SOURCES SOUGHT
R -- Eligibility Verification
- Notice Date
- 8/14/2007
- Notice Type
- Sources Sought
- NAICS
- 541611
— Administrative Management and General Management Consulting Services
- Contracting Office
- Department of Health and Human Services, Centers for Medicare & Medicaid Services, Office of Acquisition and Grants Management, 7500 Security Blvd. C2-21-15, Baltimore, MD, 21244-1850, UNITED STATES
- ZIP Code
- 00000
- Solicitation Number
- Reference-Number-CMS-71609
- Response Due
- 8/29/2007
- Archive Date
- 10/1/2007
- Small Business Set-Aside
- Total Small Business
- Description
- 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. Perform Eligibility Verification for Point of Sale Facilitated Enrollment (POS FE) INTRODUCTION This announcement constitutes a Sources Sought Synopsis in support of the Centers for Medicare & Medicaid Services (CMS), Center for Beneficiary Choices (CBC). CMS is seeking capability statements from small and minority business firms (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 are qualified to support CMS as an Eligibility Contractor to provide a second-level verification of the Medicaid eligibility of dual eligible and other low-income beneficiaries who have presented at the Point of Sale (POS) (i.e., at a pharmacy) with an immediate need for prescription drug coverage. Point of Sale Facilitated Enrollment (POS FE) refers to the process in which a National Prescription Drug Plan provides immediate drug coverage to certain full-benefit dual eligible, or other low-income subsidy (LIS) eligible individuals. The individual presents to a pharmacist, who bills the claim in real time to the POS FE contractor. The POS FE contractor has in place front end edits to confirm the person meets the initial criteria for claims payment (i.e., is Part D eligible and is not already enrolled in another Medicare Part D prescription drug plan). At that point in time, the POS FE also determines whether the person has dual eligible or LIS status per CMS' systems. If it is determined that the beneficiary is Part D eligible, not enrolled in a Part D plan, and is a full-benefit dual eligible or other LIS eligible, then the POS FE Contractor can adjudicate the claim at POS and immediately enroll the beneficiary into their PDP. If the POS FE Contractor determines the beneficiary is Part D eligible and not enrolled in a Part D plan, but CMS data cannot confirm Medicare or LIS status, the POS FE Contractor will pay the claim at POS until such eligibility can be confirmed. The POS FE Contractor will request the Eligibility Contractor to verify Medicaid dual eligible status, and/or LIS eligibility status if available, for those whose eligibility status is unknown. The Eligibility Contractor will then verify dual eligibility status with the appropriate state, and will then return data on their findings to the POS FE Contractor. The Eligibility Contractor will also submit data on eligible beneficiaries to CMS' Medicare Beneficiary Database (MBD), to ensure that the MBD reflects accurate LIS status. For those whose eligibility status cannot be confirmed, the Eligibility Contractor will check CMS systems for LIS eligibility, as directed by CMS. Those with LIS eligibility will be sent to the POS FE Contractor as eligible. HISTORY On December 8, 2003 the President signed The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), authorizing a new Medicare Part D benefit that provides prescription drug insurance coverage to individuals who are entitled to Part A or enrolled in Part B. Coverage began January 1, 2006. The Part D benefit is being administered by private health plans. That is, eligible individuals in the traditional fee-for-service Medicare program may obtain the coverage through a stand-alone private PDP. Those enrolled in private health plans under Medicare Part C (Medicare Advantage (MA)) may only obtain drug coverage through plans (herein called MA-PD plans) offered through those MA organizations (with some exceptions). Full-benefit dual eligibles are individuals who are: 1) entitled to Part A or enrolled in Part B under Medicare; and 2) eligible for full Medicaid benefits. Prior to the effective date of the MMA, Medicaid paid for most prescription drugs and Medicare paid for a very limited set of prescription drugs. The MMA directed that Medicaid reimbursement for Part D covered prescription drugs end on December 31, 2005. Commensurately, the MMA created Section 1860D-1(b)(1)(C) of the Social Security Act (the Act) and full Medicare coverage began on January 1, 2006, which directed that full-benefit dual eligibles who failed to enroll in a PDP or MA-PD plan be auto-enrolled in a PDP that had a monthly beneficiary premium that did not exceed the region-specific low-income premium