Business Proposal Forms For Quality Improvement Organizations (QIOs)

BUSINESS PROPOSAL FORMAT

FOR UTILIZATION AND QUALITY CONTROL

QUALITY IMPROVEMENT ORGANIZATIONS

FORMS AND INSTRUCTIONS

CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)

BALTIMORE, MARYLAND

TABLE OF CONTENTS PAGE

I.	INTRODUCTION	2
II.	GENERAL INSTRUCTIONS	3
III.	ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSALS	4
IV.	BUSINESS PROPOSAL FORMS AND INSTRUCTIONS
	CMS Form 718 BP - Quality Improvement Organization Business Proposal Summary.	8
	CMS Form 719 BP - Quality Improvement Organization Business Proposal.	10
	CMS Form 720 BP - Fringe Benefit Proposal.	14
	CMS Form 721 BP - Indirect and Other Direct Cost.	18
	CMS Form STAFFING - Personnel Loading Charts.	22
	CMS Form SC 1 - Subcontracts Proposal - Physician Reviewers	28
	CMS Form SC 2 – Subcontracts Proposal - Other.	31
	CMS Form SUM - Staffing Proposal Summary.	34
	CMS Form QIO ODC – Other Direct Costs – Supplemental Schedule	39
	CMS Form Beneficiary & Family Centered Care Costs – Supplemental Schedule.	41
	Travel Detail Form	45
V.	APPENDIX	A-1
	1: DEFINITIONS AND GUIDELINES: QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL	A-2

I. INTRODUCTION

PURPOSE

This guideline package will assist you in preparing the standardized business proposal forms used to award Medicare Quality Improvement Organization (QIO) contracts.

SCOPE

Offerors must use the electronic file that CMS provides to prepare and submit the business proposal. This guideline package provides instructions for completing the various business proposal forms in the CMS electronic file. The hardcopy version of this package includes a sample of the various forms.

Business proposals are required to include the appropriate supporting information, cross-referenced to the related column, line item, and form. The supporting information should be detailed and, as appropriate, fully explain calculations, bases for estimates, etc. Failure to supply the supportive documentation for all proposed costs may be grounds of rejection and the proposal will be returned accordingly. Examples include:

1. Quotes and estimates from vendors;

2. Market surveys;

3. Historical data;

4. Specific calculations used to estimate proposed costs and an explanation;

5. Catalog prices; and

6. Previous billing statements/ expense vouchers.

METHOD OF SUBMISSION

CMS is providing you with the business proposal forms in an Excel spreadsheet file titled _____. You should enter your cost data in the Excel files and submit your completed business proposal in both electronic and hard-copy format.

The cost information in the electronic version of your completed business proposal must be in Excel format. The narrative supporting information can be in Excel or Word format.

II. GENERAL INSTRUCTIONS

The following general instructions for the completion and submission of the business proposal forms are in addition to those instructions contained in the RFP issued by CMS to all offerors and in addition to the attached Section III – ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL.

1. The CMS-provided electronic file and the specified Excel and Word versions are the only acceptable format for your cost proposal submission. Proposals received in any other format will be considered unacceptable.

The business proposal spreadsheets are formatted to accept one decimal place for entries relating to hours and whole dollars for entries relating to costs. However, where appropriate (e.g., hourly rates), the formatting will permit 2 decimal places for costs.

2. As used in this cost proposal process, the term "QIO" refers to both present QIO and potential QIO organizations.

3. A QIO organization proposing a Medicare contract in more than one QIO area must complete a separate business proposal for each QIO area.

4. All blocks on the forms that are shaded are filled out by formulae from within the form or from other forms or are for CMS use only, and they should not be filled out by the submitting QIO. Please fill out, as appropriate, only the unshaded blocks.

5. OMB INSTRUCTIONS REQUIRE THE FOLLOWING BURDEN DISCLOSURE NOTICE TO BE INCORPORATED ON ALL COLLECTIONS OF INFORMATION OR THE ACCOMPANYING INSTRUCTIONS.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-0579 (Expiration Date: XX/XX/XXXX).  The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Benjamin Bernstein 410-786-6570.

ADDITIONAL EXPLANATION AND JUSTIFICATION FOR BUSINESS PROPOSAL

General

As a general rule you should explain how you calculated all items in your business proposal, with the exceptions provided below. ALL COSTS MUST BE VERIFIABLE. With the exception of salaries, which are discussed below, the QIO should not inflate any line item for a year to year increase of greater than ___% without providing further justification. The QIO should also make sure to indicate what rate of increase it is using on all non-salary line items, even when they are at or below the ___% rate of increase per year. Note: The escalation rate is based on current market conditions and the rate used in FY____ budget assumptions.

Full Time Equivalents (FTEs) and Salaries

Full Time Equivalents (FTEs) and Salaries

FTEs proposed should be proposed on the basis of the most efficient method of performing each sub-task. The total direct labor hours, and their distribution across labor categories (e.g. professional, support staff) proposed for each sub-task should be justified on the basis of the information provided in the technical proposal and/or capability.

All proposed labor rates shall be supported with matching rates or formal salary survey information conducted by your organization from an acceptable source {i.e. www.salary.com, www.indeed.com, or etc.}. Escalation of salaries should not exceed ___% based on current market conditions. QIOs shall also explain organizational salary increases. The organizational salary increase will be determined each year by the “Grand Total Percent Change” cell on the Person Loading Chart – Staffing (i.e. for the year 1 over the current year it is cell “O 112” on the Form Staffing).

Program Manager

Annapolis Junction, MD

Median Salary - $XXX,XXX

10% - $XXX,XXX

25% - $XXX,XXX

75% - $XXX,XXX

90% - $XXX,XXX

Your Projected Salary

$0-$0

Top of Form

Bottom of Form

Program Manager Salary in Annapolis Junction, MD

Top of Form

Bottom of Form

Average Salary of Jobs Matching Your Search

In USD as of Mar XX, 2011		40k	80k	120k
Program Manager in Annapolis Junction, MD	$XXX,XXX

Average Program Manager salaries for job postings in Annapolis Junction, MD are X% higher than average Program Manager

Leave

Please summarize your leave policy. Also, explain any increase in your leave rate as a percentage of direct labor cost. All leave should be reported as part of the Fringe Benefit Category or in your approved Indirect Leave Rate.

Fringe Benefits

For Fringe Benefits, if you have an approved provisional rate, it can serve as the justification for the Fringe Benefit expense. If you do not have an approved provisional rate or you do not believe that this rate is correct for your three-year budget, please justify the rate requested, with emphasis on the major items of increase.

Other Consultants/Subcontracts

Form SC 1 requests information on the number of reviews, the time per review and the hourly rate for Physician Reviewers/Advisors. Please explain how you determined these factors and why and how they are different from the current year. The Form SC 1is provided for Beneficiary Protection and Special Studies. For all other tasks, enter Physician Reviewers/Advisors costs directly into the appropriate cell on the Form 719BP fully justify the need for Physician

Reviewers/Advisors cost for these tasks and explain the basis for the amount entered. If the Physician Reviewers/Advisors cost for these other tasks is based on the number of reviews performed, you should provide the detail in the same format as on the Form SC 1.

