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Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing items 8 and 15, and returning or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

E. IMPORTANT: Contractor is not is required to sign this document and return copies to the issuing office.

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE

2. AMENDMENT/MODIFICATION NUMBER 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQUISITION NUMBER 5. PROJECT NUMBER (If applicable)

7. ADMINISTERED BY (If other than Item 6) CODE

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

FACILITY CODE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended. is not extended.

12. ACCOUNTING AND APPROPRIATION DATA (If required) copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NUMBER AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NUMBER IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15C. DATE SIGNED

15A. NAME AND TITLE OF SIGNER (Type or print)

16C. DATE SIGNED

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

PAGE OF PAGES

6. ISSUED BY CODE

8. NAME AND ADDRESS OF CONTRACTOR (Number, street, county, State and ZIP Code) (X)

CODE

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

Previous edition unusable topmostSubform[0]:

Page1[0]:

AmendmentNo[0]: 0001

Code[0]: 15BFAO

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D13[0]:

NameandTitleSigner[0]:

NameandTitleOfficer[0]:

Description[0]: Amendment #0001 is established to incorporate the following change: Attachment 1-page 2 the Inpatient Days are 110(estimated) for the Base and all four option years. Visit duration is hours and visit quantity is per contract year, not hours.

Attachment 1 page 1 the CBSA code is 41700 San Antonio-New Braunfels, Texas. The locality is 99 for the rest of the state of Texas and all counties. Attachment 5: The CBSA Code is 41700 which calculates new totals see document.

FacilityCode[0]:

Code[2]: 15B516

IssuedBy[0]: Federal Bureau of Prisons Field Acquisition Office 346 Marine Forces Drive Grand Prairie, TX 75051

NameandAddress[0]:

AdministeredBy[0]: Federal Bureau of Prisons FCI Three Rivers HWY 72 West Three Rivers, TX 78071

ContractIDCode[0]:

ReqNumber[0]: 15B51620R00000001

AmendmentNo[1]: 15B51620R00000001

ModificationNo[0]:

ProjectNo[0]:

Page[0]:

Pages[0]:

EffectiveDate[0]: 11/22/2021

Dated9B[0]: 11/22/2021

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CheckBox11[0]: 1

CheckBox13A[0]: Off

CheckBox13B[0]: Off

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CheckBox13D[0]: Off

IsNot[0]: Off

Is[0]: 1

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DateSigned[0]:

DateSigned[1]:

Copies[0]: 1

CopiesReturned[0]: 1

Attachment 1: Contract Pricing & Sub-Contract Certification FCI Three Rivers -Comprehensive Medical Service

15B51620R00000001

Blocks 19 through 24 – Contract Pricing and Sub-Contract Certification

Overview

Services are required to be provided in accordance with the Performance Work Statement included in this solicitation/contract. Offerors are required to submit, as a part of their business proposal, a completed copy of Schedule of Items and Sub-Contract Certification.

Pricing Methodology

Price proposals will be calculated from benchmarks utilizing Medicare reimbursement methodologies. For each category of service to be provided, Offerors will be allowed to propose a variance from the benchmark Medicare rate in the form of a discount from or a premium to Medicare rates established by the Centers for Medicare and Medicaid Services.

The rates established in the resulting contract shall not be construed as participation in the Medicare program; contract rates will merely be equated to Medicare rates of reimbursement without reductions for deductibles, copayments, or coinsurance. When appropriate, outlier payments calculated in accordance with Medicare reimbursement methodologies shall be made in recognition of extremely costly stays. The outlier payment shall be calculated based upon the defined benchmark and will consist of the operating portion only. This structuring of the pricing methodology is not intended to be restrictive of any Offeror; Offerors need only to propose that percentage discount from or premium to the Medicare benchmark rate which will reflect the desired level of payment for the category of services rendered. If during contract performance, it is determined that a necessary contract deliverable is not covered by Medicare reimbursement methodologies, a separate rate shall be negotiated for such deliverable(s).

Medicare Part A. The Medicare benchmark to be utilized for all services covered by

Medicare Part A shall be the most current Basic MS-DRG Payment (i.e., Operating Federal Rate) established for Core Based Statistical Area (CBSA) 41700 San Antonio- New Braunfels, Texas. The Basic MS-DRG calculation shall not include any provider-specific adjustments allowed under actual Medicare participation. Offerors may propose a discount from or a premium to Basic MS-DRG rates. (Refer to Attachment 5 of this solicitation)

Medicare Part B Physician Services and Non-physician Services. The

Medicare benchmark to be utilized for all physician and non-physician services covered by Medicare Part B shall be those rates established in the most current Medicare Part B Fee Schedule for Payment Locality 99 the Rest of the State of Texas and all counties.

