### CENTERS FOR MEDICARE & MEDICAID SERVICES

### AND 

# ADMINISTRATION ON AGING

### THROUGH

### OGILVY PUBLIC RELATIONS WORLDWIDE

### MEDICARE-APPROVED DRUG DISCOUNT CARD 

### OUTREACH CAMPAIGN

### 

### Request for Proposals

# Requests for Funding Due July 30, 2004 

# 

## MEDICARE-APPROVED DRUG DISCOUNT CARD

## OUTREACH CAMPAIGN

## REQUESTS FOR PROPOSALS

## 

## [Table of Contents]{.smallcaps}

#### [summary 3]{.smallcaps}

#### [background 3]{.smallcaps}

####  {#section-3 .unnumbered}

#### [purpose 4]{.smallcaps}

#### [eligible applicants 4]{.smallcaps}

####  {#section-4 .unnumbered}

#### [targeted areas 4]{.smallcaps}

####  {#section-5 .unnumbered}

#### [eligible activities 5]{.smallcaps}

#### [application and funding options 6]{.smallcaps}

####  {#section-6 .unnumbered}

#### [project duration and match 7]{.smallcaps}

####  {#section-7 .unnumbered}

#### [application due date 7]{.smallcaps}

####  {#section-8 .unnumbered}

#### [letter of intent to abide by terms and conditions 7]{.smallcaps}

####  {#section-9 .unnumbered}

#### [instructions for developing a proposal 7]{.smallcaps}

####  {#section-10 .unnumbered}

#### [proposal assistance 10]{.smallcaps}

####  {#section-11 .unnumbered}

#### [reporting requirements 10]{.smallcaps}

####  {#section-12 .unnumbered}

#### [proposal checklist 11]{.smallcaps}

####  {#section-13 .unnumbered}

#### [proposal review criteria 11]{.smallcaps}

#### Summary 

####  {#section-14 .unnumbered}

#### HHS is conducting a nationwide outreach and education campaign to help Medicare beneficiaries learn about and enroll in the new Medicare-approved drug discount card program and transitional assistance credit. As part of this effort, the Centers for Medicare & Medicaid Services (CMS) and the Administration on Aging (AOA) are making funds available to community-based organizations (CBO) to support outreach, education and enrollment activities targeted specifically at low-income beneficiaries. This announcement describes the terms and conditions under which a community-based organization can apply for funds under this special initiative.  {#hhs-is-conducting-a-nationwide-outreach-and-education-campaign-to-help-medicare-beneficiaries-learn-about-and-enroll-in-the-new-medicare-approved-drug-discount-card-program-and-transitional-assistance-credit.-as-part-of-this-effort-the-centers-for-medicare-medicaid-services-cms-and-the-administration-on-aging-aoa-are-making-funds-available-to-community-based-organizations-cbo-to-support-outreach-education-and-enrollment-activities-targeted-specifically-at-low-income-beneficiaries.-this-announcement-describes-the-terms-and-conditions-under-which-a-community-based-organization-can-apply-for-funds-under-this-special-initiative. .unnumbered}

#### Background

The Medicare-approved Drug Discount Card and Transitional Assistance
Credit Program was enacted into law on December 8, 2003, as part of the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Medicare beneficiaries, except for those who have Medicaid drug
coverage, now have the opportunity to enroll in a Medicare-approved drug
discount card program which can help to lower their prescription drug
costs. The drug discount cards provide discounts off the regular cash
price of prescription drugs.

In addition, beginning in June 2004, Medicare began to provide \$600 in
2004 and will provide up to an additional \$600 in 2005 to Medicare
beneficiaries whose incomes are not more than 135 percent of the poverty
line (\$12,569 for single individuals or \$16,862 for a married couple
in 2004) if they do not have certain other drug coverage.

These new opportunities for Medicare beneficiaries are accompanied by an
extraordinary challenge for those who serve them. The benefits of
Medicare modernization can only be realized if beneficiaries and their
family caregivers are sufficiently informed to make the complex choices
that they will face. This challenge is especially significant for older
members of minority, low-income, limited English-speaking, and other
underserved populations.

While news stories, ads, high profile events, and other outreach are
planned to help build awareness, many beneficiaries and caregivers will
continue to rely on trusted local community-based organizations for
information on comparing, choosing, and using a drug card. This is
particularly true for the low-income beneficiaries who will be eligible
for the \$600 credit.

