CCN Region 5 Alaska SF30 36C10G20R0014 Amendment 0003 .pdf

5. PROJECT NUMBER (if applicable)

CODE 7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER 3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO. 1. CONTRACT ID CODE

FACILITY CODE CODE

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:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; 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 is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office. is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

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.

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

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

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.

15A. NAME AND TITLE OF SIGNER 16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30 PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243

(Type or print) (Type or print)

(Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code)

(If other than Item 6)

(Specify type of modification and authority)

(such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

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

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

1 4

0003 06-03-2020

None

Y 36C10G

U.S. Department of Veterans Affairs

OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400

Fredericksburg VA 22408-2697

Y 36C10G

U.S. Department of Veterans Affairs

OPAL | Strategic Acquisition Center

10300 Spotsylvania Ave | STE 400

Fredericksburg VA 22408-2697

To all Offerors/Bidders

36C10G20R0014

05-11-2020

X

X X

X 1

Amendment (0003) for RFP # 36C10G20R0014-1 is hereby issued to:

1. Update the chart in section 4.1, PWS Table 3. CCN Healthcare Services

2. All other Terms and Conditions are unchanged

See Continuation Page for Specifics

36C10G20R0014 0003

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

The following items are applicable to this Amendment:

SUMMARY OF CHANGES (ADJUSTED)

Note: The words struck out in the “From” sections of each change denote the language that will be removed in each revision. The words in red font in the “To” sections of each change denote the new language to be added in each revision.

CHANGE 1

Section 4.1 CCN Healthcare Services

From:

PWS Table 3. CCN Healthcare Services

Health Benefit Coverage

Basic Medical Benefits Package, includes:

• Comprehensive Rehabilitative Services

• Hospital Services

• Ancillary Services

• Behavioral/Mental Health (to include professional counseling)

• Residential Care

• Home Healthcare (Skilled and Unskilled)

• Hospice/Palliative Care/Respite

• Geriatrics (Noninstitutionalized extended care services, including but not limited to non-institutional geriatric evaluation, non-institutional adult day healthcare, and non-institutional respite care)

• Outpatient Diagnostic and Treatment Services (including laboratory services)

• Inpatient Diagnostic and Treatment Services

• Long Term Acute Care

• Acupuncture

• Maternity and Women’s Health

• Telehealth

• Chronic and Acute Dialysis Treatment

• Infertility, Work-up, Counseling, and Treatment

• Flu Shots

• Therapeutic Vaccines

All Eligible Veterans

Skilled Nursing Facility Care Limitation of rehab services not to exceed 100 days per calendar year

Pharmacy All Eligible Veterans; Contractor shall provide pharmacy services only for urgent and emergent prescriptions

Dental Requires special eligibility (see Section 17.1, “Dental Network Adequacy ”)

Emergent Care Under certain conditions pursuant to 38 C.F.R. §17.4020

DME, Medical Devices, Orthotic, and Prosthetic Items

Contractor shall provide DME, Medical Devices, Orthotic, and Prosthetic Items for only urgent and emergent prescriptions for Eligible Veterans or otherwise specified in Section 16.0

Reconstructive Surgery Under certain conditions pursuant to 38 C.F.R. § 17.38

Immunizations Under certain conditions pursuant to 38 C.F.R. § 17.38

Implants When provided as part of an authorized surgical or medical procedure

Assisted Reproductive Technology, including In Vitro Fertilization (IVF)

Under certain conditions pursuant to AP 94 final regulation rule.

Urgent Care Under certain conditions pursuant to C.F.R. 1725A(h)

To:

PWS Table 3. CCN Healthcare Services

Health Benefit Coverage

Basic Medical Benefits Package, includes:

• Comprehensive Rehabilitative Services

• Hospital Services

• Ancillary Services

• Behavioral/Mental Health (to include professional counseling)

• Residential Care

• Home Healthcare (Skilled and Unskilled)

• Hospice/Palliative Care/Respite

• Geriatrics (Noninstitutionalized extended care services, including but not limited to non-institutional geriatric evaluation, non-institutional adult day healthcare, and non-institutional respite care)

• Outpatient Diagnostic and Treatment Services (including laboratory services)

• Inpatient Diagnostic and Treatment Services

• Long Term Acute Care

• Acupuncture

• Maternity and Women’s Health

• Telehealth

• Chronic and Acute Dialysis Treatment

• Infertility, Work-up, Counseling, and Treatment

• Flu Shots

• Therapeutic Vaccines

All Eligible Veterans

Skilled Nursing Facility Care Limitation of rehab services not to exceed 100 days per calendar year

Pharmacy All Eligible Veterans; Contractor shall provide pharmacy services only for urgent and emergent prescriptions

Dental Requires special eligibility (see Section 17.1, “Dental Network Adequacy ”)

Emergent Care Under certain conditions pursuant to 38 C.F.R. §17.4020

DME, Medical Devices, Orthotic, and Prosthetic Items

Contractor shall provide DME, Medical Devices, Orthotic, and Prosthetic Items for only urgent and emergent prescriptions for Eligible Veterans or otherwise specified in Section 16.0

Reconstructive Surgery Under certain conditions pursuant to 38 C.F.R. § 17.38

Immunizations Under certain conditions pursuant to 38 C.F.R. § 17.38

Implants When provided as part of an authorized surgical or medical procedure

Assisted Reproductive Technology, including In Vitro Fertilization (IVF)

Under certain conditions pursuant to 38 C.F.R. § 17.38, 38 C.F.R. § 17.380, and 38 C.F.R §. 17.412.

Urgent Care Under certain conditions pursuant to 38 C.F.R. 1725A(h)

---------------------- End of Summary of Changes ----------------------