subsidy amount. Consistent with final regulations at 42 CFR 423.34, CMS has conducted Auto-Enrollment of full-benefit dual eligibles into PDPs since October 2005, and Facilitated Enrollment of other LIS eligibles into PDPs since March 2006. (Other LIS eligibles - means those who are deemed eligible by virtue of eligibility for Supplemental Security Income (SSI)-only (i.e., SSI and Medicare, but no Medicaid eligibility), or Medicare Savings Programs (MSPs, i.e. QMB-only, SLMB-only, or QI); as well as those who apply and are determined eligible by the Social Security Administration or their State Medicaid Agency.) CMS continues to make every effort to identify and auto-enroll all full-benefit dual eligibles, and identify and facilitate the enrollment of other low income subsidy (LIS) eligibles on a timely basis. However, in the event of omission or error, a full-benefit dual eligible may not be auto-enrolled, or an LIS eligible may not be facilitated enrolled. TASK DESCRIPTION Eligibility Verification Under the North American Industry Classification System (NAICS) (formerly known as the SIC code): 541611 - (Size Standard: $6.5 million. Additional information on NAICS codes can be found at www.sba.gov), the Eligibility Contractor shall, in addition to providing all necessary services, qualified personnel, materials, equipment, supplies, and facilities, not otherwise provided by the Government as required, verify eligibility for POS FE and LIS deeming for dual eligibles. This effort will include, but is not limited to, the following tasks: 1. The Eligibility Contractor shall establish the technical capability and develop the infrastructure for intake/receipt of cases, processing, and notification of denied facilitated enrollments. The Eligibility Contractor shall: a. Establish ability to query CMS' systems. b. Obtain necessary Data Use Agreement (DUA) and obtain CMS user ID and password. c. Establish secure connectivity as necessary (i.e., with MBD, the POS FE Contractor's systems, all 51 State EVS systems and other CMS systems as necessary). d. Establish policies and procedures and build systems requirements that comply with applicable privacy and data security laws. e. Establish policies and procedures and build systems requirements that comply with eligibility rules for intake, processing and reporting on facilitated enrollments and LIS deeming. f. Establish capability to send to and receive from CMS, standard data on those determined eligible for facilitated enrollment and LIS deeming. g. Begin testing with CMS and the POS FE Contractor, on information systems interfaces and data exchanges in time to permit successful implementation by January 1, 2008. h. Establish capability to store and retrieve facilitated enrollment data and LIS deeming data. 2. The Eligibility Contractor shall establish the technical capability and develop the infrastructure for verifying Medicaid dual eligibility status. The Eligibility Contractor shall establish query capability with State Medicaid Agencies in the 50 States and the District of Columbia, which should include EDI 270 query capability, and may include telephone or web-based individual queries, batch queries, or telephone contact with a live person. The preferred method for batch query is EDI. The Eligibility Contractor shall establish alternative capability to verify Medicaid eligibility with State Medicaid Agencies in the 50 States and the District of Columbia. For network connectivity and file transfer, the Eligibility Contractor will need to establish a direct connection between the contractor and CMS. 3. The Eligibility Contractor shall establish connectivity with the POS FE Contractor in order to receive data on a daily basis on beneficiaries for whom claims were submitted by a pharmacy as dual eligibles or other LIS eligibles, who did not have Part D plan enrollment in the service month of the date of service, and presented with a prescription drug need. 4. The Eligibility Contractor shall determine if a beneficiary qualifies for POS FE. a. The Eligibility Contractor shall obtain sufficient information about the beneficiary from the POS FE Contractor to verify dual eligibility status and eligibility for POS FE or LIS, respectively, including name, date of birth, state of residence, mailing address, state in which she/he has Medicaid, Medicaid ID number, SSN, DOB, gender code, and HICN/RRB number. b. For each beneficiary submitted by the POS FE Contractor, the Eligibility Contractor shall verify Medicaid eligibility with the state of residence for the month of the date of service by querying State systems. For those who cannot be found to be eligible through State systems, the Eligibility Contractor will query CMS' systems for Medicaid or LIS eligibility for the service month. c. In the event that the data elements specified in 4a are not provided, or appear to conflict with existing data (i.e., from the state), the Eligibility Contractor shall verify such data elements in the MBD, and return any discrepancies to the POS FE Contractor. d. The Eligibility Contractor shall verify dual eligibility of the beneficiary, and return data to the POS FE Contractor either confirming or denying that individual's eligibility for the POS FE process within 3 business days of the receipt of the data for 95% of beneficiaries, and within 6 business days for 99% of beneficiaries. 