For Consultants and Other Subcontracts, please justify the purpose of each proposed Consultant and Subcontract. Explain the methodology used to formulate each Consultant Service or Subcontract cost, including hourly rates and number of hours requested for the Consultants or for the personnel employed in the Subcontract. The QIO’s cost detail shall also include the determination if the rates are fully loaded, travel costs [number of trips, purpose, per diem, airfare, mileage, means of travel, number of days and nights, lodging, & any miscellaneous costs/fees], volumes and unit costs for all Other Direct Costs, etc. For all Subcontracts, you shall use the subcontractor’s business proposal as supporting documentation. Essentially, the Consultant(s)/Subcontractor(s) must complete the same level of detail as the Prime. If the Consultant(s)/Subcontractor(s) are not comfortable with submitting their proposal to the Prime, they may send it to CMS directly. Note: with the exception of the Physician Reviewers, Subcontract consent (submission of the required Request for Consent - Section J Attachment __) must be submitted for each Subcontract/Consultant proposed according to the thresholds provided in Section I of the RFP.

Example (for a Consultant):

Name	Cost	Description
Dr. John Doe	$15,000	These are the costs for Dr. John Doe to provide 150 hours of program management time over the course of the contract for case review related activity. Additionally Dr. Doe is an internist by training and bills at a consultant hourly rate of $100.

Travel

All QIOs are required to explain how you calculated your Travel costs by Task. The QIO’s travel justification should include, but are not limited to, the following for each trip: (1) trip title, description, & purpose, (2) means of travel (air, car, bus, train) and its cost, (3) locations (origin and destination), (4) lodging, (5) number of travelers, (6) mileage and the rate used, (7) number of rental cars, if needed, (8) daily rental car rate, (9) miscellaneous costs per person – includes parking, gas, taxi, etc. and explain each cost in great detail, (10) number of days and nights, and (11) meals and incidentals. Furthermore, QIOs are asked to provide printouts with matching price quotes from a reliable source and/or historical data (including billing statements/expense vouchers, etc.). CMS will use the Federal Travel Regulations as a means to determine reasonable travel costs.

Other Direct Costs

Explain how you calculated all Other Direct Costs (ODC) by showing unit costs, volume details, and explain rationale of how the QIO determined the ODCs. CMS must be able to crosswalk the proposed costs to the supporting documentation and proposed rationale. QIOs are asked to provide, but are not limited to:

• Specific price quotes;

• Market surveys;

• Historical data;

• Specific calculations used to estimate proposed costs and an explanation;

• Previous billing statements/expense vouchers; and/or

• Catalog prices.

For example, your Reproduction and Printing justification should show the number of specific items that you expect to print and the cost per item. If you report Rent under Other Direct Costs, please provide the details of how many square feet are currently rented, and the number of square feet you propose to rent under the new contract. Also, provide the cost per square foot in the prior year and each year of the proposed contract.

Example: Reproduction and Printing

Description	Purpose	Frequency	Cost Estimate/ unit cost	Basis of Estimate	Yr 1 - costs
Printing: 400 Copies	Brochures/Handouts for Physician Collaboration Annual Meeting	3 annual meetings	$0.50 a brochure/ $200 per meeting	Price quote	$600
Printing: 500 Copies	Presentation for Regional Meeting	4 regular meetings per year	$0.05 per page printing, 40 pages per presentation. $1,000 per meeting	Estimate from previous year cost	$4,000
Grand Total					$4,600

Indirect Costs

For Indirect Costs, if you have an approved provisional Indirect Rate it can serve as the justification for this cost. However, you should always explain how you calculated Rent. For rent, please provide the details of how many square feet are currently rented, the number of square feet you propose to rent under the new contract, and the cost per square foot in the prior year and each year of the proposed contract. In addition, if you report AHQA dues, make sure that you report the amount per year and how the amount was determined. If you report Board of Directors fees, please detail your basis of compensation per board meeting or for travel performed on behalf of the organization.

If you do not have an approved provisional rate, or you do not believe that this rate is correct for your three-year budget, please fill out all the line items on Form 721 and justify the rate requested, with emphasis on the major items of increase.

Pass-thru Costs

Explain how you calculated Pass-thru Costs, indicating how many records are involved, how the QIO projected the number of records, and the cost per record.

INSTRUCTIONS FOR CMS FORM 718 BP

QUALITY IMPROVEMENT ORGANIZATION

BUSINESS PROPOSAL SUMMARY

ITEM

1. Name and Address of QIO Organization. Enter the name and address of the organization submitting the proposal (make sure the information is entered in the boxes shown at cells A3, A4 and A5)

2. QIO Area. Enter the State or other area that the proposed QIO contract will cover (make sure the information is entered in the box shown at cell C7).

3. RFP Number. Enter the CMS RFP number for the proposed QIO contract (make sure the information is entered in the box shown at cell J3.)

4. Proposed Contract Period. Enter the beginning and ending dates of the proposed QIO contract (make sure the information is entered in the boxes shown at cells K7 and K9.)

5. Total Proposed Costs. This column contains your total proposed costs for the 5-year contract period. The proposed costs are listed for each line item category. No entries are required because the proposed costs automatically flow from Form 719 BP.

6. CMS Recommended Costs. No entries required. For CMS internal use only.

7. $ Difference. No entries required. For CMS internal use only.

8. % Difference. No entries required. For CMS internal use only.

9. Fringe, Indirect, and Other Rates. QIOs should enter their approved fringe benefit rate and indirect cost rate in the appropriate spaces. Leave the fringe and indirect rate spaces blank if you are a new QIO and do not have approved rates.

10. Signature of Authorized Official. The appropriate official of the organization submitting the business proposal should sign here.

11. Type Name and Title. Insert the name and title of the official signing in item 10.

12. Date. Enter the date the business proposal is submitted.

13. Telephone #. Enter the organization’s phone number, starting with the area code.

14. For CMS use only.

15. For CMS use only.

15. For CMS use only.

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RESERVED FOR INSERTION OF FORM 718 BP SUM

INSTRUCTIONS FOR CMS FORM 719 BP

QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

ITEM

1. RFP#. No entry required. This information automatically flows from Form 718 BP.

2. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

3. QIO Area. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

COST CENTER COLUMNS

THE NEXT COLUMNS SERVES AS THE COST CENTERS FOR THE SPECIFIED SOW:

Note: For direct contract costs that cannot be attributed to provided costs centers, the QIO/Offeror shall allocate those direct costs to each of the cost centers, using an allocation method consistent with organization practice. This does not include costs related to governance. These costs benefit the entire organization and should be included in indirect.

