CMS 230483 IMRE SSN Final.docx

Sources Sought Notice 230483 Insurance Market Reform Enforcement (IMRE)

THIS IS NOT A FORMAL REQUEST FOR PROPOSAL (RFP) AND DOES NOT COMMIT THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) TO AWARD A CONTRACT NOW OR IN THE FUTURE

This is a SOURCES SOUGHT NOTICE (SSN) issued for the purpose of planning and performing market research. The purpose of this Notice is to determine the availability of small businesses on the United States General Services Administration (GSA) Multiple Award Schedule (MAS)(e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that have the capability to support CMS with examining Issuers (i.e health insurance issuers), plans approved as minimal essential coverage (MEC) by CMS, and non-federal governmental plans to assess compliance with the Market reform and other provisions under title XXVII of the PHSA, including provisions added by Title I (No Surprises Act) and Title II (Transparency) of Division BB of the Consolidated Appropriations Act of 2021 (CAA), the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), the Women’s Health and Cancer Rights Act of 1998 (WHCRA), the Genetic Information Nondiscrimination Act of 2008 (GINA), Michelle’s Law the Paul Wellstone and Pete Domenici Mental Health Parity and Addition Equity Act of 2008 (MHPAEA) as well as any ancillary statues, regulations and sub-regulatory guidance related to the laws listed here. This work includes supporting CMS with reviewing insurance policies, plan documents, and contracts, conducting examinations (including Market Conduct exams), investigations, and audits of health insurance issuers (Issuers), plans approved as MEC by CMS, and non-federal governmental group health plans, and performing ongoing research and trend analysis of changing industry, states and federal regulatory guidelines.

PLEASE NOTE – This is a re-competition of an existing GSA Task Order entitled ” Insurance Market Reform Enforcement (IMRE) Support” (Contract No. FS-23F-0081X Task Order No. 75FCMC19F0078, Current Contractor – Examination Resources, LLC). This new task order is planned to be significantly larger than the existing task order as described and noted in the Background section below.

1. 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. CMS also provides consumers with comprehensive information on coverage options currently available so they may make informed choices on the best health insurance for their family.

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA), as amended by the Health Care and Education Reconciliation Act of 2010 (HCA) (the ACA and HCA are referred to herein together as the “Act”). The Act, in part, amended the Public Health Service Act (PHSA) by adding the Market Reforms, which became effective on September 23, 2010. CMS started implementing the Market Reforms on September 24, 2010.

On December 27, 2020 the Consolidated Appropriations Act of 2021 (CAA) was signed into law, thus, Title XXVII of the PHS Act, was amended by Title I (No Surprises Act) and Title II (Transparency) of Division BB of the CAA; establishing new protections for consumers related to surprise billing and transparency in health care.

The goal under this task order is for the Contractor to conduct agreed-upon activities relating to examining and assessing Issuers’ and non-federal governmental group health plans’ compliance with the Market Reforms and other provisions under Title XXVII of the PHS Act. The provisions include those added by Division BB, Title I, Division BB, Title II, Section 203 of the CAA, “Strengthening parity in mental health and substance use disorder benefits,” Title I of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), the Women’s Health and Cancer Rights Act of 1998 (WHCRA), the Genetic Information Nondiscrimination Act of 2008 (GINA), Michelle’s Law, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), as well as any related ancillary statutes, regulations, and sub-regulatory guidance.

Specifically, the Contractor shall:

· Review insurance policies and contracts, including but not limited to: schedules of benefits, amendments, endorsements, Summaries of Benefits and Coverage (SBCs), plan benefit templates, and prescription drug benefits (hereafter referred to as plan documents),

· Provide information about provisions or language within the plan documents that appear to be out of compliance with Market Reforms or other federal requirements.

· Conduct evidence-gathering services (hereafter referred to as Market Conduct Examinations or MCE)

· Document the level of compliance with specific provisions of Title XXVII of the PHS Act by Issuers conducting business in states in which CMS has direct enforcement responsibilities for those provisions, or where a state has requested CMS to assist in enforcing federal requirements, non-federal governmental group health plans, and health insurance coverage recognized as MEC by CMS.

· Provide in-depth, on-site examinations of the Issuer(s), non-federal governmental group health plan(s), or coverage recognized as MEC under review by a Contractor following the National Association of Insurance Commissioners’ (NAIC) Market Regulation Handbook as well as CMS’ examination guidelines and interpretations of provisions under Title XXVII of the PHS Act if applicable.

· Conduct investigations of group health plans and issuers offering group or individual market health insurance coverage.

· Reviews of MHPAEA non-quantitative treatment limitation comparative analyses selected by CMS from non-federal governmental group health plans and Issuers offering group or individual health insurance coverage.

