CCIIO-393-2021-0112 Statement of Work 4-6-2021.pdf

Contract No.

Task Order No.

Attachment 1 – Statement of

Work

STATEMENT OF WORK

No Surprises Act Technical Support

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) is responsible for providing national leadership in setting and enforcing standards for health insurance that promote fair and reasonable practices to ensure affordable, quality health coverage is available to all Americans.

The “No Surprises Act” (the NSA) and “Transparency Act” included in the Consolidated Appropriations

Act (CAA), 2021, Public Law 116-260, effective December 27, 2020, prohibit surprise bills for individuals covered by group health plans and health insurance issuers of group and individual health insurance coverage when receiving emergency services (and post-stabilization services) furnished by a nonparticipating provider or nonparticipating facility, and when receiving non-emergency services furnished by nonparticipating providers in participating facilities without notification of the provider’s non-participation or “out of network” status and consent by the individual.

The NSA requires HHS to issue regulations laying out the application of the NSA’s requirements as it pertains to plans, issuers and providers regarding surprise bills, balance billing, the determination of qualifying payment amounts, transparency regarding in-network and out of network cost sharing, the provision of an advanced explanation of benefits and continuity of care. The regulations need to include information about enforcement of the NSA and the Secretary’s authority to conduct investigations and audits to identify potential violations.

While States can enforce the NSA’s federal requirements, the NSA specifies that if the Secretary of HHS determines that a State has failed to substantially enforce one or more of the provisions of the NSA or does not have the authority to enforce one or more provisions, the Secretary of HHS is responsible for enforcement. If a provider, facility, or air ambulance violates the provisions of the NSA relating to the prohibition of balance billings in cases of emergency, non-emergency services in specific situations, and ambulance services with respect to enrollees in a non-Federal governmental health plan or group or individual health insurance coverage offered by an issuer, and the State is not substantially enforcing, the

Secretary is responsible for taking enforcement action.

The Transparency Act includes provisions designed to increase transparency in group health plans and health insurance coverage, including a requirement that group health plans and issuers that offer individual and group health insurance coverage that impose non-quantitative treatment limits (NQTLs) on mental health or substance use disorder benefits must perform comparative analyses of the design and application of NQTLs, and make the analyses available upon request to the state or, as applicable, HHS. The Secretary of HHS is required to request not fewer than 20 analyses per year, based on potential violations, complaints, or when the Secretary determines appropriate, and conduct a review of the requested analyses. HHS must submit an annual public report to Congress summarizing the comparative analysis, conclusions of sufficiency of the submitted comparative analysis and supporting documentation by plans and issuers, conclusions as to whether and why the plan or coverage is in compliance with MHPAEA for that NQTL, and specifications for plans that were not in compliance.

PURPOSE

CMS is seeking a Contractor with knowledge and expertise in the Paul Wellstone and Pete Domenici

Attachment 1 – Statement of

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Public Health Service Act

(PHS Act), Patient Protection and Affordable Care Act (PPACA), and their implementing regulations and sub-regulatory guidance, consumer protections and market reforms to assist with the implementation of the CAA. In order to meet the statutorily mandated deadline to have a rule finalized by July 1, 2021, establish an enforcement structure to oversee plans, issuers and providers in States that do not enforce one or more provisions in the CAA, complete 20 statutorily mandated reviews of

NQTL comparative analyses and draft an annual report to Congress by December 27, 2021, CMS requires the support of a contractor with the specified knowledge and expertise.

TECHNICAL CONSIDERATIONS

The responsibility for information security will be the sole responsibility of the Contractor until any information is given or transmitted to CMS and becomes the property of CMS. Contractor must also complete any federally-created training courses that CMS requires of Contractors.

SPECIAL TERMS AND CONDITIONS

The Contractor is advised of the following special terms and conditions:

The Contractor must have extensive knowledge of title XXVII of the PHS Act, PPACA, MHPAEA, as well as other federal and state laws, regulations and guidance pertaining to private health insurance necessary to perform this work.

The Contractor must be available to accept assignments on short notice and to manage multiple project deadlines at one time and complete deliverables on-time.

The Contractor must abide by CMS standard operating procedures and policies to perform the work.

REQUIREMENTS

Independently and not as an agent of the United States Government, the Contractor shall furnish all the necessary services, qualified personnel, material, equipment and facilities, as needed to perform the requirements of this Statement of Work (SOW).

Tasks to Be Performed

During the Base Year, the Contractor shall consult and assist in the policy and regulatory development for the No Surprise Act and Transparency provisions. The Contractor shall also consult and assist with developing the enforcement framework to provide oversight of plans, issuers and providers in States that do not enforce one or more provisions in the CAA. In addition, the Contractor shall review the results of the 20 statutorily mandated reviews of NQTL comparative analyses to confirm any identified findings and proposed course of action(s) to remedy any identified violations.

Finally, the Contractor will assist in the development of a report due to Congress by December 27, 2021. The Contractor shall at CMS’s requests also perform ongoing research on industry, and state and federal regulatory guidelines. The Contractor shall submit monthly progress reports, periodic progress reports, and a final summary report. The Contractor shall participate in weekly calls with

CMS, or on an as-needed basis. The Contractor shall at CMS’s request attend listening sessions and

Attachment 1 – Statement of provide technical assistance and training to internal and external stakeholders.

