Attachment_J.15(a)_revised_BP_Instructions.docx

QUALITY IMPROVEMENT NETWORKS BUSINESS PROPOSAL FORMAT

FOR UTILIZATION AND QUALITY CONTROL

QUALITY IMPROVEMENT ORGANIZATIONS

FORMS AND INSTRUCTIONS

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

BALTIMORE, MARYLAND

Attachment J.15(a) Business Proposal Format

TABLE OF CONTENTS

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 11th SOW Business Proposal Summary. 8

D. CMS Form 721 BP - Indirect and Other Direct Cost. 13

F. CMS Form STAFFING - Personnel Loading Charts. 17

G. CMS Form SC 2 – Subcontracts Proposal - Other. 21

H. CMS Form SUM - Staffing Proposal Summary. 23

I. CMS Form QIO ODC – Other Direct Costs – Supplemental Schedule. 27

J. Travel Detail Form 29

V.APPENDIX A-1

1: DEFINITIONS AND GUIDELINES: QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL A-1

I. INTRODUCTION

PURPOSE

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

SCOPE

Offerors must use the electronic files 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.

Offerors are required to include the appropriate supporting documentation cross-referenced to the related column, line item, and form. Offerors do not need to submit invoices and vendor quotes. However Offerors are to submit detailed assumptions on how costs are calculated for each item. Offerors must include quantities proposed as applicable, unit costs and all calculations. CMS may request invoices and vouchers from bidders at a later point in time. The supporting documentation shall be detailed and, as appropriate, fully explain calculations, bases for estimates, etc. Examples include:

a. Market surveys;

b. Historical data;

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

d. Catalog prices; and

e. Previous billing statements/expense vouchers.

METHOD OF SUBMISSION

CMS is providing the business proposal forms in an Excel spreadsheet file titled BP11SOW. 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 Excel2010 format or older. The narrative supporting information can be in Excel2010 (or older) or Word2010 (or older) format.

Attachment J.15(a) Page 1

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 must complete a separate business proposal for each QIO state.

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.

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.}. 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 five-year budget, please justify the rate requested, with emphasis on the major items of increase.

Other Consultants/Subcontracts

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 Subcontractor(s) must complete the same level of detail as the Prime. If the 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 J.13 must be submitted for each Subcontract 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 five-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.

INSTRUCTIONS FOR CMS FORM 718 BP

QUALITY IMPROVEMENT ORGANIZATION 11th 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 5-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, and Other Rates. QIOs should enter their approved fringe benefit rate and indirect cost rate in the appropriate spaces. Leave the fringe and indirect rate 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.

Attachment J.15(a) Page 4

BLANK PAGE

RESERVED FOR INSERTION OF FORM 718 BP SUM

INSTRUCTIONS FOR CMS FORM 719 BP

QUALITY IMPROVEMENT ORGANIZATION 11th 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 QUALITY IMPROVEMENT NETWORKS AS INDICATED BELOW:

QUALITY IMPROVEMENT NETWORKS - This column is used for all costs directly attributable to the activities described in the 11th SOW under Quality Improvement Network.

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 hours and cost for each category for the 5-year contract period.

c. Fringe Benefits. Enter the fringe benefits cost for the 5-year contract period that applies to the particular column cost center. Include all paid time off (leave) unless your organization has an approved separate indirect leave rate.

e. d.1- d.2Subcontracts. Enter the hours for each subcontractor/consultant for the 5-year contract period applies to the particular column cost center. Furnish detailed supporting documentation to explain these hours.

No entry required. Subcontractor/ Consultant costs are automatically calculated from the Subcontracts Proposal sheet (Form SC 2).

f. Travel. Enter the travel cost for the 5-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 5-year contract period that applies to the particular column cost center.

h. 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.

BLANK PAGE

RESERVED FOR INSERTION OF FORM 719 BP

INSTRUCTIONS FOR CMS FORM 721 BP

INDIRECT AND OTHER DIRECT COST

QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL

NOTE*** Forms 721 b-d are only to be completed by Offerors that utilize multiple Indirect rates. Offerors are to complete one form per indirect rate type. For example; If an Offeror has both G&A and Overhead, the Offeror is to enter G&A costs on Form 721 a and Overhead costs on Form 721 b.

