75D301-22-Q-74251_WTCHP_TPA_Solicitation.pdf

11. DELIVERY FOR FOB

DESTINATION UNLESS

BLOCK IS MARKED

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

1. REQUISITION NUMBER

0000HCCP-2022-56172

PAGE 1 OF

2. CONTRACT NO.

75D301-22-C-12975

3. AWARD/EFFECTIVE

DATE

4. ORDER NUMBER

5. SOLICITATION NUMBER

75D301-22-Q-74251

6. SOLICITATION

ISSUE DATE

12/03/2021

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME Michael Crow

b. TELEPHONE NUMBER (No collect calls)

(770) 488-3208

8. OFFER DUE DATE/

LOCAL TIME

01/10/2022

10:00 AM EST

9. ISSUED BY CODE 8219 10. THIS ACQUISITION IS 12. DISCOUNT TERMS

Centers for Disease Control and Prevention (CDC) Office of Acquisition Services (OAS) 2900 Woodcock Blvd, MS TCU-4 Atlanta, GA 30341-4004

X UNRESTRICTED

SET ASIDE: % FOR

SMALL BUSINESS

SMALL DISADV. BUSINESS

8(A)

SIC:

SIZE STANDARD:

X SEE SCHEDULE

13a. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB X RFP

15. DELIVER TO CODE 16. ADMINISTERED BY CODE

Centers for Disease Control and Prevention (CDC) Office of Acquisition Services (OAS) 2900 Woodcock Blvd, MS TCU-4 Atlanta, GA 30341-4004

CODE 18a. PAYMENT WILL BE MADE BY CODE 434

Centers for Disease Control and Prevention (FMO) PO Box 15580 404-718-8100

Atlanta, GA 30333-0080

TELEPHONE NO.

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

SEE ADDENDUM

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

“See Continuation Page”

(Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

N/A.

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

X 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA X ARE ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED.

28.

X

CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN 1 COPIES

TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET

FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT

TO THE TERMS AND CONDITIONS SPECIFIED HEREIN.

29.

AWARD OF CONTRACT: REFERENCE OFFER

DATED . YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

HEREIN, IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (Signature of Contracting Officer)

30b. NAME AND TITLE OF SIGNER (Type or print)

30c. DATE SIGNED

31b. NAME OF CONTRACTING OFFICER (Type or print)

31c. DATE SIGNED

32a. QUANTITY IN COLUMN 21 HAS BEEN 33. SHIP NUMBER 34. VOUCHER NUMBER

RECEIVED INSPECTED

PARTIAL FINAL

36. PAYMENT 37. CHECK NUMBER

32b. SIGNATURE OF AUTHORIZED GOV’T REPRESENTATIVE 32c. DATE COMPLETE PARTIAL FINAL

41a. I CERTIFY THIS AMOUNT IS CORRECT AND PROPER FOR PAYMENT 41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC’D 42d. TOTAL CONTAINERS

40. PAID BY

AUTHORIZED FOR LOCAL REPRODUCTION SEE REVERSE FOR OMB CONTROL NUMBER AND PAPERWORK BURDEN STATEMENT STANDARD FORM 1449 (10-95)

ACCEPTED, AND CONFORMS TO THE

CONTRACT, EXCEPT AS NOTED

35. AMOUNT VERIFIED

CORRECT FOR

17a. CONTRACTOR/

OFFEROR

FACILITY

CODE

IS CHECKED

TABLE OF CONTENTS

Section Document/Clause/Provision Page No.

A Standard Form 1449 1 B Continuation of SF1449 (Block 19 – 24) 3 C Description/Specification/Work Statement 10 D Contract Clauses and Local Terms and Conditions 61 E Solicitation Provisions 87 F Instructions, Conditions, and Notices to Offerors 103 G Evaluation Factors for Award 112 H List of Exhibits and Attachments 115

SECTION B - CONTINUATION OF SF1449

Base Period (Transition-In) Items:

ITEM SUPPLIES / SERVICES QTY / UNIT UNIT PRICE NOT TO EXCEED

0001 Transition-In:

This is a Severable Labor-Hour Line Item.

Period of Performance: 05/01/2022 – 04/30/2023

1 Job

0002 Travel:

This is a Severable Time and Materials Line Item.

Conference-related travel requires separate Government approval and is neither authorized nor allowable for this line item.

I Lot $80,000.00 $80,000.00

0003 Other Direct Costs:

This is a Severable Time and Materials Line Item.

Other Direct Costs (ODCs) are expected to include software licenses and allowable training expenses.

1 Lot

Option Year 1 Items:

1001 Contract Management:

Period of Performance: 05/01/2023 – 04/30/2024

ITEM SUPPLIES / SERVICES QTY / UNIT UNIT PRICE EXTENDED PRICE

1002 PMPM (Member Services):

This is a Severable Firm-Fixed-Price Line Item.

