PROGRAM INTEGRITY EARLY RETIREE REINSURANCE PROGRAM

Introduction: This SOURCES SOUGHT NOTICE is to determine the availability of potential large and small businesses that can provide various audit and analysis functions that will support H.R. 3590 Affordable Care Act's provisions for the Early Retiree Reinsurance Program and the Pre-Existing Condition Insurance Plan. The information from this market research will help CMS plan their acquisition strategy. Please be sure to indicate if you have a GSA FABS contract or any other GSA Schedule contract. Project Background: Overview of ERRP The Early Retiree Reinsurance Program (ERRP) was established by section 1102 of the Patient Protection and Affordable Care Act (the Affordable Care Act) enacted on March 23, 2010. Congress appropriated $5 billion for this temporary program and directed the Secretary of Health and Human Services (HHS) to set up the program within 90 days of enactment. Accordingly, HHS published an Interim Final Rule to implement the ERRP on May 5 with an effective date of June 1, 2010, and the program began accepting applications on June 29, 2010. The ERRP is scheduled to end no later than January 1, 2014 and will serve as a bridge to the new health insurance marketplace to be established through State-based Health Insurance Exchanges in 2014. The ERRP was designed to provide financial assistance for health plan sponsors - including for-profit companies, schools and other educational institutions, unions, State and local governments, religious organizations and other non-profits - to help early retirees and their families continue to have access to quality, affordable health coverage. People in the early retiree age group (i.e., ages 55 to 65) often face difficulties obtaining insurance in the individual market because of age or chronic conditions that make coverage unaffordable and inaccessible. The ERRP provides needed financial help to group health plans that provide health coverage to retirees and their families, who depend on this coverage for their health care needs. The ERRP reimburses participating plan sponsors for a portion of the costs of providing health coverage to early retirees and their spouses, surviving spouses, and dependents. The anticipated services would support the Program Integrity efforts of the ERRP and possibly include assessments of program operations and data, to ensure plan sponsors are submitting accurate data, and to identify and prevent fraud, waste, and abuse. The anticipated activities of this requirement would be as follows: - Maintain data securely, including working with existing contractors. Develop Joint operating Agreements (JOA) for work with contractors, including: the ERRP IT/Operations contractor, primarily to coordinate data sharing tasks; and the ERRP Call Center contractor, primarily to coordinate communications with plan sponsors. Obtain and transfer data in compliance with all applicable Federal Information Security Management Act (FISMA), and CMS Information Technology standards. o https://www.cms.gov/informationsecurity/downloads/ars.pdf o https://www.cms.gov/SystemLifecycleFramework/ - Data analysis, statistical analysis, data sampling, including health insurance claims data. - Perform detailed reviews of information related to sponsors of health benefit plans, including reviews of plan sponsors': o Programs and policies designed to identify and reduce fraud waste and abuse on the part of the plan sponsor. o Programs and policies designed to reduce the cost of chronic or high-cost conditions. o Representations about their plan. o Notices to plan participants indicating participation in ERRP. - Perform detailed audits of health insurance claims data, plan enrollment information, and price concessions data (e.g. rebates) submitted by plan sponsors for the purpose of receiving reimbursement for high dollar healthcare claims through the ERRP. o Audits may include travel to plan sponsor locations throughout the country. - Review and audit plan sponsors use of received ERRP reimbursements. - Answer questions and concerns from plan sponsors in response to ERRP payment adjustments identified through audits and analysis of their claims, price concession, enrollment, program reimbursement and program fund usage. - Conduct quality assurance and continuous improvement processes. Overview of PCIP On March 23, 2010, the President signed into law H.R. 3590, the Patient Protection and Affordable Care Act (Public Law 111-148), hereafter referred to as the Affordable Care Act, as amended by the Health Care and Education Recovery Act of 2010 (Public Law 111-152). Section 1101 of the Affordable Care Act establishes a "temporary high risk health insurance pool program" (which has been named the Pre-Existing Condition Insurance Plan, or PCIP) to provide health insurance coverage to currently uninsured individuals with pre-existing conditions. The Affordable Care Act authorizes HHS to carry out the program directly or through contracts with States or private, nonprofit entities. The PCIP program is intended to remain in place from the time of its establishment until the Exchanges established under sections 1311 or 1321 of the Act go into effect on January 1, 2014. The effort would support the oversight and audit efforts of the PCIP and include assessments of medical and pharmaceutical claims data. The anticipated activities of this requirement would be as follows: - Design and execute on-site health insurance claims audits (both medical and pharmaceutical) for 27 state PCIP contractors, one audit per contractor per calendar year in a chronological order specified by HHS. These audits shall evaluate whether PCIP contractor paid claims in accordance with approved plan coverage, benefits, and member cost sharing for eligible and enrolled subscribers. - Answer questions and concerns from PCIP contractors in response to claims audit findings and recommended adjustments/recoveries. - Audits include travel to state PCIP contractor locations throughout the country. Instructions/Requirements for Submitting RFI Responses to CMS: Interested parties having the corporate capability and expertise necessary to perform the stated requirements outlined in this notice may submit capability statements via email to Georgette Vlangas@cms.hhs.gov