LINE ITEMS

a.1- a.4 Labor. No entry required. The hours and costs for each direct labor category are automatically calculated from the Staffing Proposal Summary sheet (Form SUM).

b. Leave. Note: include all paid time off (leave) in Fringe Benefit pool unless your organization has an approved separate Indirect Leave Rate (ILR). If your organization has an approved ILR, enter the appropriate hours and cost for each category for the 5-year contract period.

c. Fringe Benefits. Enter the fringe benefits cost for the 5-year contract period that applies to the particular column cost center. Include all paid time off (leave) unless your organization has an approved separate indirect leave rate.

d.1- d.3 Subcontracts. No entry required. The hours and costs for each category are automatically calculated from the Subcontracts Proposal sheets (Forms SC 1 and SC 2). However, if you have costs for Physician Reviewers/Advisors in any task other than Beneficiary Protection and Special Projects, you should enter the cost for the 5-year contract period that applies to the particular column cost center.

5. Travel. Enter the travel cost for the 5-year contract period that applies to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

f. Other Direct Costs. No entry required. The costs for each column cost center are automatically calculated from the QIO ODC sheet. Furnish detailed supporting documentation to explain these costs.

g. Indirect Costs. Enter the indirect costs for the 5-year contract period that applies to the particular column cost center.

h. Pass-thru Costs. Enter the pass-thru costs for the 5-year contract period that apply to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

i. Fee. Enter the appropriate portion of the total fee in each column cost center.

j. Total Proposed Providers. Enter the total number of proposed providers for the 5-year contract period that apply to the particular column cost center.

k. Average 5-year Cost Per Provider. Enter the average 5-year cost per provider for the 5-year contract period that applies to the particular column cost center.

TOTAL

No entry required. This column automatically calculates the total hours and costs for each line item category from the entries in the cost center columns.

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RESERVED FOR INSERTION OF FORM 719 BP

INSTRUCTIONS FOR CMS FORM 720 BP

FRINGE BENEFIT PROPOSAL

QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

ITEM

1. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

2. QIO Area. No entry required. This information automatically flows from Form 718 BP.

3. RFP#. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

NOTE: The total cost entries that you make in column 7 and 9 should include both direct and indirect costs. Also, an established QIO that has an approved provisional fringe benefit rate and which determines that this approved rate will accurately reflect projected 5-yr fringe benefit costs, does not have to complete the individual line items on Form 720 BP. Instead, enter the fringe benefit rate on Line m.

If the QIO does not believe that the approved rate is appropriate for projecting 5-yr costs or it is a new QIO that does not have an approved provisional rate, the QIO should complete the individual line items in columns 7 and 9, as explained below.

COLUMN 6. - Prior Year Total Organization Costs

LINE

a. - l. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 6.

m. Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 7 - Projected Total 5-yr Organization Costs

LINE

a. - k. Individual line item categories. (See note, above) On each line item, enter the fringe benefit cost projected for your organization for the 5-year period that the QIO contract would be operating. However, make an entry on line j. (Leave) only if you include leave in the fringe benefit pool.

Your supporting documentation should explain, in detail, any amount you enter on line item k. The supporting documentation should also fully explain the assumptions and bases you used for your organization’s projection, including appropriate cost projection schedules.

l. Total Fringe Benefits. No entry required. This line item automatically calculates the total of line items a. thru k.

m. Fringe Benefit Rate. Enter the fringe benefit rate that is applicable to the amount on line item l., Total Fringe Benefits. In your supporting documentation, give a detailed explanation of the method used to calculate this rate. It is necessary to provide the Fringe Benefit Rate even if you do not have to fill out lines a. thru l.

COLUMN 8 - Prior Year Total Medicare Costs

LINE

a. - l. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 8.

m. Fringe Benefit Rate. Enter the fringe benefit rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 9 - Projected Total 5-yr Medicare Costs

LINE

a. - k. Individual line item categories. (See note above) On each line item, enter the portion of the corresponding line item cost in column 7. (Projected Total 5-yr Organization Costs) allocated to the proposed Medicare QIO contract.

Your supporting documentation should explain, in detail, any amount you entered on line item k. The supporting documentation should also fully explain the assumptions and bases you used to allocate a portion of your organization’s total projected fringe benefits cost to the proposed Medicare QIO contract.

l. Total Fringe Benefits. No entry required. This line item automatically calculates the total of line items a. thru k.

m. Fringe Benefit Rate. Enter the fringe benefit rate that is applicable to the amount on line item l., Total Fringe Benefits. In your supporting documentation, give a detailed explanation of the method used to calculate this rate. It is necessary to provide the Fringe Benefit Rate even if you do not have to fill out lines a. thru l.

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RESERVED FOR INSERTION OF FORM 720 BP

INSTRUCTIONS FOR CMS FORM 721 BP

INDIRECT AND OTHER DIRECT COST

QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

ITEM

1. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

2. QIO Area. No entry required. This information automatically flows from Form 718 BP.

3. RFP#. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

Note: If a QIO has an approved provisional indirect cost rate and the QIO determines that this approved rate will accurately reflect projected 5-year indirect costs, it is not necessary to complete the individual line items on Form 721 BP pertaining to indirect costs. Instead, enter the indirect cost rate on Line ee.

If the QIO believes that the approved rate is not appropriate for projecting 5-year costs, the QIO should complete the individual line items in columns 6 and 8, as explained below. In any case, as explained in “Section 3 - Additional Explanation and Justification for Business Proposal” you should explain all rental costs, AHQA dues, or Board of Directors fees in that section.

COLUMN 5 - Prior Year Total Indirect Costs

LINE

a. - dd. Individual line item categories. Disregard these line items. No entries should be made on these line items in column 5.

ee. Indirect Cost Rate. Enter the indirect cost rate for the latest 12-month period completed, for which cost data is available. Identify this 12-month period in your supporting documentation and explain the base (i.e., denominator) used to calculate this rate.

COLUMN 6 - Projected Total 5-yr Indirect Costs

LINE

a. - cc. Individual line item categories. On each line item, enter the indirect cost projected for your organization for the 5-year period that the QIO contract would be operating.

Your supporting documentation should explain, in detail, any amount you entered on line item cc. The supporting documentation should also fully explain the assumptions and bases you used for your organization’s projection, including appropriate cost projection schedules.

dd. Total. No entry required. This line item automatically calculates the total of line items a. thru cc.

ee. Indirect Cost Rate. Enter the indirect cost rate that applies to the amount on line item dd. (Total). In your supporting documentation, give a detailed explanation of the method used to calculate this rate.

COLUMN 7 - Prior Year Medicare Indirect Costs

LINE

a. - ee. Individual line item categories. Disregard these line items. No entries should be made on these lines in column 7.

COLUMN 8 - Projected Medicare 5-yr Indirect Costs

LINE

a. & b. Indirect Labor and Indirect Leave. No entry required.

The amounts on these line items flow directly from the Staffing Proposal Summary Sheet (Form QIO Staff Sum).

c. - cc. Individual line item categories. On each line item, enter the portion of the corresponding line item cost in column 6. (Projected Total 5-yr Indirect Costs) allocated to the proposed Medicare QIO contract.

Your supporting documentation should explain, in detail, any amount you entered on line item cc. The supporting documentation should also fully explain the assumptions and bases you used to allocate a portion of your organization’s total projected indirect costs to the proposed Medicare QIO contract.

dd. Total. No entry required. This line item automatically calculates the total of line items a. thru cc.

ee. Indirect Cost Rate. No entry required, as the indirect rate that applies has already been provided in column 6.

