True Out of Pocket System (TrOOP)

True Out of Pocket System (TrOOP) 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 business (e.g., 8(a), service-disabled veteran owned small business, HUB-Zone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that can provide assistance in the operation and management of all aspects of the True Out of Pocket System (TrOOP). Introduction and Background Section 1860D-2(b)(4)(D) of the Social Security Act (the Act) authorizes the Secretary to establish procedures for determining whether costs for Part D eligible individuals are being reimbursed through insurance or otherwise, a group health plan, or other third party arrangement and for alerting the Part D plans in which such individual are enrolled about the other prescription drug coverage. Section 1860D-23 of the Act requires Part D plan sponsors to coordinate benefits with State Pharmaceutical Assistance Programs (SPAPs) and other providers of prescription drug coverage. When a Medicare Part D beneficiary has other prescription drug coverage, coordination of benefits (COB) permits the plans providing coverage for the same beneficiary to determine each of their payment responsibilities to avoid duplication of payment and prevent Medicare from paying primary when it is the secondary payer. Section 1860D-2 of the Act provides beneficiaries with protection against high out-of-pocket expenditures by requiring Part D sponsors to track beneficiary "true out-of-pocket" (TrOOP) expenditures. Costs for covered Part D drugs are treated as "incurred" only if they were paid by the individual, paid on behalf of a low-income subsidy-eligible individual under the Section 1860D-14 provisions, or paid under an SPAP. In Part D, COB also serves the function of providing a mechanism supporting the tracking and calculating to beneficiaries' TrOOP. To calculate TrOOP, Part D sponsors must determine what other entities made payments on covered drugs. Using the authority provided under Section 1860D-2 of the Act, CMS established a "TrOOP facilitation process" that captures TrOOP-relevant data from SPAPs and other providers of prescription drug coverage either online or in a batch process and sends it to the relevant Part D sponsor for TrOOP calculation. Part D rules require sponsors to track the beneficiary's TrOOP costs and gross covered drug spending and correctly apply these costs to the TrOOP and benefit limits in order to correctly administer the benefit and provide the catastrophic level of coverage at the appropriate time. The TrOOP threshold and gross covered drug spending are calculated on an annual basis and must be transferred between Part D plans if a beneficiary changes plan enrollment during the coverage year. An automated process to manage the plan-to-plan transfer of these data is a component of the TrOOP facilitation process. Also, a component of the TrOOP facilitation process is the functionality for pharmacies to verify beneficiary Medicare eligibility and Part D enrollment information via on-line, real-time eligibility queries to the TrOOP facilitator. Scope This effort provides for the operation and management of all aspects of the TrOOP Facilitation process and for ongoing maintenance of TrOOP Facilitation Software as directed by CMS. To accomplish the tasks described in this Statement of Work, the Contractor must be an existing pharmacy "switch" (i.e., provider of network routing services) with the systems' capacity to process a minimum of 37 million TrOOP Facilitation-related, real-time, electronic transactions per month. As detailed in the following sections, the Contractor shall: 1. Accept and respond to pharmacy-initiated eligibility queries; 2. Accept from pharmacies and other switches Part D claims transactions and route these transactions to the Part D plans; 3. Accept supplemental claims transactions from pharmacies and other switches, and create and route transactions reporting supplemental claims data to the Part D plans; and 4. Create and route automated TrOOP balance transfer transactions and accept responses to these transactions. These tasks require a 24/7 real-time, on-line switching network and connectivity with pharmacies, other pharmacy switches and all Part D plan sponsors, with the exception of Programs of All-Inclusive Care for the Elderly (PACE) organizations that do not participate in the automated TrOOP balance transfer process. Additional Assumptions and Constraints - The contractor shall use All-Fusion ERwin Data Modeler which is the standard data-modeling tool used at CMS. - The contractor shall be responsible for purchasing any hardware needed to accomplish their tasks. (For example: PC's or laptop computers). - The contractor shall establish connectivity as needed to the CMS Baltimore Data Center in order to perform required tasks. - All mid-tier (3-zone) architecture development shall be performed at the contractor's facilities. The contractor shall be responsible for the management of all mid-tier code development. - The contractor shall update and maintain all system and user documentation. Capability Submission: 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. Any information provided will not be returned. Specify the name and telephone number of a point of contact and indicate your size standard under the following North American Industry Classification System (NAICS) (formerly known as the SIC code): 541990- All Other Professional, Scientific and Technical Services - (Size Standard: $6.5 million). Additional information on NAICS codes can be found at www.sba.gov. Please include the following in your response: Business Information -- a. DUNS: b. Company Name c. Company Address d. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. e. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp f. Company Point of Contact, Phone and Email address 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. Submit capability statements not later than April 16, 2010. CMS is not looking for duplication of the language in the sources sought notice, but rather, capabilities to perform the actual work as referenced above. Responses shall be limited to fifteen (15) 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 electronically only to: Landerson3@cms.hhs.gov Attn: Louis Anderson, Contract Specialist Centers for Medicare & Medicaid Services Office of Acquisitions and Grants Management Please refer any questions to: Point of Contact Name: Louis Anderson, Contract Specialist Phone: 410-786-5564 Fax: 410-786-9088 Email: landerson3@cms.hhs.gov