Premium Stabilization Program JA Final_Redacted.pdf

Surprises Act (NSA) and its implementing regulations. Importantly, the NSA implementation work requires the establishment and maintenance of Pay.gov e-billing integration, Marketplace Assister Technical Support (MATS)/RARI Application Programming Interface (API), Pay.gov payment tracking, administrative fee refund and debt collection, and MATS/RARI reconciliation.

To date, $46,870,033 has been obligated to the original task order over a Base Period and four (4) option periods.

The current period of performance is:

Base Period: January 22, 2020 – March 15, 2021 Option Period 1: January 22, 2021 – January 21, 2022 Option Period 2: January 22, 2022 – January 21, 2023 Option Period 3: January 22, 2023 – January 21, 2024 Option Period 4: January 22, 2024 – January 21, 2025 Transition Out: October 22, 2024 – January 21, 2025

The proposed LFO period of performance is:

Base period: January 22, 2025 – January 21, 2026 Option Period 1: January 22, 2026 – August 21, 2026 Option Period 2: August 22, 2026 – February 21, 2027 Transition Out: November 23, 2026 – February 21, 2027

Program Background On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act (P.L. 111-148).

On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) was signed into law. The two laws are collectively referred to as the Affordable Care Act. The ACA creates new competitive private health insurance markets, or Federally-Facilitated Marketplaces – FFMs that have given millions of Americans and small businesses access to affordable coverage. Marketplaces help individuals and small employers shop for, select, and enroll in high quality, private health plans that fit their needs at competitive prices.

By providing a place for one-stop shopping, Marketplaces make purchasing health insurance easier and put greater control and more choice in the hands of individuals in the Marketplaces.

CCIIO promulgated regulations for the establishment and practices of Health Insurance Marketplaces and premium stabilization programs. This contract focuses on operational program support and related activities for the financial management programs operated by CCIIO’s PPFMG. PPFMG implemented the premium stabilization programs and is responsible for: performing data validations of the programs for the purposes of ensuring accurate payment calculations; reconciliation and payments/charges for all programs; monthly processing and remittance of advance premium tax credits (APTCs) payments; tracking and reconciliation of past payments for cost sharing reductions (CSRs); calculation of payments/charges for the risk adjustment program including the high cost risk pool (HCRP); user fee calculations and collections for the RA program, Federally- Facilitated Marketplace (FFM) operations and State Based Marketplace (SBM); creating and verifying vendor data and transmitting to other internal areas (e.g., accounting systems) to enable invoice and payment aggregation; all data validations related to EDGE, RADV, HCRP; and, monthly aggregated payment remittances including the netting for all payments and invoices PPFMG receives, verification and maintenance of Payee Record information (e.g. banking information), and transmission of appropriate Payee Record information to CMS’ Healthcare Integrated General Ledger Accounting System (HIGLAS) for all PPACA program payments and charges. CCRMS contains multiple instances of Salesforce (CRM tool) and is controlled under a single Authority to Operate (ATO). PPFMG customized Salesforce to monitor stakeholder outreach workflow and inquiry response, and to provide reporting, data analysis, discrepancy identification, appeals tracking, data collection and reconciliation processes, and the risk adjustment data validation (RADV) audit tool. The areas covered currently by the system address: reinsurance contributions, EDGE baseline status and submission (RA), discrepancies, user fee submissions, RADV audits, appeals tracking, vendor management tool, collections tracking, and general policy inquiry response regarding any of the premium stabilization programs.

As with the ACA, Congress also recognized the need for stronger consumer and stakeholder protections related to pricing and billing in health care and passed Title I (No Surprises Act) and Title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021, collectively referred to as the No Surprises Act (NSA). The NSA was signed into law on December 27, 2020, and established new protections for consumers related to price transparency and surprise billing in health care. For example, plans and issuers are required to provide an Advance Explanation of Benefits prior to scheduled services to include, among other things, a good-faith estimate of the cost of the service. They must also offer price comparison information to allow enrollees to compare the cost sharing for items and services furnished by any participating provider. The NSA also introduces new requirements on providers to ask about the individual’s insurance coverage status and provide a good-faith estimate of the expected charges when an individual schedules an item or service. As a result, a patient-provider dispute resolution (PPDR) process for uninsured individuals who are billed substantially more than estimated charges was established and the PSP contract facilitates the remittance of associated administrative fees from the Selected Dispute Resolution Entity (SDRE) to CMS.