COLUMN 9 - Prior Year Medicare Other Direct Costs

LINE

a. - c. Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required. These line items are not applicable to this column.

d. - cc. Individual line item categories. If applicable, on each line item, enter the other direct cost for the current Medicare QIO contract for the latest 12-month period completed.

Identify this 12-month period in your supporting documentation. Your supporting documentation should also explain, in detail, any amount you entered on line item cc.

Line item o. Consultants does not apply to this column.

Line item q. Travel does not apply to this column.

dd. Total. No entry required. This line item automatically calculates the total of line items d. thru cc.

COLUMN 10 - Projected Medicare 5-yr Other Direct Costs

LINE

a. - c. Indirect Labor, Indirect Leave, and Indirect Fringe. No entries required. These line items do not apply to this column.

d. - cc. Individual line item categories. No entry required.

The amounts on these line items flow directly from the Other Direct Costs Supplemental Schedule (QIO ODC).

dd. Total. No entry required. This line item automatically calculates the total of line items d. thru cc.

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RESERVED FOR INSERTION OF FORM 721 BP

INSTRUCTIONS FOR PERSONNEL LOADING CHARTS

STAFFING PROPOSAL

FORM STAFFING

These instructions apply to the personnel loading charts for all four labor categories. It is preferable that positions should be listed in the following order: (1) Corporate Management, (2) Professional, (3) Information Systems, and (4) Support Staff. You should not list each type of labor category on a separate sheet. Positions will be sorted by labor category based on the labor category code (see col. 3 below). The form will automatically summarize information by labor category under the Grand Total line. Please note that all entries for employees concerning proposed hours for labor and leave, whether direct or indirect, must be based on a work year of 2,080 hours.

COLUMN

1. Staff Name. For each labor category, enter the last name and first initial of each employee that you have identified as a staff person under the guideline definitions in the Appendix. If the position title listed in column 2. is not assigned to anyone, enter vacant instead of an employee’s name.

2. Position Title. Enter the employee’s position for the 5-year Medicare QIO contract.

3. Labor Category Code. Enter the employee’s Labor Category code: P for Professional; I for Information Systems; C for Corporate Management; S for Support Staff.

4. Current Hourly Rate. Enter the employee’s current hourly rate of pay.

5. Proposed Year 1 Hourly Rate. Enter the employee’s hourly pay rate for year 1 of the proposed Medicare QIO contract.

6. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from the current rate to the year 1 rate of the proposed Medicare QIO contract.

7. Proposed Year 2 Hourly Rate. Enter the employee’s hourly pay rate for year 2 of the proposed Medicare QIO contract.

8. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 1 of the proposed Medicare QIO contract to year 2.

9. Proposed Year 3 Hourly Rate. Enter the employee’s hourly pay rate for year 3 of the proposed Medicare QIO contract.

10. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 2 of the proposed Medicare QIO contract to year 3.

11. Proposed Year 4 Hourly Rate. Enter the employee’s hourly pay rate for year 4 of the proposed Medicare QIO contract.

12. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 3 of the proposed Medicare QIO contract to year 4.

13. Proposed Year 5 Hourly Rate. Enter the employee’s hourly pay rate for year 5 of the proposed Medicare QIO contract.

14. Percent Change. No entry required. This column automatically calculates the percentage change in the hourly pay rate from year 4 of the proposed Medicare QIO contract to year 5.

15. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

16. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 11 entry.

17. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

18. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 13 entry.

19. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

20. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 15 entry.

21. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

22. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 17 entry.

23. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

24. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 19 entry.

25. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

26. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 21 entry.

27. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

28. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 23 entry.

29. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

30. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 25 entry period.

31. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

32. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 27 entry.

33. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

34. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 29 entry.

35. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

36. Total 5-yr ______ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ________ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 31 entry.

37. Average _______ Hours Per Year. Enter one-fifth of the total direct labor hours the employee would devote to _______ during the 5-year Medicare QIO contract period.

38. Total 5-yr ____ Labor Costs. No entry required. This column automatically calculates the total direct labor costs for ____ based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same direct labor hours for each of the 5 contract years based on your column 33 entry.

39. Average Total Direct Labor Hours Per Year. No entry required. The amounts in this column are automatically calculated from your previous entries in the individual cost center columns dealing with average direct labor hours per year.

40. Total 5-yr Direct Labor Costs. No entry required. The amounts in this column are automatically calculated from the entries in the individual cost center columns dealing with 5-yr labor costs.

41. Average Indirect Labor Hours Per Year. Enter one-third of the total indirect labor hours estimated for the employee during the 5-year Medicare QIO contract period.

42. Total 5-yr Indirect Labor Costs. No entry required. This column is automatically calculated based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same indirect labor hours for each of the 5 contract years based on your column 37 entry.

43. Average Total Labor Hours Per Year. No entry required. This column is automatically calculated based on your previous entries for average direct and indirect labor hours per year.

44. Total 5-yr Labor Costs. No entry required. This column automatically combines the amounts entered for total direct labor costs and total indirect labor costs in previous columns.

45. Average Direct Leave Hours Per Year. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

46. Total 5-yr Direct Leave Costs. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate indirect leave rate.

47. Average Indirect Leave Hours Per Year. Enter one-third of the total indirect leave hours estimated for the employee during the 5-year Medicare QIO contract period.

48. Total 5-yr Indirect Leave Costs. No entry required. This column is automatically calculated based on the amounts you entered in the previous columns. The calculation assumes that an employee has the same indirect leave hours for each of the 5 contract years based on your column 43 entry.

49. Average Total Leave Hours Per Year. No entry required. This column is automatically calculated based on your previous entries for average indirect leave hours per year.

50. Leave as a % of Hours Worked. No entry required. This column calculates automatically based on amounts you entered in previous columns.

51. Total 5-yr Leave Costs. No entry required. This column automatically combines the amounts entered for total indirect leave costs in previous columns.

52. Average Total Labor and Leave Hours Per Year. No entry required. This column automatically combines the amounts for average yearly direct and indirect labor and leave hours in previous columns.

53. Total 5-yr Labor/Leave Costs. No entry required. This column automatically calculates the total 5-yr cost of your proposed contract for labor and leave combined.

54. FTE Per Year. No entry required. This column automatically calculates the average yearly FTE for each employee. The calculation considers all employee hours -- labor, leave, direct, and indirect.

Your proposed hours for labor and leave must be based on a work year of 2,080 hours.

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RESERVED FOR INSERTION OF FORM QIO STAFFING

INSTRUCTIONS FOR CMS FORM SC 1

SUBCONTRACTS PROPOSAL – PHYSICIAN REVIEWERS

NOTE: This form should reflect the aggregate cost information for the total number of physician reviewers/advisors that you estimate will be used. Information entered into this form will input hours and costs to the respective tasks on the 719 form automatically. However, the form is set up only for Beneficiary and Family Centered Care and Special Project. If you have Physician Reviewer cost for any other sub-task, you should provide the information in the same format as on the Form SC1 and input the totals directly in the appropriate block on the 719.