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 5-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 5-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 5-yr Indirect Costs

LINE

a. - cc. Individual line item categories. On each line item, enter the indirect cost projected for your organization for the 5-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

LINE

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 5-yr Indirect Costs

a. & b. Indirect Labor and Indirect Leave. On each line item, enter the portion of the corresponding line item cost in column 6. (Projected Total 5-yr Indirect Costs) allocated to the proposed Medicare QIO contract.

c. - cc. Individual line item categories. On each line item, enter the portion of the corresponding line item cost in column 6. (Projected Total 5-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 NOTE*** Column 9 only applies to Form 721 a. Do not make entries into 721 b-d.

LINE

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 5-yr Other Direct Costs

NOTE*** Column 10 only applies to Form 721 a. Do not make entries into 721 b-d.

LINE

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.

COLUMN

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. Proposed Year 4 Hourly Rate. Enter the employee’s hourly pay rate for year 4 of the proposed Medicare QIO contract.

12. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 3 of the proposed Medicare QIO contract to year 4.

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

14. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 4 of the proposed Medicare QIO contract to year 5.

15. Average Quality Improvement Networks Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to quality improvement networks during the 5-year Medicare QIO contract period.

16. Total 5-yr Quality Improvement Networks Labor Costs. No entry required. This column automatically calculates the total direct labor costs for Quality Improvement Networks activities 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 5 contract years based on your column 15 entry.

17. Average IS Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to information services activities during the 5-year Medicare QIO contract period.

18. Total 5-yr Information Services Labor Costs. No entry required. This column automatically calculates the total direct labor costs for Information Services 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 5 contract years based on your column 17 entry.

39. 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.

40. Total 5-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 5-yr labor costs.

41. Average Indirect Labor Hours Per Year. Enter one-fifth of the total indirect labor hours estimated for the employee during the 5-year Medicare QIO contract period.

42. Total 5-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 5 contract years based on your column 41 entry.

43. 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.

44. Total 5-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.

45. Average Direct Leave Hours Per Year. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

46. Total 5-yr Direct Leave Costs. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate indirect leave rate.

47. Average Indirect Leave Hours Per Year. Enter one-fifth of the total indirect leave hours estimated for the employee during the 5-year Medicare QIO contract period.

48. Total 5-yr Indirect 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 indirect leave hours for each of the 5 contract years based on your column 47 entry.

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

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

51. Total 5-yr Leave Costs. No entry required. This column automatically combines the amounts entered for total indirect leave costs in previous columns.

52. 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.

53. Total 5-yr Labor/Leave Costs. No entry required. This column automatically calculates the total 5-yr cost of your proposed contract for labor and leave combined.

54. FTE Per Year. No entry required. This column automatically calculates the average yearly FTE for each employee. The calculation considers all employee hours -- labor, leave, direct, and indirect.

RESERVED FOR INSERTION OF FORM QIO STAFFING

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 5-year Medicare contract but have not yet identified a particular subcontractor.

2. Total 5-yr Quality Improvement Networks Costs. For each consultant/subcontractor, enter the total costs that you propose for quality improvement networks costs during the 5-year Medicare QIO contract period.

3. Total 5-yr Information Services Costs. Enter the total information services costs that you propose for each consultant/subcontractor, for the 5-year Medicare QIO contract period.

4. Total 5-yr Costs. No entry required. The amounts in this column are automatically calculated from the entries in the individual cost center columns.

5. Current Activity. If applicable, enter a short description of the work that the consultant/subcontractor is currently performing. Otherwise, enter NA.

6. Proposed Activity. Enter a short description of the work that the consultant/subcontractor would perform during the 5-year Medicare QIO contract. Provide a detailed explanation of the activity in your supporting documentation.

RESERVED FOR INSERTION OF FORM SC 2

INSTRUCTIONS FOR CMS FORM

STAFFING SUMMARY PROPOSAL

NOTE: This form summarizes hour and cost information by labor category and cost center. No entries are required, as all information is automatically calculated from the individual personnel loading charts for each labor category.

