SSN 220623 Final.docx

Sources Sought Notice (SSN) 220623

EXECUTION OF ONGOING COMPREHENSIVE REVIEW, RISK MANAGEMENT PLAN AND LOAN TECHNICAL ASSISTANCE FOR THE CONSUMER OPERATED AND ORIENTED PLAN (CO-OP) PROGRAM

THIS IS NOT A FORMAL REQUEST FOR PROPOSAL (RFP) AND DOES NOT COMMIT THE CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS) TO AWARD A CONTRACT NOW OR IN THE FUTURE

This is a SOURCES SOUGHT NOTICE (SSN) to determine the availability of small businesses on the General Services Administration (GSA) Multiple Award Schedule (MAS) (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business, and women-owned small business) that have the capability to support CMS in carrying out the workload associated with the implementation of a continued review strategy of Consumer Operated and Oriented Plans (CO-OP(s) to include conducting a comprehensive review program to evaluate ongoing internal compliance and risk management policies, processes and key financial controls and reviews of core operational functions in those instances when deficient progress are identified. These reviews, to include risk-based targeted reviews, will provide direct oversight of CO-OP activities as a start-up consumer-run, private, nonprofit, qualified health plan options offered in the Health Insurance Exchange. In addition to CO-OP Program requirements, the CO-OPs must also comply with all applicable and other related Federal and State laws and regulations. This includes Certificate of Authority and State Insurance Solvency requirements, which govern state-licensed health insurance issuers and the Affordable Care Act rules and regulations for health plans participating in the state Health Insurance Exchanges.

The information gathered from this market research will assist the Government in determining the appropriate acquisition strategy, including whether a small business set-aside is possible. Interested vendors must submit a capability statement to demonstrate their ability to perform the requirements stated below.

A. General Background

Section 1322 of the Affordable Care Act directed the Secretary to establish the CO–OP Program to provide loans to foster the creation of new consumer governed nonprofit health insurance issuers, referred to as a CO–OP, in every State. These new consumer-run, private, non-profit insurers were one vehicle for providing higher quality care that is affordable and uses innovative care models in the Health Insurance Exchanges starting with their launch in 2014.

The statute divides the CO–OP loans into two types: loans for start-up costs, to be repaid in 5 years (‘‘Start-up Loans’’), and loans to enable CO–OPs to meet State insurance solvency and reserve requirements, to be repaid in 15 years (‘‘Solvency Loans’’). Section 1322(b)(2)(A) of the Affordable Care Act directed CMS to ensure that there was sufficient funding to establish at least one CO–OP in each State and to give priority to organizations that could offer these CO–OP qualified health plans on a Statewide basis, provide integrated care, and have significant private support. Section 1301(a) (2) of the statute deems CO–OP qualified health plans offered by a qualified nonprofit health insurance issuer eligible to participate in the Health Insurance Exchanges. By creating more health plan choices, the CO–OP Program has benefited all consumers.

The CO–OP Program also seeks to promote improved models of care. Existing health insurance cooperatives and other business cooperatives provide possible models for the successful development of CO–OPs around the country. One major barrier to continued development of this model in the health insurance market was the difficulty of obtaining adequate capitalization for start-up costs and State insurance reserve requirements. The CO–OP Program was designed to help overcome this barrier to new issuer formation by providing loans specifically for these critical activities.

Pursuant to section 156.515(c) of the CO-OP Program Final Rule, an issuer supported by the CO-OP Program will offer at least one CO-OP qualified health plan at the silver level of benefits and one at the gold level of benefits in every individual Affordable Insurance Health Insurance Exchange (Health Insurance Exchange) that serves the geographic area in which it is licensed and intends to provide health care coverage. If an applicant chooses to offer at least one plan in the small group market outside the Health Insurance Exchange, it must commit to offering a CO-OP qualified health plan at both the silver and gold benefit levels in each Small Business Health Options Program (SHOP) that serves the geographic regions in which the organization offers coverage in the small group market.

Additionally, section 1322(c) (1) (B) of the ACA requires that “substantially all” of the issuer’s activities consist of the issuance of qualified health benefit plans in the individual and small group markets in each State in which it is licensed to issue plans. To satisfy this provision, section 156.515(c)(1) of the Final Rule requires that at least two-thirds of the contracts written by a CO-OP must be CO-OP qualified health plans offered in the individual and small group markets of the States in which the CO-OP is licensed. Section 1322(c)(4) of the ACA directs that a CO-OPs profits be used to lower premiums, improve benefits, or for other programs intended to improve the quality of health care delivered to its members. Additionally, the Advisory Board recommended that revenue be used to expand enrollment, or otherwise contribute to the stability of coverage offered by the CO-OP. These new consumer-run, private, nonprofit insurers are a vehicle for providing quality plans that are affordable, coordinated, and responsive.

The original loan portfolio was approximately $2.3B across twenty-three CO-OPs. The start-up loans range in size from $ 7 - 25 million and the solvency loans range from $20-130 million. Although CMS no longer has the authority to make loans to new borrowers, CMS continues to provide technical assistance and oversight to the remaining CO-OPs which are currently operational and have active loans being monitored by CMS. This oversight includes operational and financial reviews by CMS, as well as coordination with the State Department of Insurance, which is the primary regulator of the CO-OPs in each state where they operate.

