Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC)

Statement of Work (SOW) / Performance Work Statement (PWS)

To contract with an external entity to support the Centers for Medicare & Medicaid Services (CMS) in its oversight of Medicare Parts C and D programs, ensuring the protection of the Medicare Trust Fund through fraud, waste, and abuse (FWA) detection, deterrence, and prevention activities.

The contractor, acting as the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC), will perform FWA detection, deterrence, and prevention for Medicare Parts C and D. This includes:

• Data analyses, audits, and reviews of Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs).
• Outreach and education initiatives.
• Referrals to law enforcement and other appropriate entities.
• Coordination with CMS staff and other stakeholders.
• Monitoring and addressing program vulnerabilities and risks.
• Ensuring plan sponsors adhere to regulatory requirements.
• Providing technical assistance to CMS.

Key tasks include:

• Producing data analytics reports for plan sponsors.

• Creating and managing Peer Activity Reports (PARs) to compare plan sponsor performance against peers.

• Identifying topics for and drafting Plan Sponsor Alerts (PSAs) regarding potential FWA.

• Monitoring CMS Medicare Parts C and D Plan Correspondence Mailboxes and drafting responses.

• Developing recommendations and audit strategies for Medicare Prescription Payment Oversight.

• Conducting various audits: Self-Audits, National Audits, Program Integrity (PI) Audits, and Ad hoc audits (including Part C Oversight Audits).

• Managing the first level of appeal (Reconsideration) for Part D program integrity PDE record review audits and supporting CMS in all appeal levels.

• Developing audit protocols.

• Hosting national FWA training and outreach/education missions.

• Developing quarterly reports based on data from the PI Portal for FWA Reporting module.

• Retention of all records for 10 years.

• Timely submission of various reports (e.g., Monthly Status Reports, Quarterly ROI Reports, Annual Lessons Learned Reports).

• Adherence to specific timelines for deliverables and meeting minutes.

• Maximizing audit Return on Investment (ROI) where applicable.

Not explicitly detailed in this SOW excerpt, but implies ongoing support for Medicare Parts C and D programs.

• Compliance with all applicable federal and state laws, regulations, Medicare Internet Only Manuals, and CMS requirement documents.
• Immediate contact with COR/CO if discrepancies are identified among governing documents.
• Contractor cannot assert clinical review judgment to override Medicare policy.
• Strict adherence to Information Security Requirements (Appendix B) and 508 Compliance Requirements (Appendix C).
• Personnel must undergo vetting and credentialing.
• Entry into a Data Use Agreement (DUA) with CMS.
• Development of Joint Operating Agreements (JOAs) with relevant stakeholders.
• Contractor must maintain software compatibility with current CMS versions.
• Transition activities with outgoing contractor are required.

Form / Attachment / Pricing Sheet

This document is Attachment J.2, a template for Contractors/Offerors to submit information regarding Conflicts of Interest (COI) as required by Solicitation/Contract Section H.1. A response is mandatory, even if no conflict exists. Bidders may use their own template, provided it captures all the information requested in this template.

• Organizational Structure: Requires high-level and internal organization charts, including parent/affiliated organizations, and a narrative explanation of the structure/ownership.
• Actual, Potential, and/or Apparent COIs and Financial Interests/Relationships: Requires disclosure of current/active and known future non-foreign contracts that could pose a COI for the offeror, its parents, affiliates, and potential subcontractors. This includes details on the contract, the nature of the COI (Actual, Potential, Apparent), the type of COI (Unequal Access, Biased Ground Rules, Impaired Objectivity), and an explanation with mitigation strategies.
• Personal Conflicts of Interest (PCI): Requires the organization to analyze PCIs for governing body members and key personnel. Specific financial disclosures (assets, income, liabilities, gifts) for self, spouse/domestic partner, and dependents are considered internally but not disclosed to the Government unless a PCI is identified and requires mitigation.
• Subcontractors: The Prime Contractor/Offeror must analyze each subcontractor's COI submission, ensuring they responded to criteria, determining if COIs exist and need mitigation, analyzing mitigation strategies, and recommending acceptability to the Contracting Officer.

