IMRE SOW Draft (CMS 230483).pdf

DRAFT RFQ 230483 -

INSURANCE MARKET REFORM

ENFORCEMENT (IMRE)

Statement of Work

FEBRUARY 6, 2023

RFQ 230483

Contract No. TBD

Task Order No. TBD Attachment 1 – Statement of Work

Contents

BACKGROUND

PURPOSE

TECHNICAL CONSIDERATIONS

SPECIAL TERMS AND CONDITIONS

REQUIREMENTS

Tasks to Be Performed

Task 1– Review of Plan Documents

Task 2 - Performance of Market Conduct Examinations (MCEs)

Task 3 – Plan and Issuer investigations

Task 4 – Participation in Meetings and Consultations

Task 5 – Research

Task 6 - Progress and Summary Reports

Task 7: MHPAEA NQTL Analysis Audits

Task 8 – Plan and Issuer Investigations

Task 9 – Contract Transition (Optional until the end of the new contract)

REPORT REQUIREMENTS

PERFORMANCE AND DELIVERABLES

PLACE OF PERFORMANCE

DELIVERABLE SCHEDULE

SECURITY REQUIREMENTS

STATEMENT OF WORK

Insurance Market Reform Enforcement

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) is responsible for providing national leadership in setting and enforcing standards for health insurance that promote fair and reasonable practices to ensure affordable, quality health coverage is available to all Americans. CMS also provides consumers with comprehensive information on coverage options currently available so they can make informed choices on the best health insurance for themselves and their family.

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

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

When a state notifies CMS of one or more of the following, CMS is responsible for directly enforcing provisions under Title XXVII of the PHS Act:

• the state lacks authority to enforce;

• the state is otherwise not enforcing such federal requirements; or

• CMS has determined that the state is not substantially enforcing those requirements.

In addition, CMS has primary enforcement authority over non-federal governmental group health plans and the authority to recognize plans or policies as minimum essential coverage (MEC).

CMS requires support of a contractor to implement this work.

The Contractor shall conduct plan document reviews, audits, investigations, and examinations of health insurance issuers (Issuers), plans approved as MEC by CMS, and non-federal governmental group health plans.

The Contractor shall add targeted market conduct examinations to investigate bulk complaints of non-compliance with one or more provisions of the No Surprise Act and Transparency Act (specifically, the provisions added to title XXVII of the PHS Act, part D) against Issuers, in states where CMS is enforcing such provision(s), and non-federal governmental group health plans in all states to their existing line of work procedures to ensure that Issuers and non-federal governmental group health plans comply with the requirements. Beginning with calendar year 2023, the Contractor shall 15 Qualifying Payment Amount (QPA) audits in the base year and 25 audits every option year thereafter to assess non-compliance with No Surprises Act provisions for non-federal governmental group health plans and Issuers offering group or individual health insurance coverage in states where CMS is responsible for enforcing such provision(s). Additionally, the contractor shall conduct form filling reviews in the states and territories where CMS has direct enforcement authority of one or more of the issuer focused CAA provisions.

PURPOSE

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

Specifically, the Contractor shall review insurance policies and contracts, including but not limited to:

schedules of benefits, amendments, endorsements, Summaries of Benefits and Coverage (SBCs), plan benefit templates, and prescription drug benefits (hereafter referred to as plan documents), and provide information about provisions or language within the plan documents that appear to be out of compliance with Market Reforms or other federal requirements. In addition, the Contractor shall conduct evidence-gathering services (hereafter referred to as Market Conduct Examinations or MCE) and document the level of compliance with specific provisions of Title XXVII of the PHS Act by Issuers conducting business in states in which CMS has direct enforcement responsibilities for those provisions, or where a state has requested CMS to assist in enforcing federal requirements, non-federal governmental group health plans, and health insurance coverage recognized as MEC by CMS. These Market Conduct Examinations may require in-depth, on-site examinations of the Issuer(s), non-federal governmental group health plan(s), or coverage recognized as MEC under review by a Contractor following the National Association of Insurance Commissioners’ (NAIC) Market Regulation Handbook as well as CMS’ examination guidelines and interpretations of provisions under Title XXVII of the PHS Act. The Contractor shall also conduct investigations of plans and issuers. The Contractor shall conduct audits of the MHPAEA non-quantitative treatment limitations selected by CMS from non-federal governmental group health plans and Issuers offering group or individual health insurance coverage. Additionally, the Contractor shall provide to CMS ongoing research and trend analysis of changing industry, state, and federal regulatory guidelines. The Contractor shall also conduct QPA audits.

The information collected will be used by CMS to fulfill its enforcement responsibilities with respect to Title XXVII of the PHS Act as provided under Sections 2723, 2761, and 2799A of the PHS Act and 45 CFR Part 150.