COLUMN

1. Average Current Hourly Rate. For each labor category, this amount corresponds to the related current hourly rate for that labor category. This amount is an average of the individual entries in the loading chart column.

2. Proposed Average Year 1 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 1 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

3. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from the current average rate to the average rate for year 1 of the proposed Medicare QIO contract.

4. Proposed Average Year 2 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 2 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

5. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 1 of the proposed Medicare QIO contract to year 2.

6. Proposed Average Year 3 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 3 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

7. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 2 of the proposed Medicare QIO contract to year 3.

8. Proposed Average Year 4 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 4 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

9. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 3 of the proposed Medicare QIO contract to year 4.

10. Proposed Average Year 5 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 5 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

11. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 4 of the proposed Medicare QIO contract to year 5.

during the 5-year Medicare QIO contract period.

12. Total Quality Improvement Networks Labor Costs. For each labor category, this amount is the total direct labor cost proposed for Quality Improvement Networks activities during the 5-year Medicare QIO contract period.

13. Total Quality Improvement Networks Labor Hours. For each labor category, this amount is the total direct labor hours proposed for Quality Improvement Networks activities during the 5-year Medicare QIO contract period.

14. Total Information Services Labor Hours. For each labor category, this amount is the total direct labor hours proposed for nursing home safety learning network/collaborative activities during the 5-year Medicare QIO contract period.

15. Total Information Services Labor Costs. For each labor category, this amount is the total direct labor cost proposed for nursing home safety learning network/collaborative activities during the 5-year Medicare QIO contract period.

16. Total Direct Labor Hours. For each labor category, this amount is the total direct labor hours proposed for all activities during the 5-year Medicare QIO contract period.

17. Total Direct Labor Costs. For each labor category, this amount is the total direct labor costs proposed for all activities during the 5-year Medicare QIO contract period.

18. Total Indirect Labor Hours. For each labor category, this amount is the total indirect labor hours you propose to apply to the 5-year Medicare QIO contract period.

19. Total Indirect Labor Costs. For each labor category, this amount is the total indirect labor costs you propose to apply to the 5-year Medicare QIO contract period.

20. Total Labor Hours. For each labor category, this amount is the total direct and indirect labor hours you propose for the 5-year Medicare QIO contract period.

21. Total Labor Costs. For each labor category, this amount is the total direct and indirect labor costs you propose for the 5-year Medicare QIO contract period.

22. Total Direct Leave Hours. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

23. Total Direct Leave Costs. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

24. Total Indirect Leave Hours. For each labor category, this amount is the total indirect leave hours you propose to apply to the 5-year Medicare QIO contract period.

25. Total Indirect Leave Costs. For each labor category, this amount is the total indirect leave costs you propose to apply to the 5-year Medicare QIO contract period.

26. Total Leave Hours. For each labor category, this amount is the total direct and indirect leave hours you propose for the 5-year Medicare QIO contract period.

27. Leave as a % of Hours Worked. For each labor category, this amount provides the percentage relationship of leave hours to labor hours. It is based on the entries you made on the individual personnel loading charts for each labor category regarding direct and indirect labor and leave hours.

28. Total Leave Costs. For each labor category, this amount is the total direct and indirect leave costs you propose for the 5-year Medicare QIO contract period.

29. Total Labor and Leave Hours. For each labor category, this amount is the total labor and leave hours (indirect) you propose for the 5-year Medicare QIO contract period.

30. Total Labor and Leave Costs. For each labor category, this amount is the total labor and leave costs (indirect) you propose for the 5-year Medicare QIO contract period.

31. Total FTE Per Year. For each labor category, this amount is the full-time equivalent per year. It is based on total labor and leave hours (direct and indirect) and a work year of 2,080 hours.

RESERVED FOR INSERTION OF FORM QIO STAFF SUM

INSTRUCTIONS FOR OTHER DIRECT COSTS

SUPPLEMENTAL SCHEDULE

QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL

Projected Medicare 5-yr Other Direct Costs

d. - cc. Individual line item categories. On each line item, enter the other direct cost projected for the proposed 5-year QIO contract.

