Section 1011 MMA emergency health services to undocumented aliens.

Contracting Office Address U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services, Office of Acquisition and Grants Management, 7500 Security Blvd, M/S C2-21-15, Baltimore, MD 21244-1850, UNITED STATES Introduction The purpose of this Notice is to determine the availability of potential small businesses (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) capable of acting as the national administrative contractor for the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) 1 Section 1011, Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens program. Background Section 1011 of the MMA (Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens) (http://www.cms.hhs.gov/UndocAliens/Downloads/sec1011.pdf) requires that the U.S. Department of Health & Human Services (DHHS) directly pay certain hospitals, physicians, and ambulance suppliers2 for their un-reimbursed costs of furnishing certain emergency services3 to certain patients4. In response to this statutory mandate, the Centers for Medicare & Medicaid Services (CMS) is seeking an administrative contractor for the Section 1011 program. Section 1011 appropriated $250 million per year for each of fiscal years (FYs) 2005 through 2008, for provider payments, and requires that these funds remain available until expended. As of December 2008, $328.8 million remains. Section 1011 funds are allocated by state and the amount of each state’s allocation differs from each other, each determined according to the size of its resident alien population and the number of alien apprehensions made each year, as determined by statistics provided by the U.S. Department of Homeland Security. The Section 1011 program will continue operations until all funds are expended, even though no additional monies will be appropriated beyond FY 2008. The Provider Billing Group, within the CMS Center for Medicare Management, is charged with contracting oversight, administration, and management of the Section 1011 program, which became operational at award of the first administrative contract in July 2005. The original effective date of the Section 1011 program was for claims with dates of service May 10, 2005 and after. Total provider payments have historically averaged approximately $50 million per quarter and are required to be made electronically. The program will continue operations under its current administrative contract through calendar year 2009. The contractor that is awarded the second administrative contract for the program will inherit existing government-owned systems, property, processes, and protocols for continuing program administration. The contractor will also receive training from the existing administrative contractor for a prescribed period of time (a “transition period”), after which the new administrative contractor must be fully independent and operational by January 1, 2010. The new contractor must further meet at least the requirements identified below. Contractor Requirements In order to be considered, an offeror must be able to, at a minimum: (1) Must have demonstrated experience in processing Medicare Part A and Part B claims using the Fiscal Intermediary Shared System (FISS); (2) Create, maintain, and submit a detailed project/work plan, including a critical path schedule; (3) Meet all contractor performance standards (e.g., quality, security, privacy, reporting, cost control, timeliness, business relations, management, corrective action, etc.); (4) Adhere to, and ensure compliance with, all applicable federal laws and regulations including, but not limited to, the Federal Information Security Management Act (FISMA), the Freedom of Information Act (FOIA), the Privacy Act of 1974, the Federal Managers Financial Integrity Act (FMFIA), and the Health Insurance Portability and Accountability Act (HIPAA); (5) Must demonstrate that the quality management system conforms to the ISO 9001 quality systems model; (6) Create, maintain, and submit a detailed and pro-active quality control program; (7) Maintain the dedicated mainframe based, stand-alone Undocumented Alien Reimbursement System (UARS), i.e., the Section 1011 claims processing system; (8) Receive, process and finalize provider enrollment applications within prescribed timeframes; (9) Must be capable of issuing payments to approximately 5,000 hospitals, 5,000 ambulance providers and 300,000 physicians in all 50 states and the District of Columbia; (10) Verify provider applicant Medicare enrollment and federal sanctions status; (11) Maintain provider enrollment and payment data; (12) Process provider Electronic Data Interchange (EDI) enrollments and maintain provider EDI data; (13) Receive, process and adjudicate requests for payment (i.e., claims) within prescribed timeframes; (14) Calculate accurate provider payments according to the established Section 1011 payment methodology based on the FISS system and its components including Grouper and Pricer; (15) Calculate and remit electronic payments to providers within prescribed timeframes; (16) Identify, process, and collect overpayments made to providers; (17) Provide daily customer service and support to Section 1011 providers and other interested parties via a dedicated program call center; (18) Provide call center support to providers on topics including, but not limited to, provider enrollment, provider EDI enrollment and transactions, and electronic claims submission; (19) Track all customer service/call center calls and topics; (20) Maintain and regularly update a dedicated web site to keep providers and other interested parties informed of program enrollment, claims processing, and dispute procedures and other information; (21) Perform both quarterly and annual financial reconciliation and reporting; (22) Compile, create and submit bi-weekly, monthly, annual, and ad