RFP # 75FCMC27R0001

Attachment J.23 – Government Provided Proposal Assumptions (GPPA)

J.23 GOVERNMENT PROVIDED PROPOSAL ASSUMPTIONS (GPPA)

1. CONTRACT AWARD

The Centers for Medicare & Medicaid Services (CMS) anticipates awarding the Part A and Part B Medicare Administrative Contractor (A/B MAC) contract for Jurisdiction 8 (J8) 8-12 months from receipt of proposals. J8 includes the states of Indiana and Michigan.

2. IMPLEMENTATION CUTOVER

a. Implementation Cutover The Offeror shall use the information provided in this section when developing its proposed Contract Line Item Number (CLIN) 0001 costs associated with its Jurisdiction Implementation Project Plan. The Offeror shall assume that CMS will assign new Medicare workload identification numbers to the J8 Part A and Part B workloads, effective at cutover, consistent with Change Request (CR) 6259.

At the implementation cutover, the outgoing MAC ceases Medicare operations and the incoming MAC begins to perform Medicare business functions (CLIN 0002) for that segment/jurisdiction. The following table considers each individual Customer Information Control System (CICS) Production region as an individual “segment.” Table 1 identifies all of the CICS Production regions in J8. In addition, the breakdown of User Acceptance Testing (UAT) regions for J8 mirrors the configuration (the same number and breakdown) of Production regions for J8.

For proposal purposes, the Offeror shall assume that CMS will support the build-out of new CICS production and UAT regions to mirror the configuration employed by the outgoing MAC as shown in Table 1, in order to support simulation testing and the conversion of claims history to the Offeror’s own claims history edit/audit taxonomy; further, the Offeror shall assume that CMS will arrange for necessary implementation support from the maintainers of the Fiscal Intermediary Standard System (FISS), Multi Carrier System (MCS), and Common Working File (CWF) systems as well as the Hybrid Cloud Data Center (HCDC) and the CWF host and other CMS systems. The Offerors shall not propose any change to the number or configuration of CICS production or CICS UAT regions for the Implementation period. Offerors may propose an alternative approach to Implementation period simulation testing and claims history build-out within the following parameters:

· Offerors must propose the build-out of new test and production CICS regions for every workload where they are not the incumbent. The Offeror may not propose an implementation approach that adjusts or reduces the need for four (4) CICS production and four (4) UAT regions.

· The Offeror shall not propose changes to any of the dates / timeframes for segment cutovers provided in this Attachment (J.23), item 2. However, the Offeror may propose a contract implementation approach that adjusts or reduces certain CMS-provided assumptions regarding IT infrastructure, as presented in the Statement of Work (SOW) (Attachment J.01) and / or the Medicare Administrative Contractor Workload Transition Handbook (https://www.cms.gov/files/document/medicare-administrative-contractor-workload-transition-handbook-v3012112019.pdf), such as reducing the need for conversion of edit / audit history, reducing the need for simulation testing, etc. Should the Offeror choose to adjust or reduce any such CMS-provided assumptions, the Offeror shall list these modified assumptions in Vol. II, Tab C, with clear rationale for said adjustments/reductions and a clear explanation of how the Offeror’s plan will successfully accomplish the jurisdictional systems implementation, even with such adjustments/reductions.

Table 1: Implementation Cutover CICS Regions/Segments

b. Healthcare Integrated General Ledger Accounting System (HIGLAS)

All workloads have been converted to HIGLAS. For proposal purposes, Offerors shall assume that the J8 accounting operations have already been consolidated to one HIGLAS "organization ID" for Part A and one HIGLAS “organization ID” for Part B.

c. Joint Operating Agreements (JOAs); Operational Start Dates; CLIN Start/End Dates

Joint Operating Agreements between functional contractors impacting the new MACs shall be executed prior to the operational start date. (See SOW (Attachment J.01) section C.6.1 for more information on required JOAs.) The operational start date is defined as the date that the MAC assumes all Medicare functions from an outgoing contract and is capable of processing Medicare claims for that jurisdiction. Please refer to the implementation timeframes in the chart above for proposal purposes. These timeframes are depicted in the timeline below.