Physician Reviewer Cost for Beneficiary and Family Center Care (Benef. and FCC) - Blocks 1 through 17.

1. Current Physician Reviewer Hourly Rate. Enter the current average hourly rate for your physician reviewers/advisors in beneficiary and family center care.

2. Year 1 Number of Reviews. Enter your estimate of the number of reviews for year 1 of beneficiary and family center care proposed Medicare QIO contract.

3. Year 1 Hours Per Review. Enter your estimate of the average time it takes for a

Physician Reviewer/Advisor to complete a case review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 1 Hours Per Year. No entry is required. This column automatically calculates the total number of review hours for the first year of the contract based on the amounts you entered in the previous columns.

4. Year 1 Physician Reviewer Hourly Rate. Enter the average hourly rate for your Physician Reviewers/Advisors for Year 1 of the proposed Medicare QIO contract.

4. Year 1 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection review based on the amounts you entered in the previous columns.

4. Year 2 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 2 of the proposed Medicare QIO contract.

4. Year 2 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 2 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the second year of the contract based on the amounts you entered in the previous columns.

4. Year 2 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 2 of the proposed Medicare QIO contract.

4. Year 2 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection review based on the amounts you entered in the previous columns.

4. Year 3 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 3 of the proposed Medicare QIO contract.

4. Year 3 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 3 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the third year of the contract based on the amounts you entered in the previous columns.

4. Year 3 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 3 of the proposed Medicare QIO contract.

4. Year 3 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection reviews based on the amounts you entered in the previous columns

4. Year 4 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 4 of the proposed Medicare QIO contract.

4. Year 4 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 4 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the fourth year of the contract based on the amounts you entered in the previous columns.

4. Year 4 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 4 of the proposed Medicare QIO contract.

4. Year 4 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection reviews based on the amounts you entered in the previous columns

4. Year 5 Number of Reviews. Enter your estimate of the number of beneficiary protection reviews for year 5 of the proposed Medicare QIO contract.

4. Year 5 Hours Per Review. Enter your estimate of the average time it takes for a Physician Reviewer/Advisor to complete a beneficiary protection review. This estimate should include all the time that it takes a Physician Reviewer/Advisor to complete such a review.

4. Year 5 Hours Per Year. No entry is required. This column automatically calculates the total number of beneficiary protection review hours for the fifth year of the contract based on the amounts you entered in the previous columns.

4. Year 5 Physician Reviewer Hourly Rate. Enter the average hourly rate for your beneficiary protection Physician Reviewers/Advisors for Year 5 of the proposed Medicare QIO contract.

4. Year 5 Benef. and FCC Review Costs. No entry is required. This column automatically calculates the total Physician costs for beneficiary protection reviews based on the amounts you entered in the previous columns.

4. Total 5 Year Benef. and FCC Review Costs. No entry is required. This column automatically calculates based on the costs for all five years of the contract.

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RESERVED FOR INSERTION OF FORM SC 1

INSTRUCTIONS FOR CMS FORM SC 2

SUBCONTRACTS PROPOSAL - OTHER

NOTE: Please enter the requested cost information separately for each other consultant in Section 1 and each other subcontractor in Section 2. If you have more than 10 entries for Section 1 or 2, provide the additional consultant/subcontractor information on an attachment and carry the attachments subtotals to line k.

COLUMN

1. Name. Enter the first initial and last name of the subcontractor, when appropriate. If it is more appropriate to identify the subcontractor by a company or organizational name, enter this name instead of an individual’s name. Enter TBD If you are proposing a particular subcontracting activity for the 5-year Medicare contract but have not yet identified a particular subcontractor.

2. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

3. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period

4. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

5. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

6. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period

7. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period

8. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

9. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period

10. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

11. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

12. Total 5-yr _______ Costs. For each consultant/subcontractor, enter the total costs that you propose for ______ costs during the 5-year Medicare QIO contract period.

12. Total 5-yr Costs. No entry required. The amounts in this column are automatically calculated from the entries in the individual cost center columns.

12. Current Activity. If applicable, enter a short description of the work that the consultant/subcontractor is currently performing. Otherwise, enter NA.

12. Proposed Activity. Enter a short description of the work that the consultant/subcontractor would perform during the 5-year Medicare QIO contract. Provide a detailed explanation of the activity in your supporting documentation.

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RESERVED FOR INSERTION OF FORM SC 2

INSTRUCTIONS FOR CMS FORM

STAFFING SUMMARY PROPOSAL

NOTE: This form summarizes hour and cost information by labor category and cost center. No entries are required, as all information is automatically calculated from the individual personnel loading charts for each labor category.

COLUMN

1. Average Current Hourly Rate. For each labor category, this amount corresponds to the related current hourly rate for that labor category. This amount is an average of the individual entries in the loading chart column.

2. Proposed Average Year 1 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 1 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

3. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from the current average rate to the average rate for year 1 of the proposed Medicare QIO contract.

4. Proposed Average Year 2 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 2 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

5. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 1 of the proposed Medicare QIO contract to year 2.

6. Proposed Average Year 3 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 3 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

7. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 2 of the proposed Medicare QIO contract to year 3.

8. Proposed Average Year 3 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 3 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column.

9. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 3 of the proposed Medicare QIO contract to year 4.

10. Proposed Average Year 5 Hourly Rate. For each labor category, this amount corresponds to the total Proposed Year 5 Hourly Rate for that labor category. This amount is an average of the individual entries in the loading chart column

11. Percent Change. For each labor category, this amount reflects the percentage change in the average hourly pay rate from year 4 of the proposed Medicare QIO contract to year 5.

12. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

13. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

14. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

15. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

16. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

17. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

18. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

19. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

20. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

21. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

22. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

23. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

24. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

25. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

26. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

27. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

28. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

29. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

30. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

31. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

32. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

33. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

34. Total _______ Hours. For each labor category, this amount is the total direct labor hours proposed for ________ activities during the 5-year Medicare QIO contract period.

35. Total _______ Labor Costs. For each labor category, this amount is the total direct labor cost proposed for _______ activities during the 5-year Medicare QIO contract period.

36. Total Direct Labor Hours. For each labor category, this amount is the total direct labor hours proposed for all activities during the 5-year Medicare QIO contract period.

37. Total Direct Labor Costs. For each labor category, this amount is the total direct labor costs proposed for all activities during the 5-year Medicare QIO contract period.

38. Total Indirect Labor Hours. For each labor category, this amount is the total indirect labor hours you propose to apply to the 5-year Medicare QIO contract period.

39. Total Indirect Labor Costs. For each labor category, this amount is the total indirect labor costs you propose to apply to the 5-year Medicare QIO contract period.

40. Total Labor Hours. For each labor category, this amount is the total direct and indirect labor hours you propose for the 5-year Medicare QIO contract period.

41. Total Labor Costs. For each labor category, this amount is the total direct and indirect labor costs you propose for the 5-year Medicare QIO contract period.

42. Total Direct Leave Hours. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

43. Total Direct Leave Costs. Not Applicable. Include all paid time off (leave) in Fringe Benefits unless your organization has an approved separate Indirect Leave Rate.

