75D301-25-R-73216.docx

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

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

1. REQUISITION NUMBER

PAGE 1 OF

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NUMBER

5. SOLICITATION NUMBER

75D301-25-R-73216

6. SOLICITATION ISSUE DATE

01/16/2025

Joshua Houston

b. TELEPHONE NUMBER (No collect calls)

(404) 498-2384

8. OFFER DUE DATE/ LOCAL TIME

04/11/2025

9. ISSUED BY11. DELIVERY FOR FOB

DESTINATION UNLESS

BLOCK IS MARKED

12. DISCOUNT TERMS

Centers for Disease Control and Prevention Chamblee Campus Building 102, MS S102-4 4770 Buford Hwy Atlanta, GA 30341-3717

X UNRESTRICTED

SET ASIDE: % FOR

SIC:

SIZE STANDARD:

SEE SCHEDULE

13a. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 C.F.R. 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ IFB X RFP

Centers for Disease Control and Prevention Chamblee Campus Building 102, MS S102-4 4770 Buford Hwy Atlanta, GA 30341-3717

CODE

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 OFFERIS CHECKED

19.

ITEM NO.

20.

SCHEDULE OF SUPPLIES/SERVICES

21.

QUANTITY

22.

UNIT

23.

UNIT PRICE

24.

AMOUNT

World Trade Center Health Program Third-Party Administrator See Continuation Pages (Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

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

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA 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.

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:

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

30c. DATE SIGNED

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

31c. DATE SIGNED

RECEIVED INSPECTED ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED

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)

TABLE OF CONTENTS

Base/Transition-In Period (9/15/2025 – 9/14/2026) 5

Option Period 1 (9/15/2026 – 9/14/2027) 6

Option Period 2 (9/15/2027 – 9/14/2028) 15

Option Period 3 (9/15/2028 – 9/14/2029) 23

Option Period 4 (9/15/2029 – 9/14/2030) 31

Option Period 5 (9/15/2030 – 9/14/2031) 39

Option Period 6 (9/15/2031 – 9/14/2032) 47

Option Period 7 (9/15/2032 – 9/14/2033) 55

Option Period 8 (9/15/2033 – 9/14/2034) 63

Transition-Out Period (8/15/2034 – 8/14/2035) 71

Option Period 9 (9/15/2034 – 8/14/2035) 72

Transition-Out Dual Operations Period (8/15/2035 – 9/14/2035) 80

Labor rates table 81

Section 1 – Background 82

Section 2 – Purpose/Objective 84

Section 3 – Scope of Work 84

Section 4 – Tasks to be Performed 85

Section 4.1 – Transition-Related Services 85

Section 4.2 – Contract Management 90

Section 4.3 – Member Services 97

Section 4.4 – Provider Network Management 102

Section 4.6 – Claims Processing 110

Section 4.8 – Regulatory Compliance 123

Section 5 – Government Furnished Property 125

Section 6 – Place of Performance and Contract Support Hours 125

Section 7 – Travel 125

Section 8 – Deliverables/Reporting Schedule 126

Section 9 – Reference Materials 138

Section 10 – Additional Requirements 140

C1. FAR 52.252-2 Clauses Incorporated by Reference 162

C2. FAR 52.212-5 Contract Terms and Conditions Required To Implement Statutes or Executive Orders—Commercial Products and Commercial Services 162