RFP # 75FCMC27R0001

Attachment J.23 – Government Provided Proposal Assumptions (GPPA)

Implementation and Base Periods Illustration:

6 months for Part B

Overlapping Implementation and Base Periods are shown below:

CLIN 0001 – Implementation

Start of CLIN 0001

End of CLIN 0001

CLIN 0002 – Base Period Start of Part A Base Period Start of CLIN 0002 Start of Part B Base Period End of Base Period End of CLIN 0002

Table 2: Periods of Performance (POPs)

Part B Date of contract award – 4 months Date of contract award – 6 months

Part B Date of Part A cutover – 8 months Date of Part B cutover – 6 months

Workload Initiative (MCRWI)

3. JURISDICTION 8 – FACILITIES POPULATION BY TYPE

Within the Audit & Reimbursement Tables (Attachment J.23A), there is a tab titled “Facilities by Type” which presents the health care facilities populations, by type, that will be served by the A/B J8 MAC. The Offeror shall use these facility counts when proposing hours and costs for its provider audit and reimbursement activities (in addition to the workloads in the Basis of Estimate (BOE) (Attachment J.22)), as well as provider education and outreach activities, when completing the BOE and the Business Proposal. Below is a brief description of the tables that are presented on the “Facilities by Type” tab in Attachment J.23.A:

· Table 3: Hospital Population by Type

· Table 4: Other Facilities Population by Type

· Table 5: Total Freestanding Facilities

· Table 6: Hospital Based Subproviders Populations by Type

4. JURISDICTION 8 – FACILITIES BY STATE

Within the Audit & Reimbursement Tables (Attachment J.23.A), there is a tab titled “Facilities by State” which presents the health care facilities populations by state and type that will be served by the A/B J8 MAC. For J8, the Offeror shall assume a total of 2,320 Part A “in-jurisdiction” and 164 “out-of-jurisdiction” facility-type providers, many of which are chain-affiliated providers. The Offeror shall assume that it will service all of these facilities for all periods of performance, including Base Period (BP) through Option Year 8 (OY8). The Offeror shall use these volumes when proposing hours and costs for its provider audit and reimbursement activities as well as provider education and outreach activities when completing the BOE (Attachment J.22) and the Business Proposal. The total health care facility mix of the A/B J8 MAC will be comprised of the providers listed in Table #7-8. Below is a brief description of the tables that are presented on the “Facilities by State” tab of Attachment J.23.A:

· Table 7: Jurisdiction 8 Facilities by State – Facilities Within Jurisdiction

· Table 8: Jurisdiction 8 Facilities by State – Facilities Out of Jurisdiction

5. JURISDICTION 8 ESTIMATED ANNUAL WORKLOADS

Within the Audit & Reimbursement Tables (Attachment J.23.A) there is a tab titled “Estimated Annual Workloads” that presents a breakdown of the estimated annual audit workloads by type and task. The Offeror shall use this information when proposing hours and costs for its provider audit and reimbursement activities when completing the BOE (Attachment J.22) and the Business Proposal. Below is a brief description of the tables that are presented on the “Estimated Annual Workloads” tab of Attachment J.23.A.

· Table 9: Estimated Annual Workloads – Cost Report/Cost Statement Acceptance

· Table 10: Estimated Annual Workloads – Tentative Settlement

· Table 11: Estimated Annual Workloads – Full Desk Reviews

· CMS used the numbers and types of providers in this jurisdiction to estimate the reasonable number of direct labor hours (shown in Table 11) expected to complete the OY1 full desk review workload as shown in the BOE. CMS will use this estimate when reviewing proposals for this workload. Offerors that propose to adjust the CMS-estimated hours for full desk reviews must explain why the adjustment is reasonable.