This template outlines critical information bidders must provide regarding organizational and personal conflicts of interest. Failure to adequately address COIs and provide proposed mitigation plans can impact proposal evaluation and contract award. Bidders must ensure their submissions, whether using this template or their own, comprehensively address all required COI elements.

Form / Attachment / Pricing Sheet

This document is a template provided for vendors to submit questions and comments regarding the solicitation (75FCMC26R0041) for PPI MEDIC.

• Company Information: Fields for Name, UEI, and Small Business Designation.
• Designated Point of Contact: Fields for Name, Title, Phone Number, and Email.
• Questions and/or Comments: A table to log questions, including Document Name, Section Number, Section Name, Page No., and the Question/Comment itself.

Vendors must use this template to formally submit any questions or comments they have about the solicitation. This ensures that all inquiries are captured in a standardized format for the government to address.

Form / Attachment / Pricing Sheet

This document is a Responsibility Questionnaire designed to assist the Contracting Officer in determining the responsibility of prospective contractors in accordance with FAR 9.1. Offerors must provide responses to the questions posed, supported by appropriate explanations and references to substantiating information.

The questionnaire covers the following areas of responsibility:

• Financial Resources: Ability to perform the contract or obtain necessary resources.
• Performance Schedule Compliance: Ability to meet delivery or performance schedules, considering existing commitments.
• Satisfactory Performance Record: Assessment of past performance, with consideration for circumstances beyond the contractor's control or corrective actions taken.
• Integrity and Business Ethics: Evaluation of the Offeror's record in this regard.
• Organizational and Technical Skills: Possession of necessary organization, experience, accounting/operational controls, and technical skills, or the ability to obtain them.
• Technical Equipment and Facilities: Possession of necessary technical equipment and facilities, or the ability to obtain them.
• Other Qualifications: Eligibility to receive an award under applicable laws and regulations.

Prospective prime contractors must complete this questionnaire to demonstrate their capability and eligibility to perform the contract. Responses should be detailed and supported by evidence. The questionnaire also reminds Offerors that they are responsible for determining the responsibility of their prospective subcontractors.

Form / Attachment / Pricing Sheet

This document is an Excel spreadsheet containing a checklist for ensuring compliance with Section 508 accessibility standards for PDF documents, specifically for the Centers for Medicare & Medicaid Services (CMS). It outlines various accessibility criteria based on WCAG (Web Content Accessibility Guidelines) and provides columns for compliance status, remarks, and additional notes for CMS use.

• Report Details Sheet: Contains fields for reviewer information, procurement name, document description, and overall assessment.
• Results Sheet: Details specific WCAG guidelines and corresponding compliance criteria (e.g., Text Alternatives, Keyboard Accessible, Navigable). Each criterion includes a WCAG reference number, standard ID, conformance level, and space for remarks.
• Time-Based Media Sheet: Focuses on accessibility requirements for audio and video content, including captions and audio descriptions.

Bidders submitting PDF documents as part of their proposals or deliverables should use this checklist to ensure their documents meet Section 508 accessibility requirements. Understanding these criteria is crucial for compliance and may impact the evaluation or acceptance of submitted materials.

Solicitation / RFP / RFQ

This solicitation is for a Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) to serve as a national contractor responsible for providing oversight of the Medicare Parts C and D programs to ensure the protection of the Medicare Trust Fund. The PPI MEDIC will support the Centers for Medicare & Medicaid Services' (CMS') strategy in maintaining and strengthening program integrity for Medicare Parts C and D programs by monitoring and addressing program vulnerabilities, risks, and ensuring plan sponsors' adherence to regulatory requirements.

• The work to be performed is detailed in the PPI MEDIC Statement of Work (SOW), provided as Attachment J.1.

• Deliverables shall be submitted in accordance with the SOW Appendix A - Deliverable Schedule.

• All work is subject to inspection and final acceptance by the Contracting Officer or their representative.

• Contract Type: Cost-Plus-Fixed-Fee (CPFF).

• Period of Performance: Base Period (June 28, 2026 - June 27, 2027) with five Option Periods extending through June 27, 2031, and an Optional Transition-Out Period.

