10th SOW Attach J-23 Revised.docx

BUSINESS PROPOSAL FORMAT

FOR UTILIZATION AND QUALITY CONTROL

QUALITY IMPROVEMENT ORGANIZATIONS

FORMS AND INSTRUCTIONS

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

BALTIMORE, MARYLAND

Attachment J-23 Business Proposal Format - Amendment #2 as of May 6, 2011 May 2011

TABLE OF CONTENTS

PAGE

I. INTRODUCTION 2

II. GENERAL INSTRUCTIONS 3

III. ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS

PROPOSALS 4

IV. BUSINESS PROPOSAL FORMS AND INSTRUCTIONS

A. CMS Form 718 BP - Quality Improvement Organization 10th SOW Business Proposal Summary. 8

C. CMS Form 720 BP - Fringe Benefit Proposal. 14

D. CMS Form 721 BP - Indirect and Other Direct Cost. 18

F. CMS Form STAFFING - Personnel Loading Charts. 22

G. CMS Form SC 1 - Subcontracts Proposal - Physician Reviewers. 28

H. CMS Form SC 2 – Subcontracts Proposal - Other. 31

I. CMS Form SUM - Staffing Proposal Summary. 34 J. CMS Form QIO ODC – Other Direct Costs – Supplemental Schedule. 39

K. CMS Form Beneficiary & Family Centered Care Costs – Supplemental Schedule. 41

L. Travel Detail Form 45

V. APPENDIX A-1

1: DEFINITIONS AND GUIDELINES: QUALITY IMPROVEMENT ORGANIZATION 10th SOW BUSINESS PROPOSAL A-2

I. INTRODUCTION

PURPOSE

This guideline package will assist you in preparing the standardized business proposal forms used to award Medicare Quality Improvement Organization (QIO) contracts.

SCOPE

Offerors must use the electronic file that CMS provides to prepare and submit the business proposal. This guideline package provides instructions for completing the various business proposal forms in the CMS electronic file. The hardcopy version of this package includes a sample of the various forms.

Business proposals are required to include the appropriate supporting information, cross-referenced to the related column, line item, and form. The supporting information should be detailed and, as appropriate, fully explain calculations, bases for estimates, etc. Failure to supply the supportive documentation for all proposed costs may be grounds of rejection and the proposal will be returned accordingly. Examples include:

a. Quotes and estimates from vendors;

b. Market surveys;

c. Historical data;

d. Specific calculations used to estimate proposed costs and an explanation;

e. Catalog prices; and

f. Previous billing statements/ expense vouchers.

METHOD OF SUBMISSION

CMS is providing you with the business proposal forms in an Excel spreadsheet file titled REVISED BP10SOW. You should enter your cost data in the Excel files and submit your completed business proposal in both electronic and hard-copy format.

The cost information in the electronic version of your completed business proposal must be in Excel2007 format. The narrative supporting information can be in Excel2007 or Word2007 format.

Revised J-23 April 2011 Page 3

II. GENERAL INSTRUCTIONS

The following general instructions for the completion and submission of the business proposal forms are in addition to those instructions contained in the RFP issued by CMS to all offerors and in addition to the attached Section III – ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL.

1. The CMS-provided electronic file and the specified Excel and Word versions are the only acceptable format for your cost proposal submission. Proposals received in any other format will be considered unacceptable.

The business proposal spreadsheets are formatted to accept one decimal place for entries relating to hours and whole dollars for entries relating to costs. However, where appropriate (e.g., hourly rates), the formatting will permit 2 decimal places for costs.

2. As used in this cost proposal process, the term "QIO" refers to both present QIO and potential QIO organizations.

3. A QIO organization proposing a Medicare contract in more than one QIO area must complete a separate business proposal for each QIO area.

4. All blocks on the forms that are shaded are filled out by formulae from within the form or from other forms or are for CMS use only, and they should not be filled out by the submitting QIO. Please fill out, as appropriate, only the unshaded blocks.

5. OMB INSTRUCTIONS REQUIRE THE FOLLOWING BURDEN DISCLOSURE NOTICE TO BE INCORPORATED ON ALL COLLECTIONS OF INFORMATION OR THE ACCOMPANYING INSTRUCTIONS.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0579. The time required to complete this information collection is estimated to average (22hours)(45minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

III. ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL

General

As a general rule you should explain how you calculated all items in your business proposal, with the exceptions provided below. ALL COSTS MUST BE VERIFIABLE. With the exception of salaries, which are discussed below, the QIO should not inflate any line item for a year to year increase of greater than 1.5% without providing further justification. The QIO should also make sure to indicate what rate of increase it is using on all non-salary line items, even when they are at or below the 1.5% rate of increase per year. Note: The escalation rate is based on current market conditions and the rate used in FY2012 budget assumptions.