Task 1 – Program Assistance

The Contractor shall, as directed by the COR, consult and assist in the policy and regulatory development for the No Surprise Act and Transparency provisions. The Contractor shall also consult and assist with developing the enforcement framework to provide oversight of plans, issuers and providers in States that do not enforce one or more of the provisions in the CAA. In addition, the

Contractor shall review the results of the 20 statutorily mandated reviews of NQTL comparative analyses to confirm any identified findings and proposed course of action(s) to remedy identified violations. Finally, the Contractor will assist in the development of a report summarizing the NQTL reviews and any corrective actions taken by plans and issuers.

Task 2 – Participation in Meetings and Consultations

Task 2.a. Meetings.

The Contractor may be asked to participate in meetings and consultations with Issuers, non-federal governmental plans, including discussions related to the review of plan documents from NQTL comparative analysis reviews, and related findings.

Task 2.b. Technical Assistance Support.

Under the direction of the COR, the Contractor shall also provide technical assistance support that arises out of any NQTL comparative analysis review. This technical assistance support can arise from a variety of sources, including general questions from senior leadership at CMS, CMS staff, state regulators, and/or the issuers or plans undergoing review.

Task 3 - Progress and Summary Reports

The Contractor shall submit Monthly Progress Reports, a Final Summary Report, and other Periodic

Progress reports as requested by CMS.

Task 3.a. Monthly Progress Reports.

The Contractor shall provide written monthly progress reports to update CMS on the status of any tasks that are being conducted by the Contractor. Report specifications will be provided by CMS at least ten (10) business days prior to the first deliverable due date.

Task 3.b. Final Summary Report.

The Contractor shall provide a written final summary report of activities conducted during the year of performance. Report specifications will be provided by CMS at least thirty (30) calendar days prior to the deliverable due date.

Task 3.c. Periodic Progress Reports.

The Contractor shall provide verbal and written periodic progress reports such as spreadsheets, power point slides, memoranda (or e-mails) to CMS, as requested.

See Tasks 1 – 3 and the Schedule of Deliverables for specific reporting requirements and instructions for individual deliverables.

Attachment 1 – Statement of

PERFORMANCE AND DELIVERABLES

PLACE OF PERFORMANCE

The work shall be performed at one or more of the following: 1) the Contractor’s office; or 2) CMS offices.

There may be an occasional need for the Contractor to be on site at the Bethesda or Baltimore, Maryland CMS locations. The Contractor shall be reimbursed for travel to provide support at a

Government site. The travel must be approved by the COR prior to the commencement of travel and should be the most cost-effective method. The Contractor shall be reimbursed for actual allowable, applicable, and reasonable travel costs incurred during the performance of this effort in accordance with the Federal Travel Regulations in effect on date(s) of travel.

DELIVERABLE SCHEDULE

The Contractor shall submit deliverables that are clear, concise, and complete, and conform to standards that shall be agreed to in advance between the Contractor and the COR. Deliverables due for the base year are listed in the chart below. Deliverables shall be submitted electronically using a system designated by CMS.

***See Deliverable Schedule on the following page.***

Attachment 1 – Statement of

Deliverable

Number *

Deliverables Due

Each

Contract Year

Due Date Recipient

All deliverables listed are due during the Base Year.

* Deliverable numbers correspond to task and sub-task numbers used in this Statement of Work. Not all subtasks have a deliverable.

1. Consult and assist in the policy and regulatory development for the No

Surprise Act and Transparency provisions; assist in the development of the enforcement framework to provide oversight of plans, issuers and providers in

States that do not enforce one or more provisions in the CAA;

review the results of the 20 statutorily mandated reviews of

NQTL comparative analyses to confirm any identified findings and proposed course of action(s) to remedy any identified violations;

and assist in the development of a report summarizing NQTL audits.

On-going throughout duration of the contract unless otherwise specified by

CMS

COR and team lead for NQTL reviews

2.a. Participate in meetings and consultations with federal government employees, Issuers, and non-federal governmental plans in the review of plan documents from NQTL comparative analysis reviews and related findings.

On-going throughout duration of the contract unless otherwise specified by

CMS

COR and team lead for NQTL reviews

2.b. Provide technical assistance, training, and communications support. Provide a plan for the completion of any communication support function where the estimated time to complete is more than two (2) hours.

As requested by

COR or team lead

COR and team lead for NQTL reviews

Attachment 1 – Statement of

3.a. Provide written monthly progress reports to update CMS on the status of any tasks that are being conducted by the Contractor.

Report specifications will be provided by CMS at least ten

(10) business days prior to the first deliverable due date.

By 10th calendar day of every month.

COR,

Contract

Specialist

3.b. Provide a written final summary report of activities conducted during the base year of performance. Report specifications will be provided by CMS at least thirty

(30) calendar days prior to the deliverable due date.

Fifteen (15) business days after the last day of the Base Year, unless otherwise specified by

CMS. Contractor will have another thirty (30) days to create the final version, if CMS has edits and comments.

COR

3.c. Provide verbal and written periodic progress reports such as spreadsheets, power point slides, memoranda (or e-mails) to CMS, as requested.

Due date(s) and format will be determined by

CMS when report is requested.

COR