TECHNICAL CONSIDERATIONS

The Contractor must use standard market conduct procedures consistent with the guidelines set forth in the NAIC Market Regulation Handbook or procedures provided by or agreed to by CMS. In addition, the procedures and systems employed must ensure the confidentiality of information and evidence collected. Information must be collected, stored, and delivered to CMS in a manner that ensures that only the following parties can view the information: 1) the Issuer, plan sponsors submitting plans for recognition as MEC, or non-federal governmental group health plans being examined; 2) the Contractor performing the work; and 3) the Contracting Officers Representative (COR) and/or appropriate CMS staff. In addition, security procedures and systems must observe all federal regulations concerning the integrity and security of all paper and electronic information. The responsibility for information security will be the sole responsibility of the Contractor until any information is given or transmitted to CMS and becomes the property of CMS. The Contractor and their staff must also complete any federally-created training courses that CMS requires of Contractors.

SPECIAL TERMS AND CONDITIONS

The Contractor is advised of the following special terms and conditions:

• Plan document reviews increase in volume starting in June and continuing through October of each year. Strict due dates apply to these reviews. Generally, reviews should be completed within five (5) business days from date assigned by CMS, unless otherwise specified.

• Market Conduct Examination assignments will made on a rolling basis throughout the year with the possibility of multiple examinations in different locations being performed simultaneously, as well as the possibility of periods without any examinations being performed.

• Issuers or non-federal governmental group health plans reviewed or investigated may be located in any of the 50 States, the District of Columbia, and the Territories.

• Plans recognized as MEC may be located in any of the 50 States, the District of Columbia, the Territories, and abroad.

• The Contractor must be knowledgeable in the area of plan document review and general market conduct examination procedures. The Contractor must also have extensive knowledge Title XXVII of the PHS Act, as well as other federal and state laws, regulations, and guidance pertaining to private health insurance necessary to perform this work.

• The Contractor must be available to accept assignments on short notice, to manage multiple project deadlines at one time, and complete deliverables on-time.

• The Contractor must abide by CMS standard operating procedures and policies to perform the work.

REQUIREMENTS

Independently and not as an agent of the United States Government, the Contractor shall furnish all the necessary services, qualified personnel, material, equipment and facilities, as needed to perform the requirements of this Statement of Work (SOW).

The Contractor shall employ examiners and analysts with appropriate regulatory education and experience, as demonstrated by certifications such as the Certified Insurance Examiner (CIE), Accredited Insurance Examiner (AIE), and Market Conduct Management (MCM) certifications. An Examiner-in-Charge or Analyst-in-Charge performing the requirements of this SOW must have CIE certification; and a Senior Examiner or Senior Analyst performing the requirements of this SOW must have an AIE or MCM certification.

Additionally, the Contractor shall employ a prescription drug benefit specialist with appropriate education and experience, as demonstrated by certifications such as the ACPE Accredited doctorate of pharmacy (Pharm D) or a Bachelor of Science in Pharmacy with informatics background. This specialist must understand the fundamentals of pharmacoeconomic and balancing clinical, regulatory, pharmaceutical industry and consumer access to formulary system development.

The Contractor shall employ or have access to an actuary with appropriate education and experience, as demonstrated by designation and membership with the American Academy of Actuaries (MAAA).

The actuary must have experience in analyzing health insurance rates and premium changes, and demonstrate knowledge of the requirements for rate filings with the state departments of insurance, and rate templates for On-Marketplace plan certification.

The Contractor shall employ or have access to a statistician with appropriate education and experience, as demonstrated by completed coursework in quantitative and qualitative analysis, demographic techniques and analysis, business and economic statistics, intermediate procedures for data collection, and intermediate and advanced social statistics. The statistician must understand the fundamentals of health insurance including topics such as policy forms, underwriting, terminations, rescissions and denials, and claims data.

The Contractor shall employ or have access to a substance abuse and mental health clinician with appropriate education and experience as demonstrated by completed graduate degree in social work, psychology, mental health counseling, or marriage and family therapy from an accredited school and/or hold certification to be eligible to obtain clinical hours (under direct supervision if applicable) through a local state or county-wide governing body. Experience with private health insurance form review and health benefit design is preferred.

The Contractor shall employ or have access to a clinical medical doctor with appropriate education and experience as demonstrated by completed doctoral degree from an accredited medical school; currently licensed or eligible with active board certification or board eligibility to practice medicine; and should have appropriate certifications without restrictions in accordance to their state laws. Experience with private health insurance form review and health benefit design is preferred.

The Contractor shall utilize the following:

• TeamMate+™ audit management software, or another audit software program or method designated by CMS, to record market conduct examinations, plan and issuer investigations, MEC reviews, and track time for examiners by each project.

• System for Electronic Rate and Form Filing (SERFF™) for form filing submissions.

• File Maker Pro™ database software or another database software program or method designated by CMS, for creating customized reports and tracking on-going research and trend analysis of changing industry, state, and federal regulatory guidelines as well as any ancillary statutes, regulations, and sub-regulatory guidance related to the laws.

