CCIIO-393-2022-0064 STATEMENT OF WORK 01.19.2022.docx

Contract No.

Task Order No.

Attachment 1 – Statement of Work

STATEMENT OF WORK

No Surprises Act Technical Support 01/19/2022

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.

CMS anticipates issuing rules, with the Departments of Labor and Treasury, regarding the CAA’s requirements as it pertains to plans, issuers, health care providers, facilities, and providers of air ambulance services regarding surprise bills, balance billing, the determination of qualifying payment amounts (QPA), prohibition of the gag clause, transparency regarding in-network and out-of-network cost sharing, the provision of an advanced explanation of benefits, continuity of care, and compensation disclosure requirements for agents and brokers.

While States can enforce the CAA’s federal requirements, the CAA specifies that if the Secretary of HHS determines that a State has failed to substantially enforce one or more of the provisions of the CAA 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 Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Public Health Service Act (PHS Act), Patient Protection and Affordable Care Act (PPACA), the CAA and their implementing regulations and sub-regulatory guidance, consumer protections and market reforms to assist with the implementation of the CAA. The Contractor will assist CMS in the establishment and update of an enforcement structure to oversee plans, issuers and health care providers, facilities, and providers of air ambulance services in States that do not enforce one or more provisions in the CAA, provide technical assistance in regards to provisions of the PHS Act that were amended or added by the CAA, review and provide technical assistance regarding up to 20 statutorily mandated reviews of NQTL comparative analyses, review other CAA investigation and examination reports (such as QPA audits), and review the annual report to Congress by October 1. 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, as amended by PPACA and the CAA, 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, Option Period 1, and Option Period 2 the Contractor shall consult and assist in the policy and regulatory development for the NSA and Transparency provisions of the CAA. The Contractor shall also consult and assist with developing and updating the enforcement framework to provide oversight of plans, issuers, health care providers, facilities, and providers of air ambulance services in States that do not enforce one or more provisions in the CAA, as well as provide technical assistance of provisions of the PHS Act as amended or added by the CAA. In addition, the Contractor shall review the results of up to 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 review other CAA related investigation and examination reports (such as qualifying payment amount (QPA) audits). Finally, the Contractor will review the report due to Congress by October 1. 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 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 NSA and Transparency provisions of the CAA. The Contractor shall also consult and assist with developing and updating the enforcement framework to provide oversight of plans, issuers, health care providers, facilities, and providers of air ambulance services in States that do not enforce one or more of the provisions in the CAA. In addition, the Contractor shall review the results of up to 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 review 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, CMS staff and other Federal and state regulatory agencies, including discussions related to the review from NQTL comparative analysis reviews, and other CAA provision investigation and examination reports (such as QPA audits), and reports.

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. Additional technical assistance regarding other provisions of the PHS Act that were amended or added by the CAA (such as QPA audits) shall also be provided upon request.

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.

PERFORMANCE AND DELIVERABLES PLACE OF PERFORMANCE

The work shall be performed at the Contractor’s office.

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.***

Deliverable Number * Deliverables Due Each Contract Year

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.

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

COR