make informed decisions about definitions and methodologies for calculating MLRs, the Affordable Care Act directed the National Association of Insurance Commissioners (NAIC) to make recommendations to the Secretary, subject to certification by the Secretary. An interim final regulation (IFR) to implement the MLR requirements was issued in December 2010 and became effective January 1, 2011. This regulation adopts and certifies in full all of the recommendations in the model regulation of the NAIC regarding MLRs. Publication was designed to implement section 2718(a) through (c) of the PHS Act: - Subpart A of the IFR implements the requirements for reporting the data to be considered in determining that ratio. - Subpart B of the IFR addresses the requirements for health insurance issuers (issuers) in the group and/or individual market, including grandfathered health plans, to provide an annual rebate to enrollees if the issuer's MLR fails to meet minimum requirements: generally, 85 percent in the large group market and 80 percent in the small group or individual market. - Subpart C of the IFR establishes a process and provides criteria for the Secretary of Health and Human Services (the Secretary) to determine whether application of the 80 percent MLR in the individual market in a State may destabilize that individual market. - Subparts D-F of the IFR address enforcement of the reporting and rebate requirements of section 2718(a) and (b). PURPOSE CCIIO is seeking multiple small businesses to conduct agreed-upon procedures surrounding analysis, desk audit (reviews) and field examinations of issuers related to the MLR Interim Final Regulation. CCIIO's overall goal is to determine the availability of qualified and experienced contractors to: - Analyze and determine the potential magnitude of MLR rebates that may be paid to subscribers as a result of issuers not meeting the MLR requirements for the respective markets they serve in each state; - Review, analyze and examine issuers at the holding company level for the appropriate allocation of expenses as they relate to MLR calculations and the reasonableness of each allocation; - Examine issuers for the accuracy of reported elements of the MLR calculation; - Assess company compliance with rebate calculation, payment and reporting in compliance with the IFR. The contractors will provide a full range of statistical, analytical, examination and/or professional business services as required. They will also assess areas of strength and vulnerability in the management, administration, operation and monitoring of elements affecting MLR reporting and rebate calculations. Tasks to be performed, as outlined below, are to be performed in accordance with any CCIIO-provided handbooks, guidelines, requirements, practices and procedures in conjunction with Generally Accepted Auditing Standards (GAAS), as promulgated by the American Institute of Certified Public Accountants (AICPA) and the NAIC Financial Examiner's Handbook. TASKS TO BE PERFORMED Potential small businesses must be capable of performing the following tasks: The analysis and examination engagements must be conducted utilizing the Desk Analysis/Audit Manual and Field Examination Manual and related schedules, as provided by CMS. Examinations must be conducted in accordance with established NAIC financial examination practices in conjunction with generally accepted auditing standards. The goal is to perform an annual desk analysis (review) of all issuers' reported MLR data within 180 days of filing [but in no event later than 270 days] and to provide a summary analysis of each review. The goal of examinations is to validate reporting and compliance with the IFR as well as to document any year-over-year trends or differences among issuers. Contractors will have a primary obligation to compile, test, analyze, review and manipulate issuers' MLR Data to determine compliance with the IFR. Tasks include performing, providing and interpreting analytics of various markets, companies, peers, industry, state and holding companies, as directed by CMS and providing a summary of findings. Contractors will also undertake an Impact Analysis on potential public policy issues as determined by CMS. Contractors will be obligated to review and examine the data elements of the MLR calculation for compliance with the IFR, including but not limited to all the data elements on the Supplemental Health Care Exhibit (SHCE) ) and all the data elements on any forms to be developed and utilized by CMS. Contractors must evaluate the reasonability of allocations across company and product lines (including product lines not subject to the MLR IFR) and report their findings in a form and manner acceptable to CMS. Contractors must utilize any related non-IFR filings that may be required by the various States or Federal regulatory agencies to cross-check data for validity. CCIIO will require that each Field Examination of a multi-State company or holding company and its related Report of Findings be conducted and reported by a Certified Financial Examiner (CFE) who is a member in good standing of the Society of Financial Examiners and that all work papers be reviewed and signed off on by a CFE. Contractor personnel (and any independent contractors) should be certified professionals within the insurance regulatory industry (i.e. SOFE (CFE) (AFE), with strong statutory/regulatory and insurance financial reporting background). The Managing Director (or proposed similar position with the required expertise) (CPA or CFE) must