· Table 12: Estimated Annual Workloads – Limited Desk Reviews

· CMS used the numbers and types of providers in this jurisdiction to estimate the reasonable number of direct labor hours (shown in Table 12) expected to complete the OY1 limited desk review workload as shown in the BOE. CMS will use this estimate when reviewing proposals for this workload. Offerors that propose to adjust the CMS-estimated hours for limited desk reviews must explain why the adjustment is reasonable.

· Table 13: Estimated Annual Workloads – Audits

· CMS used the numbers and types of providers in this jurisdiction to estimate the reasonable number of direct labor hours (shown in Table 13) expected to complete the OY1 audit workload as shown in the BOE. CMS will use this estimate when reviewing proposals for this workload. Offerors that propose to adjust the CMS-estimated hours for audits must explain why the adjustment is reasonable.

· Table 14: Estimated Annual Workloads – Interim Rates – PIP Reviews

· Table 15: Estimated Annual Workloads – Interim Rates

· Table 16: Estimated Annual Workloads – Cost Report Settlements

· Table 17: Estimated Annual Workloads – Reopenings (Completed)

· The workload numbers provided in this table and in the BOE represent completed annual workload numbers rather than anticipated receipts. Offerors shall propose the staffing resources and costs for completion of the Reopening workloads provided. Offerors shall not change the workload numbers for Reopenings (Completed).

· Table 18: Estimated Annual Workloads – Cost Report Appeals

· Table 19: Estimated Annual Workloads – Wage Index

· Table 20: Estimated Annual Workloads – S-10 Audits

· Table 21: Estimated Annual Workloads – Hospice CAPs

· Table 22: Estimated Annual Workloads – File Maintenance

· Table 23: Estimated Annual Workloads – Special Payment Status

· Table 24: Estimated Annual Workloads – End Stage Renal Disease (ESRD) Special Audits

6. JURISDICTION 8 ADDITIONAL INFORMATION

Within the Audit & Reimbursement Tables (Attachment J.23.A), there is a tab titled “Additional Information” that presents Offerors with jurisdiction specific information relative to the audit and reimbursement workloads presented on the "Estimated Annual Workloads" tab. For proposal purposes, Offerors shall review and consider this information when proposing hours and costs for its provider audit and reimbursement activities. Below is a brief description of the tables that are presented on the “Additional Information” tab of Attachment J.23.A:

· Table 25: Additional Information – Reimbursement Areas

· Table 26: Additional Information – PIP Providers

· Table 27: Additional Information – Cost Report Appeals

· Table 28: Additional Information – Cost Report Preliminary Position Papers by Provider Type

· Table 29: Additional Information – Reopening Requests - Inventory

7. HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT (HITECH)

CMS is not providing HITECH annual workloads in the BOE (Attachment J.22). The HITECH program sunset with the Fiscal Year (FY) 2016 cost reports. Offerors shall note that as MACs currently have an open inventory of cost reports, some of which may have HITECH payments, CMS is not assigning the MACs HITECH reviews; if a MAC feels a HITECH review is merited, the Agency may allow the MAC to complete the HITECH review as warranted.

The J8 A/B MAC shall perform the activities required by section C.5.11.3.6 of the SOW (Attachment J.01). For proposal purposes, Offerors shall assume that the J8 MAC has successfully accomplished the initial data load activities mentioned in this SOW provision and include costs associated with periodic data maintenance activities as required by the SOW provision. CMS Regulations pertaining to the HITECH program (CMS-0033-F) are located in the Federal Register at: Federal Register: Medicare and Medicaid Programs; Electronic Health Record Incentive Program (https://www.federalregister.gov/documents/2010/07/28/2010-17207/medicare-and-medicaid-programs-electronic-health-record-incentive-program)

8. ELECTRONIC DATA INTERFACE INQUIRIES

For proposal purposes, the Electronic Data Interface Inquiries (EDI) workloads are included in the overall inquiries workloads provided in the BOE (Attachment J.22). Offerors shall prepare proposals assuming that a workload transition will generate higher EDI inquiries during the Implementation and Base Period of the contract. The Offeror shall use the overall inquiries volumes when proposing hours and costs for the overall inquiries workloads.