· Provide to CMS ongoing research and trend analysis of changing industry, state, and federal regulatory guidelines.

· Conduct Qualified Payment Amounts (QPA) audits. Constant changes in regulations and administrative priorities relative to the CAA result in fine tuning of requirements related to QPA audits.

PLEASE NOTE: The Contractor shall perform up to 50 targeted market conduct examinations (this includes bulk NSA complaint targeted exams) to investigate bulk complaints of non-compliance with one or more provisions of the No Surprise Act and Transparency Act (specifically, the provisions added to title XXVII of the PHS Act, part D) against Issuers, in states where CMS is enforcing such provision(s), and non-federal governmental group health plans in all states to their existing line of work procedures to ensure that Issuers and non-federal governmental group health plans comply with the requirements: initiate up to 40 NonFed plan investigations based on complaints received; perform form filing reviews for four provisions in 20 states/territories for issuers of individual and group health coverage, both grandfathered and non-grandfathered and where CMS has direct enforcement authority of one or more of the issuer focused CAA provisions and; initiate a minimum of 20 NQTL comparative analysis reviews for non-Fed plans and issuers in states where we have jurisdiction over MHPAEA requirements. Additionally, beginning calendar year 2023, the Contractor shall initiate 25 QPA audits the base year and each year thereafter to assess non-compliance with the Qualifying Payment amount provisions in the No Surprises Act for non-federal governmental group health plans and Issuers offering group or individual health insurance coverage in states where CMS is responsible for enforcing such provision(s).

2. Required Knowledge and Experience

This requirement has a potential conflict of interest in that Offerors also performing services for the insurance industry and/or any of its trade associations must be able to perform examinations without the appearance of or actual/potential conflicts of interest or need not respond

At a minimum, the following knowledge and experience are required:

· Knowledge, expertise, and experience with Title XXVII of the PHSA, as well as other related federal and state laws, regulations and guidance pertaining to private health insurance necessary to perform this work

· Experience in conducting plan document reviews

· Experience in performing Market Conduct Examinations consistent with the guidelines set by the NAIC Market Regulation Handbook

· Experience in performing health insurance investigations

· Experience performing data analysis

· Experience in performing ongoing research on industry, and state and federal regulatory requirements, such as statutes, regulations, and bulletins

· Experience in performing multiple form reviews, market conduct examinations, and investigations.

· Experience in observing all federal regulations concerning the integrity and security of all paper and electronic information

· Have the ability to accept assignments on short notice as well as a track record of managing multiple project deadlines at one time and completing deliverables on-time

· Experience providing technical assistance and training to internal and external stakeholders

· Experience producing progress and summary reports with analysis of trends

· Track record of effective project management

· Track record of managing and staying within budgets

· Track record of quality assurance for deliverables

· Track record of effective communication and customer relations With regards to staffing, a contractor must be able to:

· Employ examiners and analysts with appropriate insurance regulatory education, experience, and certifications.

· Employ or have access to an actuary with appropriate education and experience in analyzing health insurance rates and premium changes, and demonstrate knowledge of the requirements for rate filings with the state departments of insurance, and rate templates for On-Marketplace plan certification.

· Employ or have access to a statistician with appropriate education and experience, who understands the fundamentals of health insurance including topics such as policy forms, underwriting, terminations, rescissions and denials, and claims data.

· Employ or have access to a clinical medical doctor with appropriate education and experience.

· Employ or have access to a pharmacist with appropriate education and experience.

· Employ or have access to clinical experts for mental health and substance use disorder

· Contractors will be required to develop quality control plan and a management plan as part of their proposal submissions. The Government will evaluate and may renegotiate these plans.

3. Capability Statement Requirements

In response to this Notice, CMS is seeking capability statements. Capability statements are NOT proposals and do not address price/cost. Industry is merely asked to provide information, which may demonstrate that they have expertise and capacity to meet the requirements of this work as a prime contractor, with subcontractors, as they deem necessary.

No marketing literature should be submitted in response to this Sources Sought Notice. When responding to this notice, vendors must demonstrate their experience in meeting and performing capabilities listed below. A mere statement that the vendor has a required capability is not sufficient.

Responses should provide enough information for CMS to make an informed determination of a respondent’s capability to perform the work. Describe your capabilities and detailed experience performing similar activities to those listed below.

1) The capability to demonstrate an understanding of XXVII of the PHSA, as well as other federal and state laws, regulations and guidance pertaining to private health insurance necessary to perform this work and of how to conduct plan document reviews, market conduct examination procedures consistent with the guidelines set by the NAIC Market Regulation Handbook, and investigations.

2) Ability to demonstrate experience and knowledge of how to perform ongoing research on industry, and state and federal regulatory guidelines.