The benchmark charges shall be those established for participating providers. Offerors may propose a discount from or a premium to the benchmark charges.

Medicare Part B Facility Services (including hospital outpatient services and ambulatory surgical centers).

The Medicare benchmark to be utilized for all facility services covered by Medicare Part B shall be the most current APC and ASC rates calculated for CBSA 41700 San Antonio-New Braunfels, Texas. Offerors may propose a discount from or a premium to the benchmark charges.

Long Term Care Facility Services:

The Medicare benchmark utilized for long-term care hospital services covered by Medical Part A shall be the most current MS-LTC-DRG payment amount (i.e.

Adjusted LTCH PPS Standard Prospective Payment) established for CBSA 41700 San Antonio-New Braunfels, Texas.

Estimated Quantities

Estimated quantities for the base year and all option years are detailed below.

The estimated quantities provided are not a representation to the Offeror/Contractor that the estimated quantities will be required or ordered or that conditions affecting requirements will be stable or normal.

Inpatient and Outpatient Facility and Physician Services

Base Year – Effective Date of Award (EDOA) through twelve (12) months from EDOA.

Inpatient Days: 110 days (estimated) Outpatient Days: 225 visits (estimated) LTAC Days: 45 days Option Year 1 - Thirteen (13) months through twenty-four (24) months from EDOA.

Inpatient Days: 110days (estimated) Outpatient Days: 225 visits (estimated) LTAC Days: 45 days (estimated)

Option Year 2 - Twenty-five (25) months through thirty-six (36) months from EDOA.

Inpatient Days: 110 days (estimated) Outpatient Days: 225 visits (estimated) LTAC Days: 45 days (estimated)

Option Year 3 - Thirty-seven (37) months through forty-eight (48) months from EDOA.

Inpatient Days: 110 days (estimated) Outpatient Days: 225 visits (estimated) LTAC Days: 45 days (estimated)

Option Year 4 - Forty-nine (49) months through sixty (60) months from EDOA.

Inpatient Days: 110 days (estimated) Outpatient Days: 225 visits (estimated) LTAC Days: 45 days (estimated)

Outpatient Institution Services

Estimated quantities shall remain constant for the base year and all option years. For Medicare-based services, duration of visits is listed for informational purposes only, as contracted rates will be based upon the Medicare allowable per procedure performed. Mobile MRI, Mobile Ultrasound, and Optometrist shall be paid based upon the provision of defined sessions.

Note: Session priced items which exceed the established session or are less than full session shall be pro-rated to the nearest quarter hour.

Orthopedic Surgeon: Visit duration-8 hours (approximate) Visit quantity-4 per contract year (approximate)

Gastroenterology: Visit duration-8 hours (approximate) Visit quantity-4 per contract year (approximate)

General Surgeon: Visit duration-8 hours (approximate) Visit quantity-4 per contract year (approximate)

Optometrist: Session duration 8 hours. (approximate)

Session quantity 36 per contract year (estimated)

Mobile MRI: Session duration 8 hours. (approximate) Session quantity 4 Per contract year (estimated)

Mobile Ultrasound: Session duration 8 hours (approximate) Session quantity 4 Per contract year (estimated)

Schedule of Items

Offerors shall complete the following Schedule of Items. All proposed pricing and participation targets will be evaluated in accordance with Federal Acquisition Regulation (FAR) 52.212-2, Evaluation - Commercial Items, and Attachment 4, Submission and Evaluation of Proposals, of this solicitation.

Effective Date of Award (EDOA) through twelve (12) months from EDOA.

1a. Inpatient Facility Services: -__Discount or +___ Premium to Medicare Part A 1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B 2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Institution Services: -Other Physicians -_ Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1 Mobile MRI ______ per session 2c2.Mobile Ultrasound ____ per session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT APPLICABLE

"-/+" PERCENTAGE. IF NO VARIANCE, ENTER "0".

Thirteen (13) months through twenty-four (24) months from EDOA.

1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B 2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Institution Services: -Other Physicians: -__Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1.Mobile MRI ______ per session 2c2.Mobile Ultrasound ____ per session

Twenty-five (25) months through thirty-six (36) months from EDOA.

