R -- Compliance and Oversight Activities for the Medicare Drug Benefit Program

Sources Sought for Services Related to Compliance and Oversight Activities for the Medicare Drug Benefit Program THIS IS NOT A FORMAL REQUEST FOR PROPOSAL (RFP) AND DOES NOT COMMIT THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) TO AWARD A CONTRACT NOW OR IN THE FUTURE. This announcement constitutes a Sources Sought Synopsis in support of the Centers for Medicare and Medicaid Services (CMS), Center for Beneficiary Choices. CMS is seeking capability statements from business firms who have proven expertise in health care and pharmacy benefits management with an emphasis on program management, compliance and auditing. Background Title I of the Medicare Prescription Drug, Improvement and Modernization Action of 2003 (MMA) established a new prescription drug benefit under Part D of title XVIII of the Social Security Act (Act). This new voluntary benefit, referred to as Medicare Part D begins on January 1, 2006. CMS has contracted with licensed risk-bearing entities to administer the prescription drug benefit (Part D) in designated regions to beneficiaries in the Medicare fee-for-service market. We refer to these Part D plans as stand alone, risk-bearing PDPs. Many Medicare managed care plans will also be adding a Part D benefit to their existing program. Finally, these Medicare Advantage-Part D (MA-PD) benefits will also be provided under a risk arrangement. The MMA also contains a retiree drug subsidy (RDS) program to provide support for qualified employer/union health plans in reducing their drug costs while allowing Medicare eligible retirees to retain their current plan designs. All Part D plans must offer a standard drug benefit, but may also vary the benefit offering within defined parameters. Title II of the MMA modified and renamed Medicare+Choice (M+C), Part C to the Medicare Advantage (MA) program. Changes to the MA program beginning with the 2006 contract year include the authority to establish new MA regional plans organized as preferred provider organizations (PPOs). Subpart J of the final MA regulation provides special rules for the new regional PPOs. The MMA also introduced a new process for determining beneficiary premiums and benefits for 2006 and future years under which MA organizations will submit a - bid reflecting their revenue needs for covering the benefits they plan to offer. Subparts F and G of the final MA regulation have been rewritten because of the new bidding process. Additional information about the MMA can be found at http://www.cms.hhs.gov/MMAUpdate/. The final rule implementing Part D and regulating the MA program are available from the Federal Register online database at http://www.gpoaccess.gov/fr/index.html. CMS is seeking qualified contractors to perform various duties in the following functional areas for Parts C and D: 1) performing compliance and oversight audits; 2) provision of specialized expertise in any or all of the areas detailed below and the ability to provide technical assistance to health plans in these areas; 3) evaluating the business operations of health plans for stability and viability; and 4) testing health plans customer service resources and evaluating their beneficiary protection systems. The following web site address contains information on the Prescription Drug Plans and links to the guidance documents that have been released http://new.cms.hhs.gov/PrescriptionDrugCovGenIn/. Information on the Medicare Modernization Act is available at http://new.cms.hhs.gov/MMAUpdate/. Respondents shall provide a capability statement which offers information regarding practical knowledge in performing compliance and oversight audits, provision of technical assistance, and the ability to arrive on-site at a contractor's location within one week of request. Responses must reference Request for Information (RFI) number I51219 and include the following: - Name and address of firm including point of contact name, title, phone, fax, and email. - The Central Contractor Registration (CCR) completed enrollment form with CCR number. - DUNS number. - The North American Industrial Classification System (NAICS) code for this effort has been identified as 524292, insurance plan administrative services (except claims adjusting only), third-party; size standard is $6,000,000. - Contractor's capabilities statement: providing information on specific work previously performed or being performed relating to this effort. - List of customers covering the past 2 years: highlight relevant work including a summary of work performed, contract number, contract type, your role as either the Prime or Subcontractor, dollar value for each customer, and customer point of contact with phone number. - Any other specific and pertinent information as it may pertain to this Sources Sought Notice that would enhance CMS consideration and evaluation of the information submitted. Responses shall be limited to seven (7) pages and may be submitted via electronic mail to BJ Erbe, Contract Specialist, email: Barbara.Erbe@cms.hhs.gov as soon as possible but no later than February 17, 2006. In addition to the information listed above, please include answers to the following questions when submitting a response to this Sources Sought notice: Part I: Address your responses for Medicare Advantage programs only: A. For the following areas of specialized expertise, please respond to all areas where your company has the expertise and experience to provide the requested services. The requested services may include technical assistance conducted via conference call or on-site visit, a desk audit, an on-site audit, analysis of data, or review of program policies and procedures. For each area below please include the following: 1) Number of years of experience; 2) Types and number of staff currently employed that have the requested expertise; 3) Types of health programs your company has worked with (for example - HMOs, PPOs, HCPPs, Cost Plans, or the new Special Needs Plans, etc.); and 4) Provide an example of relevant work in this area where your company provided technical assistance or guidance to a health care entity. 