36C10G18R0208-1-0019002.pdf

36C10G18R0208-1 Amendment 0019

524114

1. THIS CONTRACT IS A RATED ORDER RATING PAGE OF PAGES

UNDER DPAS (15 CFR 700)

2. CONTRACT NUMBER 3. SOLICITATION NUMBER 4. TYPE OF SOLICITATION 5. DATE ISSUED 6. REQUISITION/PURCHASE NUMBER

SEALED BID (IFB)

NEGOTIATED (RFP)

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

NOTE: In sealed bid solicitations "offer" and "Offeror" mean "bid" and "bidder".

9. Sealed offers in original and _____________________________ copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the depository located in until local time _______________________ (Hour) (Date)

CAUTION - LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All Offers are subject to all terms and conditions contained in this solicitation.

A. NAME B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS

AREA CODE NUMBER EXTENSION

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM I CONTRACT CLAUSES

B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

C DESCRIPTION/SPECS./WORK STATEMENT J LIST OF ATTACHMENTS

D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

E INSPECTION AND ACCEPTANCE

F DELIVERIES OR PERFORMANCE

G CONTRACT ADMINISTRATION DATA L INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

H SPECIAL CONTRACT REQUIREMENTS M EVALUATION FACTORS FOR AWARD

K

REPRESENTATIONS, CERTIFICATIONS AND OTHER

STATEMENTS OF OFFERORS

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ________ calendar days (60 calendar days unless a different period is inserted by the Offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

13. DISCOUNT FOR PROMPT PAYMENT 10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%)

(See Section I, Clause No. 52-232-8)

14. ACKNOWLEDGEMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

(The Offeror acknowledges receipt of amendments to the SOLICITATION for Offerors and related documents numbered and dated):

DUNS: DUNS+4: CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER 15A. NAME AND

ADDRESS OF

OFFEROR

(Type or print)

15B. TELEPHONE NUMBER 17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXTENSION

15C. CHECK IF REMITTANCE ADDRESS IS DIFFERENT FROM

ABOVE - ENTER SUCH ADDRESS IN SCHEDULE.

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION: 23. SUBMIT INVOICES TO ADDRESS SHOWN IN ITEM (4 copies unless otherwise specified)

10 U.S.C. 2304(c) 41 U.S.C. 3304(a) ( )

24. ADMINISTERED BY (If other than Item 7) 25. PAYMENT WILL BE MADE BY CODE

PHONE: FAX:

26. NAME OF CONTRACTING OFFICER (Type or print) 27. UNITED STATES OF AMERICA 28. AWARD DATE

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

(Signature of Contracting Officer)

(REV. 6/2014)

10. NAICS

11. TABLE OF CONTENTS

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 33

Previous edition is unusable Prescribed by GSA-FAR (48 CFR) 53.214(c)

SOLICITATION, OFFER AND AWARD

SOLICITATION

OFFER (Must be fully completed by Offeror)

AWARD (To be completed by Government)

1 275 N/A

36C10G18R0208-1 X

36C10G

U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

See Section L

11:00 AM EDT 06-10-2019

Lori A Smith Contracting Officer 540-479-8450 Ext. 214 Lori.Smith3@va.gov

See Attached Table of Contents

X 1

X 8

X 62

X 149

X 150

X 151

X 167

X 185

X 186

X 211

X 213

X 235

X 261

U.S. Department of Veterans Affairs OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400 Fredericksburg VA 22408-2697

VAFSC

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

(see Section G.15 invoicing/payment) Austin TX 78714-8917

1 (877) 489-6135

Table of Contents

SECTION B- SUPPLIES OR SERVICES AND PRICE

SECTION C - DESCRIPTION/SPECIFICATIONS/STATEMENT OF WORK

1.0 GENERAL INFORMATION

1.1 Introduction

1.2 Background

1.3 Scope of Services

2.0 PROJECT MANAGEMENT

2.1 Post Award Meeting

2.1.1 Kickoff Meeting

2.2 Project Management Plan (Project Plan)

2.2.1 Implementation Strategy

2.2.2 CCN Deployment Plan

2.3 Risk Management Plan

2.4 Operational Quality and Reporting Requirements

2.4.1 Quality Assurance Plan

2.4.2 Supplemental Project Management Reporting Requirements

2.5 CCN Communications Plan

2.6 Accreditation

2.7 Service Organization Control Reporting (SSAE 18)

2.7.1 Service Organization Control Reporting Generally

2.7.2 Service Organization Control Reporting Specifications and Deliverables SOC 1 and SOC 2 Reporting Specifications and Deliverables