C3. FAR 52.217-8 Option to Extend Services 170

C4. FAR 52.217-9 Option to Extend the Term of the Contract 170

C7. HHSAR 352.224-71 Confidential Information 173

C9. CDC0_G008 Contracting Officer’s Representative (COR) 175

C10. CDCA.G009 Contracting Officer 175

C11. CDC0.G018 Payment by Electronic Funds Transfer 175

C13. CDCA_H005 Data Subject to Privacy Act Requirements 176

C14. CDCA_H007 Subcontracting Plan 176

C15. CDCA_H009 Key Personnel 176

C16. CDC0_ H022 Smoke Free Working Environment 177

C17. CDCA_H042 Records Management Obligations 177

C19. CDC0_H053 Health Information Technology 179

C20. CDC37_0001 Non-Personal Services 180

C23. Contract type conversion 183

E2. 52.201-1 Acquisition 360: Voluntary Survey 187

E3(e). Summary of acquisition process 188

E3(f). Pre-proposal conference 188

E3(g). Questions-and-answers period 188

E3(h). Discovery sessions 189

E3(i). Proposals 190

E3(i)(1)(i). Written proposal Volume 1: Transition-in 190

E3(i)(2). Virtual session 203

E3(j). Discussions 204

E3(k). Award 205

E3(l). Debriefing 205

E4(a)(1)(i). Transition-in technical sub-factor 206

E4(a)(1)(iii). Member services technical sub-factor 207

E4(a)(1)(vi). Claims processing technical sub-factor 208

E4(a)(1)(viii). Key personnel technical sub-factor 209

E4(a)(2). Past performance factor 210

E4(a)(3). Price factor 210

Relative importance of factors and sub-factors 211

E6. HHSAR 352.204-74 Supply Chain Risk Assessment 228

E8. CDC100.0004 Data Management Plan (Instructions) 231

E9. CDC100.0005 Evaluation of the Data Management Plan (DMP) 232

SECTION B - CONTINUATION OF SF1449

Base/Transition-In Period (9/15/2025 – 9/14/2026) Items:

Description: Includes Sections 4.1.1, 4.1.2, and 4.1.3; New York Metropolitan Area (NYMA) External Provider Network (EPN) adoption under Section 4.4.1; Nationwide Provider Network (NPN) network development before Start of Healthcare Delivery (SHCD) under Section 4.4.2; and initial provider enrollment and credentialing under Section 4.4.3.

Severability: Non-severable line item.

Contract type: Time-and-materials line item.1 Labor to be invoiced in accordance with the labor categories and labor rates in the labor rates table, below.

Period of performance: 9/15/2025 – 9/14/2026.

1 Job

Description: Travel in support of the Base/Transition-In Period.

Severability: Severable line item.

Contract type: Cost-only. All travel will be reimbursed at-cost in accordance with the Federal Travel Regulation, 41 C.F.R. Subtitle F.

The Contractor shall obtain written approval from the Contracting Officer’s Representative (COR) prior to undertaking any travel.

Period of performance: 9/15/2025 – 9/14/2026.

1 Job

1 This contract line item number (CLIN) may be converted to a firm-fixed-price CLIN through mutual written agreement of the Contractor and Government Contracting Officer. See the contract type conversion clause in Section C23.

Option Period 1 (9/15/2026 – 9/14/2027) Items:

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Sections 4.2 and 4.8 upon SHCD on 9/15/2026. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

Period of performance: 9/15/2026 – 9/14/2027.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Section 4.3.1 upon SHCD on 9/15/2026. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.2

9,500 Enrollment Applications

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.3 upon SHCD on 9/15/2026, except Section 4.3.1. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.3

Period of performance: 9/15/2026 – 9/14/2027.

1,831,200 Units (based on members eligible for benefits)

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.4 upon SHCD on 9/15/2026, except NYMA EPN adoption under Section 4.4.1; initial NPN network development before SHCD under Section 4.4.2; and initial provider enrollment and credentialing under Section 4.4.3, all of which are performed during the Transition-In Period. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.5 upon SHCD on 9/15/2026, except Section 4.5.2. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Section 4.5.2 upon SHCD on 9/15/2026. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.4

Period of performance: 9/15/2026 – 9/14/2027.

1,044,000 Units (based on active members only)

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.6 upon SHCD on 9/15/2026. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.5

780,400 Medical Claims

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.7 upon SHCD on 9/15/2026, except Sections 4.7.5 and 4.7.6. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Sections 4.7.5 and 4.7.6 upon SHCD on 9/15/2026. The first 30 days of performance are during the Dual Operations phase following the Transition-In Period, as described in Section 4.1.4. At the end of the Dual Operations phase, the Sustainment phase will begin as described in Section 4.1.5.

Severability: Severable line item.

Contract type: Time-and-materials line item.6 Labor to be invoiced in accordance with the labor categories and labor rates in the labor rates table, below.

1 Job

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Travel in support of Option Period 1.

Severability: Severable line item.

Contract type: Cost-only. All travel will be reimbursed at-cost in accordance with the Federal Travel Regulation, 41 C.F.R. Subtitle F.

The Contractor shall obtain written approval from the COR prior to undertaking any travel.