684,000 Each

1003 PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management):

540,000 Each

1004 Travel:

This is a Severable Time and Materials Line Item.

Conference-related travel requires separate Government approval and is neither authorized

I Lot $81,800.00 $81,800.00

1005 Other Direct Costs:

This is a Severable Time and Materials Line Item.

Other Direct Costs (ODCs) are expected to include software licenses and allowable training

Option Year 2 Items:

2001 Contract Management:

Period of Performance: 05/01/2024 – 04/30/2025

2002 PMPM (Member Services):

692,400 Each

2003 PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management):

545,400 Each

2004 Travel:

Conference-related travel requires separate Government approval and is neither authorized

I Lot $83,640.50 $83,640.50

2005 Other Direct Costs:

This is a Severable Time and Materials Line Item.

Other Direct Costs (ODCs) are expected to include software licenses and allowable training

Option Year 3 Items:

3001 Contract Management:

Period of Performance: 05/01/2025 – 04/30/2026

3002 PMPM (Member Services):

700,800 Each

3003 PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management):

550,800 Each

3004 Travel:

Conference-related travel requires separate Government approval and is neither authorized

I Lot $85,522.41 $85,522.41

3005 Other Direct Costs:

This is a Severable Time and Materials Line Item.

Other Direct Costs (ODCs) are expected to include software licenses and allowable training

Option Year 4 (Transition Out) Items:

4001 PMPM (Member Services):

Period of Performance: 05/01/2026 – 04/30/2027

709,200 Each

4002 PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management):

556,200 Each

4003 Travel:

This is a Severable Time and Materials Line Item.

Conference-related travel requires separate Government approval and is neither authorized

I Lot $87,446.67 $87,446.67

4004 Other Direct Costs:

This is a Severable Time and Materials Line Item.

Other Direct Costs (ODCs) are expected to include software licenses and allowable training expenses.

B.1 Estimated Labor Category & Level of Effort Summary:

The labor categories below are suggestions based on historical data related to similar requirements under a similar contract. Offerors are not required to use these labor categories or exact amounts/number of hours. They are only provided as an example to all Offerors. Each Offeror should review the RFP and its requirements and determine what level of effort labor categories and skills levels are required to fully complete the requirements based upon the Offeror’s business knowledge and the Offeror’s proposed technical approach. Labor for all other tasks should be included in the Per Member Per Month (PMPM) unit prices.

Per 12-Month Period:

Task Estimated Labor Category Estimated LOE in Hours

Task 4.1 (Base Period)

Program Manager/Executive Account Manager 1,920.00 Transition-In Team Lead /Project Manager 1,920.00 Medical Director 1,920.00 Data and IT Lead 1,920.00 QA/QC Specialist 1,920.00 Program Control Specialist 1,920.00 Management Consultant II 3,840.00 User Support Spec. I 3,840.00 Utilization Management (UM) Coordinator 1,920.00 Customer Service Supervisor 1,920.00 Systems Administrator I 5,760.00 Systems Administrator III 1,920.00 Systems Administrator II 3,840.00 Claims Services Supervisor 3,840.00 Enterprise Systems Architect II 1,920.00 Technical Writer 1,920.00 Computer Programmer I 1,920.00 Tester I 3,840.00 Data Warehousing/Business Intelligence Sp. 3,840.00

Task 4.2 Each 12-Month Period

Program Manager/Executive Account Manager 1,920.00 Deputy Program Manager 1,920.00 Director, Project Management 1,920.00 Assistant Program Manager 1,920.00 QA/QC Specialist 1,920.00 Program Control Specialist 1,920.00 Management Analyst Professional II 3,840.00 Processor I 3,840.00 Management Consultant I 3,840.00

B.2 PMPM Units:

Per Member Per Month (PMPM) units, CLINs 1002, 1003, 2002, 2003, 3002, 3003, 4001, and 4002 reflect the current number of Active Members and the Government’s estimated increase in Active Members per contract period.

Active Members are those who have at least 1 paid Medical claim within the last 18 months.

B.3 Skills and Experience Requirements for Key Personnel:

Transition-In Team Lead/Project Manager:

• A minimum of five years of experience in health plan program and systems deployment activities;

• Functional capabilities to plan for, execute, monitor, and complete transition/installation activities;

• A minimum bachelor’s degree in business, health administration, or related field;

• Experience in change management (Preferred).

Program Manager/Executive Account Manager:

• A minimum of ten years of experience in health plan account or program management;

• A minimum bachelor’s degree in business, health administration, or related field.

Medical Director:

• Education and experience as a physician, MD or DO, preferably specializing in occupational health;

• Understanding of standards of care and industry best practices to provide clinical guidance and counsel to enhance medical benefit administration;

• A minimum of five years of relevant clinical experience working in a health plan advising client that enables them to make independent clinical recommendations to the Program regarding the member population benefits.

QA/QC Specialist:

• A minimum of 5 years of experience in a health plan quality monitoring and improvement;

• A deep understanding of program operations and needs;

• A minimum bachelor’s degree in Health Administration, Quality Improvement, or related field.