2.8 Transition

2.8.1 Reserved

2.8.2 Transition Out

3.0 HIGH PERFORMING NETWORK

3.1 Network Establishment and Maintenance

3.2 Provider Networks

3.2.1 CCN Healthcare Services Network

3.2.2 CCN Complementary and Integrative Healthcare Services Network

3.3 Out-of-Network Providers

3.4 Identification of High-Performing Providers

3.4.1 Institutional Providers

3.4.2 Group Practice Providers

3.4.3 Individual Providers - CCN

3.5 CCN Region

3.6 Network Adequacy Management

3.7 Credentialing

3.7.1 Credentialing Requirements

4.0 CCN HEALTH BENEFIT PACKAGE

4.1 CCN Healthcare Services

4.1.1 CCN Healthcare Service Exceptions

4.2 CCN Complementary and Integrative Healthcare Services

4.3 Excluded CCN Healthcare Services

4.4 CCN Assisted Reproductive Technology Services

5.0 ELIGIBILITY

6.0 CUSTOMER SERVICE

6.1 Contractor VA Support Call Center Functions

6.2 CCN Provider Call Center Function

6.3 Reserved

6.4 Contractor Customer Service Technology

6.5 Veteran Complaints and Grievances and Customer Service Procedure

6.6 Congressional and VA Inquiries

6.7 CCN Provider Satisfaction Surveys

6.8 Call Center Operations and Customer Service Technology Performance Requirements and Metrics

7.0 REFERRALS AND PRIOR AUTHORIZATION

7.1 Notification of Emergent, or Behavioral Health Care

7.2 Referrals from VA to CCN Provider

7.3 Referrals Requested from a CCN Provider for VA Provided Care or Another CCN Provider

7.4 Prior Authorizations

8.0 SCHEDULING OF APPOINTMENTS

9.0 MEDICAL DOCUMENTATION

9.1 Medical Documentation Submission Process

9.2 Medical Documentation Data Elements

9.3 Medical Documentation Submission Timeframes

9.4 Medical Documentation Submission Format

9.5 Reserved

9.6 Critical Findings

9.7 Identification and Documentation of Transplant Candidates

9.8 Medical Documentation and Audit

10.0 TRAINING – CONTRACTOR PROCESSES, SYSTEMS, AND INTERFACES

10.1 Training Plan

10.1.1 Training Program for Contractor CCN Providers, Contractor Personnel, and VA Staff Training Program

10.1.2 Contractor CCN Provider and Contractor Personnel Outreach and Education Program

10.1.2.1 Provider Only Training

10.1.3 Contractor-Provided VA Staff Training Sessions

10.2 Contractor Training Materials

10.3 VA Provided Training

11.0 OPTIONAL TASK: MEDICAL ADMINISTRATIVE MANAGEMENT

11.1 Optional Task: Appointment Scheduling and Comprehensive Care Coordination

11.1.1 Contractor Schedules

11.1.2 Veteran Self-Schedules

11.1.3 Comprehensive Care Coordination

11.1.4 Daily Appointment Scheduling and Comprehensive Care Coordination Reporting

11.2 Optional Task: Care Coordination Follow-up

11.3 Optional Task: Comprehensive Case Management Program Administration

11.4 Optional Task: Comprehensive Disease Management Program

Administration

12.0 CLAIMS PROCESSING AND ADJUDICATION FOR CCN HEALTHCARE SERVICES

RENDERED

12.1 Claims Processing System Functions

12.1.1 Claims Adjudication and Payment Rules

12.2 Paper Claims

12.3 Signature Requirements

12.3.1 Signature on File Procedure

12.3.2 Network Provider Signature on Claims

12.4 Claims Submission and Processing Timeframes

12.5 Issuance of EOB

12.6 Issuance of Remittance Advice

12.7 Coordination of Benefits

12.7.1 VA Designation of Primary or Secondary Payer of Healthcare Services

12.7.2 Other Health Insurance

12.8 Claims for Services Rendered to Veterans Assigned to Other CCN Region

12.9 Claims Auditing

12.10 Reserved

12.11 Reserved

12.12 Claims Reporting

12.13 Federal Codes and Regulations

12.14 Improper Payments Elimination and Recovery Improvement Act

12.14.1 Payment Accuracy

12.14.2 Accounting and Access to Records

12.14.3 Agreed-Upon-Procedures

12.14.4 Error Determination Rebuttals

12.14.5 Additional Reviews

12.14.6 Recoveries

12.14.7 Reduction of improper payment performance goals

13.0 VETERAN CLAIM APPEALS AND PROVIDER RECONSIDERATIONS

13.1 Veteran Appeals

13.2 Practitioner and Provider Reconsiderations

14.0 CLINICAL QUALITY AND PATIENT SAFETY MONITORING

14.1 Clinical Quality Monitoring Plan (CQMP)

14.1.1 Reserve

14.1.2 Clinical Quality and Patient Safety Improvement Component of the

CQMP 127

14.2 Clinical Quality and Patient Safety Issues Identification

15.0 PHARMACY

15.1 Urgent/Emergent Prescriptions

15.2 Urgent/Emergent Prescription Network Adequacy

15.2.1 Urgent/Emergent Prescription Performance Metrics

15.3 Routine/Maintenance Prescriptions

15.4 Contingency Plan for Disaster Response

15.5 Walk-In Prescriptions

16.0 DURABLE MEDICAL EQUIPMENT

16.1 Urgent/Emergent Prescriptions for DME and Medical Devices

16.2 Routine Prescriptions for DME and Medical Devices

16.3 Reserved

16.4 Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA)