9. CHANGE REQUESTS

SOW (Attachment J.01) section C.5.4.8 Participation in Change Management Process: The BOE (Attachment J.22) includes a line item to account for CRs being implemented by the shared system maintainers using a Hybrid Agile approach. Offerors shall use the BOE as directed for proposal purposes. CMS issues approximately 633 draft CRs to Medicare Contractors, Shared System Maintainers (SSMs), and the CWF Maintenance Contractor for review and comment each year. This is otherwise known as the Point of Contact (POC) Review period, which is described in detail in SOW (Attachment J.01) section C.5.4.8 Participation in Change Management Process and includes the review of corrections. On average, a draft CR will go through approximately three rounds of POC review.

10. REFERENCES TO MANUALS IN THE SOW

The Offeror shall prepare their proposal based upon the version of the Manuals, both the Internet-Only Manual (IOM) (https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms) and Paper-Based Manuals (https://www.cms.gov/medicare/regulations-guidance/manuals/paper-based-manuals) as of the date of the RFP release. In the event of any conflict, the SOW (Attachment J.01) has precedence over the IOM, which in turn has precedence over the Paper-Based Manuals. The Offeror shall not respond to manual changes issued after the RFP release date unless otherwise instructed by CMS.

11. RECORDS RETENTION ASSUMPTIONS

For A/B MAC J8 the Offeror shall assume 155,592 boxes of hard copy Medicare records located in the facilities listed in Table 30. The current breakout of this total by locale is provided in the chart below. All boxes are currently stored in a National Archives and Records Administration (NARA) compliant facility that is certified by CMS and approved by NARA. These boxes are not required to be moved, but they must be maintained as directed by CMS in a NARA certified facility.

For proposal purposes, the Offeror may assume that zero (0) boxes of Medicare records will need to be moved to a CMS certified NARA compliant facility. The approximately 155,592 boxes of hard copy Medicare records for this Jurisdiction may be transferred via a tri-partite agreement (or a chain of custody agreement) between the current J8 contractor, their file storage subcontractor, and the incoming J8 contractor. CMS will approve this subcontract agreement prior to final execution by all parties. If the Offeror is moving these files, they need to be moved prior to the end of CLIN 0002 Base Period of the new J8 contract.

The Offeror shall also include in their proposal (CLINs 0002–0003) the ongoing costs of storing a total of 155,592 boxes of Medicare records in a NARA compliant facility. The Offeror shall also provide an estimate of additional and ongoing storage costs for boxes of any hard-copy program records to be created during the performance of this new J8 contract and include these costs in their proposal. For instance, records created during CLIN 0002 would need to be stored for the balance of CLIN 0002, as well as for CLINs 0003-0032 (to the extent required by the federal records destruction schedule), etc. For proposal purposes, Offerors shall use the conversion factor that one (1) box = 1.2 cubic feet.

Table 30: Records Storage Facilities

(1 box = 1.214341833 cubic feet)

Iron Mountain 1501 East Wilson Street, Batavia, IL 60510

Iron Mountain 1565 Hunter Road Hanover Park, IL 60133

Iron Mountain 2755 Alft Lane Elgin, IL 60124

12. MANAGEMENT PAPER BILLS/CLAIMS

In the management of paper bills and claims addressed in section C.5.8 of the SOW (Attachment J.01) the electronic images from the outgoing contractor(s) will be transferred to the incoming contractor. For proposal purposes, the Offeror shall assume that the formats of these images are compatible with their systems. Additional information regarding the images from the outgoing contractor will be provided after contract award and during the implementation period.