Full Time Equivalents (FTEs) and Salaries

Full Time Equivalents (FTEs) and Salaries

FTEs proposed should be proposed on the basis of the most efficient method of performing each sub-task. The total direct labor hours, and their distribution across labor categories (e.g. professional, support staff) proposed for each sub-task should be justified on the basis of the information provided in the technical proposal and/or capability.

All proposed labor rates shall be supported with matching rates or formal salary survey information conducted by your organization from an acceptable source {i.e. www.salary.com, www.indeed.com, or etc.}. Escalation of salaries should not exceed 1.5% based on current market conditions. QIOs shall also explain organizational salary increases. The organizational salary increase will be determined each year by the “Grand Total Percent Change” cell on the Person Loading Chart – Staffing (i.e. for the year 1 over the current year it is cell “O 112” on the Form Staffing).

Program Manager

Annapolis Junction, MD Median Salary - $XXX,XXX

10% - $XXX,XXX

25% - $XXX,XXX

75% - $XXX,XXX

90% - $XXX,XXX

Your Projected Salary $0-$0

Top of Form

Bottom of Form

Program Manager Salary in Annapolis Junction, MD Top of Form Bottom of Form Average Salary of Jobs Matching Your Search

Average Program Manager salaries for job postings in Annapolis Junction, MD are X% higher than average Program Manager

Leave

Please summarize your leave policy. Also, explain any increase in your leave rate as a percentage of direct labor cost. All leave should be reported as part of the Fringe Benefit Category or in your approved Indirect Leave Rate.

Fringe Benefits

For Fringe Benefits, if you have an approved provisional rate, it can serve as the justification for the Fringe Benefit expense. If you do not have an approved provisional rate or you do not believe that this rate is correct for your three-year budget, please justify the rate requested, with emphasis on the major items of increase.

Other Consultants/Subcontracts

Form SC 1 requests information on the number of reviews, the time per review and the hourly rate for Physician Reviewers/Advisors. Please explain how you determined these factors and why and how they are different from the current year. The Form SC 1is provided for Beneficiary Protection and Special Studies. For all other tasks, enter Physician Reviewers/Advisors costs directly into the appropriate cell on the Form 719BP fully justify the need for Physician

Reviewers/Advisors costs for these tasks and explain the basis for the amount entered. If the Physician Reviewers/Advisors cost for these other tasks is based on the number of reviews performed, you should provide the detail in the same format as on the Form SC 1.

For Consultants and Other Subcontracts, please justify the purpose of each proposed Consultant and Subcontract. Explain the methodology used to formulate each Consultant Service or Subcontract cost, including hourly rates and number of hours requested for the Consultants or for the personnel employed in the Subcontract. The QIO’s cost detail shall also include the determination if the rates are fully loaded, travel costs [number of trips, purpose, per diem, airfare, mileage, means of travel, number of days and nights, lodging, & any miscellaneous costs/fees], volumes and unit costs for all Other Direct Costs, etc. For all Subcontracts, you shall use the subcontractor’s business proposal as supporting documentation. Essentially, the Consultant(s)/Subcontractor(s) must complete the same level of detail as the Prime. If the Consultant(s)/Subcontractor(s) are not comfortable with submitting their proposal to the Prime, they may send it to CMS directly. Note: with the exception of the Physician Reviewers, Subcontract consent (submission of the required Request for Consent - Section J Attachment 22) must be submitted for each Subcontract/Consultant proposed according to the thresholds provided in Section I of the RFP.

Example (for a Consultant):

Travel

All QIOs are required to explain how you calculated your Travel costs by Task. The QIO’s travel justification should include, but are not limited to, the following for each trip: (1) trip title, description, & purpose, (2) means of travel (air, car, bus, train) and its cost, (3) locations (origin and destination), (4) lodging, (5) number of travelers, (6) mileage and the rate used, (7) number of rental cars, if needed, (8) daily rental car rate, (9) miscellaneous costs per person – includes parking, gas, taxi, etc. and explain each cost in great detail, (10) number of days and nights, and (11) meals and incidentals. Furthermore, QIOs are asked to provide printouts with matching price quotes from a reliable source and/or historical data (including billing statements/expense vouchers, etc.). CMS will use the Federal Travel Regulations as a means to determine reasonable travel costs.

Other Direct Costs

Explain how you calculated all Other Direct Costs (ODC) by showing unit costs, volume details, and explain rationale of how the QIO determined the ODCs. CMS must be able to crosswalk the proposed costs to the supporting documentation and proposed rationale. QIOs are asked to provide, but are not limited to:

· Specific price quotes;

· Market surveys;

· Historical data;

· Specific calculations used to estimate proposed costs and an explanation;

· Previous billing statements/expense vouchers; and/or

· Catalog prices.