17.0 DENTAL

17.1 Dental Network Adequacy

17.2 Dental Network Provider Credentialing

17.3 Dental Network Compliance

17.4 Dental Care Referrals and Prior Authorization

17.5 Return of Dental Records

17.6 Dental Clinical Quality Management

18.0 TECHNOLOGY

18.1 Contractor Software Configuration Management Requirements

18.2 Continuity of Operations

18.3 Contractor System Access

18.4 VA System Integration Requirements

18.5 Veteran Demographic and Administrative Data

18.6 IT Customer Service

18.7 VA Community Care Provider Portal

18.8 Contractor Self Service Website

18.9 Contractor Reporting and Data Submission

18.10 Email Communication

18.11 Reserved

18.12 Submission of EDI Transactions

18.13 Submission of Medical Documentation

18.14 Submission of OHI

18.15 Provider Data Transfer

18.15.1 Contractor Provider Data

18.15.2 VA Provider Data

18.16 Section 508 – Electronic and Information Technology Standards

18.16.1 Equivalent Facilitation

18.16.2 Compatibility with Assistive Technology

18.16.3 Acceptance and Acceptance Testing

19.0 DATA ANALYTICS

19.1 Data Specification

19.2 Data Repository and Data Repository Relational Database Schema

19.3 Reserved

19.4 Data Transmissions

19.5 Data Integrity

SECTION D - PACKAGING AND MARKING

SECTION E - INSPECTION AND ACCEPTANCE

SECTION F - DELIVERIES OR PERFORMANCE

Schedule of Deliverables

SECTION G - CONTRACT ADMINISTRATION DATA

G.1 CONTRACT ADMINISTRATION DATA

G.2 RESERVED

G.3 IT CONTRACT SECURITY

G.4 DATA RIGHTS

G.5 SMALL BUSINESS SUBCONTRACTING OPPORTUNITIES

G.6 LIMITATIONS ON SUBCONTRACTING – MONITORING AND COMPLIANCE

(JUN 2011)

G.7 SUBCONTRACTING COMMITMENTS – MONITORING AND COMPLIANCE

(JUN 2011)

G.8 SUBCONTRACTING PLAN – MONITORING AND COMPLIANCE (JUNE 2011)

G.9 TERM OF CONTRACT

G.10 PERIOD OF PERFORMANCE

G.11 KEY PERSONNEL AND TEMPORARY EMERGENCY SUBSTITUTIONS

G.12 PLACE OF PERFORMANCE

G.13 PERFORMANCE INCENTIVE PLAN

G.14 ORDERING PROCEDURES

G.15 INVOICES: ADDENDUM TO 52.212-4

SECTION H - SPECIAL CONTRACT REQUIREMENTS

SECTION I - CONTRACT CLAUSES

I.1 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

I.2 52.212-4 CONTRACT TERMS AND CONDITIONS—COMMERCIAL ITEMS (JAN

2017) 187

I.3 52.212-5 CONTRACT TERMS AND CONDITIONS REQUIRED TO IMPLEMENT

STATUTES OR EXECUTIVE ORDERS—COMMERCIAL ITEMS (JAN 2018)

ALTERNATE II (NOV 2017)

I.5 52.216-18 ORDERING (OCT 1995)

I.6 52.216-19 ORDER LIMITATIONS (OCT 1995)

I.7 52.216-22 INDEFINITE QUANTITY (OCT 1995)

I.8 52.217-7 OPTION FOR INCREASED QUANTITY—SEPARATELY PRICED LINE

ITEM (MAR 1989)

I.9 52.217-8 OPTION TO EXTEND SERVICES (NOV 1999)

I.10 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000) .. 202

I.11 52.222-35 EQUAL OPPORTUNITY FOR VETERANS (OCT 2015)

I.12 52.222-36 EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES (JUL

2014) 203

I.13 52.232-18 AVAILABILITY OF FUNDS (APR 1984)

I.14 52.244-2 SUBCONTRACTS (OCT 2010)

I.15 VAAR 852.215-70 SERVICE-DISABLED VETERAN-OWNED AND VETERAN-

OWNED SMALL BUSINESS EVALUATION FACTORS (JUL 2016) (DEVIATION)

I.16 VAAR 852.215-71 EVALUATION FACTOR COMMITMENTS (DEC 2009)

I.17 VAAR 852.219-9 VA SMALL BUSINESS SUBCONTRACTING PLAN MINIMUM

REQUIREMENTS (DEC 2009)

I.18 VAAR 852.232-72 ELECTRONIC SUBMISSION OF PAYMENT REQUESTS (NOV

2012) 207

I.19 VAAR 852.237-70 CONTRACTOR RESPONSIBILITIES (APR 1984)

I.20 VAAR 852.270-1 REPRESENTATIVES OF CONTRACTING OFFICERS (JAN

2008) 208

I.21 VAAR 852.271-70 NONDISCRIMINATION IN SERVICES PROVIDED TO

BENEFICIARIES (JAN 2008)

I.22 MANDATORY WRITTEN DISCLOSURES

SECTION J - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACHMENTS

LIST OF ATTACHMENTS

SECTION K - REPRESENTATIONS, CERTIFICATIONS AND OTHER STATEMENTS OF

OFFERORS

K.1 52.203-18 PROHIBITION ON CONTRACTING WITH ENTITIES THATREQUIRE

CERTAIN INTERNAL CONFIDENTIALITY AGREEMENTS OR STATEMENTS—

REPRESENTATION (JAN 2017)

