Sources_Sought_Notice_-_200303_-_MSPOS_Program.pdf

Sources Sought Notice (SSN) 200303 Market Stabilization Programs Operational Support

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

Purpose of Notice

This is a SOURCES SOUGHT NOTICE (SSN) issued for the purpose of planning and market research. This is NOT a solicitation for proposals, proposal abstracts, or quotations and this does not obligate the Centers for Medicare & Medicaid Services (CMS) to award a task order.

The purpose of this notice is to determine the availability of 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 on the GSA Professional Services Schedule (PSS) that have the capability to support CMS in all activities associated with providing technical support services that will enhance assisters’ knowledge and skills to facilitate enrollment in insurance coverage through the Patient Protection and Affordable Care Act (PPACA).

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 capability assessment. All information submitted in response to this announcement must arrive on or before the closing date.

Background

On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act (P.L. 111-148). On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) was signed into law. The two laws are collectively referred to as the PPACA. The PPACA creates new competitive private health insurance market or Exchanges. It assists millions of Americans in obtaining affordable health care services and to allow more employers to offer insurance coverage in a cost effective manner to their employees. The Center for Medicare and Medicaid Services (CMS), an agency within the US Department of Health and Human Services (HHS).

Market Stabilization Programs Overview

The Center for Consumer Information and Insurance Oversight (CCIIO) promulgated regulations for the establishment and practices of Health Insurance Marketplace programs established by the Patient Protection and Affordable Care Act of 2010. CMS works with States (including the District of Columbia and the territories) with the health insurance markets or exchanges. The Secretary of HHS tasked CMS with the creation of the Federally Facilitated Exchange (FFE).

PPACA provides states the opportunity to participate in a FFE or choose to establish a State Based Exchange (SBE). Exchanges help individuals and small employers shop for, select, and enroll in high quality, private health plans that fit their needs at competitive prices.

CCIIO focuses on operational program support and related activities for the financial programs associated with the Affordable Care Act of 2010. These financial programs include all tasks related to the permanent risk adjustment program within CMS’ CCIIO Payment Policy and Financial Management Group (PPFMG).

Risk Adjustment

Risk Adjustment is a permanent program created by Section 1343 of the Affordable Care Act and applies to issuers in and out of the Marketplace. The primary goal of the risk adjustment program is to spread the financial risk borne by health insurance issuers. This will help to ensure that premiums remain stable and that issuers will be able to offer a variety of plans to meet the needs of a diverse population. The risk adjustment program intends to provide payments to health insurance issuers that attract higher risk populations by transferring funds from plans that enroll the lower risk individuals to plans that enroll the higher risk individuals. Under this program, charges are assessed to issuers with lower than average risk enrollees, and payments are made to issuers with higher than average risk enrollees. CMS developed a risk adjustment methodology to be used when CMS operates risk adjustment on behalf of a State to determine average actuarial risk of risk adjustment covered plans in that State. Utilizing this risk adjustment methodology, CMS will calculate individual enrollees’ risk scores and determine the average actuarial risk of a plan. CMS calculates corresponding charges and payments upon comparison of Plan average actuarial risk to the State average actuarial risk.

High Cost Risk Pool

CMS finalized the High-Cost Risk Pool (HCRP) as part of the permanent Risk Adjustment program in the 2019 HHS Notice of Benefit & Payment Parameters to begin in benefit year 2018. HCRP is determined in May 2019. HCRP charges begin processing in the August 2019 payment cycle, with payments beginning in the September 2019 payment cycle. Compensation paid to issuers is for a percentage of their costs above a certain threshold at a coinsurance rate via a system of transferred charges and payments within two aggregated national risk/pool markets (individual and small group) calculated independently of, yet similarly to, risk adjustment payment transfer.

In contrast to risk adjustment, which is budget-neutral within each state’s market risk pool, the HCRP program is budget-neutral in each nationwide market pool, with total national charges equaling total national payments. In addition, all issuers in each national market pool will have an HCRP charge, and some will have both a charge and a payment. All issuers in risk adjustment, on the other hand, have either a charge or payment in a respective state risk pool, but never both.

Distributed Data Collection All issuers of risk adjustment covered plans are required to establish an External Data Gathering Environment (EDGE) server where they submit enrollment and claims data for program calculations. Annually, CMS determines which issuers should participate and requires issuers to submit information supporting their EDGE server data submissions. This enables CMS to complete data assessments to ensure sufficient and quality data.