1 Job

2 To develop the maximum quantity of 9,500 enrollment applications, the Government used its projection for the estimated number of enrollment applications anticipated during this option period. This line item is to be invoiced monthly in arrears for the number of enrollment applications finalized in a given month as of the last day of such month. A finalized enrollment application is defined as an enrollment application submitted by the Contractor to the World Trade Center Health Program (the “Program”) that has sufficient information for the Program to make an enrollment eligibility decision (e.g., Enroll, Deny, Defer). The determination of whether there is sufficient information is made by the Program and is based on the enrollment eligibility criteria described in the Program Administrative Manual, which is incorporated by reference herein as if fully set forth herein. The Program Administrative Manual is available at https://www.cdc.gov/wtc/ppm.html or any successor website. Enrollment applications that are determined by the Program to be incomplete (i.e., placed on Suspend) or duplicates of another enrollment application for the same unique individual are not considered finalized.

The Contractor is required to finalize up to the maximum quantity of 9,500 enrollment applications during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of enrollment applications that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 8,075 enrollment applications. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 6,500 enrollment applications. The minimum guarantee is defined both by the number of finalized enrollment applications (as such term is defined above) and the number of enrollment applications received by the Contractor but not yet finalized during the 12-month period of performance of this line item. An enrollment application that is received by the Contractor but not yet finalized means (1) an application submitted online and received in the Centralized Accessible Real-time Enterprise (CARE) Portal but does not have sufficient information for the Program to make an enrollment eligibility decision or has not yet been submitted to the Program, or (2) an application submitted through the Mail/Document Center that the Contractor has entered into the CARE Portal but does not have sufficient information for the Program to make an enrollment eligibility decision or has not yet been submitted to the Program. The Contractor is not paid for enrollment applications that are received by the Contractor but not yet finalized. Whether the minimum guarantee has been met will be determined by the Program using the following two-step procedure:

1. If the Contractor has finalized 6,500 or more enrollment applications during the 12-month period of performance of this line item, the minimum guarantee has been met.

2. If the Contractor has finalized fewer than 6,500 enrollment applications during the 12-month period of performance of this line item, the number of enrollment applications received by the Contractor but not yet finalized during the 12-month period of performance of this line item will then be added to the number of finalized enrollment applications during the 12-month period of performance of this line item.

a. If the total of finalized enrollment applications plus received-but-not-yet-finalized enrollment applications is 6,500 or more enrollment applications during the 12-month period of performance of this line item, the minimum guarantee has been met.

b. If the total of finalized enrollment applications plus received-but-not-yet-finalized enrollment applications is fewer than 6,500 enrollment applications during the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units (enrollment applications) adding up to the minimum guarantee of 6,500 enrollment applications.

Any invoice for additional units the Contractor is entitled to submit to meet the minimum guarantee, if any, shall be determined by the Program and submitted by the Contractor after the 12-month period of performance of this line item is complete.

For example, assuming that the unit price per enrollment application is $5.00:

· If the Contractor finalizes 8,000 enrollment applications during the 12-month period of performance of this line item, the minimum guarantee of 6,500 enrollment applications has been met and the Contractor is not entitled to any further compensation. The Contractor would be paid the unit price of $5.00 multiplied by 8,000 finalized enrollment applications, or $40,000.00.

· If the Contractor finalizes 6,000 enrollment applications during the 12-month period of performance of this line item, the Contractor would be paid the unit price of $5.00 multiplied by the 6,000 finalized enrollment applications, or $30,000.00. Assume further that 1,000 enrollment applications were received by the Contractor but not yet finalized during the 12-month period of performance of this line item. The total of finalized (6,000) plus received-but-not-yet-finalized (1,000) enrollment applications is 7,000. The minimum guarantee of 6,500 enrollment applications has been met and the Contractor is not entitled to any further compensation beyond the $30,000.00.