Your supporting documentation should explain, in great detail, any amount you entered on line items d - cc. The supporting documentation should also fully explain the assumptions and bases you used for your projection, including appropriate supporting schedules.

Line item o. Consultants does not apply to this column. Enter direct costs related to consultants on Form SC-2 (Excel tab: QIO Subconts2).

Line item q. Travel does not apply to this column. Enter direct costs related to travel on Form 719 BP, line e.

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

RESERVED FOR INSERTION OF OTHER DIRECT COSTS

SUPPLEMENTAL SCHEDULE

INSTRUCTIONS FOR TRAVEL DETAIL

11th SOW BUSINESS PROPOSAL

ITEM

1. RFP Number. 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.

5. Mileage Rate. Enter the current Federal Travel Regulation mileage rate.

6. Area. Enter the quality improvement element the proposed trip relates to.

7. Trip Title and Description/Purpose. Enter the trip title and provide a brief description/purpose of the trip.

8. # of Days per Trip. Enter the number of days the trip will occur.

9. # of Night per Trip. Enter the number of nights the trip will occur.

10. # of Travelers per Trip. Enter the number of travelers, per trip, in whole figures.

11. Airfare per Person. Enter airfare amount per person.

12. Departing From. Enter the city and state the travelers are departing from.

13. Arriving To. Enter the city and state the travelers will arrive to.

14. FTR Meals and Incidentals Daily Rate. Enter the current Federal Travel Regulations (FTR) Meals and Incidental Rate for the location. Note: The formula in the Total column will calculate the max Per Diem rate for the first and last day of travel based on the number of days reported.

15. FTR Lodging per Night. Enter the current the current Federal Travel Regulations (FTR) maximum Lodging Rate (excluding taxes) for the Primary Destination for each trip. Note: The formula in the Total column will calculate the lodging costs based on the nights reported previously.

16. # of Trips. Enter the number of trips for the respective year.

17. Mileage per Traveler per Trip. Enter the roundtrip mileage per trip, if applicable.

18. # of Rental Car(s) per Trip. Enter the number of rental cars needed for each trip.

19. Daily Rental Car Rate. Enter the proposed daily rental car rate.

20. Miscellaneous Costs per Person per Trip. Enter the miscellaneous cost per person per trip. You may include parking fees, gas, taxi, metro fees, and the like.

21. Total. No entry required. This line item automatically calculates the total travel costs for the listed trip.

22. Notes. Provide a detailed explanation of the miscellaneous cost calculations (what and how your organization reached the proposed figures – i.e.: $20 taxi & $3 airport parking).

23. Grand Total. No entry required. This line item automatically calculates the total travel costs for all 3 years.

** Shaded cells represent no entry required and the totals for these activities DO NOT roll into the TRAVEL line item listed on the forms entitled, "QIO F719" or "QIO ODC".

V. APPENDIX

APPENDIX 1: DEFINITIONS AND GUIDELINES

QUALITY IMPROVEMENT ORGANIZATION 11th SOW BUSINESS PROPOSAL

I. GENERAL.

The forms that you need to complete your business proposal are forwarded electronically in an Excel spreadsheet file. (Sample forms are also included in the hardcopy version of this guideline package.) Upon opening the Excel file, the forms are accessible by clicking the various tabs at the bottom of your screen. Each tab represents one of the hardcopy business proposal forms. The forms and their related tab titles are as follows:

Form Tab Title Description

718 BP F718 BP SUM Business proposal summary

719 BP QIO F719 5-year proposed costs by cost center

720 BP QIO F720 Fringe benefit proposal

721 BP QIO F721 Indirect and Other Direct Cost

Staffing QIO Staff Personnel loading chart for all QIO Staff

SC 2 QIO Subconts2 Personnel loading chart for other consultants and other subcontractors

Sum QIO Staff Sum Personnel loading chart summary

QIO ODC QIO ODC Other Direct Costs

Travel Detail Form Travel Detail Form Travel Detail Form

Most of the cost information is entered on the individual Personnel Loading Charts and the Subcontracts Proposal form. The information you enter on these forms flows to the Form 719 BP. There are only a few line items on Form 719 BP that require your direct entry. Cells that do not require your entry are blocked. For specific data entry instructions, please see Section IV of the Table of Contents.