For example, your Reproduction and Printing justification should show the number of specific items that you expect to print and the cost per item. If you report Rent under Other Direct Costs, please provide the details of how many square feet are currently rented, and the number of square feet you propose to rent under the new contract. Also, provide the cost per square foot in the prior year and each year of the proposed contract.

Example: Reproduction and Printing

Printing:

400 Copies

$0.50 a brochure/ $200 per meeting

Printing:

500 Copies

Grand Total

$4,600

Indirect Costs

For Indirect Costs, if you have an approved provisional Indirect Rate it can serve as the justification for this cost. However, you should always explain how you calculated Rent. For rent, please provide the details of how many square feet are currently rented, the number of square feet you propose to rent under the new contract, and the cost per square foot in the prior year and each year of the proposed contract. In addition, if you report AHQA dues, make sure that you report the amount per year and how the amount was determined. If you report Board of Directors fees, please detail your basis of compensation per board meeting or for travel performed on behalf of the organization.

If you do not have an approved provisional rate, or you do not believe that this rate is correct for your three-year budget, please fill out all the line items on Form 721 and justify the rate requested, with emphasis on the major items of increase.

Pass-thru Costs Explain how you calculated Pass-thru Costs, indicating how many records are involved, how the QIO projected the number of records, and the cost per record.

INSTRUCTIONS FOR CMS FORM 718 BP

QUALITY IMPROVEMENT ORGANIZATION 10th SOW

BUSINESS PROPOSAL SUMMARY

ITEM

1. Name and Address of QIO Organization. Enter the name and address of the organization submitting the proposal (make sure the information is entered in the boxes shown at cells A3, A4 and A5)

2. QIO Area. Enter the State or other area that the proposed QIO contract will cover (make sure the information is entered in the box shown at cell C7).

3. RFP Number. Enter the CMS RFP number for the proposed QIO contract (make sure the information is entered in the box shown at cell J3.)

4. Proposed Contract Period. Enter the beginning and ending dates of the proposed QIO contract (make sure the information is entered in the boxes shown at cells K7 and K9.)

5. Total Proposed Costs. This column contains your total proposed costs for the 3-year contract period. The proposed costs are listed for each line item category. No entries are required because the proposed costs automatically flow from Form 719 BP.

6. CMS Recommended Costs. No entries required. For CMS internal use only.

7. $ Difference. No entries required. For CMS internal use only.

8. % Difference. No entries required. For CMS internal use only.

9. Fringe, Indirect, Indirect Leave, and Other Rates. QIOs should enter their approved fringe benefit rate, indirect cost rate, and Indirect Leave Rate in the appropriate spaces. Leave spaces blank if you are a new QIO and do not have approved rates.

10. Signature of Authorized Official. The appropriate official of the organization submitting the business proposal should sign here.

13. Telephone #. Enter the organization’s phone number, starting with the area code.

14. For CMS use only.

15. For CMS use only.

16. For CMS use only.

Revised J-23 May 2011 Page 46

BLANK PAGE

RESERVED FOR INSERTION OF FORM 718 BP SUM

INSTRUCTIONS FOR CMS FORM 719 BP

QUALITY IMPROVEMENT ORGANIZATION 10th SOW BUSINESS PROPOSAL

ITEM

1. RFP#. No entry required. This information automatically flows from Form 718 BP.

2. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

3. QIO Area. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

COST CENTER COLUMNS

THE NEXT COLUMN SERVES AS THE COST CENTER FOR BENEFICIARY AND FAMILY CENTERED CARE AS INDICATED BELOW:

BENEFICIARY AND FAMILY CENTERED CARE - This column is used for all costs directly attributable to the activities described in the 10th SOW under Beneficiary and Family Centered Care.

THE NEXT FIVE COLUMNS COVER THE COST CENTERS FOR IMPROVE INDIVIDUAL PATIENT CARE AS INDICATED BELOW:

CLABSI,, CAUTI, SSI, & CDI HOSPITAL LEARNING NETWORK/COLLABORATIVE - This column is used for all cost directly attributable to the activities described in the 10th SOW under CLABSI,, CAUTI, SSI & CDI Hospital Learning Network/Collaborative.

PRESSURE ULCERS & RESTRAINTS TECHNICAL ASSISTANCE - This column is used for all cost directly attributable to the activities described in the 10th SOW under Pressure Ulcers & Restraints Technical Assistance.