5. The Eligibility Contractor shall submit data on all beneficiaries found to be eligible for Medicaid from the POS FE Contractor to CMS, on a schedule to be determined by CMS (but on no less than a monthly basis) for inclusion in the LIS Deeming Process. The LIS Deeming file shall be submitted in a format to be determined by CMS. A. REQUIRED DEMONSTRATED KNOWLEDGE, EXPERIENCE, OR THE ABILITY TO PROVIDE 1) Demonstrated specialized knowledge and an operational understanding of Section 101 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). 2) Provide both sufficient personnel and appropriately skilled professionals. Staff should be experienced in establishing secure connections to query multiple systems, as this contract requires connectivity with 51 State Medicaid Agencies' Eligibility Verification Systems, including securing the necessary data use agreements and testing access to each. Staff should be skilled at interpreting data from multiple entities, especially in situations in which each system defines the same information with different types of data. Staff should also be experienced with conducting frequent and accurate data exchanges with multiple entities. 3) Ability to secure locations in which to maintain and store confidential and proprietary information (i.e., paper and electronic versions) and ability to shred confidential documents as instructed by CMS. 4) Maintaining and storing electronic data in a HIPAA-compliant environment throughout and after the conclusion of the project. 5) Specific corporate experience directly related to our requirements; include references (point of contact and phone number). B. BUSINESS INFORMATION Please provide the following: a. DUNS: b. Company Name c. Company Address d. Current GSA IT 70 and MOBIS Schedules appropriate to this Sources Sought. (This may or may not be a GSA procurement) e. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. f. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp. g. Company Point of Contact, Phone and Email address. h. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. It is essential that the contractor be free of all perceive, potential or actual conflicts. Specifically, the contractor must not have any relationships or arrangements through its business operations or its employees that could be considered as possibly lessening the company's objectivity concerning any aspect of this work. If such relationships or arrangements exist, contractors shall be required, during the procurement process, to identify potential conflicts of interest and discuss how the conflicts will be addressed and mitigated. The synopsis is for information and planning purposes and is not to be construed as a commitment by the Government. This is not a solicitation announcement for proposals and no contract will be awarded from this announcement. No reimbursement will be made for any costs associated with providing information in response to this announcement and any follow-up information requests. Respondents will not be notified of the results of the evaluation. All information submitted in response to this announcement must arrive on or before the closing date. Small and minority businesses interested in documenting their capabilities should address A & B above to perform in the functional areas provided herein. Responses to this sources sought announcement should be sent as soon as possible, but no later than August 29, 2007. Capability statements shall be limited to ten (10) pages and no more than ten (10) pages of attachments, and shall include any/all teaming arrangements. Documentation should be sent to: Centers for Medicare & Medicaid Services Attn: Chip Farmer, Contract Specialist Office of Acquisitions and Grants Management Acquisitions and Grants Group Division of Beneficiary Support Contracts Mailstop: C2-21-15 7500 Security Boulevard Baltimore, MD 21244 Questions may be referred to Chip Farmer at 410-786-1997. Point of Contact Chip Farmer, Contract Specialist, Phone 410-786-1997, Fax 410-786-9088, Email - edward.farmer@cms.hhs.gov
- Record
- SN01371705-W 20070816/070814220450 (fbodaily.com)
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