Tasks to Be Performed

The Contractor shall provide subject matter expertise of plan document reviews, MEC application reviews, non-federal governmental group health plan document reviews, plan and issuer investigations, and market conduct examinations (MCEs) of Issuers and of non-federal governmental group health plans, pursuant to a work plan and provide complete written reports (with supporting documentation) of such examinations, as outlined below. Subject matter expertise is defined as having a deep knowledge of the process, functions, and technology of plan and issuers and the ability to share that knowledge. In addition, the Contractor must possess a working knowledge of the PHS Act, as amended by CAA, provisions, and regulations applicable to Issuers and non-federal governmental group health plans providers. The Contractor shall assist CMS to develop, improve, and document an enforcement strategy for the PHS Act Part E provisions, as enacted by the CAA and implementing regulations, applicable to Issuers and non-federal governmental group health plans. The Contractor shall provide research support to CMS to determine best practices for enforcement oversight.

Task 1– Review of Plan Documents

The Contractor shall perform a review of an Issuer’s, a non-federal governmental group health plan sponsor’s, or a MEC applicant’s plan documents to highlight areas of concern with compliance of applicable provisions of the PHS Act. The Contractor shall review plan documents, both individual and group, to ensure that they include language that reflects the relevant requirements of the specific provisions of Title XXVII of the PHS Act that are subject to CMS’ direct enforcement. The Contractor’s review of plan documents may include, but is not limited to, the following types of documents: the contract; policy forms; certificates and outlines of coverage; schedules of benefits;

amendments; policy riders and endorsements; SBC; documents related to waivers; marketing materials; applications; Plan and Benefit Templates; Rx templates; Actuarial value documentation; and notices. The Contractor shall assign employees or subcontractors as examiners for plan document reviews in a manner that avoids actual or apparent conflicts of interest. The Contractor shall access industry form filings via System for Electronic Rate and Form Filing (SERFF™) and Health Information Oversight Systems (HIOS). Similarly, the Contractor will access industry plans seeking recognition as MEC via the Health Information Oversight System (HIOS) and will use the TeamMate+™ audit system or similar system for documentation of reviews, which may be located on Amazon WorkSpaces or similar remote server such as CMS CITRIX VAMS. Non-federal governmental group health plan materials will be primarily provided to the Contractor via email and will use the TeamMate+™ audit system or similar system for documentation of reviews, which may be located on Amazon WorkSpaces or similar remote server such as CMS CITRIX VAMS. Therefore, all policy form review functions can be performed remotely by the Contractor.

The Contractor shall track time for examiners by each project.

Immediately upon conclusion of each plan document review by the Contractor, the Contractor shall notify CMS through an agreed upon method that the review has been completed and that any findings have been documented and saved in an audit software system such as SERFF or TeamMate+™ as directed by CMS. The Contractor shall report any instances where the language in the policy form and related documents under review does not appear to comply with the specific provisions of Title XXVII of the PHS Act. As needed and under the direction of the COR(s), the Contractor shall also plan to participate in up to 20 meetings per year with CMS in other consultations and plan document revisions, such as formulary review and mental health parity discussions directed at achieving compliance, with the Issuer or Plan.

Work Papers: It is essential that any and all potential violation(s) of federal law be thoroughly documented. The Contractor must maintain all findings and documentation of potential violations found in the plan documents in the appropriate system, such as the TeamMate+™ project or SERFF system.

Documentation shall include the following:

• Attachment of any documents that contain the language or provision of concern;

• Specific citation and language from the statute, regulation, or guidance applicable to the finding presented;

• Specific language or provision found in the plan documents, including identification of the document by SERFF tracking number or HIOS Filing ID number, page number, and quoted language; and

• General direction to the issuer telling them what they need to do to correct the issue.

Generally, reviews should be completed within five (5) business days from date assigned by CMS, unless otherwise specified.

Task 2 - Performance of Market Conduct Examinations (MCEs)

At the discretion of CMS, the Contractor shall perform MCEs of Issuers, plans recognized as MEC by CMS, and non-federal governmental group health plans. The Contractor shall follow the NAIC Market Regulation Handbook or procedures provided by or agreed to by CMS as well as CMS’ examination guidelines and interpretations of provisions under Title XXVII of the PHS Act for MCEs of the Issuer(s), non-federal governmental group health plan(s), or plans recognized as MEC. The market conduct examinations shall consist of three levels of complexity, as listed below. Note that the actual number and type of provisions to be reviewed and the scope of the review will be established on an examination-specific basis when MCEs are assigned to the Contractor.

MCEs will fall into one of the following three categories:

1) Comprehensive Examinations - A full scope examination reviewing all business practices and documentation of an Issuer or non-federal governmental group health plan that may have an impact on the Issuer’s or non-federal governmental group health plan’s compliance with the relevant provisions of the PHS Act which are under review. These examinations shall be performed as desk examinations, on-site examinations, or a combination of both desk and on-site examinations.