SECTION C - DESCRIPTION/SPECIFICATION/WORK STATEMENT

Title: World Trade Center Health Program (WTCHP) Third Party Administrator (TPA) Support

SECTION 1 – BACKGROUND

On January 2, 2011, the President signed Public Law No. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). Title I of the Zadroga Act amended the Public Health Service Act to add Title XXXIII establishing the World Trade Center (WTC) Health Program, referred to herein as “the Program” within the Department of Health and Human Services (HHS). Title I is codified at 42 U.S.C. §§ 300mm

– 300mm-61. The Zadroga Act was amended in 2015 by Public Law No. 114-113 to provide authority and funding and for the Program to continue through 2090 and further amended in 2019 by Public Law. No 116-59.

The Zadroga Act, as amended, can be found at:

https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter31&edition=prelim. In addition to the statutory requirements for the Program codified in 42 U.S.C. §§ 300mm – 300mm-61, the WTC Program Administrator has also promulgated regulations governing the administration of the Program at 42 C.F.R. pt. 88.

As of June 30, 2021, the Program had 112,042 members enrolled, including 81,460 responders and 30,582 survivors. Current Program statistics and reports can be found at https://www.cdc.gov/wtc/ataglance.html#enrollmentWTC.

The Program is a limited health benefit program, meaning that treatment is only available for specific covered health condition(s) for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001 terrorist attacks has been determined to be substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition in an individual member. The Program is administered by the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC), a component of HHS, and provides medical monitoring and treatment for Program members. Members comprise responders to the 9/11 terrorist attacks in New York City (NYC), responders at the Pentagon and near Shanksville, Pennsylvania, and survivors in NYC disaster sites. To receive treatment for a specific health condition, members must be both enrolled in the Program and certified for that condition by the Program. Only certain health conditions qualify for coverage, and this is therefore a limited benefit plan. Both Program enrollment and certification decisions are made by Program enrollment and certification specialists within NIOSH. The Zadroga Act establishes responsibilities associated with the administration and performance needed to enroll, initially evaluate, medically monitor, manage, and reimburse services for covered health conditions. The Program contracts with partners to carry out specific Program functions and operations of the limited benefit plan.

Monitoring and treatment are administered to members in the New York Metropolitan Area (NYMA) by eight Clinical Centers of Excellence (CCEs), and members outside of the NYMA through the Nationwide Provider Network (NPN); the CCEs and NPN are administered by entities and institutions under separate contracts in support of the Program. The Government also contracts with a Pharmacy Benefit Manager (PBM) to administer prescription benefits in the Program. In addition to these contracts, the Government also contracts with a Third- Party Administrator (TPA), for which this contract refers to herein as “the Contractor,” that receives and processes enrollment and certification applications for NIOSH decision-making, maintains member demographic information, manages a call center, manages, and maintains the NYMA provider network on behalf of the Program, administers benefits, and processes medical claims. These data are maintained by the Contractor and shared with stakeholders, such as other contractor partners (e.g., CCEs, NPN, PBM, DC) based on a pre-determined schedule. See Section 1.2 for descriptions.

SECTION 1.1 – Definitions Abuse: Practices that may directly or indirectly result in unnecessary costs to the Program; includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

Examples include:

• Billing for services that were not medically necessary;

• Charging excessively for services or supplies;

• Coding and billing for one hour when the visit was only 15 minutes.

https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter31&edition=prelim https://www.cdc.gov/wtc/ataglance.html#enrollmentWTC

Adjunct Condition: Conditions that may be treated under the Program without certification because they are deemed medically necessary to effectively treat a certified WTC-Related Health Condition or certified Health Condition Medically Associated with a WTC-Related Health Condition.

Applicant: An individual that has applied to the Program for enrollment but has not yet received a final decision on their eligibility status.

Appellant: An individual that has submitted an appeal to the Program to reverse an enrollment or certification determination.

Business Days: Monday through Friday, except for designated Federal Holidays.

Benefit Administration: Services performed on behalf of the Program to ensure coverage of medical services aligned with limited benefit requirements per the Zadroga Act and Title 42 Part 88 CFR.

Calendar Days: Monday through Sunday, including designated Federal holidays.

CARE Portal: The Centralized Accessible Real-time Enterprise (CARE) Portal is a web application and portal managed by the Program. The CARE Portal allows authorized staff (Program, the Contractor, CCEs/NPN, and other contractors) to perform work related responsibilities such as enrolling members, reviewing certifications, and transferring members. The Program’s CARE Portal also ensures secure sharing of Electronic Protected Health Information (ePHI) and Personally Identifiable Information (PII) in a manner that protects patient privacy and complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Privacy Act.