NURSING HOME SAFETY LEARNING NETWORK/COLLABORATIVE - This column is used for all cost directly attributable to the activities described in the 10th SOW under Nursing Home Safety Learning Network/Collaborative.

ADVERSE DRUG EVENTS LEARNING NETWORK/COLLABORTIVE – This column is used for all cost directly attributable to the activities described in the 10th SOW under Adverse Drug Events Learning Network/Collaborative.

QUALITY REPORTING & IMPROVEMENT – This column is used for all cost directly attributable to the activities described in the 10th SOW under Quality Reporting & Improvement.

THE NEXT COLUMN SERVES AS THE COST CENTER FOR INTEGRATED CARE FOR POPULATIONS & COMMUNITIES AS INDICATED BELOW:

TECHNICAL ASSISTANCE FOR COMMUNITIES – This column is used for all cost directly attributable to the activities described in the 10th SOW under Technical Assistance for Communities.

THE NEXT THREE COLUMNS COVER THE COST CENTERS FOR IMPROVING HEALTH FOR POPULATIONS & COMMUNITIES AS INDICATED BELOW:

PREVENTION LEARNING NETWORK/COLLABORATIVE – This column is used for all cost directly attributable to the activities described in the 10th SOW under Prevention Learning Network/Collaborative – Section C.9.1.B (3).

PREVENTION TECHNICAL ASSISTANCE – This column is used for all cost directly attributable to the activities described in the 10th SOW under Prevention Technical Assistance – Sections C.9.1.B (2) and C.9.1.B (5).

CARDIAC DISEASE LEARNING NETWORK & TECHNICAL ASSISTANCE – This column is used for all cost directly attributable to the activities described in the 10th SOW under Cardiac Disease Learning Network & Technical Assistance – Section C.9.1.B (4).

THE NEXT COLUMN SERVES AS THE COST CENTER FOR GENERAL PROTOCOL REQUIREMENTS AS INDICATED BELOW:

CARE REINVENTION THROUGH INNOVATION SPREAD (CRISP) MODEL – This column is used for all cost directly attributable to the activities described in the 10th SOW under Care Reinvention through Innovation Spread (CRISP) Model – Section C.10 (3).

THE NEXT COLUMN SERVES AS THE COST CENTER FOR INFORMATION SERVICES AS INDICATED BELOW:

INFORMATION SERVICES – This column is used for all cost directly attributable to information services activities described in the SOW, and which are further described in the Appendix to these instructions under the section on Information Services.

Note: For direct contract costs that cannot be attributed to provided costs centers, the QIO/Offeror shall allocate those direct costs to each of the cost centers, using an allocation method consistent with organization practice. This does not include costs related to governance. These costs benefit the entire organization and should be included in indirect.

LINE ITEMS

a.1- a.4 Labor. No entry required. The hours and costs for each direct labor category are automatically calculated from the Staffing Proposal Summary sheet (Form SUM).

b. Leave. Note: include all paid time off (leave) in Fringe Benefit pool unless your organization has an approved separate Indirect Leave Rate (ILR). If your organization has an approved ILR, enter the appropriate cost for each category for the 3-year contract period.

c. Fringe Benefits. Enter the fringe benefits cost for the 3-year contract period that applies to the particular column cost center. Include all paid time off (leave) unless your organization has an approved separate ILR.

d.1- d.3 Subcontracts. No entry required. The hours and costs for each category are automatically calculated from the Subcontracts Proposal sheets (Forms SC 1 and SC 2). However, if you have costs for Physician Reviewers/Advisors in any task other than Beneficiary Protection and Special Projects, you should enter the cost for the 3-year contract period that applies to the particular column cost center.

e. Travel. Enter the travel cost for the 3-year contract period that applies to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

f. Other Direct Costs. No entry required. The costs for each column cost center are automatically calculated from the QIO ODC sheet. Furnish detailed supporting documentation to explain these costs.

g. Indirect Costs. Enter the indirect costs for the 3-year contract period that applies to the particular column cost center.

h. Pass-thru Costs. Enter the pass-thru costs for the 3-year contract period that apply to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

i. Fee. Enter the appropriate portion of the total fee in each column cost center.

TOTAL

No entry required. This column automatically calculates the total hours and costs for each line item category from the entries in the cost center columns.

RESERVED FOR INSERTION OF FORM 719 BP

INSTRUCTIONS FOR CMS FORM 720 BP

FRINGE BENEFIT PROPOSAL

QUALITY IMPROVEMENT ORGANIZATION 10th SOW BUSINESS PROPOSAL

ITEM

1. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

2. QIO Area. No entry required. This information automatically flows from Form 718 BP.

3. RFP#. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

NOTE: The total cost entries that you make in column 7 and 9 should include both direct and indirect costs. Also, an established QIO that has an approved provisional fringe benefit rate and which determines that this approved rate will accurately reflect projected 3-yr fringe benefit costs, does not have to complete the individual line items on Form 720 BP. Instead, enter the fringe benefit rate on Line m.