2) Targeted Examinations - An examination specific to particular area(s) of concern with regard to an Issuer’s or non-federal governmental group health plan’s compliance with the relevant provisions of the PHS Act which are under review. These examinations shall be performed as desk examinations, on-site examinations, or a combination of both desk and on-site examinations.

3) Re-examinations - Follow-up examinations based on specific issues identified in a previous examination. The focus of the examination is on compliance with previous market conduct examination recommendations and/or compliance directives. These examinations shall be performed as desk examinations, on-site examinations, or a combination of both desk and on-site examinations.

In performing comprehensive examinations, targeted examinations and re-examinations, the Contractor shall perform one or more of the following tasks directed at compliance with the specific provisions of the PHS Act which are the subject of the market conduct examination:

• Review and analysis of the Issuer’s complaint register;

• Review of selected Issuer company information;

• Review of the Issuer’s marketing and advertising;

• Review of the Issuer’s policy forms;

• Review of the Issuer’s underwriting, terminations, rescissions, and denials;

• Review of the Issuer’s policyholder and certificate-holder files;

• Review of the Issuer’s claims data and claims handling practices;

• Review of the Issuer’s changes in rates and premiums;

• Review of the Issuer’s appeals process;

• Review of the Issuer’s and plan’s qualifying payment amount calculation;

• Review of non-federal governmental group health plan’s claims data and claims handling practices;

• Review of non-federal governmental group health plan’s appeals process;

• Review of the MEC plan sponsor’s claims handling practices;

• Review of plans recognized as MEC claims data and claims handling practices;

• Review of plans recognized as MEC’s appeals process;

• Review of any other applicable documents and data as determined necessary for a particular examination

The Contractor shall obtain information from Issuers, plans recognized as MEC by CMS, and non-federal governmental group health plans via secure file transfer protocol (SFTP) or a program or method approved by CMS. Each MCE of an Issuer, plan recognized as MEC, or non-federal governmental group health plan and its related reporting, as outlined below, shall be reported and signed by a Certified Insurance Examiner (CIE). The Contractor shall provide a status report for each market conduct examination that will include the hours per labor category and overall hours worked and total amount spent for each exam every two (2) weeks to CMS.

Task 2.a. Draft MCE Work Plan The Contractor, in conjunction with the CMS Market Conduct Examination team, shall provide to the COR(s) a Work Plan for each MCE to be conducted under this task order (MCE Work Plan). The Contractor must submit a Draft MCE Work Plan for each market conduct examination ten (10) business days prior to beginning a market conduct examination, reflecting the negotiated completion date for the market conduct examination. A conflict of interest statement from each employee or subcontractor assigned as an examiner shall be attached to each MCE Work Plan. The MCE Work Plan shall reflect the completion date for the market conduct examination, which will be based on such factors as the size and scope of the examination, the size and location of the Issuer, MEC Plan Sponsor, or non-federal governmental group health plan, estimated staff required, estimated number of hours, and the volume of materials to be reviewed.

Task 2.b. Conducting Entrance Conference Meeting and Participating in Exit Conference Meeting

The Contractor shall prepare the agenda, send out the meeting invitation, take meeting minutes, lead the entrance conference meeting as instructed by CMS, and invite CMS MCE team lead and examiner to participate in the meeting. Agendas must be sent no later than twenty-four (24) hours before each meeting.

The Contractor shall participate and be available to respond to any questions from the Issuers, plans recognized as MEC by CMS, and non-federal governmental group health plans regarding the draft report during the exit conference meeting. The Contractor shall also take meeting minutes. Meeting minutes must be sent to CMS no later than twenty-four (24) hours after each meeting.

Task 2.c. Review and Documentation of Market Conduct Work The Contractor shall provide MCE status report(s) every two weeks while a market conduct examination is on-going.

The Contractor shall thoroughly review and document the entire review based on scope of the Work Plan within the TeamMate+™ project for the Market Conduct Examination. The Findings box shall include, but be not limited to:

1. The citation and language from the statute, regulation, or guidance that is applicable to the finding;

2. Identification of the document(s) reviewed where the concern was found, the location(s) in the document(s), and the specific language or concern; and

3. For each finding, a chart indicating the sample(s) reviewed for the issue, the total population, the sample size, the number of errors found, and the percentage of errors based on the sample size.

In addition, attach supporting documentation to the procedure in TeamMate+™, including:

• Documents that contained errors;

• Requests for Information (known as RFIs that are sent by examiners to issuers to ask for additional information), with issuer responses, related to the procedure;

• Criticisms related to the procedure, including issuer’s response; and,

• Issuer’s proposed corrective action for resolving the issue.

Task 2.d. Draft MCE Report The Contractor must complete and submit to CMS a written Draft MCE Report (with supporting documentation) within ten (10) business days following the completion of a market conduct examination. The MCE Report, and all pertinent work papers, should include detailed summaries of the market conduct examination findings, in Exhibit format, with regard to specific areas of non-compliance.