Certification: A Program review of a health condition in a particular member for the purpose of identification and approval of a WTC-related health condition included on the List of WTC-Related Health Conditions in 42 CFR § 88.15, or a health condition medically associated with a WTC-related health condition. For a health condition to be certified as WTC-related by the Program, a Program-affiliated provider must determine that the member’s 9/11 exposures are substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition such that the health condition is eligible for treatment by the Program. Program members receive coverage only for services deemed medically necessary to treat certified conditions. Certifications become part of the Member’s record to authorize treatment from the effective date.

Certified Condition: A determination by the Program that authorizes a member’s health condition to be eligible for treatment by the Program. The condition must be included on the List of WTC-Related Health Conditions and it must be determined that the member’s 9/11 exposure is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. Program members receive coverage only for services deemed medically necessary to treat certified conditions.

Certified-Eligible Survivor: Certified-eligible survivors include (1) individuals who have been identified as eligible for medical monitoring and treatment as of January 2, 2011; or (2) screening-eligible survivors who are eligible for follow-up monitoring and treatment pursuant to 42 CFR § 88.12(b).

Clean Claim: A claim that does not require any investigation or external development prior to processing and is filed within the timely filing period.

Controlled Unclassified Information (CUI): Controlled Unclassified Information (CUI) is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations, and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.

Designated Representative: Designated representative refers to an individual selected by an applicant, WTC responder, or a screening-eligible or certified-eligible survivor to represent his or her administrative interests to the Program.

Enrollment: A determination by the Program that an applicant is eligible as one of the four groups served by the Program (FDNY Responders, WTC General Responders, WTC Survivors, Pentagon/Shanksville Responders) and that their reported 9/11 exposure meets criteria for the activity, location, duration, time period and, if applicable, qualifying symptoms of a WTC-related condition as outlined in the Zadroga Act. An approved enrollment entitles a new member to an initial health evaluation/screening visit.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Examples include:

• Providing false statements on an enrollment application to obtain coverage or concealing information about past medical history/preexisting conditions.

• Failing to report other insurance or to disclose claims that were a result of an injury unrelated to 9/11 exposure.

• Billing for services that were not rendered including upcoding and unbundling or providing services that are not medically necessary.

Fulfillment Services: The receipt, processing, and distribution of materials by a third party on behalf of another organization. This includes processing via mail, facsimile, telephonic, or electronic methods.

Health Condition Medically Associated with a WTC-Related Health Condition: A condition that results from the treatment or progression of a certified WTC-related health condition. Once certified, health conditions medically associated with a WTC-Related Health Condition are eligible for treatment covered by the Program.

Health Program Support (HPS): To support various Program functions per this Contract herein, including processing member enrollment and certification applications, managing the customer-service call center, managing the provider network, administering benefit plans, processing medical claims, maintaining the member database, and coordinating member communications.

Limited Health Benefit Program: A limited health benefit program covers a specific and restricted set of treatments, services, and supplies for a specific and restricted set of conditions. The Program’s limited health benefit program covers limited medically necessary services to diagnose, monitor, and/or treat qualifying conditions as required in the Zadroga Act, 42 CFR Part 88.

Medical Policy: Medical policy establishes guidelines for determining what medical services, procedures, and supplies are medically necessary for the treatment or monitoring of qualifying conditions and therefore eligible for coverage. Medical policy is grounded in best and most current scientific evidence and is updated to reflect changes in such evidence. For the purposes of the Program, medical policy indicates what services shall be covered for each of the Program’s qualifying WTC-Related Conditions, Health Conditions Medically Associated with a WTC-Related Condition, and Adjunct Conditions.

Member: A responder, screening-eligible survivor, or certified-eligible survivor enrolled in the WTC Health Program. A responder may include eligible family members of a Fire Department of the City of New York (FDNY) responder.

Member Services: Member services include all member-facing operations provided by the Contractor to include, operations support for enrollment, certification, and member transfer, mail center administration, member communications, customer service including operation of a call center and self-service portal, and management and maintenance of member demographic information.

Monitoring Exam: Periodic physical and mental health assessment of a WTC responder or certified-eligible survivor in relation to exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks and which includes a medical and exposure history, a physical examination and additional medical testing as needed for surveillance or to evaluate symptom(s) to determine whether the individual has a WTC-related health condition. Generally, a WTC responder or certified-eligible survivor receives annual physical and mental health assessments.

OASIS: Online Application Submission Information System (OASIS) is a public-facing Web-based application developed and managed by the Program that allows potential members to apply for enrollment in the Program via a Web browser on any Internet-connected device (e.g., desktop, laptop, tablet, smart phone). OASIS securely transmits enrollment information directly to the CARE Portal.

Other Health Insurance (OHI): A member’s personal health insurance, whether public or private, including group health, government, or workers’ compensation insurance that must be billed prior to processing claims via the Program in instances when the Program is not primary payer.

Personally Identifiable Information (PII): Any information about an individual maintained by an agency that includes (1) any information that can be used to distinguish or trace an individual's identity, such as name, social security number, date and place of birth, mother's maiden name, or biometric records; or (2) any other information that is linked or linkable to an individual, such as medical, educational, financial, and employment information.