• Estimated Cost/Fee: TBD for total estimated cost, total estimated fixed fee, and total estimated CPFF.

• Level of Effort (LOE): TBD for each performance period.

• Proposals are due by 10:00 AM local time on April 17, 2026.

• Evaluation factors for award are detailed in Section M.

• Not explicitly stated in the provided sections, but standard FAR clauses related to small business concerns and set-asides are included.

• The solicitation includes numerous FAR and HHSAR clauses covering various aspects such as contract administration, information security, HIPAA, personnel security, records management, and conflict of interest.

• Attachment J.1 (SOW) and J.2 (COI Submission Template) are referenced.

• Key personnel are identified in Section H.

Solicitation / RFP / RFQ

This document outlines the instructions, conditions, and notices for offerors responding to Solicitation RFP- 75FCMC26R0041 for the PPI MEDIC program. It details the requirements for proposal submission, evaluation, and award.

• Proposals must be submitted in separate volumes: Technical (Phase 1 & 2), Business, and 508 Compliance & Conflict of Interest.

• Technical proposals require responses to specific scenarios related to Medicare Part C and Part D fraud, waste, and abuse audits, as well as a technical approach to SOW tasks, key personnel, staffing, and past performance.

• Business proposals must include contract forms, indirect cost rate information, Service Contract Act details, accounting system adequacy, uncompensated overtime policy, responsibility questionnaire, prime proposal checklist, consent to subcontract, joint venture agreements (if applicable), and a business proposal spreadsheet.

• 508 Compliance requires submission of CMS Accessibility Checklists. Conflict of Interest requires completion of the COI template.

• Contract type: Cost-Plus-Fixed-Fee.

• Award will be made using a Best Value Tradeoff Process.

• Proposals must be valid for at least 180 days.

• Questions Due: April 8, 2026, 10:00 AM local time.

• Notice of Intent (Phase 1) Due: April 13, 2026, 10:00 AM local time.

• Phase 1 Proposals Due: April 17, 2026, 10:00 AM local time.

• Phase 2 Proposals Due: TBD (approx. two weeks after Advisory Notification).

• Evaluation is two-phased: Phase 1 focuses on Technical Understanding and Approach. Phase 2 includes Key Personnel, Staffing, Past Performance, and Business Proposal evaluation.

• Technical factors are listed in descending order of importance: Technical Understanding and Approach (Phase 1), Key Personnel and Staffing Plan (Phase 2), Past Performance (Phase 2).

• Cost/price is considered, but technical/management features are more important.

• No specific set-aside mentioned.

• Offerors must be deemed responsible per FAR Part 9.

• Must address organizational conflicts of interest.

• Award may be made without discussions based on initial proposals.

• Late proposals will generally not be considered.

• All communications must be directed to the Contracting Officer or Contract Specialist.

Form / Attachment / Pricing Sheet

This document outlines the "Assumptions" related to workload projections for the PPI MEDIC program. It provides estimated volumes for various tasks over a 12-month period (Base and Option Years) to aid in budgeting and planning.

• Workload Projections: Detailed estimates for:
  • Audits (Part C, Part D, Appeals - Reconsiderations, CMS Support Requests)
  • Recurring/Discrete Reports (Part C, Part D)
  • Recurring Internal Reports (ROI, Status, Project Management, Audit Issues, Self-Assessment, Workload/Costs, M3P)
  • Meetings (Project Contractor, PAR, Ad-Hoc, PPI MEDIC/IMEDIC Collaboration, PIDUG, IDR, CMS DASG Collaboration)
  • Presentations/Conferences (FWA Training, Outreach, External Conferences)
  • Other Activities (Audit Protocols, Data Analysis Projects, Ad Hoc Deliverables, Model Development, Vulnerabilities, Correspondence Mailboxes, Plan Sponsor Alerts, RFI/Investigations, OIG Recommendations, Congressional Inquiries, FOIA Requests).
• Variability: Projections are subject to a +/- 10% variance.
• Specific Notes: Clarifications are provided for certain audit types, appeal timelines, and the inclusion of OIG recommendations within other tasks.