1) Appeals and grievances 2) Enrollment 3) Claims processing 4) Disenrollment 5) Marketing 6) Service area 7) Quality Assurance 8) Contract and subcontracts 9) Provider network Part II: Address your response regarding prescription drug benefits programs only: A. For the following areas of specialized expertise, please respond to all areas where your company has the expertise and experience to provide the requested services. The requested services may include technical assistance conducted via conference call or on-site visit, a desk audit, an on-site audit, analysis of data, or review of program policies and procedures. For each area below please include the following: 1) Number of years of experience; 2) Types and number of staff currently employed that have the requested expertise; 3) Types of health programs your company has worked with (for example - commercial, Medicaid, Medicare, etc.); and 4) Provide an example of relevant work in this area where your company provided technical assistance or guidance to a health care entity. 1) Long term care 2) Medication therapy management 3) Therapeutic interchange programs 4) Formulary review and benefit design 5) Drug utilization management 6) Data analysis and validation 7) Coordination of benefits - For payment purposes (primary, secondary, tertiary payers) 8) Measurement of pharmacy network adequacy 9) Claims payment and adjudication B. Describe your experience in testing health care plans customer service resources and evaluating their systems for beneficiary protections. In answering this question please detail your experience with the following: mystery shopping, market conduct analysis, beneficiary satisfaction surveys, and evaluation of exceptions, appeals and grievance procedures. Part III: Address your responses for Medicare Advantage and prescription drug benefits programs: A. What is your organization's experience performing compliance audits for MA, MA-PD and PDP plans? In responding to this question please provide responses to the following: 1) What is your experience in interpretation and application of the Medicare Modernization Act of 2003? How did you gain this experience? How have you applied this experience? Please provide an example. 2) What is your experience in review and establishment of corporate compliance plans for health care entities? How did you gain this experience? How have you applied this experience? Please provide an example. 3) What is your experience in conducting audits of health care entities? How did you gain this experience? How have you applied this experience? Please provide an example. 4) What is your experience with review and/or design of information technology systems for health care entities? How did you gain this experience? How have you applied this experience? Please provide an example. B. What is your experience in evaluating the licensing, solvency, and liquidity and performing financial analysis to determine the stability and viability of the business operations of health care companies? C. What is your experience developing audit protocols? Describe the type of audits conducted based on these protocols? What is your procedure to ensure the audit tool is functional prior to the first audit visit? D. What is your organization's capacity to arrive on-site and conduct an audit anywhere in Continental United States and the Territories within one week of notification that an audit is required? E. What is your experience with the enforcement process and the monitoring and development of corrective action plans? Please refer to - 423.750 of the Medicare Prescription Drug Benefit Code of Federal Regulations (CFR) regarding intermediate sanctions for Part D and 42 (CFR) - 422.750 regarding intermediate sanctions for Part C. Please provide specific examples of previous enforcement actions, the type of plan involved in the action, the development and monitoring of a corrective action plan, the outcome and any referral to law enforcement agencies. Finally, please provide the availability of staff and their background to conduct this type of work. As a contractor, you must disclose to CMS any conflicts of interest (COI) that would render you unable to perform any of the following work outlined in this document. This would include any present or future work with MA, MA-PD or PDP plans (Part C and D). The contractor will not conduct audits or compliance actions with a plan that the contractor already has an established working relationship. Proprietary information: CMS recommends that you do not provide proprietary information since CMS will consider all comments and may incorporate them in any future requirements. In the event you do submit proprietary information, Potential Responders should identify any proprietary information in their RFI responses. Proprietary materials will neither be distributed to nor discussed with any other potential Responder. CMS will evaluate comments received from the general public at the end of the comment period. CMS will not respond directly to any comments submitted. Respondents will not be notified of the results of the evaluation. THIS 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. ALL INFORMATION SUBMITTED IN RESPONSE TO THIS ANNOUNCEMENT MUST ARRIVE ON OR BEFORE THE CLOSING DATE.