13. ELECTRONIC DOCUMENT AND DATA RETRIEVAL

For obtaining, reading and storing historical electronic files addressed in section C.5.3 of the SOW, (Attachment J.01), for proposal purposes, Offerors shall assume that historical electronic file formats are compatible with their systems. Additional information will be provided after contract award and during the implementation period.

14. PARTICIPATION IN CONFERENCES

In accordance with section C.5.4.7 of the SOW (Attachment J.01), the contractor shall participate in conferences. For proposal purposes, Offerors shall plan for 12 conferences annually, four (4) attendees at each conference, and two (2) overnights at each conference. In addition to the 12 conferences, the Offeror shall also propose to attend one (1) CMS Security Control Oversight and Update Training (CSCOUT) conference annually in August, with three (3) overnights at each conference attended by the MAC System Security Officer (SSO).

The Offeror shall propose to the following conferences and workgroups in the Provider Customer Service Program (PCSP) functional area: (a) In accordance with section C.5.4.7 of the SOW, a PCSP Conference once a year. Three (3) contractor staff may attend from a jurisdiction. Attendees will typically include a high-level representative from provider outreach and education, provider contact center, and provider self-service (Interactive Voice Response (IVR) system, website, portal), (b) a Monthly PCSP User Group teleconference. Contractor jurisdiction representatives knowledgeable about provider outreach and education activities, provider contact center operations (telephone and written inquiries), and IVR, website, and portal operations/functions may attend, (c) Periodic workgroups (about two (2) per year) with CMS staff to address PCSP issues. Generally, a contractor jurisdiction would have two (2) representatives on each workgroup (a primary and a secondary) who are familiar with the issues to be addressed. The workgroups always meet by teleconference, usually on a monthly basis.

15. PROVIDER OUTREACH AND EDUCATION – DIRECT MAILINGS

For proposal purposes, Offerors shall plan for two (2) direct mailings a year, to all enrolled providers within their jurisdiction, in accordance with the Internet Only Manual Pub 100-9, Chapter 6 located at: IOM Pub 100-9, Chapter 6 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/com109c06.pdf)

16. BANKING

CMS provides banking services to MACs through standard commercial banking contracts between the commercial bank and CMS. The new A/B J8 MAC workload will be assigned to US Bank for their MAC Medicare Bank Account.

CMS does not provide lockbox services as part of these standard commercial banking contracts. Therefore, Offerors shall include as part of this proposal any costs associated with creating their own subcontract for lockbox services. If the Offeror utilizes lockboxes but wishes to change their banking procedures for this contract such that lockboxes are no longer needed for MAC functions, the Offeror shall include all associated implementation costs in their proposal.

Scenario: The MAC Contractor could coordinate with CMS and its assigned bank to open a lockbox and link that lockbox with the MAC’s Medicare Bank Account. In this example, the MAC Contractor would have to form a separate subcontract with the Bank to pay for the use of the lockbox, which shall be billed as an expense to the MAC Contract for which it has been established.

17. PARTICIPATING PHYSICIANS PART B WORKLOADS

The Base Period (BP) volume for Participating Physicians Part B Workloads is dependent on the timing of the start of operations. Offerors shall assume, for proposal purposes, that they will be responsible for Participating Physicians Part B activities/workloads during the Base Period (BP) (i.e., Offerors will disregard the timeline in item #2 above for this one purpose only).

18. PM & MIP PROVIDER CUSTOMER SERVICE, PROVIDER OUTREACH AND EDUCATION

For PM & MIP Provider Customer Service, Provider Outreach and Education activities, the Offeror shall reference the tables in the J.23.A Attachment and below containing the provider population for the specified jurisdiction. It is up to the Offeror to determine the workload appropriate for each type of provider outreach and education activity. There are no CMS-specified staffing or workload requirements, so the Offeror must develop their own strategy for how they can best service the provider populations identified. Based on its strategy, the Offeror shall complete the proposal and history/baseline columns on the BOE (Attachment J.22). Any assumptions or narrative explanations shall be included in Proposal Volume II, TAB C, Offeror Proposal Assumptions.