44. Total Indirect Leave Hours. For each labor category, this amount is the total indirect leave hours you propose to apply to the 5-year Medicare QIO contract period.

45. Total Indirect Leave Costs. For each labor category, this amount is the total indirect leave costs you propose to apply to the 5-year Medicare QIO contract period.

46. Total Leave Hours. For each labor category, this amount is the total direct and indirect leave hours you propose for the 5-year Medicare QIO contract period.

47. Leave as a % of Hours Worked. For each labor category, this amount provides the percentage relationship of leave hours to labor hours. It is based on the entries you made on the individual personnel loading charts for each labor category regarding direct and indirect labor and leave hours.

48. Total Leave Costs. For each labor category, this amount is the total direct and indirect leave costs you propose for the 5-year Medicare QIO contract period.

49. Total Labor and Leave Hours. For each labor category, this amount is the total labor and leave hours (indirect) you propose for the 5-year Medicare QIO contract period.

50. Total Labor and Leave Costs. For each labor category, this amount is the total labor and leave costs (indirect) you propose for the 5-year Medicare QIO contract period.

51. Total FTE Per Year. For each labor category, this amount is the full-time equivalent per year. It is based on total labor and leave hours (direct and indirect) and a work year of 2,080 hours.

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RESERVED FOR INSERTION OF FORM QIO STAFF SUM

INSTRUCTIONS FOR OTHER DIRECT COSTS

SUPPLEMENTAL SCHEDULE

QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

Projected Medicare 5-yr Other Direct Costs

LINE

d. - cc. Individual line item categories. On each line item, enter the other direct cost projected for the proposed 5-year QIO contract.

Your supporting documentation should explain, in great detail, any amount you entered on line items d - cc. The supporting documentation should also fully explain the assumptions and bases you used for your projection, including appropriate supporting schedules.

Line item o. Consultants does not apply to this column. Enter direct costs related to consultants on Form SC-2 (Excel tab: QIO Subconts2).

Line item q. Travel does not apply to this column. Enter direct costs related to travel on Form 719 BP, line e.

dd. Total. No entry required. This line item automatically calculates the total of line items d. thru cc.

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RESERVED FOR INSERTION OF OTHER DIRECT COSTS

SUPPLEMENTAL SCHEDULE

INSTRUCTIONS FOR BENEFICIARY AND FAMILY CENTERED CARE

SUPPLEMENTAL SCHEDULE

QUALITY IMPROVEMENT ORGANIZATION

BUSINESS PROPOSAL

ITEM

1. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

2. QIO Area. No entry required. This information automatically flows from Form 718 BP.

3. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

COST CENTER COLUMNS – For each cost center column (4-10), enter the amounts, both hours and costs (a-j), on average for each case.

4. QUALITY OF CARE REVIEWS COST PER CASE - This column is used for all costs directly attributable to quality of care review activities as described in the under Beneficiary and Family Centered Care.

5. HOSPITAL BASED NOTICE APPEALS COST PER CASE - This column is used for all cost directly attributable to hospital based notice appeals activities as described in the under Beneficiary and Family Centered Care.

6. FEE-FOR SERVICE (FFS) EXPEDITED APPEALS COST PER CASE - This column is used for all cost directly attributable to fee-for service expedited appeal activities as described in the under Beneficiary and Family Centered Care.

7. MEDICARE ADVANTAGE (MA) FAST TRACK APPEALS COST PER CASE - This column is used for all cost directly attributable to Medicare Advantage fast track appeal activities as described in the under the Beneficiary and Family Centered Care.

8. EMTALA: 5-DAY REVIEWS - COST PER REVIEW – This column is used for all cost directly attributable to the Emtala 5-day review activities as described in the under Beneficiary and Family Centered Care.

9. EMTALA: 60-DAY REVIEWS - COST PER REVIEW – This column is used for all cost directly attributable to the Emtala 60-day review activities as described in the under Beneficiary and Family Centered Care.

10. HIGHER WEIGHTED DRG – COST PER REVIEW – This column is used for all cost directly attributable to higher weighted DRG activities as described in the under Beneficiary and Family Centered Care.

COST CENTER COLUMNS – For each cost center column (11-15), enter total cost at these activities for the three year period.

11. QUALITY IMPROVEMENT INTERVENTIONS (QII)/ TECHNICAL ASSISTANCE COSTS – This column is used for all cost directly attributable to quality improvement interventions/ technical assistance activities as described in the under Beneficiary and Family Centered Care.

12. SANCTION ACTIVITIES – This column is used for all cost directly attributable to sanction activities as described in the under Beneficiary and Family Centered Care.

13. COLLABORATION– This column is used for all cost directly attributable to collaboration activities as described in the under Beneficiary and Family Centered Care.

14. TRANSPARENCY THROUGH REPORTING – This column is used for all cost directly attributable to transparency though reporting activities as described in the under Beneficiary and Family Centered Care.

15. OTHER NON-REVIEW ACTIVITIES – This column is used for all cost directly attributable to other non-review activities as described in the Beneficiary and Family Centered Care, but not in any other cost columns.

Examples:

- Training,

- General oversight and review activities,

- Beneficiary and provider education,

- ‘On-call time for appeals review when no review is underway and meetings associated with these appeal reviews,

- Training attended by QIO staff in order to conduct review of MA or FFS appeals,

- On-call time during which no review activity is conducted,

1. - Appeals-related administrative duties not associated with a specific MA or FFS appeal review,

2. - Appeals-related time spent by Review Coordinators (communicating with providers, beneficiaries and Physician Reviewers not associated with a specific review),

3. - Appeals-related time spent by Physician Reviewers (communicating with providers, beneficiaries to research guidelines and regulations not associated with a specific review),

4. - Appeals-related conference calls, and

- General discussions of appeals with beneficiaries on site.

LINE ITEMS

a.1- a.4 Labor. Enter the labor cost for each case to the particular column cost center.

b. Leave. Enter the leave cost for each case to the particular column cost center.

c. Fringe Benefits. Enter the fringe benefit cost for each case to the particular column cost center.

d.1- d.3 Subcontracts. Enter the subcontracts cost for each case to the particular column cost center.

5. Travel. Enter the travel cost for each case to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

f. Other Direct Costs. Enter the other direct costs for each case to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

g. Indirect Costs. Enter the indirect costs for each case to the particular column cost center.

h. Pass-thru Costs. Enter the pass-thru costs for each case that apply to the particular column cost center. Furnish detailed supporting documentation to explain these costs.

1. Fee. Enter the appropriate portion of the total fee in each column cost center.

TOTAL - No entry required. This line item automatically calculates the total hours and costs for each line item category from the entries in the costs center columns.

PROJECTED VOLUME - # OF CASES FOR (AS APPLY):

YEAR 1: Enter the projected volume of cases in each column cost center.

YEAR 2: Enter the projected volume of cases in each column cost center.

YEAR 3: Enter the projected volume of cases in each column cost center.

YEAR 4: Enter the projected volume of cases in each column cost center.

YEAR 5: Enter the projected volume of cases in each column cost center.

GRAND TOTAL: No entry required. This line item automatically calculates the total cost for all 5 years based on the projected volumes in each costs center column.