The U.S. Department of Health and Human Services (HHS) has already
launched a nationwide outreach and education campaign to assist Medicare
beneficiaries in learning about and enrolling in the approved drug
discount card program. As part of this effort, CMS and AOA are making
available up to \$3.7 million to CBOs for Medicare-approved drug
discount card outreach, education and enrollment activities targeted at
low-income beneficiaries.

This new funding opportunity is part of a public and private sector
partnership announced by HHS Secretary Thompson on May 27, 2004 to
ensure that low-income Medicare beneficiaries take advantage of the
substantive savings provided by the Medicare-approved drug discount
cards.

######## Purpose

The purpose of this Request for Proposals is to provide resources to
community-based organizations (CBO) to increase their capacity to help
low-income Medicare beneficiaries learn about and enroll in the
Medicare-approved drug discount card program and the transitional
assistance credit program.

Community-based organizations, as visible and trusted sources of
information at the local level, are recognized as an important avenue
for expanding the awareness of Medicare beneficiaries about
Medicare-approved drug discount cards and assisting them with enrollment
in drug discount card and transitional assistance credit programs.

Using information and tools developed by HHS, awardees of this
initiative will conduct outreach, education and enrollment assistance
activities with low-income and underserved Medicare beneficiaries to
ensure that they understand and enroll for a Medicare-approved drug
discount card. Successful applicants will commit to coordinating with
and participating in community-wide efforts relevant to Medicare drug
discount card outreach, education and enrollment.

I.  **Eligible Applicants**

To be eligible for an award, an organization must meet the following
criteria:

-   Be a community-based non-profit organization or public entity that
    serves low-income and underserved Medicare beneficiaries.

-   Have a mission that is compatible with the focus of this RFP and
    demonstrated experience in providing outreach and education to the
    target population; and

-   Have access to e-mail and the Internet.

For-profit organizations/institutions are **not** eligible for funding
under this RFP.

All organizations selected for funding will be required to meet the
programmatic and operating criteria listed in the attached Letter of
Intent to Abide by Terms and Conditions. These criteria have been
established to show the applicant's interest in and commitment to
disseminating CMS messages and materials about the discount card and
\$600 credit and that the applicant meets specified contractual and
policy requirements. Applicants must submit a signed Letter of Intent to
Abide by Terms and Conditions at the time they submit their application
for funding.

All organizations selected for funding will also be required to
participate in a training session to be held on a date between September
13 and 30, 2004. In addition, applicants are required to visit and
complete web-based training "Module 1 and Module 4" at
http://www.cms.hhs.gov/partnerships/tools/materials/medicaretraining/ to
familiarize themselves with the Drug Discount Card program prior to
submitting their proposal.

II. **Targeted Areas**

HHS will give priority to supporting community-based organizations
(CBO), including partnerships of CBOs, in 30 targeted U.S. Primary
Metropolitan Statistical Areas (PMSAs). HHS estimates that almost 70% of
beneficiaries eligible for the transitional credit program reside in
these areas. Applications from urban or rural areas with demonstrated
need, not listed below, will be accepted. The 30 targeted PMSAs are:

-   New York, NY

-   Los Angeles -- Long Beach, CA

-   Chicago, IL

-   Philadelphia, PA -- NJ

-   Miami, FL

-   Detroit, MI

-   Tampa -- St. Petersburg -- Clearwater, FL

-   Boston, MA

-   San Diego, CA

-   Riverside -- San Bernardino, CA

-   Atlanta, GA

-   Houston, TX

-   Baltimore, MD

-   Pittsburgh, PA

-   Dallas, TX

-   Washington, DC -- MD -- VA -- WV

-   Orange County, CA

-   St. Louis, MO -- IL

-   Phoenix -- Mesa, AZ

-   Cleveland -- Lorain -- Elyria, OH

-   Newark, NJ

-   Nassau -- Suffolk, NY

-   Ft. Lauderdale, FL

-   San Francisco, CA

-   Charlotte, Gastonia, Rock Hill, NC -- SC

-   Indianapolis, IN

-   San Antonio, TX

-   Portland -- Vancouver, OR -- WA

-   Denver, CO

-   Kansas City, MO - KS

There is no limit to the number or type of applications that may be
received from a single PMSA. However, the number of applications funded
will be limited by available resources.