If the QIO does not believe that the approved rate is appropriate for projecting 3-yr costs or it is a new QIO that does not have an approved provisional rate, the QIO should complete the individual line items in columns 7 and 9, as explained below.

COLUMN 6. - Prior Year Total Organization Costs

LINE

a. - l. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 6.

m. Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 7 - Projected Total 3-yr Organization Costs

LINE

a. - k. Individual line item categories. (See note, above) On each line item, enter the fringe benefit cost projected for your organization for the 3-year period that the QIO contract would be operating. However, make an entry on line j. (Leave) only if you include leave in the fringe benefit pool.

Your supporting documentation should explain, in detail, any amount you enter on line item k. The supporting documentation should also fully explain the assumptions and bases you used for your organization’s projection, including appropriate cost projection schedules.

l. Total Fringe Benefits. No entry required. This line item automatically calculates the total of line items a. thru k.

m. Fringe Benefit Rate. Enter the fringe benefit rate that is applicable to the amount on line item l., Total Fringe Benefits. In your supporting documentation, give a detailed explanation of the method used to calculate this rate. It is necessary to provide the Fringe Benefit Rate even if you do not have to fill out lines a. thru l.

COLUMN 8 - Prior Year Total Medicare Costs

LINE

a. - l. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 8.

m. Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 9 - Projected Total 3-yr Medicare Costs

LINE

a. - k. Individual line item categories. (See note above) On each line item, enter the portion of the corresponding line item cost in column 7. (Projected Total 3-YR Organization Costs) allocated to the proposed Medicare QIO contract.

Your supporting documentation should explain, in detail, any amount you entered on line item k. The supporting documentation should also fully explain the assumptions and bases you used to allocate a portion of your organization’s total projected fringe benefits cost to the proposed Medicare QIO contract.

l. Total Fringe Benefits. No entry required. This line item automatically calculates the total of line items a. thru k.

m. Fringe Benefit Rate. Enter the fringe benefit rate that is applicable to the amount on line item l., Total Fringe Benefits. In your supporting documentation, give a detailed explanation of the method used to calculate this rate. It is necessary to provide the Fringe Benefit Rate even if you do not have to fill out lines a. thru l.

RESERVED FOR INSERTION OF FORM 720 BP

INSTRUCTIONS FOR CMS FORM 721 BP

INDIRECT AND OTHER DIRECT COST

QUALITY IMPROVEMENT ORGANIZATION 10th SOW BUSINESS PROPOSAL

ITEM

1. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

2. QIO Area. No entry required. This information automatically flows from Form 718 BP.

3. RFP#. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

Note: If a QIO has an approved provisional indirect cost rate and the QIO determines that this approved rate will accurately reflect projected 3-year indirect costs, it is not necessary to complete the individual line items on Form 721 BP pertaining to indirect costs. Instead, enter the indirect cost rate on Line ee.

If the QIO believes that the approved rate is not appropriate for projecting 3-year costs, the QIO should complete the individual line items in columns 6 and 8, as explained below. In any case, as explained in “Section 3 - Additional Explanation and Justification for Business Proposal” you should explain all rental costs, AHQA dues, or Board of Directors fees in that section.

COLUMN 5 - Prior Year Total Indirect Costs

LINE

a. - dd. Individual line item categories. Disregard these line items. No entries should be made on these line items in column 5.

ee. Indirect Cost Rate. Enter the indirect cost rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 6 - Projected Total 3-yr Indirect Costs

LINE

a. - cc. Individual line item categories. On each line item, enter the indirect cost projected for your organization for the 3-year period that the QIO contract would be operating.

Your supporting documentation should explain, in detail, any amount you entered on line item cc. The supporting documentation should also fully explain the assumptions and bases you used for your organization’s projection, including appropriate cost projection schedules.

dd. Total. No entry required. This line item automatically calculates the total of line items a. thru cc.

ee. Indirect Cost Rate. Enter the indirect cost rate that applies to the amount on line item dd. (Total). In your supporting documentation, give a detailed explanation of the method used to calculate this rate.

COLUMN 7 - Prior Year Medicare Indirect Costs

a. - ee. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 7.

COLUMN 8 - Projected Medicare 3-yr Indirect Costs

c. - cc. Individual line item categories. On each line item, enter the portion of the corresponding line item cost in column 6. (Projected Total 3-yr Indirect Costs) allocated to the proposed Medicare QIO contract.