NOTE: PLEASE PROVIDE YOUR ASSUMPTIONS IN DETERMINING YOUR ESTIMATES, INCLUDING VOLUME ESTIMATES.

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RESERVED FOR INSERTION OF BENEFICIARY AND FAMILY CENTERED CARE

SUPPLEMENTAL SCHEDULE

INSTRUCTIONS FOR TRAVEL DETAIL

BUSINESS PROPOSAL

ITEM

1. RFP Number. No entry required. This information automatically flows from Form 718 BP.

2. Name and Address of QIO Organization. No entry required. This information automatically flows from Form 718 BP.

3. QIO Area. No entry required. This information automatically flows from Form 718 BP.

4. Proposed Contract Period. No entry required. This information automatically flows from Form 718 BP.

5. Mileage Rate. Enter the current Federal Travel Regulation mileage rate.

6. Area. Enter the quality improvement element the proposed trip relates to.

7. Trip Title and Description/Purpose. Enter the trip title and provide a brief description/purpose of the trip.

8. # of Days per Trip. Enter the number of days the trip will occur.

9. # of Night per Trip. Enter the number of nights the trip will occur.

10. # of Travelers per Trip. Enter the number of travelers, per trip, in whole figures.

11. Airfare per Person. Enter airfare amount per person.

12. Departing From. Enter the city and state the travelers are departing from.

13. Arriving To. Enter the city and state the travelers will arrive to.

14. FTR Meals and Incidentals Daily Rate. Enter the current Federal Travel Regulations (FTR) Meals and Incidental Rate for the location. Note: The formula in the Total column will calculate the max Per Diem rate for the first and last day of travel based on the number of days reported.

15. FTR Lodging per Night. Enter the current the current Federal Travel Regulations (FTR) maximum Lodging Rate (excluding taxes) for the Primary Destination for each trip. Note: The formula in the Total column will calculate the lodging costs based on the nights reported previously.

16. # of Trips. Enter the number of trips for the respective year.

17. Mileage per Traveler per Trip. Enter the roundtrip mileage per trip, if applicable.

18. # of Rental Car(s) per Trip. Enter the number of rental cars needed for each trip.

19. Daily Rental Car Rate. Enter the proposed daily rental car rate.

20. Miscellaneous Costs per Person per Trip. Enter the miscellaneous cost per person per trip. You may include parking fees, gas, taxi, metro fees, and the like.

21. Total. No entry required. This line item automatically calculates the total travel costs for the listed trip.

22. Notes. Provide a detailed explanation of the miscellaneous cost calculations (what and how your organization reached the proposed figures – i.e.: $20 taxi & $3 airport parking).

23. Grand Total. No entry required. This line item automatically calculates the total travel costs for all 5 years.

** Shaded cells represent no entry required and the totals for these activities DO NOT roll into the TRAVEL line item listed on the forms entitled, "QIO F719", "QIO ODC", or "BFCC Sup Sch".

V. APPENDIX

APPENDIX 1: DEFINITIONS AND GUIDELINES

QUALITY IMPROVEMENT ORGANIZATION BUSINESS PROPOSAL

I. GENERAL.

The forms that you need to complete your business proposal are forwarded electronically in an Excel spreadsheet file. (Sample forms are also included in the hardcopy version of this guideline package.) Upon opening the Excel file, the forms are accessible by clicking the various tabs at the bottom of your screen. Each tab represents one of the hardcopy business proposal forms. The forms and their related tab titles are as follows:

Form Tab Title Description

718 BP F718 BP SUM Business proposal summary

719 BP QIO F719 5-year proposed costs by cost center

720 BP QIO F720 Fringe benefit proposal

721 BP QIO F721 Indirect and Other Direct Cost

Staffing QIO Staff Personnel loading chart for all QIO Staff

SC 1 QIO Subconts1 Calculation of cost for Physician Reviewers and Physician Advisors

SC 2 QIO Subconts2 Personnel loading chart for other consultants and other subcontractors

Sum QIO Staff Sum Personnel loading chart summary

QIO ODC QIO ODC Other Direct Costs

BFCC Sup Sch BFCC Sup Sch Beneficiary and Family Centered Care – Supplemental Schedule

Travel Detail Form Travel Detail Form Travel Detail Form

Most of the cost information is entered on the individual Personnel Loading Charts and the Subcontracts Proposal form. The information you enter on these forms flows to the Form 719 BP. There are only a few line items on Form 719 BP that require your direct entry. Cells that do not require your entry are blocked. For specific data entry instructions, please see Section IV of the Table of Contents.

II. LINE ITEM CATEGORIES.

The following information is provided in a format consistent with the line item categories on CMS Form 719 BP. This information also applies to similar terms on other forms and worksheets used for the business proposal end for the Financial Information and Vouchering System (FIVS).

a. LABOR. Direct labor hours and costs, excluding leave and fringe benefit costs, are to be proposed and reported in the following four labor categories:

1. Professional

2. Information Systems

3. Corporate Management

4. Support Staff

Specified tasks within the Scope of Work require certain core competencies for the individuals performing the task. Since job titles are not always indicative of the type of work performed, the following chart should be used as a guide in deciding what labor category is appropriate for specific employees. Examples of various job titles are also included in the chart for each of the four labor categories.

These examples are not all inclusive, nor are they suggestions or requirements for QIOs to have jobs similarly titled. The title of a particular job at one QIO can be different from the title of a job covering similar work at another QIO. Examples of the different job titles that QIOs might use to cover similar work are: (1) Director/Manager/Supervisor and (2) Clerk/Assistant. QIOs should continue to use job titles specific to their organization.