· If the Contractor finalizes 6,000 enrollment applications during the 12-month period of performance of this line item, the Contractor would be paid the unit price of $5.00 multiplied by the 6,000 finalized enrollment applications, or $30,000.00. Assume further that 200 enrollment applications were received by the Contractor but not yet finalized during the 12-month period of performance of this line item. The total of finalized (6,000) plus received-but-not-yet-finalized (200) enrollment applications is 6,200. The minimum guarantee of 6,500 enrollment applications has not been met. The Contractor is entitled to submit an invoice for 300 additional units (enrollment applications) to meet the 6,500 minimum guarantee (6,500 – 6,200). At the end of the 12-month period of performance, the Contractor would submit an invoice for 300 additional enrollment applications and be paid the unit price of $5.00 multiplied by 300 enrollment applications, or $1,500.00. The Contractor’s total compensation for this line item would be $31,500.00 ($30,000.00 for the 6,000 finalized enrollment applications plus the additional $1,500.00).

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services, regarding changes to the minimum guarantee.

3 To develop the maximum quantity of 1,831,200 units for the year, the Government multiplied the estimated average number of members anticipated to be eligible for benefits during this option period by 12 months (152,600 members * 12 months = 1,831,200 per member per month [PMPM] units). This PMPM compensation arrangement establishes a fixed unit price to be invoiced monthly in arrears for each member eligible for benefits as of the close of business on the last day of the month. The number of members eligible for benefits is defined as the number of unique individuals who are currently enrolled in the Program, meaning that they have not disenrolled from the Program and are not deceased. For example, if the number of members eligible for benefits as of the close of business on the last day of the month is 150,000 members, the Contractor would submit an invoice for 150,000 units for that month. If the number of members eligible for benefits as of the close of business on the last day of the month remained at 150,000 members for each month of the year, the Contractor would have cumulatively billed for 1,800,000 units for the year (150,000 members * 12 months = 1,800,000 PMPM units).

The Contractor is required to perform up to the maximum quantity of 1,831,200 units during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of units that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 1,556,520 units. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 1,591,200 units during the 12-month period of performance of this line item. This minimum guarantee was developed by multiplying the estimated minimum average number of members anticipated to be eligible for benefits during this option period by 12 months (132,600 members * 12 months = 1,591,200 PMPM units). To the extent that fewer than 1,591,200 units have been invoiced at the end of the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units adding up to the minimum guarantee.

For example, assuming that the unit price is $2.00 PMPM:

· At the end of the 12-month period of performance of this line item, there were 1,600,000 units invoiced, and the Contractor was paid $3,200,000.00. The minimum guarantee of 1,591,200 units has been met and the Contractor is not entitled to any further compensation beyond the $3,200,000.00.

· At the end of the 12-month period of performance of this line item, there were 1,500,000 units invoiced, and the Contractor was paid $3,000,000.00. The minimum guarantee of 1,591,200 units has not been met. The Contractor is entitled to submit an invoice for an additional 91,200 units to meet the 1,591,200 unit minimum guarantee. At the end of the 12-month period of performance, the Contractor would submit an invoice for 91,200 additional units and be paid $182,400.00, for a total compensation of $3,182,400.00 for the period of performance of this line item.

Any invoice for additional units the Contractor is entitled to submit to meet the minimum guarantee, if any, shall be determined by the Program and submitted by the Contractor after the 12-month period of performance of this line item is complete.

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services, regarding changes to the minimum guarantee.

4 To develop the maximum quantity of 1,044,000 units for the year, the Government multiplied the estimated average number of active members anticipated during this option period by 12 months (87,000 members * 12 months = 1,044,000 PMPM units). This PMPM compensation arrangement establishes a fixed unit price to be invoiced monthly in arrears for each active member as of the close of business on the last day of the month. The number of active members is defined as the number of unique members who have demonstrated participation in the Program, as evidenced by the Contractor’s receipt of at least one medical (to include dental) claim for WTC-related services in the prior 18 months as of the last day of the month. For example: At the close of business on December 31, 2025, the number of active members would equal the number of members for whom the Contractor has received at least one medical claim for WTC-related services in the period of time starting on July 1, 2024, and ending on December 31, 2025 (18 total months). If the number of active members as of the close of business on the last day of the month is 75,000 members, for example, the Contractor would submit an invoice for 75,000 units for that month. If the number of active members as of the close of business on the last day of the month remained at 75,000 members for each month of the year, the Contractor would have cumulatively billed for 900,000 units for the year (75,000 members * 12 months = 900,000 PMPM units).