Your supporting documentation should explain, in detail, any amount you entered on line item cc. The supporting documentation should also fully explain the assumptions and bases you used to allocate a portion of your organization’s total projected indirect costs to the proposed Medicare QIO contract.

dd. Total. No entry required. This line item automatically calculates the total of line items a. thru cc.

ee. Indirect Cost Rate. No entry required, as the indirect rate that applies has already been provided in column 6.

COLUMN 9 - Prior Year Medicare Other Direct Costs

a. - c. Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required. These line items are not applicable to this column.

d. - cc. Individual line item categories. If applicable, on each line item, enter the other direct cost for the current Medicare QIO contract for the latest 12-month period completed.

Identify this 12-month period in your supporting documentation. Your supporting documentation should also explain, in detail, any amount you entered on line item cc.

Line item o. Consultants does not apply to this column.

Line item q. Travel does not apply to this column.

dd. Total. No entry required. This line item automatically calculates the total of line items d. thru cc.

COLUMN 10 - Projected Medicare 3-yr Other Direct Costs

a. - c. Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required. These line items do not apply to this column.

dd. Total. No entry required. This line item automatically calculates the total of line items d. thru cc.

RESERVED FOR INSERTION OF FORM 721 BP

INSTRUCTIONS FOR PERSONNEL LOADING CHARTS

STAFFING PROPOSAL

FORM STAFFING

These instructions apply to the personnel loading charts for all four labor categories. It is preferable that positions should be listed in the following order: (1) Corporate Management, (2) Professional, (3) Information Systems, and (4) Support Staff. You should not list each type of labor category on a separate sheet. Positions will be sorted by labor category based on the labor category code (see col. 3 below). The form will automatically summarize information by labor category under the Grand Total line. Please note, the work year apportionment (labor and leave) is at the discretion of the QIO. The current formulas are based on a work year 2,080; however, QIOs may adjust based on proposed leave and labor hours (not to exceed 2,080 hours).

COLUMN

1. Staff Name. For each labor category, enter the last name and first initial of each employee that you have identified as a staff person under the guideline definitions in the Appendix. If the position title listed in column 2. is not assigned to anyone, enter vacant instead of an employee’s name.

2. Position Title. Enter the employee’s position for the 3-year Medicare QIO contract.

3. Labor Category Code. Enter the employee’s Labor Category code: P for Professional; I for Information Systems; C for Corporate Management; S for Support Staff.

4. Current Hourly Rate. Enter the employee’s current hourly rate of pay.

5. Proposed Year 1 Hourly Rate. Enter the employee’s hourly pay rate for year 1 of the proposed Medicare QIO contract.

6. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from the current rate to the year 1 rate of the proposed Medicare QIO contract.

7. Proposed Year 2 Hourly Rate. Enter the employee’s hourly pay rate for year 2 of the proposed Medicare QIO contract.

8. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 1 of the proposed Medicare QIO contract to year 2.

9. Proposed Year 3 Hourly Rate. Enter the employee’s hourly pay rate for year 3 of the proposed Medicare QIO contract.

10. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 2 of the proposed Medicare QIO contract to year 3.

11. Average Beneficiary and Family Centered Care Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to beneficiary and family centered care during the 3-year Medicare QIO contract period.

12. Total 3-yr Beneficiary and Family Centered Care Labor Costs. No entry required. This column automatically calculates the total direct labor costs for beneficiary and family centered care based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 11 entry.

13. Average CLABSI, CAUTI, SSI, & CDI Hospital Learning Network/Collaborative Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to CLABSI, CAUTI, SSI, & CDI hospital learning network/collaborative costs during the 3-year Medicare QIO contract period.

14. Total 3-yr CLABSI, CAUTI, SSI, & CDI Hospital Learning Network/Collaborative Labor Costs. No entry required. This column automatically calculates the total direct labor costs for CLABSI, CAUTI, SSI, & CDI hospital learning network/collaborative costs based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 13 entry.

15. Average Pressure Ulcers & Restraints Technical Assistance Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to pressure ulcers & restraints technical assistance during the 3-year Medicare QIO contract period.

16. Total 3-yr Pressure Ulcers & Restraints Technical Assistance Labor Costs. No entry required. This column automatically calculates the total direct labor costs for pressure ulcers & restraints technical assistance based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 15 entry.

17. Average Nursing Home Safety Learning Network/Collaborative Hours Per Year. Enter one-third of the total direct labor hours the employee would devote nursing home safety learning network/collaborative during the 3-year Medicare QIO contract period.

18. Total 3-yr Nursing Home Safety Learning Network/Collaborative Labor Costs. No entry required. This column automatically calculates the total direct labor costs for nursing home safety learning network/collaborative based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 17 entry.