This document provides crucial quantitative data on the expected workload for the PPI MEDIC program. Bidders can use these projections to understand the scale and scope of services required, estimate resource needs, and inform their pricing strategies. The detailed breakdown across various categories helps in assessing the specific areas of focus for the contract.

Form / Attachment / Pricing Sheet

This document is a Past Performance Questionnaire required by the Centers for Medicare & Medicaid Services (CMS) for Solicitation No. 75FCMC26R0041, "Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC)". It is used to gather feedback from references on an Offeror's past performance.

• Offeror/Contractor Information: Fields to identify the company being evaluated, the contract title, a brief description of work, contract type, total value, and performance period.
• Rating Scale: A scale from N/A (Not Applicable) to Exceptional (4), with definitions for each level (Unsatisfactory, Marginal, Satisfactory, Very Good, Exceptional).
• Evaluation Questions: Specific questions covering Quality, Cost Control, Schedule, and Management. Each question requires a numerical rating and a detailed justification comment.
• Agency/Company Completing Questionnaire: Fields for the evaluating agency/company to provide their details and signature.

Potential bidders must provide this questionnaire to their references (customers/clients) and ensure it is completed and submitted to CMS by the specified deadline. The feedback gathered through this questionnaire will be a significant factor in the evaluation of the Offeror's past performance for this solicitation. Bidders should coordinate with their references to ensure timely and accurate completion.

Form / Attachment / Pricing Sheet

This document is a Prime Proposal Checklist intended to assist bidders in organizing and submitting their proposals. It requires bidders to provide specific company information, proposal validity details, subcontractor information, and self-certifications regarding business size and subcontracting limitations.

• Company Information: Name, address, point of contact, telephone number.
• Newly Formed Company Details: Parent company information if applicable.
• Proposal Validity Period: Duration for which the proposal is valid.
• Subcontractor List: Names of proposed subcontractors (if applicable).
• Business Size Designation: Prime entity's business size (Large, Small, and specific small business categories).
• Identification Numbers: TIN, UEI, Cage Code.
• Productive Hours: For exempt and non-exempt employees.
• Limitations on Subcontracting Self-Verification: Bidders must certify compliance with 13 C.F.R. 125.6, selecting one of three options regarding subcontracting percentages.
• Subcontractor Details Table: Requires information for each subcontractor including name, business size/designation, UEI, description of work, whether they are similarly situated, and if they are subcontracting further work.
• Self-Performance Calculation: Totals for cost of contract performance incurred by prime's employees, similarly situated concerns, and other subcontractors.

This checklist is critical for proposal preparation. Bidders must accurately complete all sections to ensure their proposal is compliant and readily evaluated. Specific attention should be paid to the Limitations on Subcontracting section, as violations carry severe penalties. Failure to provide complete and accurate information may impact proposal acceptability.

Form / Attachment / Pricing Sheet

This document is a "Consent to Subcontract" form, as referenced by FAR 44.201-3. It requires the Prime Offeror to provide detailed information to the contracting officer for review and consent regarding proposed subcontracts.

• Prime Offeror: Identification of the prime contractor.
• Proposed Subcontractor: Identification of the intended subcontractor.
• Proposed Subcontract Arrangement: Type of subcontract (e.g., Time & Materials, Firm-Fixed-Price).
• Description of Services: Details on the work to be performed by the subcontractor.
• Justification for Selection: Rationale for choosing the specific supplies, equipment, or services.
• Small Business Compliance: Confirmation of adherence to subcontracting requirements for small, veteran-owned, HUBZone, etc., businesses.
• Price Competition: Explanation of how adequate price competition was obtained, or justification for a sole-source award.
• Subcontractor Responsibility: Basis for selecting and determining the subcontractor's responsibility.
• Cost or Price Analysis: Details of the analysis performed, including price comparisons or certified cost/pricing data.
• Risk Assessment: Explanation of how the subcontract type aligns with risks and policy.
• Requirement Translation: Description of how prime contract technical requirements are translated into subcontract requirements.
• SAM Exclusion Check: Confirmation that the proposed subcontractor is not listed as excluded in the System for Award Management.

Prime Offerors must complete and submit this form for each proposed subcontract. It requires thorough documentation and justification regarding subcontractor selection, pricing, and compliance with federal regulations, including small business subcontracting goals and price reasonableness. Bidders should be prepared to provide all requested information to facilitate the contracting officer's consent.

