J.1 Statement of Work

Attachment J.1 A/B MAC Statement of Work

RFP # 75FCMC19R0023

Jurisdiction E V.6.5 Part A and Part B Medicare Administrative Contractor Statement of Work Jurisdiction E Last Revised: 02/15/2019

Contents

1. Scope The Contractor, as an independent Contractor and not as an agent of the government, shall furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the government, as needed to perform the work described in this Statement of Work (SOW).

The Contractor shall perform all Medicare Administrative Contractor (MAC) functions specified in this SOW and further defined in either the Internet-Only-Manuals (IOMs, http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage) or the Paper-Based Manuals, in accordance with Section C.2.3 of this SOW. For purposes of this contract, when differences or conflicts occur, this SOW shall take precedence over the IOMs unless otherwise specified. The Contractor shall contact the Contracting Officer (CO) and the Contracting Officer’s Representative (COR) if budgetary concerns occur because of this conflict. The Contractor is advised that any and all references in the SOW (including manuals, IOMs, etc.) to “RO-Regional Office” shall be replaced with “CO-Contracting Officer” unless otherwise specified in this SOW. Appendix A contains definitions of all abbreviations used in this SOW.

Purpose of Contract The purpose of this contract is to obtain a Medicare Administrative Contractor (hereinafter, referred to as “the Contractor” or “MAC”) to provide specified health insurance benefit administration services, including Medicare claims processing and payment services, in support of the Medicare fee-for-service (FFS) program. The Contractor will perform its responsibilities under the direction of the Centers for Medicare & Medicaid Services (CMS).

Under this contract, the Contractor will perform numerous functions to support health care services for Medicare beneficiaries, which include performing claims-related activities and establishing relationships with providers of health care services, both institutional and professional, for a defined geographic area or “jurisdiction.” The Contractor will perform the requirements of this contract in accordance with applicable laws, regulations, Medicare manuals, and CMS requirements to ensure the financial integrity of the Medicare program. The Medicare program’s legal, policy, and operating environment is complex, and the Contractor will utilize or interact with certain CMS-required payment schedules, systems, equipment, and operational capabilities in the performance of its functions. Further, the Contractor will coordinate its activities not only with the CMS, but also with a broad range of agencies (at the federal, state, and local levels of government), other CMS partners and Contractors, and a diverse range of stakeholders within the health care system of the United States.

The Contractor will receive and control Medicare claims from institutional and professional providers, suppliers, and beneficiaries within its jurisdiction and will perform standard or required editing on these claims to determine whether the claims are complete and should be paid. In addition, the Contractor will calculate Medicare payment amounts and arrange for remittance of these payments to the appropriate party. The Contractor also will enroll new providers; conduct redeterminations on appeals of claims; operate a Provider Customer Service Program (PCSP) that educates providers about the Medicare program and responds to provider telephone and written inquiries; respond to complex inquiries from Call Center Operations (CCOs); and make coverage decisions for new procedures and devices in local areas. The Contractor also will conduct a variety of different provider services, such as enrolling new providers in the program, answering written inquiries, and educating providers on Medicare’s rules, regulations, and billing procedures.

The Contractor shall furnish services to all the providers CMS designates as within the Contractor’s workload. The Contractor’s workload will, from time to time, contain out-of-jurisdiction providers. Out-of-jurisdiction providers will be moved to their destination workloads at a later date when CMS systems are capable of supporting the move.

The mission of CMS is to ensure health care security for beneficiaries. This contract specifically applies to that mission by fostering excellence in the design and administration of CMS’ programs.

Background The Medicare program is an integral component of the federal government’s commitment to the health and welfare of the American people, which includes the Social Security system, the Medicaid program (which is primarily administered by the states), and other programs. The Medicare program provides affordable health insurance to (1) eligible individuals aged 65 and over; (2) certain individuals eligible for disability benefits under the Social Security system; and (3) individuals with acute kidney failure (end-stage renal disease, or ESRD). Approximately 52 million people were enrolled for Medicare coverage in Calendar Year 2013.