Attachment J.15(a) Page A-1

II. LINE ITEM CATEGORIES.

The following information is provided in a format consistent with the line item categories on CMS Form 719 BP. This information also applies to similar terms on other forms and worksheets used for the business proposal end for the Financial Information and Vouchering System (FIVS).

a. LABOR. 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.).

NOTE: The Line designations listed below apply both to the Forms BP719 of the FIVS 719 + 719A

b. LEAVE. This line item should be completed by all organizations that have an approved Indirect Leave Rate. This line item includes all indirect leave such as vacation, sick, holiday, and military leave. Accounting treatment of leave as an indirect cost must be consistent for all contracts or lines of business.

c. FRINGE BENEFITS. This line item includes allowances provided by the contractor to its employees as compensation in addition to regular wages and salaries. The Fringe Benefits line includes all direct costs such as employer’s share of FICA, federal unemployment tax, state unemployment insurance, disability insurance, pension expense, workers compensation, group health insurance, group life insurance, employee relations, and welfare. It also covers leave costs for those organizations that include these costs in the fringe benefit pool. This category does not include benefits provided some, but not all, full-time employees.

d. SUBCONTRACTS

1. PHYSICIAN REVIEWERS/ADVISORS. This line item includes all direct hours and costs related to subcontracts or agreements with physician reviewers or physician advisors to perform medical case review (and related) activities required by the statement of work (SOW). This applies to physicians who are not employees.

2. OTHER CONSULTANTS. This line item includes all direct costs related to subcontracts with physician and non-physician consultants (other than the physician reviewers and physician advisors performing medical case review, noted above) to perform activities required by the SOW.

3. OTHER SUBCONTRACTS. This line item is for all direct subcontracting costs not reportable on lines d.1. or d.2. This includes all direct hours and costs for subcontract arrangements (including those with universities and other organizations) meeting the requirements of the FAR, incurred in performance of the SOW, and not involving consultative services.

e. TRAVEL. This line item includes all travel directly chargeable to the contract.

f. OTHER DIRECT COSTS. This line item includes all direct costs applicable to the Medicare contract that are not reportable on other line items. Accounting treatment of other direct costs must be applied consistently to all contracts or lines of business and in accordance with the FAR or OMB Circular A-122.

All direct costs (excluding information services costs) not directly associated with a specific task should be included in the other direct cost pool and allocated to each task based on an allocation methodology developed by the offeror. Offerors must provide supporting documentation describing the proposed allocation method.

g. INDIRECT COSTS. This line item includes costs allocated to the Medicare contract but incurred for common or joint objectives. These costs fit in one of the following categories:

1. Costs that benefit all lines of business.

2. Costs that directly benefit the Medicare contract but which cannot be readily allocated to one or more specific cost centers. These costs are also referred to as general overhead costs of the Medicare contract.

Accounting treatment of indirect costs must be applied consistently to all contracts or lines of business and in accordance with the FAR and OMB Circular A-122.

h. FEE. This is the element of potential total compensation that may be received for contract performance over and above allowable costs and shall not exceed statutory limitations.

III. COST CENTER COLUMN CATEGORIES

a. QUALITY IMPROVEMENT NETWORKS - This column is used for all cost directly attributable to the activities described in the 11th SOW under Quality Improvement Networks.

b. INFORMATION SERVICES. This column includes all costs directly attributable to information services activities described in the SOW. This includes standard data processing system costs. Except for data entry costs, report all costs for activities that allow QIOs to comply with their data processing and reporting responsibilities (i.e., reporting, retrieval, data validation, ADP systems analysis, and electronic data interchange).

Include costs for the following activities:

5. FIVS compilation and reporting (but do not include financial accounting activities).

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