SAM #260146J

CMS limited-sources justification for NCQA Medicare Advantage SNP Model of Care review and HEDIS data services

CMS’s limited-sources justification describes a five-year, firm-fixed-price engagement with NCQA to support Medicare Advantage Special Needs Plan (SNP) Model of Care reviews and related quality-measurement work. - Notice context: This is a limited-sources justification notice, not an open solicitation. The initial notice describes it as post-award; the attached justification outlines the proposed task-order scope and period. - Agency and provider: Centers for Medicare & Medicaid Services (CMS); National Committee for Quality Assurance (NCQA). - Scope of services: - Program management, including kickoff, work plan, monthly progress reports, annual reports, and an AI MOC Enhancement Plan. - Review, scoring, and approval of SNP Models of Care against CMS standards, including off-cycle submissions and MOC Matrix improvements. - Starting in Option Year 1, an AI-assisted review strategy using commercially available large language models to help identify missing information and assess compliance with CMS rules and scoring guidance. - Collection of plan-benefit-level Medicare Advantage HEDIS quality-improvement data for SNPs. - Limited-source rationale: The justification identifies NCQA as the legally required MOC approver and exclusive owner of the relevant HEDIS methodology and measures. - Estimated total value: $9,777,718 for the base year and four option years. - Period: September 29, 2026, through September 28, 2031, if all options are exercised. The document does not describe an annual subscription. - Items and quantities: No product line items, part numbers, or product quantities are identified; the requirement is for services.

Description

This posting provides notice that the Limited Sources Justification (LSJ) for the Performance Measurement for the Medicare Advantage Program procurement is being posted pursuant to GSAR 538.7104-3(b)(3)(i), which requires the ordering activity to publish a notice and post the justification within 14 days after placing an order exceeding the simplified acquisition threshold that is supported by an LSJ.

Section 1859(f)(5) of the Social Security Act (“the Act”) requires that organizations offering specialized Medicare Advantage (MA) plans for special needs individuals have in place an evidenced-based model of care (MOC) with appropriate networks of providers and specialists. In addition, Section 1859(f)(7) of the Act requires that a Medicare Advantage Organization (MAO) offering a specialized MA plan for special needs individuals (i.e., special needs plan, or SNP) be approved by the National Committee for Quality Assurance (NCQA) based on standards established by the Secretary. This requirement is implemented at 42 CFR §§422.101(f) and 422.152(g) and requires MAOs offering SNPs to have NCQA review and approve the required MOC each SNP submits to CMS on a regular basis.

The Healthcare Effectiveness Data and Information Set (HEDIS®) is a widely used set of health plan performance measures employed by both private and public health care purchasers to promote accountability and to assess the quality of care provided by managed care organizations. NCQA owns the proprietary rights to HEDIS® and the system that collects HEDIS® data. It is the only organization authorized to add quality measurements to HEDIS® and to provide technical assistance to commercial and Medicare health plans and auditors in the use of these measurements. Section 1853(o)(6)(A) of the Act states that the Secretary may require reporting of data under section 1852(e) for, and apply under this subsection, quality measures at the plan level for specialized MA plans for special needs individuals instead of at the contract level.

The purpose of this task order is to support CMS in the evaluation and approval of each SNP’s model of care (MOC). As noted above, Section 1859(f)(7) of the Act and 42 CFR §§422.4(a)(1)(iv), 422.101(f), and 422.152(g) require that each MAO offering a SNP must submit a MOC to be approved by NCQA.

Please see the Attachments section of this notice for a complete copy of the approved LSJ.

Note - This is NOT an active procurement opportunity but is instead a required posting of an approved LSJ subsequent to task order award.

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