Nearly all Medicare beneficiaries may access their insurance benefits through one of two health care delivery systems:

First, in all areas of the country, a beneficiary may enroll in the traditional Medicare program (the Medicare FFS program) under which benefits are largely provided in keeping with an indemnity insurance model. That is, the beneficiary chooses his/her health care providers, the providers bill the appropriate Medicare claims administrator for their services, and the claims administrator pays the provider based on the eligibility, coverage, and payment rules of the Medicare Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) programs. The federal government bears all financial (underwriting) risk for the cost of program benefits and develops detailed administrative requirements and processes to support the claim administration process. This national entitlement program has a strong imperative to provide a common level of benefits and service in all areas of the country, while maintaining adequate flexibility to account for local and regional medical practices. More than 72% of all Medicare beneficiaries participate in the traditional Medicare program.

Second, in many areas of the country, beneficiaries have the option to enroll in one or more privately sponsored Medicare plans under the Medicare Advantage (MA, formerly Medicare+ Choice) program. These private Medicare plans may organize themselves in keeping with one of several health care delivery and payment models (health maintenance organizations, preferred provider organizations, etc.). These private Medicare plans are required to cover the same basic benefits that the traditional Medicare program offers, but they are given fairly broad responsibility and latitude to set up their internal requirements and processes as they see fit. About 28% of Medicare beneficiaries are enrolled in Medicare Advantage.

The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) includes significant incentives to increase the participation in Medicare Advantage. However, for the next decade at least, a significant majority of all Medicare beneficiaries will likely remain enrolled in the traditional FFS Medicare program. FFS coverage in the Medicare program consists of two distinct parts: (1) HI, and (2) SMI, which provides coverage for the professional medical services of physicians and certain other licensed practitioners, as well as coverage for a variety of other services and items (ambulance, durable medical equipment, etc.). In common usage, the HI program is known as “Medicare Part A,” although both the Part A and B trust funds are used to reimburse institutional claims. The SMI program is known as “Medicare Part B”; only the Medicare Part B trust fund is used to reimburse Part B claims.

Medicare Part A Services covered under Part A are: hospital inpatient services, skilled nursing facility (SNF) inpatient services, and swing bed services (SNF level in a rural hospital having less than 50 beds), hospice services, and some Home Health services. Institutional services processed by FIs but paid under Part B include: hospital outpatient services, SNF outpatient services, all specialty facility services, such as dialysis for End Stage Renal Disease beneficiaries, outpatient rehabilitation services, regardless of the type of institution, and some Home Health services.

Nearly all Medicare beneficiaries are entitled to receive their Medicare Part A (HI) without payment of any insurance premium. Beneficiaries must elect to enroll in Medicare Part B (SMI), for which they must pay a monthly premium, and nearly all do so. In FY 2013, about 47.2 million individuals were enrolled in both Medicare Part A and Part B. A relatively small number of beneficiaries were enrolled in Part A only (4.3 million) or Part B only (0.4 million).

Under Medicare law, the Medicare HI (Part A) benefit is funded through the HI trust fund. The primary revenue source for the HI trust fund is a wage tax administered through the Social Security system. The HI trust fund accumulates a significant balance in excess of the amount needed for ongoing satisfaction of claims. The trustees of the HI trust fund include the Secretaries of the Treasury, Labor, and Health and Human Services. The Social Security Administration (SSA) Commissioner and two members of the public also serve as trustees of the HI trust fund.

Medicare Part B The Medicare SMI (Part B) benefit is administered through the SMI trust fund. Unlike the HI fund, however, the SMI trust fund does not accumulate a significant balance in excess of the amount needed for ongoing satisfaction of claims. In addition to receipts from beneficiary premiums, the primary revenue source for the SMI trust fund is an annual congressional appropriation from the Treasury’s general revenues. The trustees for the SMI trust fund are the same as those for the HI trust fund.