III. **Eligible Activities**

Community-based organizations may apply under this funding opportunity
to conduct outreach, education and enrollment activities for the
Medicare-approved drug discount card and transitional assistance
program. These activities are defined as follows:

-   **Outreach and Education**

The goals of outreach and education are to:

-   Find Medicare beneficiaries who are likely to be eligible for the
    Medicare-approved Drug Discount Card and the transitional assistance
    program;

-   Educate them about opportunities to save money;

-   Encourage them to seek further assistance; and

-   Help them to collect the information they will need to get
    assistance with enrollment.

Key strategies for outreach include:

-   Public awareness efforts;

-   Group education;

-   Individual outreach;

-   Marketing to targeted lists (e.g. people eligible for other
    low-income benefits); and

-   Special efforts for underserved populations.

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-   **Enrollment**

The goals of enrollment are to:

-   Assist people to determine for which benefits they want to apply;
    and

-   Help them to complete and send in applications for desired benefits.

Key strategies for enrollment include:

-   Self-help (by beneficiaries or their family members) through the
    www.medicare.gov Web site, and with other CMS tools and information
    materials;

-   Enrollment Centers -- Centralized phone banks and processing centers
    with staff and volunteers trained to assist with decision-support
    and enrollment; and

-   "Out-stationed" enrollment specialists who are deployed in key
    community locations.

IV. **Application and Funding Options**

The application options for funding under this RFP are as follows:

> **Option 1: Single CBO Applicant** -- An eligible community-based
> organization may apply on its own for:

-   **\$5,000** to conduct outreach and education activities to a single
    community or population group (e.g. African American, Hispanic
    American etc.), or

-   **\$10,000** to conduct outreach and education activities in more
    than one community or across several population groups, or

-   **\$15,000** to conduct enrollment activities in addition to
    outreach and education in more than one community or across several
    population groups.

> **Option 2: Collaborative Applicant** -- A group of CBOs may decide to
> come together to submit a single application. Collaborative applicants
> must designate a single lead agency to make application and to receive
> funding under this initiative. The amount requested under a
> collaborative application should reflect the number of CBOs in the
> collaborative and the funding amounts outlined above for Single CBO
> Applications. The maximum award for a collaborative applicant will be
> \$50,000.

Under either Option 1 or Option 2, no more than 10% of the total amount
requested by any applicant can be used for management and administrative
purposes.

Under both Option 1 and Option 2, HHS will require successful applicants
to coordinate closely with CMS Regional Offices, SHIPs, and other
outreach and enrollment activities in their communities.

Ogilvy PR will make provisions to provide successful candidates with
upfront funding to fund their work plans (as described in their
proposal) with subsequent funds disbursed upon successful achievement of
outreach goals and objectives.

V.  **Project Duration and Match**

The funding period for this initiative is expected to be August 2004
through February 2005 and funding will be on a one-time basis with no
option for renewal.

Financial match is not required.

VI. **Application Due Date**

-   Full proposals must be received by **[4:00 PM (EDT) on July 30,
    2004]{.underline}**

-   Applicants are required to submit an original (not stapled or bound)
    and six (6) copies. Proposals that do not include an original and
    six (6) copies may not be accepted.

-   Please submit proposals to:

Tom Beall, Project Director

Medicare Drug Discount Card Outreach Program

c/o Ogilvy Public Relations Worldwide

1901 L Street, NW

Suite 300

Washington, DC 20036

This Request for Proposals provides all the information needed to apply
for funding: background information, timelines, proposal contents, etc.

**Potential applicants are asked to inform Ogilvy Public Relations of
their intention to bid for an award. Please email Joel Hochanadel at
<joel.hochanadel@ogilvypr.com> by close of business on July 23, 2004.**

VII. **Letter of Intent to Abide by Terms and Conditions**

Organizations that request funding under this RFP are required to submit
a Letter of Intent to Abide by Terms and Conditions with their proposal.
Submitting a Letter of Intent confirms the applicant's eligibility to
receive funds under this solicitation and expresses the applicant's
intention to abide by all relevant terms and conditions. The Letter of
Intent includes a disclosure statement to ensure that privileged
communications are protected. The Letter of Intent also includes a
statement that indicates that the organization understands that funding
under this RFP is one-time and non-renewable.