and Desiree Wheeler@cms.hhs.gov. Please email responses on or before 10:00am (eastern time) April 14, 2011. Please limit responses to no more than 25 pages for ERRP and no more than 10 pages for PCIP. CMS software standard is MS Word. Therefore, responses should be submitted in a Word or Word comparable document. Page size should be 8.5 by 11 inches. CMS requests that respondents specifically address each question identified below. In general, while this RFI is not a request for a technical proposal, respondents should provide enough information for CMS to make a determination as to the capability to perform the same or similar work. It is important to note that any future solicitations will include strict conflict of interest requirements. RFI responses should include, at a minimum, the information identified in each of the following: 1. Business Information a. Company Name b. Company Address c. DUNS Number d. Does your organization have a Government approved accounting system? If so, please identify the agency that approved the system or provide a copy of approval letter. e. Type of company (e.g., large business, small business, 8(a), veteran-owned small business, service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, and/or women owned small business) as validated via the Central Contractor Registration (CCR). f. Company Point of Contact - Name, Phone and Email address g. Point of contact, phone and email address of individuals who can corroborate the demonstrated capabilities identified in the responses. 2. CMMI Certification: CMS prefers CMMI certification for this effort. Is your organization CMMI certified? If so, what level of certification has been obtained? CMS prefers level Three or higher. 3. Please demonstrate your knowledge of and experience (including length of experience) with as many of the following as apply (including laws, regulations, manuals, etc.): - The Patient Protection and Affordable Care Act - The Early Retiree Reinsurance Program - The Pre-Existing Condition Insurance Plan (PCIP) Program - Employer based group health plans - Medicare Part A; - Medicare Part B; - Medicare Part C (including MedicareAdvantage (MA), Cost Contract, PACE, Private fee-for-service (PFFS), Medical Savings Accounts (MSA), HCCP and MedicareAdvantage-Prescription Drug (MA-PD); - Medicare Part D. 4. Please demonstrate your knowledge, experience (including length of experience) and abilities pertaining to the development and maintenance of data systems and data warehouses, using ORACLE, DB2, and other CMS standard software tools, for example Microstrategy, Microsoft Office tools, and SAS. 5. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to data analysis, for the purpose of determining the accuracy of health care claims data and identification of claims for additional review, including the analytical software and tools used in the analyses that comprise the knowledge, experience, and abilities in this area; 6. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to designing and conducting audits of health plans, (i.e., audit, settlement, reconciliation of cost discrepancies, and reimbursement of cost reports), particularly for organizations in the health benefits industry (including third party administrators, insurance companies, pharmacy benefit managers, and plan sponsors), nationally, and assessing entities across a range of variables to identify candidates for more detailed assessment; 7. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to performing quality assurance and continuous improvement activities related to operational assurance and repeated processes; 8. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to detecting and preventing fraud, waste, and abuse in government programs, particularly health benefit programs (e.g. Medicare, Medicaid, etc.) 9. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to conducting investigations on fraud and aberrant behavior identified by entities as potentially fraudulent 10. Please demonstrate your knowledge, experience (including length of experience), and abilities pertaining to providing Information Technology security and physical security of Protected Health Information (PHI), and Personally Identifiable Information (PII), including the secure transfer of such information with other entities 11. Demonstrate your knowledge experience (including length of experience), and abilities pertaining to responding to questions and concerns from entities in response to audit findings 12. Please also identify any active federal contracts. 13. Please disclose if your organization is participating in, intends to participate in, or is supporting other entities' participation in the ERRP or PCIP. Other Information: - Proprietary Information and Disclaimers: All transmitted information marked proprietary shall be treated as such. Therefore, respondents should identify any proprietary information in its RFI response. Information submitted in response to this RFI will be used at the discretion of the Government. Proprietary materials will neither be distributed, nor discussed with, any other organization or business. Further, the information submitted will remain confidential insofar as permitted by law, including the Freedom of Information and Privacy Acts. CMS reserves the right to utilize any non-proprietary technical information in the anticipated SOW or solicitation. Teaming Arrangements: All teaming arrangements should also include the above-cited information and certifications for each entitiy on the proposed t eam. Teaming arrangements are encouraged. . THIS SOURCES SOUGHT NOTICE IS FOR INFORMATION AND PLANNING PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS A COMMITMENT BY THE GOVERNMENT. THIS IS NOT A SOLICITATION ANNOUNCEMENT FOR PROPOSALS AND NO CONTRACT SHALL BE AWARDED FROM THIS NOTICE. NO REIMBURSEMENT WILL BE MADE FOR ANY COSTS ASSOCIATED WITH PROVIDING INFORMATION IN RESONSE TO THIS NOTICE. RESPONDENTS WILL NOT BE NOTIFIED OF THE RESULTS OF THIS EVALUATION. CAPABILITY STATEMENTS WILL NOT BE RETURNED AND WILL NOT BE ACCEPTED AFTER THE DUE DATE. Contact information: Georgette Vlangas, Contract Specialist (georgette.vlangas@cms.hhs.gov) 410-786-8372 Desiree Wheeler, Contracting Officer (desiree.wheeler@cms.hhs.gov) 410-786-2404