Medicare spending – both HI and SMI – is a substantial portion of the federal government’s annual budget and the health care economy of the United States. In 2013, total HI spending for Medicare Fee-For-Service (FFS) equated to $190.9 billion, and total SMI Part B for Medicare FFS spending equated to $176.2 billion. These amounts are reflective of Medicare FFS only and do not include expenditures for Part C and Part D.

The CMS relies on a network of contractors to process Medicare claims; enroll health care providers in the Medicare program and educate them on Medicare billing requirements; handle claims appeals; and answer beneficiary and provider inquiries. Fiscal intermediaries (FIs) handle claims processing and benefit payment functions for institutional providers under Part A and Part B of the Medicare program; carriers perform the same functions for professional providers under Part B of the program.

Contracting Reform On December 8, 2003, the President signed into law the MMA (Public Law 108-173). Section 911 of MMA directed implementation of Medicare FFS Contracting Reform. Medicare Contracting Reform requires that the CMS use competitive procedures to replace its current FIs and carriers with a uniform type of administrative entity, referred to as a MAC.

Roles and Responsibilities The roles and responsibilities of the parties are outlined below.

The Centers for Medicare & Medicaid Services The Medicare program’s authorizing statutes charge the Secretary of the Department of Health and Human Services (DHHS) with administrative responsibility for the Medicare program. The Secretary has delegated the program authority for Medicare (both the traditional FFS program and Medicare Advantage) to the CMS Administrator.

The CMS administers the Medicare program, including formulation and promulgation of Medicare program policy and guidance, contract execution, operation and management, maintenance and review of utilization records, and general Medicare financing. The CMS is the largest purchaser of health care in the United States and provides health care coverage to nearly one in four Americans. The CMS’ annual budget places it among the largest businesses in the world; its programs channel one out of every three dollars in the health care market, and its policies influence the other two dollars. In FY 2013, CMS Contractors processed approximately 1.2 billion Medicare claims.

As part of its responsibility to administer the Medicare program, the CMS manages the work of the contractors engaged in its day-to-day operation. This management is accomplished through a variety of avenues such as periodic conferences on topics of general interest; targeted sessions with selected subsets of the contractors; issuance of manual updates describing changes in coverage, pricing, and eligibility; and evaluation of the performance of those contractors within the description of the work the CMS engages them to do.

Business Function Leads and Technical Monitors Within the CMS, specialists on various Medicare topics shall serve as Business Function Leads (BFLs) and Technical Monitors (TMs) to assist the COR and the CO in administering the contract. These BFLs/TMs shall provide technical guidance to the Contractor on matters within each BFL’s/TM’s area of responsibility. The BFL/TM shall consult with the COR on Technical Direction as necessary. The BFL/TM is not authorized to direct changes to contract work.

The MACs shall support the CMS field offices in their efforts to combat fraud, waste, or abuse and protect the Medicare Trust Fund.

Medicare Administrative Contractor (“The Contractor”) Section 1861 of the Social Security Act (“the act”) defines the items and services for which Medicare may pay. It also defines the provider types recognized by the Medicare program. The Contractor is responsible for handling all the claims identified in the act, and related requirements identified in section C.5 of this Statement of Work (SOW), that are within its jurisdiction, except for the distinct types of claims that are identified as additional services in section C.7 of this SOW. The MAC is also responsible for processing Part A claims for Railroad Retirement Board Beneficiaries (RRB). The types of claims identified as additional services in Section C.7 are also mandatory requirements under the contract.

The complexity of Medicare payment systems and policies and the numbers of contractors, providers, and insurers involved in the Medicare FFS program create vulnerabilities for error. To minimize these vulnerabilities and reduce the Medicare claims payment error rate, CMS has made paying claims right, the first time, one of its primary goals. This means paying the right amount, to legitimate providers, for Medicare-covered, reasonable and necessary services provided to eligible beneficiaries. Paying right the first time saves resources required to recover improper payments and ensures the proper expenditure of valuable Medicare trust fund dollars.

In the interest of consistency across the Medicare program, during the performance of this contract, the Contractor is expected to seek and follow advice from CMS on questions of law and policy as they arise.

