CCIIO-393-2024-0155 Statement of Work FH 040224.docx

Contract No.

Task Order No.

Attachment 1 – Statement of Work

STATEMENT OF WORK

QPA Audit Technical Support April 5, 2024

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 Act) 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.

The No Surprises Act was enacted as title I of Division BB of the Consolidated Appropriations Act, 2021.[footnoteRef:1] Section 2799A-1(a)(2)(A) of the Public Health Service Act, as added by the No Surprises Act, requires the Secretary of Health and Human Services (HHS) to conduct qualifying payment amount (QPA) audits to ensure that group health plans and health insurance issuers offering group or individual health insurance coverage are in compliance with the requirements related to calculation of the QPA. HHS is required to conduct at least two and up to 25 random QPA Audits annually, and may conduct additional QPA Audits based on complaints of potential non-compliance. The statute directs HHS to conduct QPA Audits to ensure that plans and issuers are in compliance with the requirement of applying a qualifying payment amount and that the QPA satisfies the statutory and regulatory definition with respect to the year involved, including with respect to a plan or issuer. CMS conducts QPA Audits on behalf of HHS. [1: Pub. L. 116-260 (Dec. 27, 2020).]

PURPOSE

The QPA is generally the median of the contracted rates recognized by the plan or issuer on January 31, 2019, for the same or similar item or service that is provided by a provider in the same or similar specialty or facility of the same or similar facility type and provided in the geographic region in which the item or service is furnished, increased for inflation. The QPA is often used to determine patient cost sharing for items and services under the No Surprises Act[footnoteRef:2]. It is also one factor, among others, that certified independent dispute resolution (IDR) entities consider when making a payment determination under the Federal IDR process. In cases in which a plan or issuer does not have “sufficient information” to calculate the QPA using the median contracted rate, the No Surprises Act directs the plan or issuer to determine the QPA through use of any database that meets certain requirements outlined in 45 CFR 149.140(a)(3). [2: For non-air-ambulance items and services, the QPA is used unless the item or service is furnished in a state that has a specified state law in effect with respect to the group health plan or health insurance issuer, or in a state that has an All-Payer Model Agreement under section 1115A of the Social Security Act. For air-ambulance services, the QPA is used unless the billed amount for such services is less than the QPA.]

CMS is seeking a Contractor with database(s) used by plans or issuers to calculate the QPA. The database should include:

· Median in-network allowed amount benchmark, developed from imputed allowed amounts for:

· Professional—medical and anesthesia procedures and services billed through CPT®1 codes and equipment and supplies billed through HCPCS codes;

· Outpatient facility services billed through CPT codes; and

· Inpatient facility services billed through ICD-10 procedure codes and revenue codes.

In order to fulfill our statutory responsibilities under the No Surprises Act to conduct Qualifying Payment Amount (QPA) Audits, CMS on behalf of HHS requires the support of a sole source contractor with the required expertise and extensive knowledge needed to implement these provisions by the mandated deadlines.

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 contracted rates recognized by the plan or issuer on January 31, 2019, for the same or similar item or service that is provided by a provider in the geographic region in which the item or service is furnished, increased for inflation. The contractor should be able to provide data at various levels of geographic aggregation and for a variety of professional and facility services.

· 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 provide access to a reference file database that will assist CMS conducting QPA audits. The Contractor shall provide technical assistance to users to access the reference file database.

Task 1 – No Surprises Act Reference File

The Contractor shall, as directed by the COR, provide CMS access to the following features with respect to the reference file database:

· Median in-network allowed amount benchmark, developed from imputed allowed amounts for:

· Professional—medical and anesthesia procedures and services billed through CPT®1 codes and equipment and supplies billed through HCPCS codes;

· Outpatient facility services billed through CPT codes; and

· Inpatient facility services billed through ICD-10 procedure codes and revenue codes.

· Values will be provided for each procedure code at various levels of geographic aggregation:

· Geozip (a geographic area defined by the first three digits of a zip code or groups of three-digit zip codes);

· Metropolitan Statistical Area (MSA);

· Non-MSA (all areas in a state that are not included in an MSA);

· State;

· Census region; and

· National.

Task 2 – Technical Support

The Contractor shall make staff available to assist CMS in accessing the No Surprises Act Reference File, including login instructions, password reset, and troubleshooting access issues.

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 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.

Deliverable Number * Deliverables Due Each Contract Year

All deliverables listed are due during the Base Year.

* Deliverable numbers correspond to task numbers used in this Statement of Work. Not all tasks have a deliverable.