1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B 2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Physician Services:-_ Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1.Mobile MRI ______ per session 2c2.Mobile Ultrasound ____ per session

NOTE: IF OFFERING A VARIANCE FROM THE BENCHMARK MEDICARE RATE, INSERT

APPLICABLE "-/+" PERCENTAGE. IF NO VARIANCE, ENTER "0".

Thirty-seven (37) months through forty-eight (48) months from EDOA.

1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B

Base Year

Option Year 1

Option Year 2

Option Year 3

2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Institution Services: -Other Physicians: -__Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1. Mobile MRI ______ per session 2c2. Mobile Ultrasound ____ per session

Forty-nine (49) months through sixty (60) months from EDOA.

1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B 2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Institution Services: -Other Physicians: -__Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1. Mobile MRI ______ per session 2c2. Mobile Ultrasound ____ per session

Sixty one (61) months through sixty (66) months from EDOA.

1b. Outpatient Facility Services:-__ Discount or +__ Premium to Medicare Part B 1c. Long Term Acute Care Facility:-__ Discount or +__ Premium to Medicare Part B 2a. Inpatient/Outpatient Physician Services:-__ Discount or +__Premium to Medicare Part B 2b. Outpatient Institution Services: -Other Physicians: -__Discount or +__Premium to Medicare Part B 2c. Optometrist _______per session 2c1. Mobile MRI ______ per session 2c2. Mobile Ultrasound ____ per session

All Offerors are hereby advised that the successful Offeror's unit pricing (to include discount percentage from or premium percentage to the benchmark Medicare rate) for the base year and all option years is public information, in accordance with Federal Acquisition Regulation (FAR) 15.503(b) (1)(iv).

Accordingly, all successful unit pricing will be released to unsuccessful Offerors with the notification of award as well as to the general public when requested. Any party who objects to the release of their own unit pricing information, should they be awarded a contract in response to this solicitation, should not submit proposal in response to the solicitation.

This contract does _ does not___ provide for subcontracting possibilities. If answer is in the affirmative, Offeror will submit sub-contracting plan in accordance with the requirements of FAR 52.219-9.

Option Year 4

Option to Extend Services as Authorized by FAR 52.217-8

Sub-Contract Certification

Blocks 19 through 24 – Contract Pricing and Sub-Contract Certification

Estimated Quantities

Inpatient and Outpatient Facility and Physician Services

Base Year – Effective Date of Award (EDOA) through twelve (12) months from EDOA.

Option Year 1 - Thirteen (13) months through twenty-four (24) months from EDOA.

Option Year 2 - Twenty-five (25) months through thirty-six (36) months from EDOA.

Option Year 3 - Thirty-seven (37) months through forty-eight (48) months from EDOA.

Option Year 4 - Forty-nine (49) months through sixty (60) months from EDOA.

Attachment 5: Computation of Basic MS-DRG Payment

FCI Three Rivers-Comprehensive Medical Services

RFP-15B51620R00000001

Attachment 5 Computation of Basic MS-DRG Payments (i.e., Operating Federal Rate)

CBSA Code 41700-San Antonio-New Braufels, TX

Calculation of the Operating Federal Rate:

Step 1: Select the applicable average standardized amount for the full update

Step 2: Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area

Step 3: For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the applicable cost-of-living adjustment factor

Step 4: Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if applicable, under Step 3)

Step 5: Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS-DRG

Index Figures: Obtained from the Centers for Medicare and Medicaid Services for discharges on/after October 1, 2021

Step 1 Enter CBSA Code in Cell B24 41700

Table 4A, Wage Index for Rural Areas by CBSA Table: 0.8474

Area Name: San Antonio-New Braunfels, TX

Table 1A or 1B (Full Update) National Adjusted Operating Standardized Amount:

Labor-related: $3,696.01 Non-labor-related: $2,265.30

Table 5, MS-DRG Relative Weight (MS-DRG 76, Viral Meningitis w/o CC/MCC): 0.9809

Step 2 Labor-related x Wage Index 3,132.00$

Step 3 Only applicable for HI & AK

Step 4 Total of Step 2 + Non-labor related 5,397.30$

Step 5 Total of Step 4 x MS-DRG Relative Weight 5,294.21$

Payment for MS-DRG 076 under the contract would be 5,294.21$ plus or minus any premium or discount established as the contract rate.

Updated: 02/23/21

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