Prior Authorization (PA): A process required to authorize medical services for coverage before services are rendered. The Contractor’s adjudication system shall maintain business rules that require approval of prior authorizations before a claim can be processed.

Program Policy: Administrative and operational guidance provided by NIOSH/The Program.

Prospective Member: An individual who is interested in the Program but has not yet been enrolled (may include applicants).

Protected Health Information (PHI): Individually identifiable health information (health information, including demographic information, collected from an individual and created or received by a health care provider, health plan, employer, or health care clearinghouse that relates to the individual’s past, present, or future mental or physical health or condition, provision of health care, or payment for care and which identifies the individual or is reasonably believed to make the individual identifiable) that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium. PHI excludes individually identifiable health information in certain education records, certain student medical records, employment records held by a covered entity in its role as employer, and records regarding a person who has been deceased for more than 50 years.

Public Health Data: Digitally recorded factual material commonly accepted in the scientific community as a basis for public health findings, conclusions, and implementation. Public health data include material from research and non-research activities. Public health data could be quantitative, qualitative, imaging, or genomic output (for example, genome sequencing, arrays, gene expression, etc.). Public health data do not include preliminary analyses, drafts of scientific papers, plans for future research, reports, grantee progress reports, communications with colleagues, or physical objects, such as laboratory notebooks or laboratory specimens.

Responder: An individual who has been identified as eligible for monitoring and treatment as described in Program regulations based on response activities; these include workers or volunteers who provided rescue, recovery, debris cleanup, or related support services on or in the aftermath of the September 11, 2001, terrorist attacks for certain amounts of time between September 11, 2001, and July 31, 2002. There are three groups of responders in the Program: FDNY Responders (and surviving FDNY family members eligible only for mental health benefits); WTC General Responders (including NYPD); and Pentagon and Shanksville, PA Responders.

Screening-Eligible Survivor: Screening-eligible survivors are individuals who are not WTC responders and who claim symptoms of a WTC-related health condition and meet the eligibility criteria for a survivor specified in 42 CFR § 88.8.

Stakeholders: Any individual or entity interested in or affected by the Program, including CCEs and NPN, network providers, nonprofit organizations, the Program Steering Committees, Program personnel, members, government agencies, and other support contractors.

Start of Health Care Delivery (SHCD): Mutually agreed-upon date between Contractor and the Program on which all services per this contract are implemented.

Survivor: An individual who has been identified as eligible for monitoring and treatment per the Zadroga Act, 42 CFR Part 88 based on presence in the dust or dust cloud on September 11, 2001 or living, working, or attending school, childcare, or adult daycare in the NYC Disaster Area for a certain amount of time between September 11, 2001, and July 31, 2002, or certain other specified periods. The Program recognizes both screening-eligible and certified-eligible survivors.

Sustainment: Following the start of health care delivery, the period when operations are underway, and the Contractor is in the maintenance and continuous refinement phase.

Third Party Administrator (TPA): Administrative entity under contract to the Program to provide contract management, member services, network management, medical benefits management, claims adjudication, and data and IT services on behalf of the Program.

Timely Filing Period: The timeframe in which a claim must be submitted to the Contractor. Claims filed outside of the timely filing period will be denied.

Transition-In: Transition-In refers to the implementation period following contract award during which the Contractor and the Program establish operations, processes, and systems to administer the contract and achieve operational readiness.

Transition-Out: Transition-Out refers to a period at the end of the period of performance during which the Contractor and the Program conduct planning, data transfer, and other activities necessary to close out contract operations support the next generation contract.

Treatment Pending Certification: Treatment pending certification refers to treatment provided for WTC-Related Health Conditions or Health Condition Medically Associated with a WTC-Related Health Condition while certification is awaiting adjudication. In order for a CCE or NPN to provide treatment pending certification for a health condition, the condition must be eligible for treatment by the Program and a certification request must have been submitted to the Program but not yet adjudicated. The Program members sometimes require urgent or otherwise time-sensitive care for conditions pending certification and such cases may be covered by the Program if all requirements are met. As directed by Program regulations, authorization for treatment of a WTC-Related Health Conditions or a Health Condition Medically Associated with a WTC-Related Health Condition must be obtained from the Program before treatment is provided, except for the provision of treatment for a medical emergency.

Waste: Failure to control costs or regulated payments due to an inappropriate act or omission by payers with control over or access to government resources. Waste relates primarily to mismanagement, inappropriate actions, or inadequate oversight. Examples include:

• Poor execution or lack of widespread adoption of best practices, such as effective preventive care practices or patient safety best practices;

• Unnecessary hospital readmissions, avoidable complications, and declines in functional status, especially for the chronically ill;

• Use of higher-priced services that have negligible or no health benefits over less expensive alternatives;

• Writing high-cost prescriptions over less expensive but equivalent generic prescriptions.