K.2 52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS (OCT

2015) 213

K.3 52.209-7 INFORMATION REGARDING RESPONSIBILITY MATTERS (JULY 2013)

K.4 52.209-11 REPRESENTATION BY CORPORATIONS REGARDING DELINQUENT

TAX LIABILITY OR A FELONY CONVICTION UNDER ANY FEDERAL LAW (FEB

2016) 216

K.5 52.212-3 OFFEROR REPRESENTATIONS AND CERTIFICATIONS—

COMMERCIAL ITEMS (NOV 2017)

K.6 52.222-22 PREVIOUS CONTRACTS AND COMPLIANCE REPORTS (FEB 1999)

SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO OFFERORS

SECTION M - EVALUATION FACTORS FOR AWARD

SECTION B- SUPPLIES OR SERVICES AND PRICE

Item Number Description Comment Contract Period

0001 Healthcare Services

Price Not Required. This CLIN is priced at 100 % Medicare.

Assumptions/considerations related to these services are inclusive of all authorized healthcare services identified in PWS Section 4.1, “CCN Healthcare Services” and Complementary and Integrative Health Services identified in PWS Section 4.2, “CCN Complementary and Integrative Health Services” covered by the applicable Medicare Prospective Payment System (PPS). VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

Reimbursement for Highly Rural Care Areas and Scarce Medical Services

Price Required. This CLIN is priced as a percentage of Medicare.

The Contracting Officer will only authorize pricing to be paid for this CLIN when Contractor submits documentation for the rate proposed in a Highly Rural Care Area and/or for Scarce Medical Services.

VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

0002AA Arizona (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AB Arizona (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AC California (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AD California (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AE Colorado (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AF Colorado (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AG Hawaii (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AH Hawaii (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AI Idaho (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AJ Idaho (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AK Montana (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AL Montana (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AM New Mexico (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AN New Mexico (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AO Nevada (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AP Nevada (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AQ Oregon (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

0002AR Oregon (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AS Texas (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AT Texas (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AU Utah (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AV Utah (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AW Washington (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AX Washington (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AY Wyoming (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

0002AZ Wyoming (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Base

Urgent/Emergent Durable Medical Equipment (DME), Medical Devices, Orthotics, and Prosthetic items

Price Not Required. This CLIN is priced at 100% of Medicare.

Assumptions/considerations related to these services for purchases against this CLIN that are not bundled under other healthcare services provided pursuant to the contract (e.g. hardware used in orthopedic surgery, prosthetic valves in cardiac surgery, implantable devices), pricing will be equal to the Medicare rates for the products against this CLIN. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

0004 Home Health Care Summary CLIN, not separately priced (NSP) Base

0004AA Skilled Home Health

Price Not Required. This CLIN is priced at 100% of Medicare.

Assumptions/considerations related to Skilled Home Health services are that contract pricing for this CLIN is equal to the Medicare rate for the services being performed. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

0004AB Unskilled Home Health

Price Not Required. Contract pricing is at 100% of the VA Fee Schedule. Assumptions/considerations related to these Unskilled Home Health services includes assistance with all daily living activities such as house cleaning, food preparation, grocery shopping, laundry, accompanying Veteran to medical appointments (e.g. Homemaker/Home Health Aide). VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

0005 Seasonal Influenza Vaccination

Price required. Dollar price for administering and dispensing each vaccination. This CLIN is for the administration and dispensing fees for the influenza vaccine (trivalent, quadrivalent and high dosage). VA will pay the proposed price for the administration and dispensing fee of each vaccination.

Base

Non-Medicare Healthcare Services, VA Fee Schedule

Price Not Required. Contract pricing is equal to the VA Fee Schedule. Assumptions/considerations related to the non-Medicare Healthcare Services, VA Fee Schedule - When a given medical procedure, to include Home Infusion Therapy, is not payable under Medicare rules or is payable under Medicare rules but does not have established pricing at the local level, such medical procedures will be paid based on the applicable VA Fee Schedule. Outpatient services performed by Inpatient Prospective Payment System (IPPS) - exempt facilities are also included under this CLIN. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Non-Medicare, Non-VA Fee Schedule - Medical and Surgical Healthcare Services

Price Not Required. Assumptions/considerations - when a given medical procedure is not payable under Medicare rules, or is payable under Medicare rules but does not have established pricing at the local level, and is not included in the VA Fee Schedule, VA will reimburse the healthcare claims based on a percentage of billed charges for services. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

0008 Home Infusion Therapy (HIT)

Price required. Offeror will provide a single fixed percentage rate for future HCPCS or CPT billing applications that do not have an associated/established Medicare or VA Fee reimbursement rate at time of service. The VA will not reimburse in excess of proposed percentage (%) of billed charges for HIT services. The Contracting Officer will only authorize payment for this CLIN when accompanied by adequate documentation and will be reimbursed at the percent proposed as reflected in the Offeror’s Price Proposal. Home infusion drugs billed at CLIN X009 rates.