have sufficient experience and expertise to know how to apply proper audit techniques and procedures to analyze, review and utilize the MLR data, Desk Audit and Field Examination Handbooks and any related guidelines for the oversight of their personnel and in the performance of the tasks for CCIIO. The Managing Director (or proposed similar position with the required expertise) must have achieved sufficient breadth of perspective to determine properly whether all material considerations have been addressed within the scope of the examinations and regarding any analysis. Other technical experts and support staff may also be used in the review process if and as necessary. Tasks associated with the performance of analysis or examinations should be limited to the lowest but most appropriate pay grade first and reviews of the work should be undertaken by the fewest number of supervisors or managers. Further, field and in-person meeting assignments should also be based on geographical proximity to the issuer being examined or people being interviewed and meetings should be conducted telephonically where feasible. Each contractor should have a sufficient number of staff (including independent contractors) to meet the required staffing standards of the NAIC regarding the performance of multi-state and single-state company analysis and examinations, as applicable. For example, this may include: one Managing Director (CFE); one Field Manager (CFE); a minimum of three Sr. Examiner/Analysts (CFE/AFE); a minimum of three Examiner/Analysts (AFE); and, an actuary who is available during examinations on an as-needed basis (this information is supplied for informational purposes only). The contractor's Managing Director (or proposed similar position with the required expertise) must be readily available to answer questions from staff and CCIIO. If at any time the Field Manager (or proposed similar position with the required expertise) is absent, an alternate Manager with the proper delegation of authority and expertise must available. The MLR IFR requires issuers to submit to CMS a report concerning premium revenues and expenses related to the group and individual health insurance coverage that they issued. For the majority of issuers, the first MLR reports subject to the IRF must be submitted to CMS by June 1, 2012. An issuer must provide a rebate to enrollees in plans issued if the MLR is less than the percentage for the market as determined in accordance with the IFR. Rebates must be issued no later than August 1 following the end of the MLR reporting year. The first rebates must be issued by August 1, 2012. Calculation of the MLR is based on a number of factors as set forth in the IFR, and may be modified by a credibility adjustment, depending on the number of life-years covered by the issuer. Miscalculation of the MLR may result in an issuer not paying a rebate to its enrollees where one is due. It is important, therefore, that the contractors understand the various elements and factors that go into the calculation in order to perform an analysis of the data that is reported. It is also important that the contractors understand and have knowledge of healthcare insurance and operations, policies, and state insurance regulations in order to perform analytics and identify trends and anomalies by lines of business and by state. Due to the sensitive nature of the data to be reported and analyzed, conflicts of interests are a concern for the MLR audit program. For the purpose of identifying conflicts of interest, a conflict exists with a business concern or its affiliate (as that term is explained in FAR 19.101) if the business concern or affiliate is engaged or affiliated with, another entity that is involved with the determination, analysis or review of an MLR calculation for any issuer subject to the MLR IFR. The contractor will have to demonstrate that its performance of the services set forth in the Statement of Work will not directly or indirectly result in any potential conflicts of interest. The contractor will also have to disclose all current clients that are licensed health and life insurance carriers issuing fully-insured comprehensive major medical products in the individual and group health insurance markets. CAPABILITY STATEMENT INFORMATION Interested parties must demonstrate that they possess the knowledge and experience (gained within the last three years) to fulfill points (A) through (I) shown below. If a teaming relationship is proposed, the prime small business must effectively demonstrate the capability to effectively manage and coordinate this relationship in order to seamlessly fulfill (without disruption) project tasks. Small businesses and 8(a) concerns must be in compliance with the restrictions on subcontracting contained in FAR 52.219-14 entitled "Limitations on Subcontracting." (A) Conduct analysis and examination engagements utilizing the Desk Analysis/Audit Manual, Field Examination Manual and related schedules as provided by CCIIO. Such examinations shall be conducted in accordance with established NAIC financial examination practices in conjunction with generally accepted audit standards. The goal is to perform an annual desk analysis of all issuers' reported MLR data within 180 days of filing and to provide a summary analysis of each review. The goal of the examinations is to validate reporting and compliance with the IFR as well as to document year-over-year trends or differences among issuers. (B) Compile, test, analyze and review the issuers' MLR data to