VIII. **Instructions for Developing a Proposal**

Proposals shall be single spaced using 12-point Arial font and 1-inch
margins and shall not exceed 7 pages in total length for an individual
CBO submission (option 1) or 12 pages for collaborative applications
(option 2). HHS encourages applicants to submit proposals shorter in
length as long as they address all components listed below. Proposals
exceeding the total page limits will not be considered for funding.

Proposals shall include a table of contents and pages should be
numbered.

Proposals shall include a cover page that includes the title of the RFP,
the organization's (or lead organization's) name, address, and tax
identification or Federal Identification Number, and the name, telephone
and fax numbers, and email address for the contact person.

Proposal should include the following sections:

1.  Target Audience

2.  Organizational and Staff Capability

3.  Measurable Goals and Objectives

4.  Work plan and Timeframe

5.  Funding Requested

6.  Required Documentation

Requirements for each of these sections are described below.

**1. [Target Audience]{.underline}**

Provide no more than one-half page describing the population you will be
targeting and the geographic area you will be covering. Please describe
the demographic and lifestyle characteristics of the population and any
geographic/neighborhood/civic boundaries or features that could affect
your outreach strategy.

**2. [Organizational and Staff Capability]{.underline}**

In your proposal describe your organization and its ability to respond
to the requirements of the RFP. You **must** include the following
information:

> **Organizational Capabilities**

1)  State your organization's mission and discuss how it relates to the
    goals of this initiative;

2)  Describe your organization, including its structure, the size of
    your membership or client population;

3)  Discuss your organization's experience working with low income and
    underserved populations including African Americans, Hispanic
    Americans, Asian -- Pacific Islanders, the non-elderly disabled, and
    other minority groups as appropriate; and

4)  Discuss your organization's experience managing outside funding and
    the systems you have in place for tracking expenditures.

> **Staff Capabilities**

1)  Identify key staff for this project and where the project fits in
    the organizational structure;

2)  Discuss the project manager's role and how this person will oversee
    the project activities. Describe the manager\'s experience working
    with and understanding the population(s) to be targeted;

**3. [Measurable Goals and Objectives]{.underline}**

Each organization must develop a list of goals and objectives that meet
the purpose of the RFP and meet the needs of the target population(s)
that will be served.

In your proposal, include the following information:

1)  State the overall **goal(s)** of the project. These goals should
    relate directly to the intent of the RFP;

2)  Depending on the funding option selected (see Section VII above),
    specify which of the following measurable **objectives** your
    program will achieve and community(s) and populations (African
    American, Hispanic American, Asian -- Pacific Islanders, the
    non-elderly disabled etc.) to be targeted.

    a.  For applications for **\$5,000**:

        i.  Projected number of people to be educated about
            Medicare-approved drug discount card and \$600 transitional
            assistance credit programs.

        ii. Projected number of people who will be assisted in applying
            for these programs.

    b.  For applications for **\$10,000**:

        i.  Projected number of people in each community and/or targeted
            population groups to be educated about Medicare-approved
            drug discount card and \$600 transitional assistance credit
            programs.

        ii. Projected number of people who will be assisted in applying
            for these programs.

    c.  For applications to provide outreach, education and enrollment
        activities (single CBO applications for **\$15,000**):

        i.  Projected number of people to be educated about
            Medicare-approved drug discount card and \$600 transitional
            assistance credit programs.

        ii. Projected number of people who will be assisted in applying
            for these programs.

        iii. Projected number of people who will be enrolled in these
             programs.

**4. [Work Plan and Timeframe]{.underline}**

Provide a work plan for meeting the specified goals and objectives
listed above. Include the following information in the description:

-   The activities that you will undertake to achieve each objective and
    the timeline for completing those activities;

-   Key partners that could assist in outreach activities; and

-   Plans for coordination with other outreach and enrollment activities
    occurring in your community.

**5. [Funding Requested]{.underline}**

We are not requesting a detailed budget with this application.
Applicants only need to indicate the total amount of funding requested.
However, applicants must identify if they are currently receiving CMS
funding either directly or indirectly.

Single CBO Applicants can request funding only in the amounts \$5,000,
\$10,000 or \$15,000. Collaborative Applicants can request funding that
reflects the number of CBOs involved and the activities to be
undertaken, up to a limit of \$50,000, as outlined in Section VII.
Collaborative applicants must detail the amount of funding to be
allocated to each of the participating CBOs.