Form / Attachment / Pricing Sheet

This document is Exhibit E.8, a Business Proposal Template for the Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC) opportunity (75FCMC26R0041). It provides a structured format for bidders to submit their pricing and labor details.

• Summary Sheet: Outlines the overall cost structure including direct labor, fringe benefits, overhead, ODCs, travel, subcontracts, G&A, fee/profit, and total estimated values across a base period and four option years.
• Fill-Ins Sheet: Details the Contract Line Item Numbers (CLINs) for the base period and option years, including their respective start and end dates.
• Labor Rollup Sheet: Provides definitions for labor categories (I-IV) and a detailed breakdown of proposed labor hours, rates, and subtotals for each CLIN and task, including prime and subcontract labor. It also includes columns for indirect costs (Fringe, Overhead, G&A) and Fee/Profit.
• CLIN Sheets (0001-0005): Break down direct labor costs by task for each contract period (Base and Option Years 1-4).
• CLIN 0006 (Transition Out): Details costs associated with outgoing transition.
• Travel Sheet: Provides a template for estimating travel costs, broken down by reason for trip, destination, number of people, and cost components (airfare, hotel, meals, car rental, etc.) for each contract period.
• ODCs Sheet: A template for detailing Other Direct Costs, categorized by task and contract period.

Bidders must use this template to structure and submit their detailed cost proposals. It is crucial for understanding the expected labor mix, rates, indirect cost application, and other direct costs required for each CLIN. Accurate completion of this template is essential for proposal evaluation.

Form / Attachment / Pricing Sheet

This document provides instructions for completing the CMS Accessibility Compliance Checklist. Bidders are required to use this checklist to document the accessibility compliance of their deliverables.

• Checklist Tabs: The checklist includes three tabs: 'Report Details' (for CMS use only), 'Results', and 'Time-Based Media'. Offerors must complete the 'Results' and 'Time-Based Media' tabs, if applicable.
• Column Guidance: Instructions are provided for each column heading within the checklist, including:
  • WCAG Guideline
  • WCAG Ref#s
  • Standard ID Number (CMS internal use)
  • Compliance Criterion
  • Conformance Level (Offerors must select from 'Supports', 'Partially Supports', 'Does not Support', or 'N/A')
  • Remarks and Explanations
  • Additional Notes (CMS internal use)
• Conformance Level Terms: Definitions are provided for 'Supports', 'Partially Supports', 'Does not Support', and 'Not Applicable'.

Bidders must use these instructions to accurately complete the accessibility compliance checklist for their proposed deliverables. The 'Remarks and Explanations' column requires detailed justification for the selected conformance level, especially when indicating 'Partially Supports' or 'Does not Support'.

Form / Attachment / Pricing Sheet

This document is a checklist for assessing the Section 508 compliance of web applications for the Centers for Medicare & Medicaid Services (CMS). It outlines various accessibility criteria based on WCAG (Web Content Accessibility Guidelines) and provides a framework for reviewers to evaluate compliance.

• Report Details: Fields for reviewer name, date, URL, site description, and overall assessment.
• Review Environment: Specifies operating system and browser for testing.
• Guidelines: Detailed criteria categorized by WCAG success criteria (e.g., Text Alternatives, Keyboard Accessible, Readable, Compatible).
• Compliance Criterion: Specific requirements within each guideline.
• Conformance Level: Indicates the required level of compliance.
• Remarks and Explanation: Space for reviewers to provide details on findings.
• Time-Based Media Sheet: Specific criteria for audio and video content accessibility.

Bidders developing or providing web applications for CMS should use this checklist to ensure their products meet Section 508 accessibility standards. Understanding these requirements is crucial for proposal development and successful contract performance. It highlights the technical and compliance obligations related to accessibility for web-based solutions.

Form / Attachment / Pricing Sheet

This document is an Excel checklist designed to help vendors ensure their submitted documents comply with Section 508 accessibility standards, specifically for the Centers for Medicare & Medicaid Services (CMS). It outlines various accessibility criteria based on WCAG (Web Content Accessibility Guidelines) and provides instructions for vendors.