Risk Adjustment Data Validation

The purpose of data validation for risk adjustment is to promote confidence in the budget neutral payment transfer methodology by ensuring the integrity and quality of data provided from issuers operating in state markets under the HHS-operated risk adjustment program. Standards for states, or HHS on behalf of states, to implement a RADV process are provided in the Standards Related to Reinsurance, Risk Corridors, and Risk Adjustment Final Rule (45 C.F.R.

Part 153), published at http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/pdf/2012-6594.pdf on March 23, 2012. This rule is the Premium Stabilization final rule. Section 153.350 of the Premium Stabilization final rule requires states or HHS on behalf of states, to validate a statistically valid sample of data for all issuers that submit data for risk adjustment every year, and provide for an appeals process. The 2014 Final Payment Notice provides requirements to issuers under an HHS-established data validation process and communicates the use of the process for adjustments to payments transfers based on corrected health risk status of their enrolled populations. The 2014 Final Payment Notice also provided additional standards for data validation of issuers when HHS is operating risk adjustment on behalf of a state. The HHS Notice of Benefit and Payment Parameters for 2015, Final Rule (herein referred to as the 2015 Final Payment Notice) further expands on these RADV requirements, published at http://www.gpo.gov/fdsys/pkg/FR-2014-03-11/pdf/2014-05052.pdf on March 11, 2014.

The goal of the data validation audits is to validate issuer-submitted enrollee demographic and health status information used to calculate payment transfers for the risk adjustment program.

The overarching objectives of the data validation program are to:

• Ensure the risk adjustment program produces accurate risk scores for payments and charges calculations.

• Apply consistent audit requirements in order to ensure a level playing field across issuers.

• Leverage existing issuer access to data to conduct data validation activities.

In the 2014 Final Payment Notice, HHS defines a six-stage data validation program when operating risk adjustment on behalf of a state. The six stages are:

• Sampling Selection;

• Initial Validation Audit (IVA);

• Second Validation Audit (SVA);

• Error Estimation;

• Appeals; and

• Payment Adjustments.

In the 2015 Payment Notice, we finalized provisions for the risk adjustment data validation process and detailed methodology that reflect our analysis of the white paper comments and our discussion with stakeholders.

CMS will require issuers to hire IVA entities and require that issuers provide these entities with all information required to validate risk adjustment data accuracy. The IVA entities will be required to conduct the initial data validation process, in accordance with CMS-established requirements, to verify accuracy of issuer-submitted risk adjustment data.

Finally, the SVA will conduct a second level review and oversight of the findings from the initial validation processes. The goals of the CMS oversight audit are to confirm compliance with CMS http://www.gpo.gov/fdsys/pkg/FR-2012-03-23/pdf/2012-6594.pdf http://www.gpo.gov/fdsys/pkg/FR-2014-03-11/pdf/2014-05052.pdf audit requirements, verify audit findings, and compute an estimate of issuer-level error (and other levels of aggregation) in accordance with CMS requirements.

All activities related to the second validation audit including, documentation intake, demographics review, medical records review and abstraction coding, confirming final enrollee demographics and hierarchical condition categories (HCCs), inter-rater reliability calculations, calculation of risk scores, and analysis of findings will take place within the audit tool. SVA users will require direct data entry into the audit tool and need access to an on-line ICD-10 codebook (data and pdf formats) which integrates with the audit tool similar to an encoder process. The SVA contractor will require access to analytical and statistical programs and/or an automatic software program.

The Audit Tool will re-compute risk scores and payment for each enrollee in the audit. Sample error findings are extrapolated to infer overall change in risk score and adjustments to payments or charges for the population. CMS may establish an appeals process for issuers after the second validation audit process. Error estimation and appeals activities are facilitated within the audit tool.

Based on the estimated errors, CMS will derive an appropriate adjustment factor to the risk score calculation and/or payment formulas in the subsequent year to account for errors identified in the data validation process.

Vendor Management The Vendor Management Tool receives and verifies Payee Record information (e.g. banking information) from all PPACA participating issuers and some states, and the transmission of appropriate Payee Record information to CMS’ Healthcare Integrated General Ledger Accounting System (HIGLAS).

The Vendor Management Team receives and maintains Payee Record information used for all PPACA program payments and charges. The Vendor Management Team uses a Salesforce application as their VM Tool, which has both an issuer user interface and a CMS internal user interface. The VM Tool provides issuers with the ability to submit and approve Payee record information, submit questions to CMS, and access program guidance. Access to specific functionality in the VM Tool is determined by each user’s assigned role. On a daily basis, any Payee Record information approved prior to 5 PM EST is transmitted to HIGLAS via a 274 transaction.

Programs Resource Information

The Patient Protection and Affordable Care Act; Standards Related to Reinsurance, Risk Corridors and Risk Adjustment [CMS-9975-F] for the various financial management programs was published on March 23, 2012, and can be found at http://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0022-0692.

The Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 [CMS-9964-F] (Payment Notice) which amended and added certain requirements to the financial management programs can be found at:

http://www.regulations.gov/#!documentDetail;D=CMS-2012-0152-0398.

The Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified http://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0022-0692 http://www.regulations.gov/#!documentDetail;D=CMS-2012-0152-0398

Health Plans [CMS-9989-F] for implementing Health Insurance Marketplace standards was published on March 27, 2012, and can be found at http://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0020-2420.

CMS provides ongoing technical and policy information concerning the above listed premium stabilization programs on CMS website at: http://www.cms.gov/CCIIO/Programs-and- Initiatives/Premium-Stabilization-Programs/index.html

Requirements

The work requires multifunctional operations support providing assistance related to the Marketplace programs (e.g. Premium Stabilization Programs, etc.) including but not limited to developing program operating procedures, disseminating information to program stakeholders, implementing program registration systems, performing statistical calculations, analytical reviews, and program code updating of the RADV audit tool for data validation process and other collection activities within Salesforce, managing payment discrepancies and inquiry response system via triage and knowledge base responses. These functions reside within the CCIIO’s Payment Policy and Financial Management Group (PPFMG).The scope of work also includes providing stakeholder training and educational outreach via a variety of media including webinars, user group calls, and updating operational documentation and manuals, and other electronic materials for PPFMG. The support tasks include working with PPFMG to develop and maintain program support related to existing and new projects, identify critical components that require standard operating procedures, and develop an effective timeline in completing the program tasks including analysis and reporting. Training and outreach will be targeted to various audiences, including issuers, agents, brokers, Third Party Administrators (TPAs), Pharmacy Benefit Managers (PBMs), State Departments of Insurance, issuers’ vendors, and additional stakeholders. At a minimum, the following knowledge, experience, and skills are required:

Knowledge of the Healthcare Industry and PPACA

• Extensive knowledge of private health industry including PPACA nuances

• Expertise regarding healthcare laws, policies and regulations; e.g. PPACA

• Experience on providing program support for health insurance programs

• Demonstrate previous experience interpreting and operationalizing federal legislation and regulations

Outreach, Training, and Education Materials, Program Documentation Maintenance

• Expertise or experience developing SOPs and developing internal control plans

• Experience in developing, adapting or updating trainings and manuals and securely and effectively training if necessary other CMS contractors

• Extensive knowledge and support best practices in outreach, education, training, and triaging and responding to inquiries received through inquiry response tool.

• Experience with developing and implementing communication plans to stakeholders

• Demonstrate ability to conduct training activities and capacity to provide technical support to a large number of entities

• Expertise with assisting stakeholders with registration activities and needs

• Demonstrate ability to provide training and technical materials in varying formats that is clear, concise, effective, and in plain language http://www.regulations.gov/#!documentDetail;D=HHS-OS-2011-0020-2420 http://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html http://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html

Develop and Analyze Operational Metrics of Data Submissions

• Demonstrate capability to perform complex calculations, extensive data analysis, and generate reports and ad hoc statistical analysis as required

• Extensive knowledge and ability to use various tools for data analysis such as SAS® dataset, Microsoft Excel table, Microsoft Access, or other specified formatting

Salesforce Maintenance and Development Support Services

• Expertise or experience developing responses or updating inquiry knowledge base

• Extensive experience in information technology programing including Oracle, Python, JavaScript and Salesforce ; including statistical calculation programing

• Maintain experienced certified Salesforce developers and administrators including requirements writers and testers for implementation of any systematic updates

• Expertise or experience of IT regarding security, programing, testing and Salesforce;

ISSO required with ability to perform SCA and TRB reviews for any programing updates to secure an ATO by CMS.

• Support and complete applicable updates for IT initiatives such as cloud migration and enterprise identification management

Staffing Requirements

• Have sufficient knowledge and resources (staffing) to support all activities and potential competing deadlines of time sensitive programs

• Ability to adjust workflow volume and increase staffing accordingly in response to the business needs of the premium stabilization programs and stakeholders throughout the year within budgetary constraints.

• Expertise with managing multiple regulatory demands and timelines; with staffing and workflow requirements; e.g. PMP or equivalent with budgetary knowledge

• Maintain IT personnel capable of Information System Security Officer (ISSO) responsibilities along with adequately documenting the necessary information for purposes of obtaining an Authorization to Operate (ATO).

• Experienced Certified Salesforce developers, administrators, independent testing services, system documentation all related to the XLC.