As stated in the Letter of Intent to Abide by Terms and Conditions, at
least 90 percent of all funds requested under this RFP must be expended
in support of direct service (i.e. outreach, education and enrollment
activities). Management and administrative expenses, including travel
and training, cannot exceed 10 percent of the total funds requested.
Preference will be given to applicants that request less than 10 percent
for such purposes.

Capital expenditures (e.g., computers, laptops, cell phones, furniture,
renovations, etc.) are not allowed under this RFP.

Financial match or in-kind contributions are [not]{.underline} required.

**6. [Required Documentation]{.underline}** (not included in the page
limit)

Each organization applying for funding must include:

-   A copy of its current 501(c)(3) status certifying that it is a
    non-profit, community-based or a national non-profit organization;

-   A copy of the organization's latest audit report (summary pages)

IX. **Proposal Assistance**

> If you have questions about completing your application, please
> contact Mr. Joel Hochanadel, at (202) 452-9516 or by email at:
> <joel.hochanadel@ogilvypr.com>.

X.  **Reporting Requirements**

> **Progress Report** -- A progress report describing all Work Plan
> activities completed through the end of November will be due December
> 31, 2004.
>
> **Final Report** -- Each subcontractor will be required to submit a
> final report describing all activities funded under this subcontract
> and describing performance in activities identified in the proposal
> Work Plans. Final reports will be due within one (1) month of
> completion of the project -- March 31, 2005. The final report should
> include copies of all collateral materials produced with funds from
> the subcontract including flyers, brochures, handouts, etc.

XI. **Proposal Checklist**

> \_\_\_\_\_\_\_ Letter of Intent to Abide by Terms and Conditions
>
> \_\_\_\_\_\_\_ Complete proposal including:

\_\_\_\_\_\_ Target Audience

> \_\_\_\_\_\_ Organizational and Staff Capability
>
> \_\_\_\_\_\_ Goals and Objectives

\_\_\_\_\_\_ Work Plan

\_\_\_\_\_\_ Funding Requested

> \_\_\_\_\_\_\_ Copy of current 501(c)(3) status
>
> \_\_\_\_\_\_\_ Copy of most recent audit report summary (summary
> statement)

XII. **Proposal Review Criteria**

Each section of the application will be scored using the following point
system. A Review Panel will meet to discuss each application, and will
then provide guidance based on both the assigned points and the
discussion.

Funding decisions may take into consideration target populations served
and the geographic location of applicants to ensure diversity among
subcontractors.

.

**Section Points**

1\. Target Audience 15

2\. Organizational and Staff Capability 15

3\. Goals/Objectives 25

4\. Work Plan 40

5\. Funding Requested 5

6\. Required Documentation not scored

> **Total Points** **100**

Proposals will be evaluated based on the following criteria:

**1. Target Audience**

-   Does the applicant describe the population they will be targeting?

-   Does the applicant describe the geographic area they will be
    serving?

-   Does the applicant discuss the characteristics of the population
    they will be serving and any geographic/neighborhood/civic
    boundaries or features that could affect their outreach strategy?

**2. Organizational and Staff Capability**

-   Does the applicant describe the organization(s), including the
    structure, and the size of membership or constituency?

-   Does the applicant discuss the organization's experience managing
    outside funding and systems in place for tracking expenditures?

-   Does the applicant identify key staff for this project?

-   Does the applicant discuss the manager's role in managing this
    project?

**3. Goals/Objectives**

-   Does the applicant state the overall goal(s) of the project?

-   Are the goals related directly to the goals of this Campaign?

-   Does the applicant indicate the measurable objectives?

-   Do the objectives address the specific target populations to be
    served?

-   Does the applicant describe how the organization will continue to
    support this type of work in the future once the Campaign's project
    funding ends?

**4. Work Plan**

-   Does the applicant include a brief discussion of how activities will
    complement/enhance existing programs within the organization?

-   Does the applicant include a work plan describing key activities
    necessary to achieve project objectives?

-   Does the applicant describe how they plan to coordinate with other
    outreach and enrollment activities occurring in their community?

-   Is the work plan reasonable and understandable?

**5. Funding Requested**

-   Is the requested funding in line with the goals and objectives and
    activities proposed?

-   Does the applicant currently receive CMS funding either directly or
    indirectly?