• Report Details: Contains fields for internal CMS use (Reviewer Name, Date, Procurement Name, etc.).
• Results Sheet: Details specific WCAG guidelines, their corresponding Standard ID numbers, compliance criteria, and conformance levels. It includes vendor instructions for each criterion, particularly regarding alternative versions for inaccessible content, handling linked or embedded files, and specific requirements for text alternatives, time-based media, adaptability, distinguishability, keyboard accessibility, and more.
• Time-Based Media Sheet: Focuses on accessibility requirements for audio and video content, including transcripts, captions, and audio descriptions.

Vendors must use this checklist to verify that all documents submitted as part of their proposal or as deliverables meet Section 508 accessibility requirements. Failure to comply may impact the evaluation or acceptance of submissions. The checklist provides clear instructions on how to address potential accessibility issues, including providing alternative versions or remediation plans.

Form / Attachment / Pricing Sheet

This document is a checklist designed to help vendors ensure their Microsoft Office documents comply with Section 508 accessibility standards, specifically for the Centers for Medicare & Medicaid Services (CMS). It outlines various criteria based on the Web Content Accessibility Guidelines (WCAG) that need to be met.

• Report Details Sheet: Contains fields for reviewer information, procurement name, document description, and overall assessment. It also provides links to WCAG guidelines.
• Results Sheet: This is the core of the checklist, detailing specific WCAG criteria (e.g., Text Alternatives, Adaptable, Distinguishable, Keyboard Accessible, Readable, Compatible) and their corresponding compliance checkpoints. Each checkpoint includes a standard ID, criterion description, conformance level, and space for remarks.
• Time-Based Media Sheet: Specifically addresses accessibility requirements for audio and video content, including captions, audio descriptions, and transcripts.

Bidders submitting documents (e.g., proposals, reports, attachments) that are intended for use by CMS or the public may be required to ensure these documents meet Section 508 accessibility standards. This checklist provides the specific criteria that will likely be used to evaluate the accessibility of submitted documents. Vendors should use this checklist to self-assess and remediate their documents prior to submission to ensure compliance and avoid potential issues.

Form / Attachment / Pricing Sheet

This document is an Excel spreadsheet containing a checklist for ensuring compliance with Section 508 accessibility standards for documents submitted to CMS. It outlines various WCAG (Web Content Accessibility Guidelines) criteria across different categories.

• Report Details: A section for internal CMS use, including reviewer name, procurement name, and overall assessment.
• Time-Based Media: Details requirements for transcripts, captions, and audio descriptions for audio-only and video content.
• Results: A comprehensive checklist covering various accessibility aspects:
  • Text Alternatives (1.1): Requirements for alt text for images, handling of decorative images, complex images, images of text, embedded content, and animated content.
  • Time-based Media (1.2): References the 'Time-Based Media' worksheet for compliance.
  • Adaptable (1.3): Guidelines for structure, navigation pane, lists, tables, reading order, and sensory characteristics.
  • Distinguishable (1.4): Rules regarding the use of color, audio control, contrast ratios, text resizing, and images of text.
  • Keyboard Accessible (2.1): Ensures all functionality is operable via keyboard without traps.
  • Enough Time (2.2): Requirements for adjustable timing and pausing/stopping auto-updating content.
  • Seizures (2.3): Guidelines to prevent content flashing more than 3 times per second.
  • Navigable (2.4): Focuses on page titles, focus order, link purpose, and visible focus.
  • Readable (3.1): Language identification for the presentation and its parts.
  • Predictable (3.2): Rules for predictable navigation and input behavior.
  • Input Assistance (3.3): Requirements for error identification, labels, instructions, and error prevention.
  • Compatible (4.1): Ensures compatibility with current and future user agents.

Bidders should use this checklist to ensure that any documents submitted as part of their proposal (e.g., reports, presentations, or other attachments) meet CMS's Section 508 accessibility requirements. Failure to comply may result in non-compliance. The document provides specific instructions for vendors, such as providing alternate versions or remediation plans if content cannot be made accessible, and completing a checklist for any linked or embedded documents.