SOURCES SOUGHT
R -- Medicare Part C, Part D, and HHS Risk Adjustment Model Research, Development, and Maintenance - Sources Sought Notice
- Notice Date
- 7/30/2014
- 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, Maryland, 21244-1850
- ZIP Code
- 21244-1850
- Solicitation Number
- 150288
- Archive Date
- 8/28/2014
- Point of Contact
- Matthew Waskiewicz, Phone: 410-786-0253
- E-Mail Address
-
matthew.waskiewicz@cms.hhs.gov
(matthew.waskiewicz@cms.hhs.gov)
- Small Business Set-Aside
- N/A
- Description
- Sources Sought Notice - 150288 Sources Sought Notice (SSN) - 150288 Medicare Part C, Part D, and HHS Risk Adjustment Model Research, Development, and Maintenance PLEASE NOTE: This is not a formal Request for Proposal (RFP) and does not commit the Centers for Medicare & Medicaid Services (CMS) to award a contract no or in the future. This is a SOURCES SOUGHT NOTICE to determine the availability and capability of large businesses and qualified small businesses (e.g., 8(a), service-disabled veteran owned small business, HUBZone small business, small disadvantaged business, veteran-owned small business and woman-owned small business) on the GSA schedule to support the Centers for Medicare and Medicaid Services (CMS) in research and development of risk adjustment models for the Medicare Part C, Part D, and Exchange programs, in addition to implementation of model updates and management of model maintenance. This is not a request for proposals, proposal abstracts, or quotations and does not obligate the Government to award a contract. To respond to this Sources Sought Notice, interested parties must submit a capability statement to demonstrate their ability to perform the requirements. Background Part C Risk Adjustment. The purpose of risk adjustment is to pay organizations accurately for coverage of benefits under Part C by adjusting payment based on the expected expenditures of their Medicare-enrolled population, as measured by the demographics and health status of that population. Plan bids reflect the projected average risk of an enrolled population, and for approved plan bids, CMS risk adjusts beneficiary-level payments to Medicare Advantage (MA) organizations, certain demonstrations, and PACE organizations. CMS develops and maintains several Part C hierarchical condition category (CMS-HCC) models: an aged/disabled model, an ESRD model, and a model used to pay PACE organizations. Each model comprises several segments, for subpopulations of the model population. The aged/disabled model includes a community segment, a long-term institutional segment, and a new enrollee segment. The ESRD model includes segments for dialysis, transplant, and post-graft, as well as new enrollees. A risk score calculated with the appropriate CMS-HCC model/segment is applied to a monthly payment for a beneficiary. The Part C models are calibrated using FFS claims and are normalized to the average (1.0) FFS beneficiary; they recognize diagnoses from inpatient hospital, outpatient hospital, and physician settings. Part D Risk Adjustment. The purpose of risk adjustment is to pay Part D Sponsors accurately by adjusting payment based on the expected plan liability for prescription drug expenditures of their Medicare-enrolled population, measured by the demographics and health status of that population. For Part D, CMS uses a model that employs prescription drug hierarchical condition categories (Rx-HCCs). The Part D model is similar to the Part C model conceptually, except that it predicts Part D plan liability costs under the Medicare standard Part D benefit. CMS risk-adjusts beneficiary-level Part D direct subsidy payments for enrollees in Part D plans, including MA-PDs, "stand-alone" PDPs, cost plans that choose to offer the Part D benefit, certain demonstrations, and PACE organizations. Starting in 2011, the Rx‐HCC model is divided into eight segments. Age, community versus institutional status, low income status, and new enrollee status are required to determine which segment to use in calculating the beneficiary's risk score. Medicare Risk Adjustment Data Collection. CMS uses demographic characteristics of beneficiaries, and diagnostic information from original Medicare claims and from MA and other organizations to determine the appropriate risk score for each beneficiary. MA organizations are required to submit Risk Adjustment Processing System (RAPS) records with diagnoses and other data; they must submit an occurrence of a model-relevant diagnosis only once during the data collection year even though a beneficiary may have several service dates in a data collection year associated with a given diagnosis. In addition, effective for dates of service beginning on January 1, 2012, MA and other organizations are required to submit all encounters for each item and service provided to a plan enrollee. Encounter data provide CMS with information on both the utilization and cost of services at the enrollee level and will allow CMS to further refine the CMS-HCC risk adjustment models to reflect patterns of diagnoses and expenditures in the MA program. Risk Adjustment for Exchanges ("HHS Risk Adjustment"). Section 1343 of the Affordable Care Act provides for a permanent risk adjustment program. It applies to all non-grandfathered individual and small groups' plans inside and outside of Exchanges. The purpose of HHS risk adjustment is to pay plans that disproportionally attract higher-risk populations (such as individuals with chronic conditions). HHS risk adjustment requires accurately assessing payments and charges based on the expected plan liability for total medical expenditures of risk adjustment covered plans' individual market and small group market populations, measured by the demographics and health status of those populations. The HHS risk adjustment model uses an individual's demographics and diagnoses (the HHS-HCC diagnostic classification is a key element of the risk adjustment model) to determine a risk score, which is a relative measure of how costly that individual is anticipated to be to the plan (i.e., a relative measure of the individual's actuarial risk to the plan). The risk transfer formula averages all individual risk scores in risk adjustment covered plans, and uses the plan average risk scores, combined with other factors, to calculate the funds transferred between plans within a risk pool within a market within a State. The risk transfer formula is based on the difference between two plan premium estimates: 1) premium with risk selection, and 2) premium without risk selection. Transfers are intended to bridge the gap between these two premium estimates. Conceptually, the goal of risk transfers is to calculate balanced transfers that account for health risk differences while preserving permissible premium differences. HHS risk adjustment transfers must be balanced (i.e., must sum to zero across all plans within a risk pool within a market within a state). HHS uses the HHS risk adjustment methodology in all states where HHS operates risk adjustment on behalf of a state, and states may