The Draft MCE Report shall include content from the work papers and RFIs, as specified below:

• Work Papers: All relevant work papers, notes and documentation supporting a potential violation or general observation identified during the MCE must be maintained by the Contractor using the TeamMate+™ audit software. It is essential that the potential violation(s) be thoroughly documented and contain evidence of the alleged violation.

Work Papers must include the following:

o Copies of all supporting documentation and/or evidence cross-referenced to the Final Report findings;

o All work papers and work notes prepared by the Contractor;

o Memos to the File; and, o Explanations that are needed to clarify other work papers, supporting notes, and source documentation.

• RFIs and Criticisms: In addition to the above, a separate folder of all RFIs and Criticisms, and issuer’s, plan’s, or sponsor’s responses must be maintained.

CMS will review the Issuer’s response to the draft report and create the final report that includes a cover letter to direct the issuer to the report for CMS’s replies.

Task 3 – Plan and Issuer investigations

The Contractor shall also conduct investigations into issuer, non-federal governmental group health plans, and MEC plans’ compliance with specific applicable laws. Such investigations may be conducted in conjunction with the review of plan documents under Task 1. The Contractor shall work with CMS to determine proper processes and documentation of findings for these investigations, as well as an efficient way to coordinate the investigations with any review of plan documents under Task 1.

Through the course of an investigation, the Contractor shall draft RFIs that CMS will approve before the Contractor sends the request to the issuer, non-federal governmental group health plan sponsor, or MEC plan sponsor. After reviewing the documents returned from an issuer, non-federal governmental group health plan sponsor or MEC plan sponsor, the Contractor shall also write up the investigation’s findings for CMS review. As determined by CMS, the Contractor will be asked to participate in follow-up discussions with CMS as well as with the issuer or plan sponsor. The Contractor shall continue to request information from and review documents from the issuer, non-federal governmental group health plan sponsor, or MEC plan sponsor, as well as participate in follow-up discussions until CMS deems the investigation to be complete. The Contractor shall also take meeting minutes. Minutes of each meeting including descriptions of all decisions made, the reason(s) for making each decision, and any action items. The Contractor shall provide a status report for each investigation that will include the hours per labor category and overall hours worked and total amount spent for each investigation every two (2) weeks to CMS.

Task 4 – Participation in Meetings and Consultations

Task 4.a. Meetings The Contractor shall set up, facilitate, and prepare the agenda in advance of meetings and discussions with CMS. The Contractor shall set up the appointments and logistics for standing meetings between the Contractor and CMS after the effective date of the task order. It is expected that standing meetings shall take place every week with one of the calls serving as the monthly call, unless otherwise directed by CMS. The meeting agendas may include, but are not limited to, current issues and status updates on projects. In addition to the weekly general meetings, the Contractor shall also set up, facilitate, and prepare the agenda in advance of additional weekly meetings and discussions with CMS specific to Review of Plan Document activities (Task 1) from May through October.

The Contractor may also be asked to participate in additional meetings and consultations with Issuers, plan sponsors seeking recognition as MEC, and non-federal governmental group health plans, including discussions related to the review of plan documents, investigations, performance of market conduct examinations, and related findings. The Contractor shall identify and include only essential and appropriate personnel for meetings with CMS.

Task 4.b. Meeting Agendas Twenty-four (24) hours before each meeting, the Contractor shall submit to the CMS COR and project team leads a meeting agenda and all documents to be discussed at the meeting.

Task 4.c. Meeting Minutes Minutes of each meeting shall be provided within forty-eight (48) hours after the meeting, unless a request is made for a shorter turnaround by CMS in advance of the meeting. Minutes shall include a list of attendees, descriptions of all decisions made, the reason(s) for making each decision, and any action items.

Task 4.d. Communications Support, Training, and Technical Assistance Under the direction of the COR, the Contractor shall also provide technical assistance, training, and communications support that arises out of any plan document review, market conduct examination, plan and issuer investigations, or other actuarial or statistical services performed. This technical assistance and communication support can arise from a variety of sources, including general questions that arise from senior leadership at CMS, CMS staff, states, the Issuers or plans undergoing review.

The Contractor shall provide the COR with a plan for the completion of any communication support function where the estimated time to complete is more than two (2) hours.

Task 5 – Research

The Contractor shall perform ongoing research and trend analysis of changing industry, state, and federal regulatory guidelines as well as any ancillary statutes, regulations, and sub-regulatory guidance related to the laws. The Contractor shall provide such services pursuant to specifically outlined guidelines and requirements developed by CMS for each topic. Examples of such work may include market-wide research and analysis of national and state-specific health insurance-related regulatory guidelines. This information will help to identify compliance issues or problems, and to support outreach and education efforts.

Task 5.a. Tracking FileMaker Pro™ Database Development.

The Contractor shall complete periodic and track on-going research and trend analysis of changing industry, state, and federal regulatory guidelines as well as any ancillary statutes, regulations, and sub-regulatory guidance related to the laws. The Contractor will create and maintain the database following CMS guidelines and policies.

