Draft_MSPP_Application_Appendix_E_Application_Evaluation_Criteria.pdf

Appendix E: Application Evaluation Criteria

Draft MSPP Application Page 1

OPM will review all information you provide in your application with particular emphasis in the areas listed below.

Operational and Managerial Capabilities: OPM will evaluate the experience and quality of the key personnel you are committed to devoting to the MSPP. We will also evaluate your proposed use of subcontractors in the MSPP and your proposal for oversight of these subcontractors.

If you are a group of issuers, we will also evaluate your application based on how clearly it describes and documents the roles and responsibilities of each entity within the group and the extent to which these roles and responsibilities are compatible with the efficient and effective administration of an MSP.

We will evaluate your capability to perform and reconcile enrollments and collect and reconcile premiums.

Past performance: We will evaluate your past performance in providing health insurance coverage to individuals and small groups. In conducting the past performance evaluation, OPM may, at its discretion, use information obtained from other sources, as well as that provided by you. While OPM may elect to consider information obtained from other sources, the burden of providing complete information rests with you.

We will take into consideration all compliance actions, corrective action plans, and market conduct reviews on a State level when evaluating past performance. We will also consider information received from consumer organizations about the your conduct in the marketplace in determining past performance.

OPM’s evaluation will only consider past performance information as it relates to the requirements for MSP issuers or similar requirements. Failure to provide all reviews, investigations, findings, reports, sanctions, admonishments, restrictions, or other positive or negative written material for the applicant (or for each member of a group applicant) and each proposed first-tier subcontractor, covering the specified time period, may have an adverse impact on your past performance evaluation.

Claims administration: We will evaluate the adequacy of your claims payment system and processes, claims review and appeals processes and results, and your history of paying claims promptly and accurately.

Network adequacy: We will assess whether you demonstrate that you can meet the network adequacy requirements and provide access to a stable, high-quality network(s) of participating providers who are geographically dispersed and can provide a comprehensive range of services. The networks must include essential community providers, as defined in 45 CFR 156.235(c).

Appendix E: Application Evaluation Criteria

Draft MSPP Application Page 2

You will be expected to demonstrate:

• Significant use of network provider contracts to minimize patient out-of-pocket costs by preventing network providers from charging patients for the difference between the plan’s allowed benefit and the provider’s actual charge (balance billing).

• The quality of provider networks through such factors as license verification, credentialing, board certification, accreditation, customer satisfaction surveys, and attainment of quality or efficiency recognition designations.

• A process for continuous monitoring of network adequacy and procedures for responding to enrollee complaints about lack of access to network providers.

Member services: We will evaluate your approach to customer service, your ability to deliver well-coordinated, excellent customer service, your proposal for managing increases in encounter volume and enrollment, and the breadth of health and wellness programs you offer.

Marketing and Enrollment: We will evaluate your ability to provide a well-developed marketing campaign to eligible individuals and small employers, to facilitate the provision of adequate information to enrollees and small employers, and to reconcile enrollment records.

Quality: We will assess your processes for assuring the efficient delivery of high-quality medical care to enrollees, the results you have achieved, and your methods for monitoring quality and using that information for quality improvement activities. We will evaluate your current accreditation status and, if not accredited, your timeline for becoming accredited.

Fraud and Abuse: We will assess the effectiveness of your efforts to prevent, detect, and eliminate health care fraud and abuse.

IT systems: We will evaluate your progress in implementing health information technology and your ability to comply with Federal privacy and security laws and standards. We will also evaluate your ability to quickly establish necessary interfaces with OPM, Exchanges, HHS, Treasury, and reinsurance entities.

Contract performance capability assessment: OPM will assess your potential for acceptable contract performance, including avoidance of problems such as disruption of schedule, increased cost, degradation of performance, and the need for increased Government oversight. We will also assess the likelihood you will be able to meet requirements that are to be phased in over time, such as accreditation and offering of MSPs in all 50 States and the District of Columbia.

Financial capability: We will evaluate your capability to ensure adequate financial resources to perform the prospective contract.