Information relating to A/B MAC claims processing, information flows, interfaces and other supporting processes with “functional Contractors” can be found in both the Concept of Operations document located at the following URL: http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/Functional-Contractors-Overview-2013.pdf and the A/B Claims Processing Enterprise Architecture which can be found at the following URL: http://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/A-B-Enterprise-Claims-Processing-Architecture.pdf Unique Requirements for the MAC Under Title XVIII of the Social Security Act, the CMS contracted with individual fiscal intermediaries (FIs) and carriers to perform unique work and tasks beyond the base scope of the FI and Carrier contracts. These special contract arrangements were for work that may have affected beneficiaries and/or providers in every state and/or region.

Unique Core Requirements Under Medicare contracting reform, the CMS has decided to include some of these unique contract tasks within the core work requirements for each A/B MAC jurisdiction. Table 1 lists the activities that are incorporated into the core requirements for each A/B MAC jurisdiction.

Table 1 Unique Core Requirements

All bidders should ensure they understand the impact to the functional requirements of these workloads.

Jurisdiction-Specific Requirements In addition to the requirements described in section C.1.4.3.1, the CMS has identified requirements for the MACs that are specific to a jurisdiction. Jurisdiction-Specific Requirements are located in Section C.7.

Reserved Applicable Documents The following statutes, regulations, manuals, and documents apply to this contract.

Statutes The Contractor must comply with all applicable laws. The major statute governing the Medicare program is Title XVIII of the Social Security Act (“the Act”), as amended. The Act and major amendments to the Act are outlined below. The identified amendments include legislation that significantly changed the Medicare program, are being implemented, or significantly affect the scope of work. Congress may pass new legislation at any time, and the Centers for Medicare & Medicaid Services (CMS) must act to implement such legislation as timely and accurately as possible.

Social Security Act (Public Law 74-271) The Act was enacted on August 14, 1935, with subsequent amendments. The Act consists of 20 titles, four of which have been repealed. The Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) programs are authorized by Title XVIII of the Act. The vast bulk of the traditional Medicare program’s authorizing law is codified in Parts A, B and E of Title XVIII. (Part C is primarily devoted to private Medicare plans, and Part D governs the Medicare prescription drug benefit.) Other Medicare-related authorizing statutes are in Titles II and XI of the Act; other governing provisions are in the Internal Revenue Code and other statutes.

To the extent that there is no conflicting Medicare requirement, the administration of the traditional Medicare program is also governed by numerous statutes pertaining to the general administration of federal programs. The following are among the general statutory authorities with broad implications for the traditional Medicare program and the Medicare Administrative Contractor (MAC) contract:

a) Acquisition (Competition in Contracting Act, etc.)

b) Federal Information Security Management Act of 2002 (FISMA)

c) Government Performance and Results Act (GPRA)

d) Personnel and civil rights law (Drug-Free Workplace Act, Americans with Disability Act)

e) Privacy and information technology requirements (Privacy Act of 1974, Information Technology Management Reform Act of 1996).

f) Rehabilitation Act of 1973 (section 508, Accessibility Standards) Medicare Prescription Drug, Improvement and Modernization Act (Public Law 108-173) On December 8, 2003, the President signed the Medicare Prescription Drug, Improvement and Modernization Act (MMA) into law. This statute makes the most sweeping changes in the structure of the Medicare program since its inception in 1966. The significant changes made by this statute include the following:

a) Establishment of a temporary Medicare prescription drug discount card program.

b) Establishment of a permanent Medicare prescription drug program.

c) Renaming of the Medicare+Choice to Medicare Advantage and provision of significant new incentives to facilitate the participation of private plans in Medicare.

d) Provision of certain preventive benefits under both traditional Medicare and Medicare Advantage.

e) Implementation of many changes in coverage and payment policy within traditional Medicare.

f) Implementation of many administrative and regulatory reforms within traditional Medicare.

g) Under Section 911 of the MMA, restructuring of the acquisition statutes that govern traditional Medicare, commonly known as Medicare contracting reform.

h) Under Section 912 of the MMA, requirements for information security program and independent evaluations.

i) Under Section 921 of the MMA, provision requiring toll-free lines for provider inquiries and an expansion of provider education.