WTC-Related Health Condition: An illness or health condition for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks, based on an examination by a medical professional with experience in treating or diagnosing the health conditions included in the List of WTC-Related Health Conditions, is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition, including a mental health condition. Only those conditions on the List of WTC-Related Health Conditions codified in Program regulations at 42 CFR Part 88 may be considered WTC-Related Health Conditions; conditions must be certified before they are eligible for treatment.

SECTION 1.2 – Selected Roles and Business Associates

1. The following is a non-exclusive list of other WTC Health Program contractors and business associates with which the Contractor shall engage while carrying out requirements per this contract.

Clinical Center of Excellence (CCE): A center or centers under contract with the Program that:

(1) Uses an integrated, centralized health care provider approach to create a comprehensive suite of health services that are accessible to enrolled WTC responders, screening-eligible survivors, or certified-eligible survivors; (2) Has experience in caring for WTC responders and survivors, or includes health care providers who have received Program training; (3) Employs health care provider staff with expertise that includes, at a minimum, occupational medicine, environmental medicine, trauma-related psychiatry and psychology, and social services counseling; and (4) Meets such other requirements as specified by the Administrator of the Program. A CCE is a NYMA-based medical facility that, in accordance with the Zadroga Act, operates under an individual contractual relationship with the Program to provide medical monitoring, diagnosis, and treatment services for members in the NYMA. Members indicate preference for and are assigned to a CCE, which is responsible for coordinating their care under the Program. There are currently eight CCEs contracted with the Program: two for the survivor population and six for the responder population.

Comprehensive Cost Avoidance (CCA) Contractor: A vendor who implements a comprehensive cost avoidance, coordination of benefits, and recovery platform from pre- to post-payment processes to facilitate the ability of the Program to improve efficiency and control health care costs without compromising quality of care.

Data Center (DC): One of several centers under contract with the Program to support various functions, including receiving data from the Contractor, CCEs, and NPN; developing examination, monitoring, and treatment protocols;

and coordinating outreach activities. See 42 CFR § 88.1.

Health Program Evaluation (HPE) Contractor: A vendor providing consulting services for data analytics to support strategic planning and program evaluation.

Nationwide Provider Network (NPN): A network of providers throughout the United States under contract with the Program to provide an initial health evaluation, monitoring, and treatment to enrolled WTC responders, screening-eligible survivors, or certified-eligible survivors who live outside the NYMA. Generally, the NPN includes health care providers in all 50 states and territories and is administered by a third-party entity under contract with the Program to provide WTC-related health care as well as member services, network management, and claims processing.

Pharmacy Benefits Manager (PBM): A vendor who provides comprehensive pharmacy services to the WTC Health Program for filling prescriptions at retail and mail-order pharmacies, with controls on formularies, members, and prescribers.

SECTION 2 – PURPOSE

The purpose of this contract is to secure the services of a TPA, referred to herein as “the Contractor,” to support the operation and enhancement of the Program. The Contractor shall deliver services to operationalize the Program’s limited health benefit plan, ensuring eligible members are able to receive standardized monitoring, diagnostic services, and medically necessary, clinically appropriate treatment services for their certified condition(s). The Contractor shall adjudicate claims in accordance with the Zadroga Act, The Program regulations, Program Policy, and all other applicable laws, policies, and regulations. The Contractor shall manage program administration using advanced and continually improved industry standards (e.g., a secure online service). The Contractor shall provide these services with the goals of streamlining business processes, enhancing data collection and analysis, improving member access to healthcare, and providing superior customer service.

SECTION 3 – SCOPE OF WORK

The Contractor shall provide Contract Management, Member Services, Provider Network Management, Medical Benefits Administration, Claims Processing, and Data and Business Information Management in support of the Program. In supporting the Program, the Contractor shall coordinate with the Program and regularly communicate and interact with other Program contractors, including the CCEs, the NPN, the Data Centers, Health Program Evaluation (HPE) contractors, Comprehensive Cost Avoidance (CCA) contractors, and Pharmacy Benefits Manager (PBM) contractors. The Contractor will not be responsible for underwriting cost of care or developing and coding new information technology systems.

At a summary level, tasks to be performed shall include:

4.1 Transition-Related Services;

4.2 Contract Management;

4.3 Member Services;

4.4 Provider Network Management;

4.5 Medical Benefit Administration;

4.6 Claims Processing;

4.7 Data and Business Information Management.

SECTION 4 – TASKS TO BE PERFORMED

SECTION 4.1 – Transition-In

SECTION 4.1.1 – Kickoff Meeting The Contractor shall coordinate with the Contracting Officer’s Representative (COR) to schedule and facilitate a Kickoff Meeting either virtually or in-person with key Program personnel within ten business days of award. The Contractor shall, in coordination with the Program, provide an agenda for the Kickoff Meeting within five business days of award. The Contractor shall create a Kickoff Presentation presenting proposed approaches to transition all tasks to be included in the Transition-In Plan, per Section 4.1.2. In addition, the Kickoff Meeting shall serve as an opportunity for the Contractor to explain how all contract functions shall be fulfilled and operationalized within contract parameters. The Contractor shall ensure that all Program requested changes and revisions to approaches presented in the Kickoff Meeting are addressed in the Transition-In Plan, Contract Management Plan, or other relevant deliverable.