19. Average Adverse Drug Events Learning Network/Collaborative Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to adverse drug events learning network/collaborative during the 3-year Medicare QIO contract period.

20. Total Adverse Drug Events Learning Network/Collaborative Labor Costs. No entry required. This column automatically calculates the total direct labor costs for adverse drug events learning network/collaborative based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 19 entry.

21. Average Quality Reporting & Improvement Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to quality reporting and improvement during the 3-year Medicare QIO contract period.

22. Total 3-yr Quality Reporting & Improvement Labor Costs. No entry required. This column automatically calculates the total direct labor costs for quality reporting and improvement based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 21 entry.

23. Average Technical Assistance for Communities Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to technical assistance for communities during the 3-year Medicare QIO contract period.

24. Total 3-yr Technical Assistance for Communities Labor Costs. No entry required. This column automatically calculates the total direct labor costs for to technical assistance for communities based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 23 entry.

25. Average Prevention Learning Network/Collaborative Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to prevention learning network/collaborative during the 3-year Medicare QIO contract period – Section C.9.1.B (3).

26. Total 3-yr Prevention Learning Network/Collaborative Labor Costs. No entry required. This column automatically calculates the total direct labor costs for prevention learning network/collaborative based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 25 entry period – Section C.9.1.B (3).

27. Average Prevention Technical Assistance Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to the prevention technical assistance during the 3-year Medicare QIO contract period – Sections C.9.1.B (2) and C.9.1.B (5).

28. Total 3-yr Prevention Technical Assistance Labor Costs. No entry required. This column automatically calculates the total direct labor costs for prevention technical assistance based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 27 entry – Sections C.9.1.B (2) and C.9.1.B (5).

29. Average Cardiac Disease Learning Network & Technical Assistance Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to cardiac disease learning network & technical assistance during the 3-year Medicare QIO contract period – Section C.9.1.B (4).

30. Total 3-yr Cardiac Disease Learning Network & Technical Assistance Labor Costs. No entry required. This column automatically calculates the total direct labor costs for cardiac disease learning network & technical assistance based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 29 entry – Section C.9.1.B (4).

31. Average Care Reinvention through Innovation Spread (CRISP) Model Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to the care reinvention through innovation spread (CRISP) model during the 3-year Medicare QIO contract period – Section C.10 (3).

32. Total 3-yr Care Reinvention through Innovation Spread (CRISP) Model Labor Costs. No entry required. This column automatically calculates the total direct labor costs for care reinvention through innovation spread (CRISP) model based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 31entry – Section C.10 (3).

33. Average IS Hours Per Year. Enter one-third of the total direct labor hours the employee would devote to information services activities during the 3-year Medicare QIO contract period.

34. Total 3-yr IS Labor Costs. No entry required. This column automatically calculates the total direct labor costs for IS based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 3 contract years based on your column 33 entry.

35. Average Total Direct Labor Hours Per Year. No entry required. The amounts in this column are automatically calculated from your previous entries in the individual cost center columns dealing with average direct labor hours per year.

36. Total 3-yr Direct Labor Costs. No entry required. The amounts in this column are automatically calculated from the entries in the individual cost center columns dealing with 3-yr labor costs.

37. Average Indirect Labor Hours Per Year. Enter one-third of the total indirect labor hours estimated for the employee during the 3-year Medicare QIO contract period.

38. Total 3-yr Indirect Labor Costs. No entry required. This column is automatically calculated based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same indirect labor hours for each of the 3 contract years based on your column 37 entry.

39. Average Total Labor Hours Per Year. No entry required. This column is automatically calculated based on your previous entries for average direct and indirect labor hours per year.

40. Total 3-yr Labor Costs. No entry required. This column automatically combines the amounts entered for total direct labor costs and total indirect labor costs in previous columns.

41. Average Direct Leave Hours Per Year. Not Applicable.

42. Total 3-yr Direct Leave Costs. Not Applicable.

43. Average Leave Hours Per Year. Enter one-third of the total leave hours estimated for the employee during the 3-year Medicare QIO contract period.

44. Total 3-yr Leave Costs. No entry required. This column is automatically calculated based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same leave hours for each of the 3 contract years based on your column 43 entry.

45. Average Total Leave Hours Per Year. No entry required. This column is automatically calculated based on your previous entries for average leave hours per year.

46. Leave as a % of Hours Worked. No entry required. This column calculates automatically based on amounts you entered in previous columns.

47. Total 3-yr Leave Costs. No entry required. This column automatically combines the amounts entered for total leave costs in previous columns.

48. Average Total Labor and Leave Hours Per Year. No entry required. This column automatically combines the amounts for average yearly direct and indirect labor and leave hours in previous columns.