Urgent and Emergent Medication

Fixed Price payments based on Average Wholesale Price (AWP) plus/minus percent for Brand Name and Generic Medication and a dispensing fee.

Base

0009AA Brand Name Medication Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Base

0009AB Generic Medication Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Base

0009AC Dispensing Fee Dollar price for each dispensing activity for each year of the PoP. Base

0010 Dental Services

Provide price for each of the 28 codes being evaluated for each year of the PoP. Dental services will be reimbursed based on the negotiated rates per American Dental Association (ADA) Current Dental Terminology (CDT) code listing for the region where the service is provided. VA will pay the Contractor using health care CLINs (X001, X002, X006 etc.) if the dental procedure is performed in conjunction with a medical service.

Base

0011 Administrative Services

Administrative Services based on a per member per month (PMPM) model. The PMPM covers the Contractors charges for all administrative services for managing the services purchased under this contract. The PMPM charge is to be invoiced in accordance with the total number of Active Veterans per month. The PMPM fee is tiered to accommodate lower volumes and to encourage price reductions at higher volumes.

Base

0011A Administrative Services for Healthcare Services

Summary CLIN, NSP. Dollar price for each Active Veteran per month in each of the three tiers for the PoP.

Base

0011AA

Administrative Services for Healthcare Services - Tier 1

Each Active Veteran Per Month Tier 1 (0-94,999) Base

0011AB

Administrative Services for Healthcare Services - Tier 2

Each Active Veteran Per Month Tier 2 (95,000-144,999) Base

0011AC

Administrative Services for Healthcare Services - Tier 3

Each Active Veteran Per Month Tier 3 (145,000 and greater) Base

0011B Administrative Services for Dental

Summary CLIN, NSP. Dollar price for each Active Veteran per month in each of the three tiers for the PoP.

Base

0011BA

Administrative Services for Dental - Tier 1

Each Active Veteran Per Month Tier 1 (0-5,799) Base

0011BB

Administrative Services for Dental - Tier 2

Each Active Veteran Per Month Tier 2 (5,800-6,599) Base

0011BC

Administrative Services for Dental - Tier 3

Each Active Veteran Per Month Tier 3 (6,600 and greater) Base

0011CA

Administrative Services for Pharmacy Benefit Management

(PBM)

Dollar price for each Active Veteran per month for each year of the PoP. Administrative Fee for Pharmacy Benefits Management (PBM) is to be invoiced based on when an urgent /emergent pharmacy claim is paid for an Active Veteran during that billing month.

Base

0011DA

Administrative Services for Assisted Reproductive Technology services (ART)

Dollar price for each Collateral of Veteran per month for each year of the PoP.

Base

Implementation and Transition Out

Summary CLIN, NSP Base

0012AA Implementation Lump sum $ price based on # of milestones completed in year Base

0012BA Transition Out Price Not Required. Base

0013 Data Price Not Required. Base

0014 Agreed Upon Procedures Provide the price of the audit. The audit must meet Government requirements.

Base

Healthcare Services Approved Under the Veterans Millennium Health Care Act (MILLBILL)

Price Not Required. Assumptions/consideration for this CLIN refers to PWS Section 7.1 which directs the Contractor to pend claims for emergent or urgent care and submit a Referral Request in order to obtain an Approved Referral from VA. VA will review and determine if authority exists to return an Approved Referral. Care authorized by VA under the authority of 38 U.S.C. 1725, will be annotated by VA as such and paid by the Contractor at the 70th percentile of CMS rates. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Base

Optional: Appointment Scheduling & Comprehensive Care Coordination

Summary CLIN, NSP Base

0016AA

Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination

Price Not Required Base

0016BA

Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor’s site

Price Not Required Base

0016C Optional: Appointment Scheduling and Comprehensive Care Coordination

Summary CLIN, NSP. Dollar price per Unique Approved Referral for each of the tiers of unique approved referrals for a period of performance.

0016CA

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 1

Price Not Required Base

0016CB

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 2

Price Not Required Base

0016CC

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 3

Price Not Required Base

0016CD

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 4

Price Not Required Base

0016CE

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 5

Price Not Required Base

Optional: Care Coordination Follow-Up

Summary CLIN, NSP Base

0017AA

Optional: Implementation for Care Coordination Follow-Up

Price Not Required Base

0017BA

Optional: Care Coordination Follow-Up Administration

Price Not Required Base

Optional: Comprehensive Case Management Program Administration

Summary CLIN, NSP Base

0018AA

Optional: Implementation for Comprehensive Case Management Program

Price Not Required Base

0018B Optional: Comprehensive Case Management Program Administration

Summary CLIN, NSP. Dollar price per Unique Approved Referral for each of the tiers for each year of the PoP.

Base

0018BA

Optional: Comprehensive Case Management Program Administration - Tier 1

Price Not Required Base

0018BB

Optional: Comprehensive Case Management Program Administration - Tier 2

Price Not Required Base

0018BC

Optional: Comprehensive Case Management Program Administration - Tier 3

Price Not Required Base

Optional: Comprehensive Disease Management Administration

Summary CLIN, NSP Base

0019AA

Optional: Implementation for Comprehensive Disease Management

Price Not Required Base

0019B Optional: Comprehensive Disease Management Program Administration

Summary CLIN, NSP. Dollar price per Unique Approved Referral for each of the tiers for each year of the PoP.