Capability Statements

In response to this SSN, CMS is seeking capability statements. Capability statements are NOT quotes and do not address price/cost. The contractor community is asked for information which proves that they have expertise and capacity to meet the requirements of this work. A mere statement that the vendor has a required capability is not sufficient. No marketing literature should be submitted.

When answering the following questions, vendors must provide specific and detailed examples of work that was performed that demonstrate required capabilities and the attendant level of effort that was involved:

1. Do you have a thorough understanding of PPACA including the Premium Stabilization Programs, as well as related regulations and sub-regulatory guidance?

2. Do you have prior experience in responding quickly to ad hoc requests that require immediate attention due to policy or regulatory changes?

3. Do you have prior experience working collaboratively with multiple entities, including Federal agencies, States, and other contractors, to accomplish program objectives on a nationwide scale?

4. Do you have prior experience in developing and managing an effective project management plan that includes a proven track record of keeping to a schedule, managing multiple time sensitive or competing tasks, while remaining on budget?

5. Do you have prior experience developing and conducting presentations for training of stakeholders?

6. Do you have prior experience developing or updating Standard Operating Practices (SOPs), training manuals, and instructional web form guides?

7. Do you have prior knowledge, and experience of updating and developing internal control plans?

8. Do you have experience importing, exporting, securing and managing large data files, containing PII or PHI, including data programming?

9. Do you have experience with data validation, performing complex calculations, and statistical analysis?

10. Do you have experience with Python, JavaScript and Salesforce programming and to what extent? CMS utilizes Salesforce as RADV audit tool, EDGE server data collection for data analytics, and Vendor Management Tool to process banking/financial institution data for creating vendor IDs.

11. Do you have experience performing extensive healthcare related data and statistical analyses; e.g. enrollment, medical and pharmacy claims, medical record coding comprehension, and error rate calculations, etc.?

12. Do you have experience developing and implementing IT projects utilizing the eXpedited life cycle (XLC) process; including document development, testing, and review to obtain ATO and SCA (security controls assessors)?

13. What is your experience in managing multifunctional work and multiple programs; e.g.

Certified Salesforce developers, personnel with Oracle, Python and Java script programing knowledge, ISSO, technical writers for system documentation, knowledge of CMS XLC and documentation requirements and personnel to respond and triage incoming inquiries?

Responses Requested

Please submit your responses by 12:00pm on April 10, 2019 to Lakisha.Holly@cms.hhs.gov and Matthew.Waskiewicz@cms.hhs.gov in the following format:

mailto:Lakisha.Holly@cms.hhs.gov mailto:Matthew.Waskiewicz@cms.hhs.gov

• Microsoft Word (or PDF) document with page size 8.5 by 11 inches, with a minimum of 1" margins.

• Calibri Font Size 12 with no less than single spacing between lines.

• Submissions shall not exceed 6 pages. Cover Page is included in the total page count.

Please be advised that email-transmitted files over 5 megabytes are not delivered during standard working hours, are only released from the CMS server after 5:00 PM EST, and may affect the timeliness of your response.

Cover Page

Vendors shall include the following Business information on the Cover Page:

a) SSN number, title, and date of issuance

b) DUNS

c) Company Name

d) Company Address

e) Company Point of Contact, Phone and Email address

f) Current GSA Schedules appropriate to this effort

g) NAICS code under which the company conducts business as a small business and socio-economic status of the small business as validated via the System for Award Management (SAM). All potential offerors must be registered in SAM located https://www.sam.gov/portal/SAM/#1

h) Number of full-time employees

Confidentiality

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).

Disclaimer and Important Notes

This notice does not obligate the Government to award a task order or otherwise pay for the information provided in response. 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.

Teaming Arrangements

Firms seeking to respond to this notice as a team or to rely on subcontractors to perform any portion of the work must include the above-requested information and certifications for each entity on the proposed team or each proposed subcontractor. Responses must clearly indicate the nature of the teaming arrangement.

The contractor and any subcontractors must not have any relationships or arrangements through business operations or its employees that could be considered as possibly lessening the company’s objectivity concerning any aspect of the proposed tasks. If such relationships or http://www.sam.gov/portal/SAM/#1 http://www.sam.gov/portal/SAM/#1 arrangements exist, contractors or subcontractors shall be required, during the procurement process (if one occurs), to identify potential conflicts of interest and discuss how the conflicts will be addressed and mitigated.

Similar Situated Entities

Description of how the respondent will provide at least 50% of the cost of labor (including indirect charges) required to perform the services. In the event of conflict between FAR clause 52.219-14 and 15 U.S.C. § 657s, for purposes of the limitations on subcontracting, CMS will follow 15 U.S.C. § 657s.