The NSA also takes significant steps to end surprise billing by building on existing provisions that require group health plans and issuers of group and individual health insurance coverage to cover emergency services without prior authorization, and at the same cost sharing for out-of-network services that applies to in-network services.

The legislation also sets forth methodologies for determining the out-of-network rate that plans and issuers must pay providers, including air ambulance providers, for claims subject to surprise billing protections. If the plan or issuer and provider cannot agree on an amount during a 30-day negotiation period, the parties may choose to enter an IDR process.

3. Authority:

ORDER AGAINST FSS: Authority of the Multiple Award Schedule Program, Title III of the Federal Property and Administrative Services Act of 1949 (41 U.S.C. 251, et seq.); Title 40 U.S.C. 501, Services for Executive Agencies; and Section 803 of the National Defense Authorization Act of 2002 (PL 107-107) and implemented by FAR 8.405-6. Mark the applicable exception and for each discuss how the cited authority applies in accordance with FAR 8.405-6(c)(2)(iv).

An urgent and compelling need exists, and following the procedures would result in unacceptable delays (FAR 8.405-6(a)(1)(i)(A));

Only one source is capable of providing the supplies or services required at the level or quality required because the supplies or services are unique or highly specialized (FAR 8.405-6(a)(i)(B)); or

In the interest of economy and efficiency, the new work is a logical follow-on to an original Federal Supply Schedule order provided that the original order was placed in accordance with the applicable Federal Supply Schedule ordering procedures. The original order or BPA must not have been previously issued under sole-source or limited sources procedures (FAR 8.405-6(a)(1)(i)(C)); or

As detailed above, CCIIO requires the continuation of services with GDIT to ensure successful completion of current and new program operations, and most importantly, the novel work in progress related to the implementation of the NSA. For example, GDIT is currently enhancing the RARI Salesforce instance to be able to interface with the Pay.gov e-billing system and MATS to collect and track IDR administrative fees. This critical task will include the transmission of IDR disputing party data from MATS to RARI via an API, the determination of correct IDR administrative fee amounts and due dates, the creation of e-bills and e-bill accounts for IDR disputing parties, tracking payments made by IDR disputing parties against e-bills and transmitting payment status information to MATS, and facilitating IDR administrative fee refund and debt collection activities through extant RARI Vendor Management, collection, and IDR processes.

As a result of the recent NSA implementation efforts, CMS and GDIT are currently designing, developing, implementing, and enhancing the digital IDR process for insurers and providers, particularly with respect to the implementation of various provisions associated with the IDR administrative fee. This effort and other interdependent platform builds will require significant changes over the next two years as CMS and the federal tri-departments (Health and Human Services, Treasury and Labor) define and refine how these processes and platforms must perform. In the interest of economy and efficiency, it is in CMS’ best interest that GDIT continue its work until the end-to-end digital IDR process is designed, developed, and implemented.

To maximize efficiencies, CMS leveraged GDIT’s current Salesforce platform development expertise and experience under the original task order to fulfill its Congressionally mandated NSA platform development time frames and needs. Unfortunately, this task order is currently set to expire on January 21, 2025, with a possible Transition Out Optional task to begin on October 21, 2024, well before successful implementation is possible.

CMS has determined that the current task order will end before GDIT can complete development of the current IDR, platform including critical integration activities with MATS. As such, an LFO consisting of a 12-month Base Period and two Option Periods (totaling 13 months) are required to align with the estimated completion of this critical NSA related work.

In addition to the urgent statutorily mandated NSA/IDR platform development schedules, CMS is scheduled to finalize this summer (2024) an NSA Notice of Public Rule Making (NPRM) that will immediately task the PSP program with developing multiple technical solutions on its NSA Salesforce instance. The new NSA rule will immediately task the program with developing an NSA Health Plans Registry containing high level health plan information and contact information. The Health Plans Registry will enable health plans to add and manage their plan information and enable providers with the ability to search the registry to find key information about parties in which they are attempting to begin open negotiations or engage in the new NSA process. The new NSA rule will also require immediate development of a Federal IDR Process Landing Page – a one stop shop for disputing parties to interact with multiple IDR webforms. This will require the PSP contractor to collaborate quickly with MATS to integrate a new health plan registry, a Provider Payor Community, an Open Negotiations & Response webform, and multiple technical IDR user friendly enhancements to the RARI/MATS Salesforce instances.