Base

0019BA

Optional: Comprehensive Disease Management Program Administration - Tier 1

Price Not Required Base

0019BB

Optional: Comprehensive Disease Management Program Administration - Tier 2

Price Not Required Base

0019BC

Optional: Comprehensive Disease Management Program Administration - Tier 3

Price Not Required Base

Assisted Reproductive Technology (ART) Services

The CLIN is to be used for all health care and providers associated with the VA authorization type ART. Provide unit price for each of price codes in the pricing template.

Base

Urgent and Emergent Medication (Disaster Response)

Fixed Price payments based on Average Wholesale Price (AWP) plus/minus percent for Brand Name and Generic Medication and a dispensing fee.

Base

0021AA

Brand Name Medication (Disaster Response)

Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Base

0021AB

Generic Medication (Disaster Response)

Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Base

0021AC

Dispensing Fee (Disaster Response)

Dollar price for each dispensing activity for each year of the PoP. Base

1001 Healthcare Services

Price Not Required. This CLIN is priced at 100% Medicare.

Assumptions/considerations related to these services are inclusive of all authorized healthcare services identified in PWS Section 4.1, “CCN Healthcare Services” and Complementary and Integrative Health Services identified in PWS Section 4.2, “CCN Complementary and Integrative Health Services” covered by the applicable Medicare Prospective Payment System (PPS). VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

Reimbursement for Highly Rural Care Areas and Scarce Medical Services

Price Required. This CLIN is priced as a percentage of Medicare.

The Contracting Officer will only authorize pricing to be paid for this CLIN when Contractor submits documentation for the rate proposed in a Highly Rural Care Area and/or for Scarce Medical Services.

VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

1002AA Arizona (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AB Arizona (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AC California (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AD California (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AE Colorado (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AF Colorado (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AG Hawaii (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AH Hawaii (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AI Idaho (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AJ Idaho (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AK Montana (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AL Montana (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AM New Mexico (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AN New Mexico (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AO Nevada (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AP Nevada (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AQ Oregon (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AR Oregon (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AS Texas (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AT Texas (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AU Utah (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AV Utah (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AW Washington (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AX Washington (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AY Wyoming (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 1

1002AZ Wyoming (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for

Urgent/Emergent Durable Medical Equipment (DME), Medical Devices, Orthotics, and Prosthetic items

Price Not Required. This CLIN is priced at 100% of Medicare.

Assumptions/considerations related to these services for purchases against this CLIN that are not bundled under other healthcare services provided pursuant to the contract (e.g. hardware used in orthopedic surgery, prosthetic valves in cardiac surgery, implantable devices), pricing will be equal to the Medicare rates for the products against this CLIN. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

1004 Home Health Care Summary CLIN, NSP Option 1

1004AA Skilled Home Health

Price Not Required. This CLIN is priced at 100% of Medicare.

Assumptions/considerations related to Skilled Home Health services are that contract pricing for this CLIN is equal to the Medicare rate for the services being performed. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

1004AB Unskilled Home Health

Price Not Required. Contract pricing is at 100% of the VA Fee Schedule. Assumptions/considerations related to these Unskilled Home Health services includes assistance with all daily living activities such as house cleaning, food preparation, grocery shopping, laundry, accompanying Veteran to medical appointments (e.g. Homemaker/Home Health Aide). VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

1005 Seasonal Influenza Vaccination

Price Required. Dollar price for each year of the POP. This CLIN is for the administration and dispensing fees for the influenza vaccine (trivalent, quadrivalent and high dosage). VA will pay the proposed price for the administration and dispensing fee of each vaccination.

Option 1

Non-Medicare Healthcare Services, VA Fee Schedule

Price Not Required. Contract pricing is equal to the VA Fee Schedule. Assumptions/considerations related to the non-Medicare Healthcare Services, VA Fee Schedule - When a given medical procedure is not payable under Medicare rules or is payable under Medicare rules but does not have established pricing at the local level, such medical procedures will be paid based on the applicable VA Fee Schedule. Outpatient services performed by Inpatient Prospective Payment System (IPPS) - exempt facilities are also included under this CLIN. VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

Non-Medicare, Non-VA Fee Schedule - Medical and Surgical Healthcare Services

Price Not Required. Assumptions/considerations - when a given medical procedure is not payable under Medicare rules, or is payable under Medicare rules but does not have established pricing at the local level, and is not included in the VA Fee Schedule, VA will reimburse the healthcare claims pursuant to 38 CFR 17.55 or 38 CFR 17.56, including any subsequent changes to include but not limited to payment based on a percentage of billed charges or based upon usual and customary prices for services. VA’s payment to the

1008 Home Infusion Therapy

Price required: Offeror will provide a single fixed percentage rate for future HCPCS or CPT billing applications that do not have an associated/established Medicare or VA Fee reimbursement rate at time of service. The VA will not reimburse in excess of proposed percentage (%) of billed charges for HIT services. The Contracting Officer will only authorize payment for this CLIN when accompanied by adequate documentation and will be reimbursed at the percent proposed as reflected in the Offerors Price Proposal. Home infusion drugs billed at CLIN X009 rates.

