Monitoring Part C and Part D Data from Medicare Part C and Part D Sponsor Organizations

Monitoring Part C and Part D Data from Medicare Part C and Part D Sponsor Organizations (Business Requirement, Reporting Tool and Analysis) 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 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 have the capability to analyze data from Medicare Part C and Part D sponsors (as well as having expert knowledge of Medicare Part C and Part D benefits and payments); and the capability of developing business requirements for monitoring and reporting on risk adjustment, payment, and bid data. Background: The Balanced Budget Act (BBA) of 1997 established the Medicare+Choice Program or Medicare Part C and mandated the implementation of a risk adjustment methodology that accounts for variation in per capita costs based on health status. BBA granted authority to the Secretary of the Department of Health and Human Services to collect inpatient hospital data for admissions occurring after July 1997. These data were submitted by Medicare Advantage (MA) organizations (formerly Medicare+Choice (M+C)) and incorporated in the risk-adjusted component of managed care payments. The Benefits Improvement and Protection Act (BIPA) of 2000 further required that CMS collect diagnosis data from ambulatory settings (physician and hospital outpatient) to be incorporated into risk-adjusted payments beginning in 2004. The Medicare Modernization Act (MMA) of 2003 established the Medicare Part D prescription drug benefit for people with Medicare. The MMA expanded the role of private plans in providing benefits to Medicare beneficiaries. The law added a new section to the Social Security Act; 1860D (Part D) that offered partially governmental subsidized prescription benefits beginning in 2006 through private sector Prescription Drug Plans (PDPs). Part D sponsors predominantly fall into two categories: stand-alone prescription drug contracts (PDPs), and Medicare Advantage health contracts that offer a prescription drug plan(s) (MA-PDs). Secondly, the statute allowed for payments to MA - local plans and created a new type of private plan, - regional MA plans. Finally, the legislation specified that beginning with the 2006 contract year organizations bidding for contracts or with contracts that offered PDPs and MA benefits must annually submit bids that support the actuarial basis of its pricing. By statute, bids are due the first Monday in June of each year. Purpose: CMS is seeking to determine if there are small businesses capable of supporting CMS in implementing a data reporting system based on Part C and Part D data. CMS is seeking assistance with analysis of Parts C and D bid and payment data from sponsors, and development of business requirements for automated reporting of these analyses in a CMS system. A potential contractor shall be able to develop analytic approaches to examining these data based on contract and program benefit characteristics, and develop benchmark measures to which sponsor groups could be compared. Part C and Part D Bids MA organizations must submit an aggregate monthly bid amount for each coordinated care plan, private fee-for-service, or Medicare Savings Account plan the organization intends to offer under Part C. Each average bid represents the MA organization's estimate of its average monthly required revenue to provide coverage in the service area of the plan for an MA eligible beneficiary with a nationally average risk profile. Each bid is a uniform benefit package for the service area. The bid shall contain all estimated required revenue, including administrative costs and return on investment (profit, retained earnings). Part D sponsors must submit an aggregate monthly bid amount for each prescription drug plan (PD or PDP) the organization intends to offer under Medicare Part D. Each Part D bid must reflect a uniform benefit package, including premium (except as provided for the late enrollment penalty described in the Code of Federal Regulations (CFR) 42 - 423.286(d)(3)) and all applicable cost sharing, for all individuals enrolled in the plan. Each bid must reflect the sponsor's estimate of its average monthly revenue requirements to provide qualified prescription drug coverage (including supplemental coverage) for a Part D eligible individual with a national average risk profile. Part C and Part D Payments CFR 42 - 422.300 sets forth the rules for making payments to MA organizations offering local and regional MA plans, including calculation of MA capitation rates and benchmarks, conditions under which payment is based on plan bids, adjustments to capitation rates (including risk adjustment), and other payment rules. CFR 42 - 423.301 sets forth rules for the calculation of and payments to Part D sponsor for direct (risk adjustment) and reinsurance subsidies; risk corridor and risk sharing application; and retroactive adjustments and reconciliations to actual enrollment and interim payments. Payments to Part C sponsors and direct subsidy payments to Part D sponsors are risk adjusted based the health status of the enrolled populations. Part C sponsors that offer Part D (typically MA-PDs) are required by CMS to submit health status data for their Part C and Part D enrollees. For Part C payments and Part D direct subsidy, CMS pays plans a capitated amount for each of its members. CMS uses two independent prospective risk adjustment models to assign risk scores to be incorporated into capitated payments to Part C and Part D sponsors. Risk adjusted payments are based on predictive costs associated with providing health service and/or prescription drug benefits to Medicare beneficiaries based on their health status. The CMS hierarchical condition category (CMS-HCC) model calculates beneficiary risk scores based on the predicted cost for health services. The Prescription Drug HCC (RxHCC) model calculates beneficiary risk scores based on the predicted drug cost. In total, both models use approximately 6,600 chronic disease categories as assigned based on the International Classification of Disease 9th Revision (ICD-9). CMS requires MA organizations to submit relevant Part C and Part D diagnosis data for beneficiaries who are enrolled in their plan. Stand-alone PDPs are not required to submit risk adjustment data, and therefore the direct subsidy payments for their Part D enrollees are based on fee-for-service claims data and/or data submitted from MA organizations. Task Descriptions: The tasks under this potential action will focus on conducting analyses of Part C and Part D bids and payments, and developing comprehensive business requirements for routine reporting of these data. The contractor shall be able to provide and incorporate the following technical and analytic approaches: (1) Design statistical approaches to summarize monthly Part C and Part D risk scores and payments, and prepare analyses by contract/Plan Benefit Package (PBP), Special Need Plans (SNPs), Private Fee-for-Service (PFFS), PDPs and other Part C and D analyses requested by CMS. Research and identify differences payment differences associated with Part C and/or Part D benefit types and organizations types. Conduct MA to Fee-for-Service (FFS) comparative analyses. (2) Analyze Part C and Part D bids submitted by sponsors and prepare databases for CMS, including large files with numerous variables, and prepare special analyses on contract types, SNPs, PFFS plans, PDPs, geographic areas, and other Part C and D analyses requested by CMS (e.g., MA versus FFS, cost sharing classifications, rebates, etc). Research and identify differences in bids that are associated with Part C and/or Part D benefit types and organization types. (3) Identify and research Part C and D operation and policy issues related to data outcomes. (4) Develop benchmarks to which Part C and Part D sponsored could be compared and outlier organizations could be identified. This includes conducting on-going analysis to update the benchmarks as relating to the specific Part C and Part D bid and payment periods. (5) Develop sound framework to model changes in risk scores that could be explained by plan attributes, the risk adjustment model parameters and risk adjustment diagnosis data submissions, etc; thus identifying primary indicators of problematic payments for future data monitoring efforts. (6) Write business requirements for integrating Part C and D bid and payment data into a CMS data reporting system. The business requirements must also provide detail for building automated analytic summary measures into the tool. The data reporting system must incorporate a method for establishing benchmarks as defined under previous tasks. (7) Test and validate system requirements for the reporting tool. This will include working with other CMS contractors to evaluate the requirements for the system that will be used for analyzing the annual bids and monthly payments for Part C and D sponsors. (8) Develop and implement coordinated efforts with CMS and its contractors to provide technical assistance and communication to problematic plans. 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: -Specialized knowledge and experience/ability analyzing program policies under BBA (1997) and MMA (2003). -Specified knowledge and experience/ability working with and understanding the full-range of Part C and Part D Medicare risk adjustment; how risk adjustment applies to payments; and detailed understanding of the MA payment cycles as applied for Parts C and all components of Part D. -Prior/Current detailed knowledge and extensive experience/ability working with and integrating data from multiple Medicare data sources. Data sources include, but are not limited to the Medicare Beneficiary Database (MBD), Risk Adjustment Processing System (RAPS), Front End Risk Adjustment Systems (FERAS), Risk Adjustment System (RAS), Medicare Advantage and Prescription Drug (MARx) system, Health Plan Management System (HPMS), Monthly Membership Reports (MMR), and Model Output Reports (MOR). -Current knowledge and experience/ability working with HPMS and those modules related to the Part C and Part D bids. -Prior/Current experience/ability using large benefit databases to examine and manipulate data and issue reports to management. -Experience/ability with a range of quantitative data integrity/validity methods such that all tasks described in this document shall be completed efficiently and effectively; -Ability to draft data and business requirements that will be used to routinely extract data from pertinent systems to analyze, track, and report Part C and Part D plan bid and payment data. -Prior/Current knowledge and experience/ability in designing and developing integrated analysis tools that require the manipulation of CMS data sources to generate reports complete with established statistically sound benchmarks. The tool shall provide capability to: -Answer complex questions regarding Medicare Parts C and D Bids and payments across the Medicare Part C and D Programs. -Derive Medicare Part C and D, and FFS program reports that describe financial or expenditure outcomes. -Expert experience/ability identifying issues using performance measures that are associated with Part C and Part D payments. Capability Submissions: 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 10 pages. Resumes of key people are limited to 2 pages and may be submitted as an attachment, which will not count towards the page limit. Documentation should be sent to: Centers for Medicare & Medicaid Services Attn: Heather Robertson, 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 Point of Contact Name: Heather Robertson, Contract Specialist Phone: 410-786-6888 Fax: 410-786-9088 Email: heather.robertson@cms.hhs.gov