PM & MIP Provider Customer Service Part A Workload Offerors shall determine and propose the workload appropriate for each type of provider outreach and education activity. There are no minimum staffing requirements for this function, as long as SOW (Attachment J.01) and IOM requirements are met. Offerors must develop their own strategy for how they can best service the provider population.

Table 31: Part A Providers

PM & MIP Provider Customer Service Part B Workload The numbers provided below represent the provider population for the specified Jurisdiction by state. It is up to the Offerors to determine the workload appropriate for each type of provider outreach and education activity. There are no minimum staffing requirements for this function, as long as SOW (Attachment J.01) and IOM requirements are met. Offerors must develop their own strategy for how they can best service the provider population.

Table 32: Part B Providers

19. WEB PORTAL TRANSACTIONS

For proposal purposes, CMS is providing the number of Web Portal Transactions Received as defined below. This information is being provided to assist Offerors as it demonstrates the portal activity in J8 at this time.

Table 33: Web Portal Transactions

Web Portal Transactions Received

· The total number of transactions received through the portal, regardless of whether the query finds a matching record. This excludes activities related to login, registration, revocation, new access requests, re-certifications, and 1-way and 2-way communication.

21,027,768

20. PROVIDER TELEPHONE INQUIRIES

For proposal purposes, CMS provided Attachment J.23.B, CSR-Handled Telephone Inquiries Table, which shall be completed by all Offerors.

Additionally, all SOW (Attachment J.01) direction and related CRs have been incorporated into workloads and shall be included in Offerors’ proposal. Specifically, Offerors shall propose their business solution to include direction in CR 13754, Disable Beneficiary Eligibility Information from MAC IVR Systems. MACs were directed to disable beneficiary eligibility information from IVR systems by March 31, 2025. Providers and suppliers must check beneficiary eligibility through these online tools and services only:

• MAC secure online provider portal

• Billing agencies, clearinghouses, or software vendors

• Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System

(HETS)

21. AMAZON CONNECT

The timing of CMS’s migration to Amazon Connect has not yet been determined. For proposal purposes, Offerors shall include all costs associated with existing telephone systems, IVR hardware, and software.

22. TCEDI GATEWAY

For proposal purposes, Offerors shall expect the TCEDI Gateway to be implemented prior to the start of the contract and propose accordingly.

23. OUTGOING CONTRACTOR PENDING AND BACKLOGS

For proposal purposes, Offerors will anticipate all pending workloads will be within acceptable, normal ranges. In addition, Offerors will assume any known backlogs are included in workloads provided in the BOE (Attachment J.22).

24. MEDICAL REVIEW (MR) WORKLOADS

Several MR workload subcategories and numbers provided in the BOE (Attachment J.22) have been developed based on CR 9809 and CR 10249. The workload numbers provided are the four combined categories: Prepay Provider-Specific MR (Combines Prepay Provider-Specific Medical Record Review (MRR) and Prepay Provider-Specific Probe MRR Work); Postpay Provider-Specific MR (Combines Postpay Provider-Specific MRR and Postpay Provider-Specific Probe MRR Work); Prepay Service-Specific MR (Combines Prepay Service-Specific MRR and Prepay Service-Specific Probe MRR Work) and Postpay Service-Specific MR (Combines Postpay Service-Specific MRR and Postpay Service-Specific Probe MRR Work). The MR One-on-One Education workloads were developed consistent with the One-on-One definition in IOM Chapter 100-7, 7.2.2.18 One on One Education (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c07.pdf) and in the PIM Chapter 3.2.5 Targeted Probe and Educate (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/pim83c03.pdf). Further details for One-on-One Education as it relates to the Targeted Probe and Educate (TPE) are found in CR 10249 and CR 10963. CMS may direct Offerors to shift the focus of their medical review within the four combined categories, including between Part A, Part B, Home Health and Hospice, as applicable to meet environmental dynamics. These changes may result from a Public Health Emergency, Agency policy changes, etc.