### 

### CENTERS FOR MEDICARE & MEDICAID SERVICES 

## ADMINISTRATION ON AGING

###  MEDICARE DRUG DISCOUNT CARD OUTREACH CAMPAIGN

### LETTER OF INTENT TO ABIDE BY TERMS AND CONDITIONS

As a potential subcontractor of the Medicare Drug Discount Card Outreach
Campaign, we agree that, if funded, we will adhere to the following
provisions:

##### Program Criteria

Our organization, or collaborative of organizations, has:

##### 

##### Expressed interest in, willingness to, and organizational mission consistent with disseminating HHS messages and materials about the drug discount card and transitional assistance. 

-   Proven access to and credibility with a significant population of
    low-income audiences, including, but not limited to, those defined
    as under-reached or underserved due to barriers of language,
    literacy, location, or culture.

-   Commitment to provide interventions that support informed
    decision-making among low-income beneficiaries such as:

> [Outreach and Education]{.underline}

-   Public communications such as newsletters, posters, pamphlets,
    and/or local media;

-   Information days at local pharmacies and retailers---where
    CMS-developed materials are distributed and trained counselors are
    available to answer questions;

-   Individualized outreach, including outreach to individuals eligible
    for other low-income benefits and who might be identified/reached
    through that characteristic (e.g., Food Stamp, public housing or
    energy assistance eligible);

-   Neighborhood or community workshops and seminars;

-   Training for senior volunteers who provide support and friendship to
    homebound elderly; and

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-   Group education and one-on-one counseling at senior centers,
    churches, and libraries.

> [Enrollment Support]{.underline}

-   Support self-help (by beneficiaries or their family members) using
    CMS Web sites, the 1-800 number, other tools and information
    resources, and referrals to SHIPS;

-   "Out-stationed" enrollment specialists who are deployed in key
    community locations; and

-   Special efforts for underserved populations.

In addition, our organization, or coalition of organizations, agrees to:

-   Visit and complete web-based training "Module 1 and Module 4" at
    http://www.cms.hhs.gov/partnerships/tools/materials/medicaretraining/
    prior to submitting their proposal.

-   Participate in a training session on the Drug Discount Card program
    to be held on a date between September 13 and 30, 2004;

-   Direct beneficiaries to www.medicare.gov and 1-800-Medicare as
    primary information sources; however, groups may
    [secondarily]{.underline} provide CMS-developed information on their
    own Web sites and in all collateral materials (e.g. print,
    broadcast, etc.);

-   Maintain ongoing communications by telephone, in person, or in
    writing with a designated Campaign Regional Facilitator;

-   Communicate with the designated Campaign Regional Facilitator to
    coordinate outreach activities with those of the CMS REACH program
    at the relevant CMS Regional Office;

-   Coordinate with and support other community-wide efforts relevant to
    Medicare drug discount card outreach, education and enrollment;

-   Submit a final report summarizing all activities.

##### Operating Criteria

Our organization, or coalition of organizations, understands that the
following operating criteria will be incorporated into all subcontracts.
These criteria will ensure that funded organizations meet CMS'
contractual and policy requirements and include the following:

**Neutrality.** In all communications, services, materials, and support
Subcontractors will operate in an honest broker role, maintaining
neutrality regarding any and all information offered and consideration
given to various card and benefit options.

**Collaboration and coordination.** Subcontractors agree to work in
cooperation with existing REACH Networks, SHIPS, other CMS-supported
partners, and other organizations and coalitions committed to supporting
CMS Medicare education, outreach and enrollment objectives.

**Apolitical.** All activities will focus solely on enrollment support
objectives. Subcontractors will operate in a manner that is strictly
non-partisan and apolitical.

**Disclosure.** All Subcontractors will be expected to provide
disclosure of potential/apparent conflicts of interest as a condition of
participation, updated on a recurring basis.

**Transparency.** There will be full public acknowledgement of all (1)
participants/members, (2) sources of funds, and (3) activities.

**No actual or implied endorsement.** Subcontractors cannot provide a
direct or indirect endorsement of any position, product, or company.

**Message conflict.** Subcontractors agree to keep any relevant advocacy
and public policy positions/stances/or messages separate and distinct
from their public identification with this Task and its outreach efforts
and mission.

**Use of funds.** Subcontractors must establish and adhere to procedures
and policies to ensure CMS funds are not used to promote non-Medicare
related benefits.

**Privacy rights.** Subcontractors will ensure that, in all dealings
with beneficiaries or caregivers, appropriate procedures and policies
are in place to ensure adherence to their privacy rights and HIPAA
requirements.