Three of the original twenty-three ACA CO-OPs are currently operational and have start-up and solvency loan portfolio’s being monitored by CMS. The start-up loans are fully disbursed for all active CO-OPs which have- started to repay beginning in CY 2018. The loans are in two ranges: start-up loans range from $ 7.6-$13 million and solvency loans range from $ 64-$120 million.

The total outstanding loan portfolio is approximately $ 2 billion. The performance of the CO- OPs is an important aspect of monitoring the loan portfolios. The CO-OP Program has various performance measures that are reviewed and analyzed to determine the “riskiness” of the CO- OP issuer.

B. Capability Statement Requirements

In response to this SSN, CMS is seeking capability statements. Capability statements are NOT proposals and do not address price/cost. Industry is merely asked to provide information, which may demonstrate that they have expertise and capacity to meet the requirements of this work as a prime contractor, with subcontractors, as they deem necessary.

No marketing literature should be submitted in response to this Sources Sought Notice. When responding to this notice, vendors must demonstrate their experience in meeting and performing capabilities listed below. A mere statement that the vendor has a required capability is not sufficient.

When answering the following questions, vendors must provide specific and detailed examples of work that was performed that demonstrate required capabilities and the attendant level of effort that was involved:

1. Thorough understanding of the Affordable Care Act

2. Government Auditing/ Internal Controls, as it relates to the requirements of comparable scale and complexity.

3. Experience as a contractor working with CMS.

4. Health Insurers/Health Plans & Medical Claims experience, to include:

· Experience in the development and evaluation of strategies to improve the functioning of health care delivery systems and experience and expertise in conducting health plan benefit package reviews, ad-hoc clinical analyses, and use of utilization management (UM) techniques and mechanisms to identify benefit plan design quality issues.

· An in-depth understanding of Health Plan operational experience.

· Experience and knowledge of clinical administrative, billing, UM/QA, and managed care health plan functions.

· An understanding of groupings of codes used to describe common medical procedures such as Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS).

· An understanding of NCQA/URAC accreditation.

5. Statistical Studies and Data Mining experience assisting federal government agencies and commercial entities with analytic, modeling, and forecasting assignments.

6. Project Management expertise including budgeting/financial controls, project communication efforts, and process analysis

7. Ability to develop Education & Training Programs (to include Technical Assistance).

8. Actuarial expertise in the health insurance industry, including estimation of key reserves, regulatory reporting, forecasting and pro forma analyses.

C. Instructions for Submitting a Response to CMS

The following specific information is requested: (a) company descriptive literature; (b) specific related corporate experience; (c) experience with the type of capability requirements mentioned above; (d) references, to include points of contact, email addresses, and phone numbers; and (e) business information outlined below.

a) Sources Sought Notice number, title, and date of issuance

b) DUNS and/or UEI

c) Company Name

d) Company Address

e) Company Point of Contact, Phone and Email address

f) Validation of small business status under NAICS: 541219 – Budget and Financial Management Services (Size Standard: $22 million). Additional information on NAICS codes can be found at www.sba.gov.

g) Current GSA Schedules appropriate to this SSN

Please limit your documentation to the following page size, font type and size, spacing and page numbering: responses shall be submitted using a Microsoft Word /document with page size 8.5 by 11 inches. Font type shall be Times New Roman, size 10-12 using standard tabs and indent software features with no less than single spacing between lines. Responses are limited to ten (10) pages for the entire capability statement.

All transmitted information marked proprietary shall be treated as such. Therefore, businesses should identify any proprietary information in their responses. Proprietary materials will neither be distributed, nor discussed with, any other organization. Information submitted in response to this will be used at the discretion of the Government. Further, the information submitted will remain confidential insofar as permitted by law, including the Freedom of Information and Privacy Acts.

Respondents should be aware that this SSN is for marketing purposes only and any responses thereto, or lack thereof, will not constitute a commitment by CMS to treat any potential offeror more or less favorably in the anticipated forthcoming solicitation and/or ultimate award. Be advised that CMS will not respond directly to organizations submitting information in response to this SSN.

Capability statements can be submitted via e-mail to carlos.delgadosanchez@cms.hhs.gov and malissa.shin@cms.hhs.gov. Responses must be submitted no later than 4:00 PM EST, April 8, 2022.

Confidentiality No proprietary, classified, confidential, or sensitive information should be included in your response. The Government reserves the right to use any non-proprietary technical information in any resultant solicitation(s).

Disclaimer and Important Notes This notice does not obligate the Government to award a contract or otherwise pay for the information provided in response. Respondents are advised that the Government is under no obligation to acknowledge receipt of the information received or provide feedback to respondents with respect to any information submitted.

Teaming Arrangements Firms seeking to respond to this notice as a team or to rely on subcontractors to perform any portion of the work must include the above-requested information and certifications for each entity on the proposed team or each proposed subcontractor. Responses must clearly indicate the nature of the teaming arrangement

The contractor and any subcontractors must not have any relationships or arrangements through business operations or its employees that could be considered as possibly lessening the company’s objectivity concerning any aspect of the proposed tasks. If such relationships or arrangements exist, contractors or subcontractors shall be required, during the procurement process (if one occurs), to identify potential conflicts of interest and discuss how the conflicts will be addressed and mitigated.