Task 5.b. Customized Reporting The Contractor shall provide customized reports as specified by CMS guidelines and requirements.

This may require programming experience.

Task 6 - Progress and Summary Reports

The Contractor shall submit Monthly Progress Reports, an Annual Summary Report, and other Periodic Progress reports as requested by CMS.

Task 6.a. Monthly Progress Reports The Contractor shall provide written monthly progress reports to update CMS on the status of any tasks that are being conducted by the Contractor. Report specifications will be provided by CMS at least ten (10) business days prior to the first deliverable due date.

Task 6.b. Annual Summary Report The Contractor shall provide a written annual summary report of activities conducted during each year of performance as well as trend analysis from previous years. Report specifications will be provided by CMS at least thirty (30) calendar days prior to the deliverable due date.

Task 6.c. Periodic Progress Reports The Contractor shall provide verbal and written periodic progress reports such as spreadsheets, power point slides, memoranda (or e-mails) to CMS, at minimum once per week.

Task 7: MHPAEA NQTL Analysis Audits

At the direction of CMS, the Contractor shall perform Audits of MHPAEA NQTL analysis of Issuers and non-federal governmental group health plans. The Contractor shall follow the CMS’ audit guidelines in conducting audits of the Issuer(s) and non-federal governmental group health plan(s). The MHPAEA NQTL Analysis audit’s scope will be established on an audit-specific basis when audits are assigned to the Contractor.

The Contractor shall obtain information from Issuers and non-Federal governmental group health plans via secure file transfer protocol (SFTP) or a program or method approved by CMS. Each audit of an Issuer or non-federal governmental group health plan and its related reporting, as outlined below, shall be signed off in TeamMate+™ by a Certified Insurance Examiner (CIE). The Contractor shall provide for each audit the labor category and overall hours worked and total amount spent to CMS with the findings upon completion of each Audit.

The Contractor shall thoroughly review and document the entire scope of work of the audit within the TeamMate+™ project for the MHPAEA NQTL Analysis. The Findings box shall include, but be not limited to:

• The citation and language from the statute, regulation, or guidance that is applicable to the finding;

• Identification of the document(s) reviewed where the concern was found, the location(s) in the document(s), and the specific language or concern; and

In addition, attach supporting documentation to the procedure in TeamMate+™, including:

• Documents that contained errors;

• Requests for Information (known as RFIs that are sent by examiners to Issuer or non-federal governmental group health plan to ask for additional information), with Issuer/non-federal governmental plan responses, related to the procedure; and,

• Criticisms related to the procedure, including Issuer’s/non-federal governmental group health plan’s response.

Work Papers must include the following:

• Copies of all supporting documentation and/or evidence cross-referenced to the findings;

• All work notes prepared by the Contractor;

• Memos to the File; and,

• Explanations that are needed to clarify other work papers, supporting notes, and source documentation.

RFIs and Criticisms: In addition to the above, the Contractor must maintain a separate folder of all RFIs and Criticisms, and Issuer’s and non-federal governmental group health plan’s responses to such.

CMS will review the findings of the MHPAEA NQTL Analysis Audit and create the final report to the Issuer or non-federal governmental group health plan and work with the plan to implement corrective actions within the 45-day time requirement.

Task 8 – Plan and Issuer Investigations

The Contractor shall conduct the same activities in Tasks 1 through 6 but specific to the CAA.

The Contract shall conduct up to 15 targeted market conduct examinations for the base year and then 25 every year thereafter to investigate bulk complaints of non-compliance with one or more provisions of the CAA against Issuers in states where CMS is enforcing such provision(s) and non-federal governmental group health plans to ensure that issuers and non-federal governmental group health plans comply the requirements.

initiate 25 QPA audits in the base year and each year thereafter to assess non-compliance with the Qualifying Payment amount provisions in the No Surprises Act for non-federal governmental group health plans and Issuers offering group or individual health insurance coverage in states where CMS is responsible for enforcing such provision(s). Report specifications will be provided by CMS at least thirty (30) calendar days prior to the deliverable due date.

Task 9 – Contract Transition (Optional until the end of the new contract) The Contractor shall work with the CMS and any other organization(s) as designated by the CMS to ensure a smooth, orderly, and cooperative transition of services between contractors, if necessary, at the beginning or end of performance under this contract. A transition period shall not exceed three months. The Contractor shall develop, update, and maintain a Transition Management Plan that delineates the processes and approaches for:

A. Transition Plan and Transition Schedule including key milestone events;

B. Participating in and work with the incoming contractor(s) and CMS during transition meetings to transition applicable activities;

C. Coordinating all personnel and staffing issues (e.g., plans to ramp down staff, resolve outstanding technical or contractual issues);

D. Performing inventory management of Personally Identifiable Information (PII), Government-Furnished Equipment (GFE), and Contractor-owned resources;

E. Providing any other information deemed necessary by the Contractor(s) or requested by CMS; and

F. Providing transition deliverables, including updated inventory lists and an updated deliverables list.

G. If a transition to new contractor(s) is initiated, the incumbent Contractor shall submit a completion letter detailing all tasks in the SOW that have been completed.