also apply this methodology if they operate their own risk adjustment program. Description of Tasks Task Group I: Research and/or development of new or improved Part D RxHCC models or model segments, including research into incorporation of PDE data for MA enrollees into the Part D model. Includes model building and development of testing approaches to assess model performance. Task Group II: Research and/or development tasks for new or improved Part C CMS-HCC models or model segments, including analysis of encounter data and refinements to models for high-cost beneficiaries. Task Group III: Research and/or development tasks for producing and/or refining the ACA HHS risk adjustment models, the methodology to be used to implement HHS risk adjustment, and the evaluation of state alternate risk adjustment methodologies. Task Group IV: Ongoing production and maintenance of the existing Part C models. Task Group V: Ongoing production and maintenance of existing Part D models. Task Group VI: Support update of Part C frailty adjuster for revised or new models, including survey administration and factor refinement. Required Demonstrated Knowledge and Experience Any potential offeror must document mastery in all of the following areas. •All statutory, regulatory, and subregulatory policies related to risk adjustment in the Part C and Part D programs, including intersection of Part A, B, and D benefits, how different contract and plan types have distinct risk adjustment and payment rules, and which FFS rules do and do not apply to the Medicare Advantage program. •All statutory, regulatory, and subregulatory policies related to HHS-operated risk adjustment, as well as State and Federal Exchange policies, changing diagnosis or disease category policies, and the applicability of market reforms, rating rules, and other Affordable Care Act provisions to the HHS risk adjustment methodology. •Published research regarding risk adjustment methodologies and in-depth knowledge of alternative models. •Expert ability to apply statistical and econometric expertise in model development; agility and creativity in thinking through analytical challenges; and clinical expertise to assess model performance in predicting medical costs, e.g., estimating risk score trends, assessing trends across different diagnosis coding systems, modeling effects of changes in benefit thresholds and other parameter changes, and modeling impacts of model changes. •Both proactively and upon request providing frequent, detailed options memos that are well written and clearly present quantitative results, including identifying options, conducting analyses, describing and interpreting results; and making recommendations. •The conceptual foundations and goals of the HHS transfer formula and experience, including development of options and evaluating how changes to the formula would affect the overall goals of the HHS risk adjustment methodology. •How the HHS risk adjustment models and transfer formula fit together in order to assess where best to apply adjustments and assess how the methodology meets HHS objectives, and design models in the individual and small group markets in accord with premium setting regulations for each market. •All features of CMS' and HHS' risk adjustment models, including but not limited to: the clinical bases of the models, issues with diagnosis coding, determination of hierarchies, filtering methodologies for encounter data, effects of prescription drug pricing and drug markets on model development, how to construct plan liability from PDE data, model segmentation, model constraints, and interactions, frailty factors, normalization, and risk score trending. •All operational rules and systems for implementing CMS and HHS risk adjustment, and translation of current and proposed rules into models and system rules (including but not limited to enrollment, payment, and payment reconciliation rules, and knowledge of all related databases and payment systems such as RAPS, EDS, MARx, DPS, PRS, IDR, and CME table structure.) •Survey methodology (e.g., sampling frames, increasing response rates) and specific expertise in frailty adjusters, HOS and HOS-M development, and how ADL data feed into model calibration. •All aspects of CMS' encounter data requirements, encounter data systems, prescription drug event data, and prescription drug systems. •All FFS pricing systems and databases for providers, suppliers and facilities, including prospective payment pricers and ESRD bundling. •ICD-9 and ICD-10 coding systems, including development of mapping between ICD-10 and HCCs and RxHCCs (including creation of mapping options in situations where there is no simple one-to-one solution for the purpose of risk adjustment model development). •Analysis of the Medical Loss Ratio (MLR) and Supplemental Health Care Exhibit (SHCE) data, including understanding of the program regulations and requirements, comparisons across datasets and over time, trending analysis, assessing the impact of policy developments on the MLR program, and identification of potential MLR reporting errors. Along with responses demonstrating extensive experience with all items above, the following specific information is requested: (a) company descriptive literature; (b) specific related corporate experience; (c) experience with the type of performance expectations mentioned above; and (d) references (to include a point of contact and phone number) with firsthand knowledge of the experience cited in (b), and (c) above; (e) Business information outlined below. Business information: a.DUNS b.Company Name c.Company Address d.Company Point of Contact, phone number and email address e.Type of company under NAICS: 541611 - Administrative Management and General Management Consulting Services (Size Standard: $7 million), as validated via the Central Contractor Registration (CCR). All offerors must register on the CCR located at http://www.ccr.gov/index.asp. Additional information on NAICS codes can be found at www.sba.gov. f.Current GSA Schedules appropriate to this Sources Sought Notice g.Point of Contact, phone number and email address of individuals who can verify the demonstrated capabilities identified in the responses. Teaming Arrangements. All teaming arrangements should also include the above-cited information and certifications for each entity on the proposed team. This 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. All capability statements can be submitted via e-mail or regular mail to the point of contact listed below. Responses must be submitted no later than Wednesday, August 13, 2014. Responses shall be limited to 10 pages. Resumes of key people are limited to 2 pages and may be submitted as an attachment, which will not count towards the page limit.   Documentation should be sent electronically to: Centers for Medicare & Medicaid Services Matthew Waskiewicz Contract Specialist Office of Acquisitions and Grants Management 7500 Security Boulevard Baltimore, MD 21244 Email: matthew.waskiewicz@cms.hhs.gov
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