	Labor Category	Core Competencies	Definition	Job Title Examples
1	Professional	Medicine, Nursing and related medical/clinical disciplines.	Physicians (MD and DO), RNs, LPNs/LVNs, RRAs, ARTs, whose medical/clinical degrees or certifications are considered necessary to fulfill SOW requirements. Work includes design, implementation, monitoring, and/or management activities relating to medical case review, HCQIP, pattern analysis/surveillance and program integrity.	Abstractor Associate Clinical Coordinator Associate Medical Director DRG Coordinator Epidemiologist HCQIP Director Medical Director Nurse, RRA, ART Project Coordinator Nurse Reviewer Principal Clinical Coordinator Review Director
		Epidemiology, statistics, survey research, data analysis, related empirical and analytic disciplines.	Professional non-medical staff with research and analysis degrees/skills considered necessary to fulfill SOW requirements. Work includes epidemiology, biostatistics, data analysis and/or health care research to support medical case review, HCQIP, pattern analysis/surveillance and/or program integrity.	Bio-statistician Data Analyst Programmer Analyst Researcher Statistician
		Health education and promotion, public relations, social marketing and formative research, communications, social and behavioral science disciplines, CQI.	Professional non-medical staff developing educational campaigns, and intervention strategies. Beneficiary rights, outreach and education activities, and the beneficiary hotline. Research and writing for HCQIP and beneficiary publications, and survey design. Report direct labor hours and costs on line a1 of CMS BP Form 719, FIVS Forms 719 + 719A.	Beneficiary Outreach Coordinator CQI Coordinator Communications Director Health Education Coordinator Graphic Designer Market Researcher Medical Editor Medical Librarian Technical Writer
2	Information Systems	Database Administration DBA	Database information systems personnel who support the QualityNet Standard Data Processing System at the QIO. Work includes Oracle and MS Access database administration, maintenance, backup and support.	DBA Database Administrator
		PC Desktop/Help Desk Support	Information systems personnel who support the QualityNet Standard Data Processing System at the QIO. Work includes providing support for local/remote users with standard MS Windows workstations/laptop hardware and SDPS/QualityNet applications. Act as the first level support for the local QIO personnel and interface with the QualityNet Helpdesk on issues that cannot be resolved locally. Also responsible for any additional approved workstation/laptop hardware or software attached to the SDPS/QualityNet network.	PC Specialist Systems/Computer -Analyst
		Senior Network/System Administration	Information systems personnel who support the QualityNet Standard Data Processing System at the QIO. Work includes trouble shooting of local QIO network problems, working with the CMS contractors to help resolve LAN and WAN issues when necessary, backing up and restoring of data for all QIO systems platforms, and following the procedures outlined in the Operations and Administrator's Manuals. Responsible for the training of local QIO users in the proper use of the applications, LAN environment, and security requirements for QualityNet.	Senior Systems- Administrator Senior Network- Administrator
		Junior Network/System Administration	Information systems personnel who support the QualityNet Standard Data Processing System at the QIO. Work includes backing up and restoring of data on the local QIO file server and following the procedures outlined in the Operations and Administrator's Manuals.	Junior Systems -Administrator Junior Network -Administrator
		Technical Management	Information systems personnel who manage and support the QualityNet Standard Data Processing System at the QIO. Work includes managing senior and junior level systems administrators and IT support staff. Overall responsibility for backups and restores of data for the file/print server and all QIO data. In addition, serves as the QIO technical liaison or IT representative to the overall QualityNet enterprise system through various workgroups and/or boards. Duties will also include coordination efforts with the QualityNet development networks and lab environments for approved special study work and/or trade studies.	IT Manager CIO CTO IT Representative
		QIO Security Administration	Systems security personnel who support the QualityNet Standard Data Processing System at the QIO and protect the integrity of the QualityNet Infrastructure. Work includes: Managing security, including ensuring assigned POC perform the necessary tasks at their individual office locations; enforcing CMS security rules as outlined in the QualityNet System Security Policies Handbook; completing tasks assigned by the CMS Information System Security Officer (ISSO); and ensuring QIO staff are fully trained as policy states from QualityNet System Security Policies Handbook. In addition to these roles, serves as the primary POC in the event of security incidents identified from outside sources and provides first level response to security incidents identified within the QualityNet operations; ensures confidential data are destroyed or stored as identified within the QualityNet System Security Policies Handbook, and maintains the acceptance log for their QIO site location(s).	QIO Security Administrator
3	Corporate Management	Corporate management and leadership skills.	Personnel performing Administrative, Financial, Human Resource, Training and Public Relations Management for the organization as a whole. Activities are directly identifiable with specific cost centers of the QIO contract. Report direct labor hours and costs on line a3 of CMS BP Form 719, FIVS Forms 719 + 719A.	Chief Executive Officer Chief Operating Officer Contracts Administrator Controller Corporate Training Coordinator Finance Director Fiscal Analyst Accountant Human Resources Director Public Relations Director
4	Support Staff	Administrative, Secretarial and clerical support	Personnel who perform support services and staff assistance to Professional, Information Systems, and Corporate Administration staff for the QIO contract. Report direct labor hours and costs on line a4 of CMS BP Form 719, FIVS Forms 719 + 719A.	Accounting Clerk/Assistant Administrative Clerk/Assistant Data Entry Operator Human Resources Clerk/Assistant Mail Room and Photocopy Clerk Medical Records Clerk Receptionist Secretary

Note: All proposed labor rates shall be supported with matching rates or formal salary survey information conducted by your organization from an acceptable source {i.e. www.salary.com, www.indeed.com, or etc.}.

NOTE: The Line designations listed below apply both to the Forms BP719 of the FIVS 719 + 719A

b. LEAVE. This line item should be completed by all organizations that have an approved Indirect Leave Rate. This line item includes all indirect leave such as vacation, sick, holiday, and military leave. Accounting treatment of leave as an indirect cost must be consistent for all contracts or lines of business.

c. FRINGE BENEFITS. This line item includes allowances provided by the contractor to its employees as compensation in addition to regular wages and salaries. The Fringe Benefits line includes all direct costs such as employer’s share of FICA, federal unemployment tax, state unemployment insurance, disability insurance, pension expense, workers compensation, group health insurance, group life insurance, employee relations, and welfare. It also covers leave costs for those organizations that include these costs in the fringe benefit pool. This category does not include benefits provided some, but not all, full-time employees.

d. SUBCONTRACTS

1. PHYSICIAN REVIEWERS/ADVISORS. This line item includes all direct hours and costs related to subcontracts or agreements with physician reviewers or physician advisors to perform medical case review (and related) activities required by the statement of work (SOW). This applies to physicians who are not employees.

2. OTHER CONSULTANTS. This line item includes all direct costs related to subcontracts with physician and non-physician consultants (other than the physician reviewers and physician advisors performing medical case review, noted above) to perform activities required by the SOW.

3. OTHER SUBCONTRACTS. This line item is for all direct subcontracting costs not reportable on lines d.1. or d.2. This includes all direct hours and costs for subcontract arrangements (including those with universities and other organizations) meeting the requirements of the FAR, incurred in performance of the SOW, and not involving consultative services.

e. TRAVEL. This line item includes all travel directly chargeable to the contract.

f. OTHER DIRECT COSTS. This line item includes all direct costs applicable to the Medicare contract that are not reportable on other line items. Accounting treatment of other direct costs must be applied consistently to all contracts or lines of business and in accordance with the FAR or OMB Circular A-122.

All direct costs (excluding information services costs) not directly associated with a specific task should be included in the other direct cost pool and allocated to each task based on an allocation methodology developed by the offeror. Offerors must provide supporting documentation describing the proposed allocation method.

g. INDIRECT COSTS. This line item includes costs allocated to the Medicare contract but incurred for common or joint objectives. These costs fit in one of the following categories:

1. Costs that benefit all lines of business.

2. Costs that directly benefit the Medicare contract but which cannot be readily allocated to one or more specific cost centers. These costs are also referred to as general overhead costs of the Medicare contract.

Accounting treatment of indirect costs must be applied consistently to all contracts or lines of business and in accordance with the FAR and OMB Circular A-122.

h. PASS-THRU COSTS. This line item includes payments to providers or vendors as specified and negotiated in the contract as being pass-thru costs. Examples are reimbursement for medical record reproduction costs and postage costs for mailing medical records from the provider to the QIO.

i. FEE. This is the element of potential total compensation that may be received for contract performance over and above allowable costs and shall not exceed statutory limitations.

III. COST CENTER COLUMN CATEGORIES

a. TBD