If applicable, this letter shall attest that all tasks have been completed or transferred to the incoming contractor(s).

REPORT REQUIREMENTS

Written informal or formal examination and investigation reports, including Draft MCE Reports, shall be presented by the Contractor to the Issuer, MEC Plan Sponsor, or non-federal governmental group health plan sponsor that was the subject of a related market conduct examination only after review and specifically authorized by CMS. In addition, when requested by CMS, the Contractor shall also provide technical assistance to CMS in support of CMS’s discussions with Issuers, MEC applicants, and non-federal governmental group health plan sponsors, related to the market conduct examinations, and related findings and reports. The Contractor shall provide real-time access to examination work via TeamMate+™ audit software located on an authorized server.

See Tasks 1 – 6 and the Schedule of Deliverables for specific reporting requirements and instructions for individual deliverables.

PERFORMANCE AND DELIVERABLES

PLACE OF PERFORMANCE

The work shall be performed at one or more of the following: 1) the Contractor’s offices; 2) the location of the Issuer, MEC Plan Sponsor, or non-federal governmental group health plan being examined; 3) CMS offices, or 4) other sites as deemed necessary or appropriate by CMS.

There may be an occasional need for the Contractor to be on site at the Bethesda or Baltimore, Maryland CMS locations, up to two times per year. The Contractor shall be reimbursed for travel to provide support at a Government site. The travel must be approved by the COR prior to the commencement of travel and should be the most cost-effective method. The Contractor shall be reimbursed for actual allowable, applicable, and reasonable travel costs incurred during the performance of this effort in accordance with the Federal Travel Regulations in effect on date(s) of travel.

DELIVERABLE SCHEDULE

The Contractor shall submit deliverables that are clear, concise, and complete, and conform to standards that shall be agreed to in advance between the Contractor and the COR. Deliverables due for each year (base year plus each option year) are listed in the chart below. Deliverables shall be submitted electronically using a system designated by CMS.

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Deliverable Number *

Deliverables Due Each Contract Year

Due Date Recipient

All deliverables listed are due during the Base Year and each Option Year.

* Deliverable numbers correspond to task and sub-task numbers used in this Statement of Work. Not all subtasks have a deliverable.

1. Plan Document Review

Within five (5) business days from date assigned by CMS

COR/COR

Backup and team leads for Form Filing, Non-Fed Plans Review, and MEC Review, respectively

2. Status report for each market conduct examination that will include the hours per labor category and overall hours worked and total amount spent for each exam

Every two (2) weeks per year to

CMS

COR/COR

Backup and team leads for Market Conduct Exams

2.a Draft Work Plan for each market conduct examination (“MCE Work Plan”) reflecting the negotiated due date of completion of the market conduct examination. The Draft MCE Work Plan includes, as an attachment, a Conflict of Interest statement from each employee or subcontractor assigned to the

MCE.

Ten (10) prior to beginning a market conduct examination.

COR/COR

Backup and MCE team lead

2.b. Prepare the agenda, send out the meeting invitation, take meeting minutes, lead the entrance conference meeting as instructed by CMS, and invite CMS MCE team lead and examiner to participate in the meeting.

Agendas sent twenty-four (24) hours before each meeting

Backup and MCE team lead

2.b. Participate and be available to respond to any questions from the Issuers, plans recognized as MEC by CMS, and non-federal governmental group health plans regarding the draft report during the exit conference meeting. The Contractor shall also take meeting minutes. Minutes of each meeting including descriptions of all decisions made, the reason(s) for making each decision, and any action items.

Meeting minutes twenty-four (24) hours after each meeting

COR/COR

Backup and MCE team lead

2.c. Documentation of Market Conduct Work includes providing a regular status report(s), documenting findings in TeamMate+™ system, and uploading supporting documentation in the system.

Draft RFIs that CMS will approve before the Contractor sends the request and save in TeamMate+™.

Ongoing for documentation unless otherwise specified by CMS and as needed by CMS for RFIs

COR/COR

Backup and MCE team lead

2.d. Draft MCE report (with supporting documentation) of each market conduct examination.

Within ten (10) following the completion of a market conduct examination.

COR/COR

Backup and MCE team lead

3. Draft RFIs that CMS will approve before the Contractor sends the request to an issuer, non-federal governmental group health plan sponsor, or MEC plan sponsor.

As requested by

Backup or team lead

COR/COR

Backup and NF team lead

3. Write up the investigation’s findings for CMS review.

Ongoing unless otherwise specified by

CMS

COR/COR

Backup and NF team lead

3. Participate in follow-up discussions until CMS deems the investigation to be complete and write meeting minutes.

Meeting minutes twenty-four (24) hours after each meeting

COR/COR

Backup and NF team lead

3. Provide a status report for each investigation that will include the hours per labor category and overall hours worked and total amount spent for each investigation.