Further, the Offeror shall refer to TDL-180264 and TDL-190252 for specific direction on Computer-Assisted Review of Documentation (CARD) / Artificial Intelligence (AI). For proposal purposes, if relevant, Offerors shall comment on their use of CARD / AI in their Medical Review and Prior Authorization/Pre-Claim Review operation.

25. PROVIDER ENROLLMENT WORKLOADS

On July 23, 2024, CMS issued TDL-240531, which stated that CMS is still committed to modernizing PECOS and continued development of PECOS 2.0. However, PECOS 2.0 did not launch in 2024 or 2025 as previously expected. CMS has not determined a revised future timeline for PECOS 2.0. As a result, for proposal purposes, Offerors shall not include PECOS 2.0 in their proposal.

26. PRIOR AUTHORIZATION (PA) PROCESS FOR CERTAIN HOSPITAL OUTPATIENT DEPARTMENT (OPD) SERVICES

The calendar year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS -1717-FC) established a nationwide PA process and requirements for certain hospital OPD services. CR 11634 provides specific direction on this process. The BOE (Attachment J.22) includes workloads for this activity under SOW Work Breakdown Structure (WBS) section C.5.12 – Medical Review. The workload numbers in the BOE for PA OPD include anticipated workloads for Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators (CR 12203) in addition to the procedures documented in CR 11634 & CR 13053.

Note: Offerors shall propose PA OPD specific Telephone Inquiries and PA OPD specific Appeals as part of SOW WBS C.5.12, as documented in the BOE and in the SOW (Attachment J.01).

27. SUPPLEMENTARY PROGRAM MANAGEMENT (PM) AND MEDICARE INTEGRITY PROGRAM (MIP) ACTIVITIES

CMS acknowledges that current MAC contracts include customized activities, not specifically identified within the SOW (Attachment J.01). For instance, these customized activities may be in place to assist the provider community or to achieve improper payment rate reductions. To the extent applicable, if such customized approaches are being proposed for this jurisdiction, CMS requires Offerors to document these customizations within their proposal in Tab E and in the BOE (Attachment J.22) as directed.

Costs for work not required by the SOW, included in the proposal or being noted as current work in the Jurisdiction (that is not being proposed) shall be provided in Cost Proposal Templates. A separate set of templates, for supplementary activities, is not provided. Offerors shall copy the applicable provided Cost Proposal Templates and create a separate set of cost templates for each supplementary activity – whether proposed or not.

Note: See sections L.14.3.2. and L.15.2 of the RFP for additional information/direction.

28. SELF CHECK TOOL AND HISTORICAL & PROPOSED WORKSHEET ATTACHMENTS

CMS is providing the following attachments to the RFP to be submitted by Offerors: 1) Proposal Self-Check Tool (Attachment J.21), 2) Historic & Proposed FTE, Hours & Gross Cost Instructions & Narrative (Attachment J.22.A), and 3) Historic & Proposed FTE, Hours & Gross Cost Worksheet (Attachment J.22.B). Offerors are required to fully complete all of these attachments in support of its overall proposal, both technical and business. Proposal accuracy and consistency across your technical proposal, business proposal, and Attachments J.22, J.22.A and J.22.B are very important to CMS. The Self-Check Tool will be used by the Government to validate the accuracy of your data. Detailed instructions for completion of the attachments are provided within the documents.