Finally, the new Summer 2024 NSA rule will require the RARI Salesforce instance to develop the ability to collect IDR administration fees by an API connecting RARI to MATS and to Pay.gov.

For these new NSA IT regulatory mandated development efforts, GDIT must continue to collaborate with multiple stakeholders to design, develop, and implement over approximately the next two years. Conducting a competition and potentially transitioning this work in the middle of developing multiple NSA related platforms introduces significant risk to CMS’ charge under the NSA. In addition, because the NSA is a novel law, CMS cannot forecast with certainty the number of IDR disputes it will receive or how they may fluctuate in the coming months. CMS will need consistent technical support with the ability to rapidly expand based on incoming volumes. For these reasons, transitioning the PSP program presents significant risks to CMS’s ability to effectively implement NSA requirements within Congressionally mandated deadlines.

An item peculiar to one manufacturer can be a particular brand name, product, or a feature of a product, peculiar to one manufacturer). A brand name item, whether available on one or more schedule contracts, is an item peculiar to one manufacturer. (FAR 8.405-6(b);

4. Market Research:

The original GSA task order (GS00F057CA /75FCMC20F0013) was competed on the GSA PSS MOBIS SIN

874.1 in 2020. GSA has already determined the prices of supplies and fixed price services, and rates for services offered at hourly rates under schedule contracts to be fair and reasonable. Therefore, ordering activities are not required to make a separate determination of fair and reasonable pricing, except for a price evaluation as required by 8.405-2(d). Based on GDIT’s strong track record of performance with this work, CMS believes that GDIT is still capable of completing this work to ensure successful implementation of this important NSA related work. The Contracting Officer will ensure the level of effort, mix of labor proposed, and total price is reasonable for the modification.

5. Actions to Increase Competition:

Once the logical follow-on is complete, there will no longer be any barriers that lead to this exception to fair opportunity. At the completion of the new 25-month period of performance, it is anticipated that the NSA work will be successfully implemented such that a competitive procurement can be conducted without risk to CMS’ compliance with the statute.

6. Any other facts supporting the justification:

Not applicable. Please see sections 3, 4, and 5 of this J&A.

Approvals:

1. Program Office Certification: This is to certify that portions of this justification have been developed by the undersigned program office personnel, including supporting information and/or data verifying the Government’s minimum needs, schedule requirements and other rationale, which form the basis for this Limited Source Justification.

Joshua Annas - Contracting Officer Representative (COR) / Date

Beth Parish - Program/Project Manager (P/PM) / Date

Best Value Determination. By my signature below, after review of the relevant documents, I have determined that the order subject to this Limited-Sources Justification represents the best value for the Government as set forth in FAR 8.404(d), and constitutes a fair and reasonable price. The basis for my determination is as follows:

GDIT has been performing work under this program since 2014. GSA has already determined pricing to be reasonable; however, CMS will evaluate the pricing that is submitted against the current task order and Independent Government Cost Estimate (IGCE) that the program staff will produce. The evaluation of the quote against those items will enable CMS to make a fair and reasonable determination of the contractor’s pricing.

2. Contracting Officer Certification: This is to certify that the justification for the proposed acquisition has been reviewed and that to the best of my knowledge and belief, the information and/or data provided to support the rationale and recommendation for approval, is accurate and complete.

Malissa Shin - Contracting Officer / Date

I hereby confirm the circumstances described above apply and approve the Limited Source Justification.

Mark Smolenski - DMMC Division Director / Date

I hereby confirm the circumstances described above apply and approve the Limited Source Justification.

Juanita Wilson - MSCG Group Director / Date

Malissa M.

Shin -S

Digitally signed by Malissa M. Shin -S Date: 2024.05.23 09:04:45 -04'00'

Joshua C.

Annas -S

Digitally signed by Joshua C. Annas -S Date: 2024.05.22 10:15:02 -04'00'

Adrianne E.

Patterson -S

Digitally signed by Adrianne E. Patterson -S Date: 2024.05.22 10:26:06 -04'00'

Mark Smolenski -S

Digitally signed by Mark Smolenski -S Date: 2024.05.23 11:23:55 -04'00'

Juanita P. Wilson -S Digitally signed by Juanita P.

Wilson -S Date: 2024.05.29 12:15:14 -04'00'