Every two (2) weeks while the investigation is in progress for status reports

COR/COR

Backup and NF team lead

4.a. Set up, facilitate, and prepare the agenda in advance of meetings and discussions with CMS. Set up the appointments and logistics for standing meetings between the Contractor and CMS after the effective date of the task order.

Participate in additional meetings and consultations with Issuers, plan sponsors seeking recognition as MEC, and non-federal governmental group health plans, including discussions related to the review of plan documents, investigations, performance of market conduct examinations, and related findings.

On-going throughout duration of the contract unless otherwise specified by

CMS

COR/COR

Backup and team leads for Form Filing, Non-Fed Plans Review, and MEC Review, respectively

4.b. Submit to the CMS COR and project team leads a meeting agenda and all documents to be discussed at the meeting.

Twenty-four (24) hours before each meeting

COR/COR

Backup and team leads for Form Filing, Non-Fed Plans Review, and MEC Review, respectively

4.c. Provide meeting minutes and include a list of attendees, descriptions of all decisions

Minutes of each meeting shall be provided within

COR/COR

Backup and team leads for Form made, the reason(s) for making each decision, and any action items.

forty-eight (48) hours after the meeting, unless a request is made for a shorter turnaround by CMS in advance of the meeting.

Filing, Non-Fed Plans Review, and MEC Review, respectively

4.d. Provide technical assistance, training, and communications support. Provide a plan for the completion of any communication support function where the estimated time to complete is more than two (2) hours.

As requested by

Backup or team lead

COR/COR

Backup and team leads for Form Filing, Non-Fed Plans Review, and MEC Review, respectively

5.a. Track on-going research and trend analysis of changing industry, state, and federal regulatory guidelines as well as any ancillary statutes, regulations, and sub-regulatory guidance related to the laws.

Create and maintain the database following CMS guidelines and policies.

On-going throughout duration of the contract unless otherwise specified by

CMS

COR/COR

Backup

5.b. Provide customized reports as specified by CMS guidelines and requirements. This may require programming experience.

As requested by

COR/COR

Backup or team lead

COR/COR

Backup

6.a. Provide written monthly progress reports to update CMS on the status of any tasks that are being conducted by the Contractor.

Report specifications will be provided by CMS at least ten

(10) business days prior to the first deliverable due date.

By 10th calendar day of each following month.

Backup, Contract Specialist

6.b. Provide a written annual summary report of activities conducted during each year of performance as well as trend analysis from previous years.

Thirty (30) business days after the end of each Contract Year, unless

Backup

Report specifications will be provided by CMS at least thirty

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

otherwise specified by

CMS.

Contractor will have another thirty (30) days to create the final version, if CMS has edits and comments.

6.c. Provide verbal and written periodic progress reports such as spreadsheets, power point slides, memoranda (or e-mails) to CMS, as requested.

Due date(s) and format will be determined by CMS when report is requested.

7. Notice of MHPAEA NQTL Analysis Audit completion and findings notated in TeamMate+™, along with the hours and labor category for such Audit.

As each Audit is finalized, however, no later than October 1, 2021, and no later than July 1 each year thereafter.

COR/COR

Backup, MHPAEA

NQTL Analysis team lead

8. The Contractor shall provide a written report on the number of plans and issuers with respect to which QPA audits were conducted during such year.

Report specifications will be provided by CMS at least thirty

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

Thirty (30) days after the end of the calendar year.

9. Provide a Transition Management Plan and Schedule with milestones (During Optional Transition-Out Period)

• Draft: Within ten (10) business days of request from COR

• Final: Five (5) business days after approval by

COR.

SECURITY REQUIREMENTS

A. Baseline Security Requirements

1) Applicability. The requirements herein apply whether the entire contract or order (hereafter

“contract”), or portion thereof, includes either or both of the following:

a. Access (Physical or Logical) to Government Information: A Contractor (and/or any subcontractor) employee will have or will be given the ability to have, routine physical (entry) or logical (electronic) access to government information.

b. Operate a Federal System Containing Information: A Contractor (and/or any subcontractor) will operate a federal system and information technology containing data that supports the HHS/CMS mission. In addition to the Federal Acquisition Regulation (FAR) Subpart 2.1 definition of “information technology” (IT), the term as used in this section includes computers, ancillary equipment (including imaging peripherals, input, output, and storage devices necessary for security and surveillance), peripheral equipment designed to be controlled by the central processing unit of a computer, software, firmware and similar procedures, services (including support services), and related resources.

2) Safeguarding Information and Information Systems. In accordance with Federal

Information Processing Standards Publication (FIPS) 199, Standards for Security Categorization of Federal Information and Information Systems, the Contractor (and/or any subcontractor) shall:

a. Protect government information and information systems in order to ensure:

• Confidentiality, which means preserving authorized restrictions on access and disclosure, based on…