The Contractor shall coordinate with the COR to establish dates, location, and an agenda for the Kickoff Meeting.

The Contractor shall take meeting minutes, which shall be provided to the Program within five business days of the Kickoff Meeting.

SECTION 4.1.2 –Transition-In Plan The Contractor is responsible for ensuring that contract transition will be implemented within a twelve-month timeframe with minimal to no disruption to member services and access to medical benefits. The transition approach shall be presented in detail at the Kickoff Meeting, and the Contractor shall adjust and finalize the implementation timeline as necessary in coordination with the Program and the incumbent TPA Contractor within 30 calendar days following the Kickoff Meeting. The Transition-In Plan shall be adjusted throughout the Transition-In Period to reflect the actual transition implementation activities and timeline. A final Transition-In Summary Report documenting the actual transition shall be delivered ten business days following Start of Health Care Delivery (SHCD).

SECTION 4.1.3 – Requirements for Transition-In Period

The Contractor shall collaborate with the Program, partner stakeholders (e.g., CCE, NPN, PBM, CCA), and the incumbent TPA contractor during the transition period. The Contractor shall dedicate resources to a Transition-In team, led by the Transition-In Team Lead. The Transition-In Team Lead shall be designated as “Key Personnel” to manage all Program transition efforts with the priority of no disruption to members and Program operations.

Transition of all system and process shall be completed, tested, and ready for all required services to be fully operational within twelve months of award.

During the Transition-In Period, the Contractor shall perform the following tasks:

1. Track status of transition activities, tasks, and outcomes to ensure alignment with the Transition-In Plan’s Integrated Master Schedule (IMS). When data is provided and entered in the IMS that creates overall critical path slippage, the Contractor shall notify the Program within one business day. The notification shall include a proposal for how the Contractor plans to manage the slippage. The notification shall be delivered to the

COR in writing and in accordance with the Contractor’s Risk and Issue Management process, per Section 4.2.2.

2. Implement Member Services solutions to prepare for SHCD, including customer service, member-facing call center and self-service portal functionality, transition of member communications, enrollment, certification, and transfer processing, and all other responsibilities detailed in Section 4.3.

3. Implement Provider Network Management solutions to prepare for SHCD, including ramping up operations to adopt and absorb the existing NYMA network, loading the current Program network provider file, assessing the accuracy of the network provider file data, developing all processes required to assume the Program provider network in the NYMA, proposing processes to coordinate with the CCEs, and all other responsibilities detailed in Section 4.4.

4. Implement Medical Benefit Administration solutions to prepare for SHCD, including benefit administration, prior authorizations, utilization management, and all other responsibilities detailed in Section 4.5.

5. Implement Claims Processing solutions to prepare for SHCD, including incorporation of business rules into claims adjudication system, coordination of benefits, program integrity activities, administrative invoicing to the Program, and all other responsibilities detailed in Section 4.6.

6. Implement Data and Business Information Management solutions to prepare for SHCD, including data migration, conversion, and the comprehensive testing process to ensure readiness for all operations. The testing shall include industry standard QA reviews and end-to-end-transactions at least 20 business days prior to SHCD. The Contract shall also implement processes to establish data security, systems access, data storage and organization compliance, data integrity, continuity of operations, connectivity and information exchange, and all other responsibilities detailed in Section 4.7.

SECTION 4.1.4 – Transition Schedule Reports Throughout the course of the transition, the Contractor shall generate schedule reports containing the planned versus actual program/project performance against the Transition-In Plan and updated critical path information for the project. Transition schedule reports shall be submitted within five business days of the end of each month throughout transition-in, beginning the month in which the finalized implementation timeline is submitted and approved by the Program. The Contractor’s transition schedule reports shall include identification and documentation of project risks that may jeopardize any imminent milestones or the overall project timeline. These risks and any associated mitigation strategies shall be incorporated in the risk register, which shall be included with the transition schedule reports throughout transition per Section 4.2.2. Additionally, the Contractor shall establish ongoing transition meetings at a minimum of once a month during the transition period.

SECTION 4.1.5 – Readiness for SHCD Readiness for SHCD shall be assessed via integrated systems testing to be conducted prior to SHCD for each functional area (as mutually agreed upon between the Contractor and the Program). To execute the Transition-In Plan, the incoming contractor shall implement its approach to establish full readiness for SHCD. The Contractor shall schedule a systems interface meeting with the Program within 30 business days of award start date. The purpose of the meeting is to review requirements for the establishment of connectivity with Program systems and applications.