29. MEDICARE AUDIT AND REIMBURSEMENT INITIATIVES

Based on direction provided in CR 13859, Medicare Cost Report Workload Initiative, CMS has provided increased annual workloads for Full Desk Reviews (Table 11), Limited Desk Reviews (Table 12) and Cost Report Settlements (Table 16) in the Audit & Reimbursement Tables, (Attachment J.23.A). The increased workloads in Tables 11, 12 and 16 shall be used for proposal purposes for Base Period (BP) and Option Years (OYs) 1-2. The increased BP and OYs 1-2 workloads have been prepared to align with direction to all MACs to become current on their A&R workload as directed in CR 13859. (1) No cost report not selected for audit will remain unsettled more than 18 months after its date of acceptance by the MAC, (2) No cost report selected for audit and on a CMS approved audit plan will remain unsettled more than 12 months after the audit entrance conference date, and the entrance conference date must be held during the contract year in which the audit is included on that contract year’s approved audit plan, (3) No cost report that is subject to a valid CMS approved exception or extension to the above deadlines will remain unsettled beyond the time provided by that exception or extension.

As noted in section C.5.11.3.2.4 - Wage Index in the SOW (Attachment J.01), MACs are still required to collect and submit Wage Index data. The decreased level of effort for desk review/audit work for Wage Index data has been updated in this RFP, significantly reducing the level of effort for this work type which shall be factored into Offeror proposals. In the Audit & Reimbursement Tables the workload impact is represented by the reduction to five hours.

30. HIGH RISK FRAUD, WASTE, OR ABUSE AREAS (SOW C.7.19)

Offerors shall prepare their proposal based on the understanding that the workload associated with this jurisdiction specific activity is not different from activities associated with other Unified Program Integrity Contractor (UPIC) referrals, payment suspensions, etc. For proposal purposes, the workloads are included in the MIP Benefit Integrity UPIC Support workloads in the BOE (Attachment J.22). In addition, for proposal purposes, CMS directs Offerors to report cost for this jurisdiction specific activity, C.7.19, in WBS C.5.13 as the workload is combined in the BOE. The C.7.19 workloads are included in the Law Enforcement workloads. For proposal purposes, Offerors shall develop proposals with the expectation that the High Risk Fraud and Abuse, C.7.19 activities equate to 20% of the Law Enforcement workload.

31. PENALTY MAIL

CMS implemented the use of and requirements for all MACs to use United States Postal Service (USPS) penalty mail postage for Medicare Summary Notice (MSN) mailings. Penalty mail (a type of official mail) is sent by U.S. government agencies, relating solely to the business of the U.S. government, which is authorized by law to be carried in the mail without prepayment of postage. Historically, postage has been prepaid by the MAC and reimbursed by CMS. CMS will now directly coordinate payment for postage related to MSNs.

32. MEDICARE SUMMARY NOTICES (MSNS) AND ELECTRONIC MSN (EMSNS)

For this solicitation, CMS estimated a 1.25% annual increase in eMSN adoption rate. CMS used the following table of information to project the paper MSN workload for each period of performance (Base Period (BP)-Option Year (OY) 8). The projected paper MSN workloads represent single, unbundled MSNs. For proposal purposes Offerors shall use the information provided in the chart below in their business proposal. If an Offeror proposes a unique business process related to other categories of mail that would reduce proposed postage and printing costs for those categories, the Offeror must provide historic data or other supporting data for the assumed savings and describe the unique business process. (An example would be an initiative to increase provider portal use to reduce Standard Paper Remittance Advices (SPRs) sent to providers.) CMS will consider the reasonableness of each proposed unique business process, and the likelihood CMS will approve it post-award.

Table 36: MSNs and EMSNs

(A+B Unbundled)

CLIN 0002

Base

CLIN 0003

OY 1

CLIN 0004

OY 2

CLIN 0005

OY 3

CLIN 0006

OY 4

CLIN 0007

OY 5

CLIN 0008

OY 6

CLIN 0009

OY 7

CLIN 0010

OY 8

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