49. Total 3-yr Labor/Leave Costs. No entry required. This column automatically calculates the total 3-yr cost of your proposed contract for labor and leave combined.

50. FTE Per Year. This column automatically calculates the average yearly FTE for each employee. The calculation considers all employee hours -- labor, leave, direct, and indirect. The current formula is based on a work year of 2,080 hours. The apportionment is at the discretion of the QIO given leave is now included in Fringe benefits or Indirect Leave Rate.

RESERVED FOR INSERTION OF FORM QIO STAFFING

INSTRUCTIONS FOR CMS FORM SC 1

SUBCONTRACTS PROPOSAL – PHYSICIAN REVIEWERS

NOTE: This form should reflect the aggregate cost information for the total number of physician reviewers/advisors that you estimate will be used. Information entered into this form will input hours and costs to the respective tasks on the 719 form automatically. However, the form is set up only for Beneficiary and Family Centered Care and Special Project. If you have Physician Reviewer cost for any other sub-task, you should provide the information in the same format as on the Form SC1 and input the totals directly in the appropriate block on the 719.

Physician Reviewer Cost for Beneficiary and Family Center Care (Benef. and FCC) - Blocks 1 through 17.

1. Current Physician Reviewer Hourly Rate. Enter the current average hourly rate for your physician reviewers/advisors in beneficiary and family center care.

2. Year 1 Number of Reviews. Enter your estimate of the number of reviews for year 1 of beneficiary and family center care proposed Medicare QIO contract.

3. Year 1 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a case review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 1 Hours Per Year. No entry is required. This column automatically calculates the total number of review hours for the first year of the contract based on the amounts you entered in the previous columns.

5. Year 1 Physician Reviewer Hourly Rate. Enter the average hourly rate for your Physician Reviewers/Advisors for Year 1 of the proposed Medicare QIO contract.

6. Year 1 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection review based on the amounts you entered in the previous columns.

7. Year 2 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 2 of the proposed Medicare QIO contract.

8. Year 2 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

9. Year 2 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the second year of the contract based on the amounts you entered in the previous columns.

10. Year 2 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 2 of the proposed Medicare QIO contract.

1. Year 2 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection reviews based on the amounts you entered in the previous columns.

12. Year 3 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 3 of the proposed Medicare QIO contract.

13. Year 3 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

14. Year 3 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the third year of the contract based on the amounts you entered in the previous columns.

15. Year 3 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 3 of the proposed Medicare QIO contract.

16. Year 3 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection reviews based on the amounts you entered in the previous columns.

17. Total 3 Year Benef. and FCC Review Costs. No entry is required. This column automatically calculates based on the costs for all three years of the contract.

RESERVED FOR INSERTION OF FORM SC 1

INSTRUCTIONS FOR CMS FORM SC 2

SUBCONTRACTS PROPOSAL - OTHER

NOTE: Please enter the requested cost information separately for each other consultant in Section 1 and each other subcontractor in Section 2. If you have more than 10 entries for Section 1 or 2, provide the additional consultant/subcontractor information on an attachment and carry the attachments subtotals to line k.

COLUMN

1. Name. Enter the first initial and last name of the subcontractor, when appropriate. If it is more appropriate to identify the subcontractor by a company or organizational name, enter this name instead of an individual’s name. Enter TBD If you are proposing a particular subcontracting activity for the 3-year Medicare contract but have not yet identified a particular subcontractor.

2. Total 3-yr Beneficiary and Family Centered Care Costs. For each consultant/subcontractor, enter the total costs that you propose for beneficiary and family centered care costs during the 3-year Medicare QIO contract period.

3. Total 3-yr CLABSI, CAUTI, SSI, & CDI Hospital Learning Network/Collaborative Costs. For each consultant/subcontractor, enter the total costs that you propose for CLABSI,, CAUTI, SSI, & CDI hospital learning network/collaborative costs during the 3-year Medicare QIO contract period.

4. Total 3-yr Pressure Ulcers & Restraints Technical Assistance Costs. For each consultant/subcontractor, enter the total costs that you propose for pressure ulcers & restraints technical assistance costs during the 3-year Medicare QIO contract period.

5. Total 3-yr Nursing Home Safety Learning Network/Collaborative Costs. For each consultant/subcontractor, enter the total costs that you propose for nursing home safety leaning network/collaborative costs during the 3-year Medicare QIO contract period.

6. Total 3-yr Adverse Drug Events Learning Network/Collaborative Costs. For each consultant/subcontractor, enter the total costs that you propose for adverse drug events learning network/collaborative costs during the 3-year Medicare QIO contract period.

7.…