3) The capability to validate experience and knowledge of the following systems: TeamMate™ Plus or a similar auditing system and System for Electronic Rate and Form Filing (SERFF™) for form filing submissions.

4) The capability to validate experience performing multiple regulatory compliance and enforcement activities and provide technical assistance and training to internal and external stakeholders.

5) The capability to demonstrate administrative and project management duties for similar size and scale (Include dollar value and contract number whether as a prime or subcontractor. If as a subcontractor, the portion of work conducted), including but not limited to:

· Produce progress and summary reports with analysis of trends

· Ability to prepare agendas, facilitate status calls, and record minutes

· Demonstrate capability of effective project management,

· Track record of managing and staying within budgets

· Track record of quality assurance for deliverables

· Track record of effective communication and customer relations

6) The capability to handle the large volume of work as described below.

The Contractor shall perform up to 50 targeted market conduct examinations (this includes bulk NSA complaint targeted exams) to investigate bulk complaints of non-compliance with one or more provisions of the No Surprise Act and Transparency Act (specifically, the provisions added to title XXVII of the PHS Act, part D) against Issuers, in states where CMS is enforcing such provision(s), and non-federal governmental group health plans in all states to their existing line of work procedures to ensure that Issuers and non-federal governmental group health plans comply with the requirements: initiate up to 40 NonFed plan investigations based on complaints received; perform form filing reviews for four provisions in 20 states/territories for issuers of individual and group health coverage, both grandfathered and non-grandfathered and where CMS has direct enforcement authority of one or more of the issuer focused CAA provisions and; initiate a minimum of 20 NQTL comparative analysis reviews for non-Fed plans and issuers in states where we have jurisdiction over MHPAEA requirements. Additionally, beginning calendar year 2023, the Contractor shall initiate 25 QPA audits the base year and each year thereafter to assess non-compliance with the Qualifying Payment amount provisions in the No Surprises Act for non-federal governmental group health plans and Issuers offering group or individual health insurance coverage in states where CMS is responsible for enforcing such provision(s).

4. Instructions for Submitting Responses to CMS

The following specific information is requested: (a) company descriptive literature; (b) specific related corporate experience; (c) experience with the type of capability expectations mentioned above; (d) references, to include points of contact, email addresses, and phone numbers; and (e) Business information outlined below.

4. DUNS

4. Company Name

4. Company Mailing Address and Website Address

4. Must be small business through self-certification under the following NAICS Codes:

· 541611 - (size standard of $24.5 million)

· 541211 - (size standard of $26.5 million)

· 541219 - (size standard of $25.0 million)

4. Current GSA Schedules appropriate to this Sources Sought Notice

Please limit your documentation to the following Page Size, Font Type and Size, Spacing and Page Numbering. Responses shall be submitted via email using a Microsoft Word or Adobe PDF document with page size 8.5 by 11 inches. Font type shall be Times New Roman, size 10-12 using standard tabs and indent software features with no less than single spacing between lines. Responses are limited to a total of no more than ten (10) pages for the entire capability statement including any appendices or supplemental information.

All transmitted information marked proprietary shall be treated as such. Therefore, businesses should identify any proprietary information in their responses. Proprietary materials will neither be distributed, nor discussed with, any other organization. Information submitted in response to this will be used at the discretion of the Government. Further, the information submitted will remain confidential insofar as permitted by law, including the Freedom of Information and Privacy Acts.

Respondents should be aware that this SSN is for marketing purposes only and any responses thereto, or lack thereof, will not constitute a commitment by CMS to treat any potential offeror more or less favorably in an anticipated forthcoming solicitation and/or ultimate award. Please be advised that CMS will not respond directly to organizations submitting information in response to this SSN.

All capability statements can be submitted via e-mail to Malissa.Shin@cms.hhs.gov and Lakisha.Holly@cms.hhs.gov. Responses must be submitted no later than 5:00 PM EST, February 28, 2023.

Confidentiality No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s).

Disclaimer and Important Notes This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted.

Teaming Arrangements

Contractors responding to this Notice as a team or that rely on subcontractors to perform any portion of the work must include the above-requested information and certifications for each entity on the proposed team or each proposed subcontractor. Responses must clearly indicate the nature of the teaming arrangement. However, no official teaming arrangement is required at this time.

The contractor and any subcontractors must not have any relationships or arrangements through business operations or its employees that could be considered as lessening the company’s objectivity concerning any aspect of the proposed tasks. If such relationships or arrangements exist, contractors or subcontractors shall be required, during the procurement process, to identify potential conflicts of interest and discuss how the conflicts will be addressed and mitigated.

https://agx.cms.gov/epm#/project-preview/28

Attachment: Draft Statement of Work (SOW) – The SOW is subject to change.