determine compliance with the IFR. This shall include interpreting analytics of various markets, states, companies, peers, industry and holding companies as directed by CCIIO. Contractors shall also review and examine the data elements of the MLR calculation for compliance with the IFR. This shall include, but not be limited to, all the data elements on the Supplemental Health Care Exhibit (SHCE) and all the data elements on any forms to be developed and utilized by CCIIO. (C) Demonstrate that staff qualifications meet the requirements of certified professionals within the insurance regulatory industry, i.e. Society of Financial Examiners (SOFE) Certified Financial Examiner (CFE), or Accredited Financial Examiner (AFE), with strong statutory/regulatory background and knowledge of financial insurance accounting and reporting. Each Field Examination of a multi-state company, or holding company, shall be conducted by a CFE who is a member in good standing of SOFE. All Reports of Findings shall also be reviewed and signed off on by a CFE. (D) Explain any previous experience with an MLR (or similar) audits. (E) Demonstrate sufficient experience and expertise to know how to apply proper audit techniques and procedures while analyzing and reviewing the MLR data, as well as the Desk Audit and Field Examination Handbooks and any related guidelines for the oversight of their personnel while in the performance of tasks for CCIIO. The Contractor's Managing Director (or proposed similar position with the required expertise) must have achieved sufficient breadth of perspective to properly determine if all material considerations and analysis within the scope of the examination have been addressed. (F) Provide other technical experts and support to be used in the review process when necessary. Tasks associated with the performance of analysis or examinations shall be limited to the lowest, but most appropriate, pay grade first. Reviews of the support staff's work product shall be undertaken by the fewest number of supervisors or managers as possible. Field reviews and in-person meeting assignments shall also be based on geographical proximity to the issuer being examined. Interviews and meetings should be conducted electronically when feasible. (G) Provide a sufficient number of staff (including independent contractors) to meet the required staffing standards of the NAIC for company analysis and examinations. For example, this may include: one Managing Director (CFE/CPA), one Field Manager (CFE), a minimum of three Sr. Examiner/Analysts (CFE/AFE), a minimum of three Examiner/Analysts (AFE) and an actuary who is available during examinations on an as-needed basis (this information is provided for informational purposes only). (H) Provide a Managing Director (or propose a similar position with the required expertise) that is readily available to answer questions from staff and CCIIO. If at any time the Field Manager (or individual in a similar position) is absent, an alternate Manager, with the proper delegation of authority and expertise, must be available. (I) Utilize a TeamMate program for the purposes of conducting the work under this contract. This will act as documentation of the audit program steps along with electronic papers in support of the work performed. ADDITIONAL INFORMATION REQUESTED: Interested parties having the capabilities necessary to perform this requirement may submit capability statements via email to Paquetta N. Myrick-Hancock. CAPABILITY STATEMENTS MUST DEMONSTRATE THE MINIMUM REQUIREMENTS OUTLINED ABOVE. Please address each in the order listed above under "Capability Statement Information." Capability statements shall also include the following information: (Capability Statements shall be limited to 20 pages and shall designate any/all teaming arrangements and the work proposed to be performed by each team member.) Please also include the following: Business Information -- a. DUNS b. Tax ID c. Company Name d. Company Address e. Company Point of Contact, Phone and Email address f. Current GSA Contracts 1. Schedule 2. 8(a) STARS GWAC 3. Vets GWAC g. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. h. Business Size Status (e.g., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR) for the applicable NAICS code (i.e. 524298). All offerors must be registered in the CCR located at http://www.ccr.gov/index.asp. i. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. Responses must be submitted no later than 3:00PM on Tuesday, January 31, 2012. Capability statements will not be returned and will not be accepted after the due date. This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. The Government reserves the right to use information provided by respondents for any purpose deemed necessary and legally appropriate. Any organization responding to this notice should ensure that its response is complete and sufficiently detailed to allow the Government to determine the organization's qualifications to perform the work. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted. After a review of the responses received, a pre-solicitation synopsis and solicitation may be published in Federal Business Opportunities. However, responses to this notice will not be considered adequate responses to a solicitation. No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s). Questions concerning submission requirements may be in writing via email and directed to Paquetta N. Myrick-Hancock, Contracting Officer. CMS will not entertain questions related to contracting strategy.