CMS Sources Sought: Health Insurance and Medicare Part C and Part D Medical Loss Ratio (MLR) Examinations

Notice ID: 250300

This is a SOURCES SOUGHT NOTICE (Notice) to determine the availability of small businesses …

Project Requirements.  This is a CMS mission critical requirement and supports one of the primary goals of the Agency – better care and lower costs.  Beneficiaries should receive high quality, coordinated, effective, efficient care and, as a result, health care costs may be reduced.  Important knowledge requirements include, but are not limited to: strategic planning and project management expertise; sophisticated knowledge of MLR regulations, premium and claims data; ability to validate, test, analyze, review, document, and/or manipulate issuers’ MLR data, including all the data elements reported on the MLR Annual Reporting Form, and any other forms developed and utilized by CCIIO and CM to collect MLR-related data.

CMS requests that the respondent specifically address the requirements listed below; and provide enough information for CMS to make an informed determination of their capability to perform the work as identified below.  Please remember that the potential offeror or prime contractor must be able to perform at least 50% of the labor associated with this effort.  Please provide a list of contract references that your organization has had (if applicable) and your role on the contract (prime contractor or subcontractor).  If you were a subcontractor on a particular contract, please clarify the work that you did on that contract. Please describe your capabilities and detailed experience performing similar activities as those described below. Your responses should demonstrate:

1. Extensive knowledge of Section 2718 of the PHS Act, as well as other federal and state laws, regulations and guidance necessary to perform this work.
2. Experience and knowledge of how to conduct financial and regulatory reviews and examination procedures that are consistent with established industry guidelines applicable to those reviews.
3. Experience with and knowledge of how to perform research on the healthcare and insurance industry and state and federal regulations and guidance.
4. Extensive knowledge of the TeamMate™ system and ability to demonstrate use of the system.
5. Experience with and knowledge of risk-based and random selection of health insurance issuers for financial and regulatory examinations.
6. Extensive knowledge of how to review, analyze, and examine reported revenue and expense items to determine whether they meet the applicable definitions in regulations, guidance, and form instructions …

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