The work under this contract will be affected by many of these provisions; however, the primary authority governing the terms and conditions of this contract is Section 911.

Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996. Title II, Subtitle F, of HIPAA gives the Department of Health and Human Services (DHHS) the authority to mandate the use of standards for the electronic exchange of health care data; to specify what medical and administrative code sets should be used within those standards; to require the use of national identification systems for health care patients, providers, payers (or plans), and employers (or sponsors); and to specify the types of measures required to protect the security and privacy of personally identifiable health care information.

Administrative Simplification Compliance Act of 2002 (Public Law 107-105) The Administrative Simplification Compliance Act requires that providers of healthcare submit their claims to Medicare electronically, with limited exceptions, to qualify for payment.

Tax Equity and Fiscal Responsibility Act of 1982 (Public Law 97-248) The Tax Equity and Fiscal Responsibility Act (TEFRA) made Medicare the secondary payer for certain employees and dependents.

Benefit Improvement and Protection Act of 2000 (Public Law 106-554) Section 521 of the Benefit Improvement and Protection Act (BIPA) changed the Medicare appeals process to create a uniform procedure for handling all Medicare appeals (Parts A and B) and specified time frames for filing appeals and rendering decisions.

Executive Order 13410 To the extent applicable and practical, the MAC shall follow Executive Order 13410: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. This Executive Order promotes the efficient delivery of quality health care through the use of health information technology, transparency regarding health care quality and price, and incentives to promote the widespread adoption of health information technology and quality of care. To support this mission, the MAC shall use recognized health information interoperability standards at the time of this contract, in all relevant information technology systems supported, in whole or in part, through this contract. This includes existing standards from the Health Information Technology Standards Panel (HITSP) that have been recognized by the Secretary of HHS. Specific information regarding the HITSP standards can be found at www.hitsp.org.

Regulations Generally, Medicare regulations are located in Title 42 and 45 of the Code of Federal Regulations (CFR).

Medicare Manuals Medicare manuals (e.g., Internet-only manuals—IOMs) are CMS program instructions, day-to-day operating instructions, policies, and procedures that are based on statutes and regulations, guidelines, models, and directives. CMS program components, providers, Contractors, and state survey agencies use Medicare manuals to administer CMS programs. As CMS paper-based manuals are updated, the updated materials are published in the IOMs and eliminated from the paper-based manuals. The IOMs have precedence over paper-based manuals. The CMS will continue this phase-out/phase-in process until all manual instructions are in the IOMs. IOMs and paper-based manuals can be found at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage. Citations in this SOW are generally to an IOM Publication (IOM Pub.). Paper-based manual citations are used only where necessary (indicated as CMS Pub. XX).

The Contractor shall promptly notify the Contracting Officer’s Representative (COR) if the Contractor believes that any IOM or Paper-Based Manual instruction contradicts or conflicts with a Medicare policy requirement. For the purposes of this notification requirement, a “Medicare policy requirement” includes any requirement in law, regulation, a CMS ruling, a national coverage determination, or another CMS manual instruction; moreover, within the boundaries of the jurisdiction covered by this A/B MAC contract, the term “Medicare policy requirement” also includes a policy article or local coverage determination established by the Contractor. Moreover, in accordance with CMS change request (CR) number 6954, the Contractor cannot assert clinical review judgment to override, supersede, or disregard a Medicare policy requirement.

Key Definitions Several Statement of Work (SOW) appendices contain definitions critical to understanding this SOW. Appendix A is an alphabetical listing of key definitions. This appendix is not intended to be an all-inclusive list of definitions for terms used throughout the SOW. Additional definitions are available on http://www.cms.hhs.gov/apps/glossary/.

Objectives This acquisition supports the mission of the Centers for Medicare & Medicaid Services to ensure health care security for beneficiaries.