##### Additional Terms

The applicant organization agrees that at least 90 percent of all funds
requested under must be expended in support of direct service.
Management and administrative expenses, including travel and training,
will not exceed 10 percent of the total funds requested.

The applicant organization agrees that funding will be on a one-time
basis with no option for renewal.

All applicants must complete and submit a disclosure statement
identifying any potential or apparent conflict of interest between their
participation in this effort and other activities in which they are
engaged, for example, outreach or education related to a specific
Medicare-approved drug discount card and/or other drug discount
programs. If there are any real or perceived conflicts of interests,
applicants must also submit a conflict mitigation plan that establishes
how they propose to achieve a complete separation between activities
funded under this solicitation and any other relevant and competing work
in which they are or come to be engaged during the course of this
subcontract. **(Please read and complete the attached Disclosure
Statement)**.

We hereby signify that the
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
organization, and all collaborating organizations, agree to abide by the
terms and conditions outlined in this Letter of Intent.

Signed by:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name of signing official

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Title of signing official

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Organization

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date

**MEDICARE Approved drug discount card**

DISCLOSURE/CONFLICT OF INTEREST STATEMENT

The purpose of the Medicare Approved Drug Discount Card program is for
community-based organizations to maximize the enrollment of eligible
low-income Medicare beneficiaries in the \$600 transitional assistance
program provided by the Centers for Medicare & Medicaid Services (CMS),
especially among underserved populations. Through the period of
performance, the subcontractors shall conduct community-level outreach
activities to build awareness and understanding of the transitional
assistance program and motivate eligible beneficiaries to enroll for the
benefit.

DISCLOSURE BY COMMUNITY-BASED ORGANIZATIONS/SUBCONTRACTORS PARTICIPATING
IN CMS Drug Discount Card Program

a.  Subcontractors must provide an Organizational Conflict of Interest
    certificate (OCI) which concisely describes all relevant facts
    concerning any past, present or currently planned interest,
    (financial, contractual, organizational, or otherwise) relating to
    the work to be performed and bearing on whether the subcontractor
    has a possible conflict of interest. Any financial disclosure should
    include the following:

-   Percentage of ownership in any other entity;

-   Income generated from other sources;

-   A description of all instances of any level of involvement in any
    business or contractual relationship or activities that may be
    viewed by a prudent business person as a conflict of interest;

-   A list of current or known future contracts or arrangements,
    regardless of size, with any of the following, including the dollar
    amount of the contracts or arrangements, the type of work performed,
    and the period of performance:

    -   Insurance organization or subcontractor of an insurance
        organization;

    -   Institutional and non-institutional providers of services or
        other individuals or entities furnishing services for which
        payment may be made under the Medicare program; and

    -   All the entities contracted with or with which arrangements are
        made to conduct business operations.

-   The information required under this section is for all of the
    subcontractor's officers, directors and managers who would be or are
    involved with the performance of the contract.

b.  Subcontractors must also agree to keep any relevant advocacy and
    public policy positions/stances/or messages separate and distinct
    from their public identification with this project and its outreach
    efforts and mission; and

c.  If the subcontractor does not disclose any relevant facts concerning
    a conflict of interest, by submitting a proposal for review or if
    awarded, signing the Memorandum of Agreement, warrant that to the
    best of its knowledge and belief no such fact exists relevant to a
    possible conflict of interest.

REMEDIES FOR NONDISCLOSURE

The following are possible remedies should an a subcontractor refuse to
disclose, or misrepresent, any information regarding a potential OCI:

a.  Refusal to provide adequate information may result in
    disqualification for award;

b.  Nondisclosure or misrepresentation of any relevant interest may also
    result in the disqualification of the subcontractor for award
    consideration;

c.  Termination of the contract, if the nondisclosure or
    misrepresentation is discovered after award;

d.  Disqualification from subsequent CMS funded contracts; and

e.  Other remedial action as may be permitted or provided by law or in
    the resulting Memorandum of Agreement.

By signing this, I agree that I have read, understand and will comply
with the all conditions of the Disclosure Statement.

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NAME (Please Print)

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SIGNATURE

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DATE

Please promptly sign and return this form with this proposal. If you
have any questions, please call Joel Hochanadel (202) 452-9516 or
<joel.hochanadel@ogilvypr.com>.

Thank you.