Option 1

Urgent and Emergent Medication

VA will pay the Contractor for brand name medication at a Fixed Price based on Average Wholesale Price (AWP) plus/minus percent, plus a dollar amount for dispensing fee.; and generic medication at a Fixed Price based on AWP plus/minus percent, plus a dollar amount for dispensing fee.

Option 1

1009AA Brand Name Medication Fixed Price based on Percent of Average Wholesale Price for each year of the PoP

Option 1

1009AB Generic Medication Fixed Price based on Percent of Average Wholesale Price for each year of the PoP

Option 1

1009AC Dispensing Fee Dollar price for each dispensing activity for each year of the PoP Option 1

1010 Dental Services

Provide price for each of the 28 codes being evaluated for each year of the PoP. Dental services will be reimbursed based on the negotiated rates per American Dental Association (ADA) Current Dental Terminology (CDT) code listing for the region where the service is provided. VA will pay the Contractor using health care CLINs (X001, X002, X006 etc.) if the dental procedure is performed in conjunction with a medical service.

Option 1

1011 Administrative Services

Administrative Services based on a per member per month (PMPM) model. The PMPM covers the Contractors charges for all administrative services for managing the services purchased under this contract. The PMPM charge is to be invoiced in accordance with the total number of Active Veterans per month. The PMPM fee is tiered to accommodate lower volumes and to encourage price reductions at higher volumes.

Option 1

1011A Administrative Services for Healthcare Services

Summary CLIN, NSP. Dollar price for each Active Veteran per month in each of the three tiers for the PoP.

Option 1

1011AA

Administrative Services for Healthcare Services - Tier 1

Each Active Veteran Per Month Tier 1 (0-94,999) Option 1

1011AB

Administrative Services for Healthcare Services - Tier 2

Each Active Veteran Per Month Tier 2 (95,000-144,999) Option 1

1011AC

Administrative Services for Healthcare Services - Tier 3

Each Active Veteran Per Month Tier 3 (145,000 and greater) Option 1

1011B Administrative Services for Dental

Summary CLIN, NSP. Dollar price for each Active Veteran per month in each of the three tiers for the PoP.

Option 1

1011BA

Administrative Services for Dental - Tier 1

Each Active Veteran Per Month Tier 1 (0-5,799) Option 1

1011BB

Administrative Services for Dental - Tier 2

Each Active Veteran Per Month Tier 2 (5,800-6,599) Option 1

1011BC

Administrative Services for Dental - Tier 3

Each Active Veteran Per Month Tier 3 (6,600 and greater) Option 1

1011CA

Administrative Services for Pharmacy Benefit Management

(PBM)

Dollar price for each Active Veteran per month for each year of the PoP. Administrative Fee for Pharmacy Benefits Management (PBM) is to be invoiced based on when an urgent /emergent pharmacy claim is paid for an Active Veteran during that billing month.

Option 1

1011DA

Administrative Services for Assisted Reproductive Technology services (ART)

Dollar price for each Collateral of Veteran per month for each year of the PoP.

Option 1

Implementation and Transition Out

Summary CLIN, NSP Option 1

1012AA Implementation Price Optional Option 1

1012BA Transition Out

Lump sum $ price for total incremental cost to transition out above and beyond the status quo, applicable if Transition Out services exercised by VA in this Option Year. PoP goes from the time that the CO notifies the Contractor of a planned transition out start date to the later of either 6 months or completion of all processing and finalization of all open healthcare claims inventories or as mutually agreed to by the CO and Contractor.

Option 1

1013 Data Price Not Required. Assumptions/considerations for this CLIN includes all services associated with delivery of data throughout performance and at the end of the contract.

Option 1

1014 Agreed Upon Procedures Provide the price of the audit. The audit must meet Government requirements.

Option 1

Healthcare Services Approved Under the Veterans Millennium Health Care Act (MILLBILL)

Price Not Required. Assumptions/consideration for this CLIN refers to PWS Section 7.1 which directs the Contractor to pend claims for emergent or urgent care and submit a Referral Request in order to obtain an Approved Referral from VA. VA will review and determine if authority exists to return an Approved Referral. Care authorized by VA under the authority of 38 U.S.C. 1725, will be annotated by VA as such and paid by the Contractor at the 70th percentile of CMS rates.

VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 1

Optional: Appointment Scheduling & Comprehensive Care Coordination

Summary CLIN, NSP Option 1

1016AA

Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination

Implementation price per VA Facility at Government site for a PoP.

VA will pay the negotiated fixed price for each VA Facility that orders Appointment Scheduling and Comprehensive Care Coordination. The Contractor can earn only one implementation payment per VA Facility during the entire contract.

Option 1

1016BA

Optional: Implementation for Appointment Scheduling and Comprehensive Care Coordination at the Contractor’s site

Implementation price per VA Facility at Contractor's site for a PoP.

VA will pay the negotiated fixed price. The Contractor can earn only one implementation payment during the entire contract.