The incoming Contractor shall coordinate with the Program to establish the required interfaces with Program systems and applications. The Contractor shall facilitate testing sessions for the following functions to demonstrate to Program staff that operations are ready for SHCD, per the Performance Requirements Summary found in Appendix 1 of Attachment B:

• Member Services – successful completion of end-to-end integration testing to confirm enrollment, certification, and transfer processing, customer service and member communications, call center, mail center operations, and secure self-service portal shall be fully operational for SHCD. The Program accepts attestation of training completion for all enrollment, certification, and transfer processing staff.

• Provider Network Management – successful loading of provider file and availability of provider directory, to include any newly recruited providers. The Program accepts attestation of network absorption.

• Medical Benefit Administration – Program approval of proposed medical policy, achievement of key milestones, per IMS, and successful completion of claim test run in compliance with medical policy.

• Claims Processing – successful completion of end-to-end claims processing testing.

• Data and Business Information Management – successful execution of data conversion and migration plan, bidirectional data exchanges are established and operational, all systems are configured and compliant to support program operations, system access is granted to critical staff, analytical platform and data repository are available for Program staff use.

SECTION 4.2 – Contract Management The Contractor’s plans for managing ongoing operations and functional areas shall be incorporated into a single Contract Management Plan. The Contractor shall assign a dedicated account team to serve as primary liaison for contract management to the Program throughout the life of the contract. The account team shall include an Executive Account Manager who shall serve as “Key Personnel.” The Executive Account Manager shall represent a single point of contact for Program staff.

SECTION 4.2.1 – Implementation of Contract Management Plan The Contractor shall develop and execute a Contract Management Plan (CMP) addressing staffing, reporting, security, deliverables, repositories, and Quality Assurance and implementation of requirements including subcontracting services. The staffing model and organizational structure shall consist of required personnel with relevant expertise and clearly-defined roles and responsibilities. The Contractor shall dedicate appropriate personnel for each of the designated tasks who shall work with Program staff and/or Program contractors to effectively meet requirements. The CMP shall define the Contractor’s management approach for functional areas of the contract. An initial Draft Contract Management Plan shall be submitted with the proposal and shall be presented at the Kickoff Meeting with the final CMP deliverable due ten business days following the Kickoff Meeting. Throughout the period of performance, the Contractor shall engage with the COR and core Program personnel in alignment with standard project management principles (i.e., PMI PMBOK). Priorities include:

• Quality Assurance and continuous performance improvement;

• Risk and Issue Management;

• Stakeholder engagement and communications initiatives;

• Change Control Activities, including testing of system updates.

To implement the Contract Management Plan, the Contractor shall:

1) Coordinate with COR, Program personnel and partner contractors to monitor and oversee Transition-In, sustainment, and continuous enhancement/improvement of the Program.

2) Onboard, train, and retain all staff supporting this contract. The Contractor shall manage staff in a way that limits degradation or disruption of services due to staffing changes. Changes to the dedicated account team shall require written notification to the Government, per section H.

3) Ensure completed Non-Disclosure Agreements (NDAs) and deliver a roster of Contractor Staff with roles and responsibilities prior to the Kickoff Meeting.

4) Manage and communicate onboarding and offboarding documentation (including the Signed Rules of Behavior) and equipment submission per Section 7.

5) Implement a Change Control Process to address any variance from the baseline plan established during Transition-In and the contract. Any Contractor-initiated change requests and business justification shall be tracked from identification, through engagement with the Program, possible modification process, and execution. The tracked change requests shall be made available to Program staff upon request.

6) Establish internal communication channels to ensure that action items and issues that require immediate response are communicated in a timely manner to manage the services required per this contract.

7) Develop and execute trainings to support transition and readiness throughout the period of performance, including use of Program systems (i.e., CARE Portal), and ensure all Contractor and stakeholder staff are trained to support program operations throughout the period of performance, per Section 4.2.4.

a. Contractor staff shall complete applicable HIPAA, CDC, and Program trainings in advance of

SHCD.

b. Contractor shall deliver trainings and job aids to support Program staff and partner contractors (e.g., CCE, NPN, CCA, PBM) in alignment with Contractor solutions, processes, and tools

8) Establish processes for identification, tracking, mitigation, and escalation of risks and issues

9) Establish processes for collaborating with Program stakeholders (including members, providers, Program staff, and partner contractors)

10) Establish processes for complying with the Business Associate Agreement, per Section 4.2.7.

11) Establish processes for administering the Program’s limited benefit and utilization management activities, per Section 4.5.

12) Oversee all subcontractors to ensure quality of subcontractor performance

SECTION 4.2.2.1 – Change Control Process A contract change control request process allows for changes to be implemented with the mutual understanding and agreement of both the Contractor and the Government. During post-award contract management, monitoring and controlling contract changes is one of the most crucial part of contract administration, requiring extensive process integration and communication among the Contractor and Government’s project management team members.