hoc management, claims processing, and other reports; (23) Adjudicate questions, requests, disputes and appeals from various sources; (24) Perform provider outreach and education; (25) Perform program oversight, including data collection, processing, reporting and management, and various audit processes such as provider medical and compliance reviews; (26) Ensure program integrity via cooperation with the U.S. Government Accountability Office and the U.S. Department of Health & Human Services Office of the Inspector General; and (27) Monitor and adhere to all information security policies, standards, procedures, directives, templates, and guidelines that govern the CMS Information Security Program (found at http://www.cms.hhs.gov/informationsecurity/). (28) The contractor will be required to establish and maintain a contractor code of business ethics and specific internal controls to detect and prevent improper conduct in connection with the award or performance of the contract or any subcontract. For further information, visit http://www.cms.hhs.gov/UndocAliens/01_overview.asp#TopOfPage. Business Information – Please provide the following in your response: a) DUNS # b) Company Name c) Company Address d) Current GSA Schedules, if applicable, appropriate to this Sources Sought Notice 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 addresses of individuals who can verify the demonstrated capabilities identified in the responses. Due Date Responses must be submitted no later than January 21, 2009. Responses should clearly reflect the respondent’s ability to meet the requirements included in this notice. Capability statements will not be returned and will not be accepted after the due date. Respondents will not be notified of the results of the review of their submissions. Information received will be considered solely to make informed decisions regarding a potential small business set-aside. The maximum number of pages for submission is 10. This is not an invitation for bid, request for proposal (RFP), or other solicitation, and in no way obligates CMS to award a contract. The sole intent of this document is to obtain capabilities for set-aside and procurement planning purposes. The Department of Health & Human Services, Centers for Medicare & Medicaid Services intends to issue a competitive solicitation for the Section 1011 administrative contractor. It is anticipated that a contract will be awarded with a 1-year base period and 4 option years. CMS anticipates the release of the RFP on or around April 2009, which will be available on the Federal Business Opportunities (FedBizOpps) website. The anticipated award date for this effort is on or before August 2009. Notes 1 Pub. L. 108-173 2 Eligible providers include hospitals, physicians, and ambulance services (including both Indian Health Service facilities whether operated by the Indian Health Service or by an Indian tribe or tribal organization, and Critical Access Hospitals) 3 Eligible services include health care services required by the application of section 1867 of the Social Security Act (42 U.S.C. 1395dd), and related hospital inpatient and outpatient and ambulance services. Note #3 History: Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Social Security Act impose specific obligations on Medicare participating hospitals that offer emergency services. These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these individuals, regardless of whether or not they are beneficiaries of any program under the Act. Section 1867 of the Act sets forth requirements for medical screening examinations of medical conditions, as well as necessary stabilizing treatment or appropriate transfer. In addition, section 1867(h) of the Act specifically prohibits a delay in providing required screening or stabilization services in order to inquire about the individual's payment method or insurance status. Section 1867(d) of the Act provides for the imposition of civil monetary penalties on hospitals and physicians responsible for negligently violating a requirement of that section, through actions such as the following: (a) Negligently failing to appropriately screen an individual seeking medical care; (b) negligently failing to provide stabilizing treatment to an individual with an emergency medical condition; or (c) negligently transferring an individual in an inappropriate manner (Section 1867(e)(4) of the Act defines "transfer" to include both transfers to other health care facilities and cases in which the individual is released from the care of the hospital without being moved to another health care facility). These provisions, taken together, are frequently referred to as the Emergency Medical Treatment and Labor Act (EMTALA), also known as the patient anti-dumping statute. EMTALA was passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Congress enacted these anti-dumping provisions in the Social Security Act because of its concern with an increasing number of reports that hospital emergency rooms were refusing to accept or treat individuals with emergency conditions if the individuals did not have insurance. 4 Payment under Section 1011 is allowed for patients who are any of the following: (A) Undocumented aliens, (B) Aliens who have been paroled into the U.S. at a U.S. port of entry for the purpose of receiving eligible services, (C) Mexican citizens permitted to enter the U.S. under the authority of a biometric machine-readable border crossing identification card (laser visa) issued in accordance with the requirements of regulations prescribed under section 1101(a)(6) of the Immigration and Nationality Act (8 U.S.C. 1101(a)(6)). Points of Contact Jimmie Curtis, Contract Specialist, Phone 410-786-8152, Fax 410-786-9643, Email [email protected] and Kathy Markman, Contracting Officer, Phone 410-786-8916, Fax 410-786-9643, Email [email protected].