1016C

Scheduling and Comprehensive Care Coordination

Summary CLIN, NSP. Dollar price per Unique Approved Referral for each of the tiers of unique approved referrals for a period of performance.

Option 1

1016CA

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 1

Unique Approved Referral Tier 1 (0-331,400) Option 1

1016CB

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 2

Each Unique Approved Referral Tier 2 (331,401-773,300) Option 1

1016CC

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 3

Each Unique Approved Referral Tier 3 (773,301-1,215,200) Option 1

1016CD

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 4

Each Unique Approved Referral Tier 4 (1,215,201-1,657,000) Option 1

1016CE

Optional: Appointment Scheduling and Comprehensive Care Coordination - Tier 5

Each Unique Approved Referral Tier 5 (1,657,001-2,540,600) Option 1

Optional: Care Coordination Follow-Up

Summary CLIN, NSP Option 1

1017AA

Optional: Implementation for Care Coordination Follow-Up

One-time lump sum $ in the year the option is exercised. Dollar amount reflects the total lump sum for implementation services for each year of the PoP; these implementation services shall be excluded from other Contractor Administrative Service Fees.

Option 1

1017BA

Optional: Care Coordination Follow-Up Administration

VA will pay the contractor the monthly $ firm fixed price per Veteran that receives Care Coordination Follow Up Services.

Option 1

Optional: Comprehensive Case Management Program Administration

Summary CLIN, NSP Option 1

1018AA

Optional: Implementation for Comprehensive Case Management Program

One-time lump sum $ in the year the option is exercised. This CLIN reflects the total lump sum for implementation services; these implementation services shall be excluded from other Contractor Administrative Service Fees.

Option 1

1018B Optional: Comprehensive Case Management Program Administration

Summary CLIN, NSP Option 1

1018BA

Optional: Comprehensive Case Management Program Administration - Tier 1

Each Unique Approved Referral Tier 1 (0-41,000). Option 1

1018BB

Optional: Comprehensive Case Management Program Administration - Tier 2

Each Unique Approved Referral Tier 2 (41,001-82,000). Option 1

1018BC

Optional: Comprehensive Case Management Program Administration - Tier 3

Each Unique Approved Referral Tier 3 (82,001 and greater). Option 1

Optional: Comprehensive Disease Management Administration

Summary CLIN, NSP Option 1

1019AA

Optional: Implementation for Comprehensive Disease Management

One-time lump sum $ in the year the option is exercised. Pricing for this CLIN reflects the total lump sum of implementation services.

These implementation services shall be excluded from other Contractor Administrative Service Fees.

Option 1

1019B Optional: Comprehensive Disease Management Program Administration

Summary CLIN, NSP. Dollar price per Unique Approved Referral for each of the tiers for each year of the PoP.

Option 1

1019BA

Optional: Comprehensive Disease Management Program Administration - Tier 1

Each Unique Approved Referral Tier 1 (0-41,000). Option 1

1019BB

Optional: Comprehensive Disease Management Program Administration - Tier 2

Each Unique Approved Referral Tier 2 (41,001-82,000). Option 1

1019BC

Optional: Comprehensive Disease Management Program Administration - Tier 3

Each Unique Approved Referral Tier 3 (82,001 and greater). Option 1

Assisted Reproductive Technology (ART) Services

The CLIN is to be used for all health care and providers associated with the VA authorization type ART. Provide unit price for each of price codes in the pricing template.

Option 1

Urgent and Emergent Medication (Disaster Response)

Fixed Price payments based on Average Wholesale Price (AWP) plus/minus percent for Brand Name and Generic Medication and a dispensing fee.

Option 1

1021AA

Brand Name Medication (Disaster Response)

Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Option 1

1021AB

Generic Medication (Disaster Response)

Fixed Price based on Percent of Average Wholesale Price for each year of the PoP.

Option 1

1021AC

Dispensing Fee (Disaster Response)

Dollar price for each dispensing activity for each year of the PoP. Option 1

2001 Healthcare Services

Price Not Required. This CLIN is priced at 100% Medicare.

Assumptions/considerations related to these services are inclusive of all authorized healthcare services identified in PWS Section 4.1, “CCN Healthcare Services” and Complementary and Integrative Health Services identified in PWS Section 4.2, “CCN Complementary and Integrative Health Services” covered by the applicable Medicare Prospective Payment System (PPS). VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 2

Reimbursement for Highly Rural

CLIN when Contractor submits documentation for the rate proposed in a Highly Rural Care Area and/or for Scarce Medical Services.

VA’s payment to the Contractor shall be the rate identified in the applicable CLIN.

Option 2

2002AA Arizona (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AB Arizona (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AC California (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AD California (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AE Colorado (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AF Colorado (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AG Hawaii (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AH Hawaii (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AI Idaho (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AJ Idaho (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AK Montana (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AL Montana (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AM New Mexico (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AN New Mexico (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AO Nevada (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AP Nevada (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AQ Oregon (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AR Oregon (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AS Texas (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AT Texas (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AU Utah (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AV Utah (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AW Washington (Inpatient) Maximum % of the locality adjusted Medicare rate for this state for each year of the PoP

Option 2

2002AX Washington (Outpatient) Maximum % of the locality adjusted Medicare rate for this state for each…