The Contractor is required to perform up to the maximum quantity of 1,044,000 units during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of units that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 887,400 units. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 775,200 units during the 12-month period of performance of this line item. This minimum guarantee was developed by multiplying the estimated minimum average number of active members anticipated during this option period by 12 months (64,600 members * 12 months = 775,200 PMPM units). To the extent that fewer than 775,200 units have been invoiced at the end of the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units adding up to the minimum guarantee.

For example, assuming that the unit price is $2.00 PMPM:

· At the end of the 12-month period of performance of this line item, there were 800,000 units invoiced, and the Contractor was paid $1,600,000.00. The minimum guarantee of 775,200 units has been met and the Contractor is not entitled to any further compensation beyond the $1,600,000.00.

· At the end of the 12-month period of performance of this line item, there were 700,000 units invoiced, and the Contractor was paid $1,400,000.00. The minimum guarantee of 775,200 units has not been met. The Contractor is entitled to submit an invoice for an additional 75,200 units to meet the 775,200 unit minimum guarantee. At the end of the 12-month period of performance, the Contractor would submit an invoice for 75,200 additional units and be paid $150,400.00, for a total compensation of $1,550,400.00 for the period of performance of this line item.

Any invoice for additional units the Contractor is entitled to submit to meet the minimum guarantee, if any, shall be determined by the Program and submitted by the Contractor after the 12-month period of performance of this line item is complete.

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services, regarding changes to the minimum guarantee.

5 To develop the maximum quantity of 780,400 medical (to include dental) claims, the Government used its projection of estimated medical claims anticipated during this option period. This line item is to be invoiced monthly in arrears for the number of finalized medical claims sent through electronic data interchange (EDI) to the Centers for Medicare & Medicaid Services (CMS), or a designated contractor of CMS, in a given month as of the last day of such month. A finalized medical claim sent through EDI is defined as a medical claim submitted by a provider, including a corrected claim or claim appeal, that has completed adjudication (approved or denied) and has been sent to CMS or a designated CMS contractor for issuance of remittance advice (and, if approved, also the issuance of payment). This definition excludes claims that are reprocessed by the TPA Contractor solely as a result of an act, omission, or error of the TPA Contractor in processing the same claim previously.

The Contractor is required to finalize up to the maximum quantity of 780,400 medical claims during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of medical claims that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 663,340 medical claims. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 601,600 finalized medical claims during the 12-month period of performance of this line item. To the extent that fewer than 601,600 finalized medical claims have been invoiced at the end of the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units (medical claims) adding up to the minimum guarantee.

For example, assuming the unit price is $2.00 per finalized medical claim:

· At the end of the 12-month period of performance of this line item, there were 700,000 finalized medical claims invoiced, and the Contractor was paid $1,400,000.00. The minimum guarantee of 601,600 finalized medical claims has been met and the Contractor is not entitled to any further compensation beyond the $1,400,000.00.

· At the end of the 12-month period of performance of this line item, there were 600,000 finalized medical claims invoiced, and the Contractor was paid $1,200,000.00. The minimum guarantee of 601,600 finalized medical claims has not been met, and the Contractor is entitled to submit an invoice for an additional 1,600 medical claims to meet the 601,600 minimum guarantee. At the end of the 12-month period of performance, the Contractor would submit an invoice for 1,600 additional medical claims and be paid $3,200.00, for a total of $1,203,200.00 for the period of performance of this line item.

Any invoice for additional units the Contractor is entitled to submit to meet the minimum guarantee, if any, shall be determined by the Program and submitted by the Contractor after the 12-month period of performance of this line item is complete.

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services, regarding changes to the minimum guarantee.

6 This CLIN may be converted to a firm-fixed-price CLIN through mutual written agreement of the Contractor and Government Contracting Officer. See the contract type conversion clause in Section C23.

Option Period 2 (9/15/2027 – 9/14/2028) Items:

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Sections 4.2 and 4.8 during the Sustainment phase.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

Period of performance: 9/15/2027 – 9/14/2028.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Section 4.3.1 during the Sustainment phase.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.7

9,500 Enrollment Applications

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.3 during the Sustainment phase, except Section 4.3.1.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.8

Period of performance: 9/15/2027 – 9/14/2028.

1,918,800

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.4 during the Sustainment phase, except NYMA EPN adoption under Section 4.4.1; initial NPN network development before SHCD under Section 4.4.2; and initial provider enrollment and credentialing under Section 4.4.3, all of which are performed during the Transition-In Period.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.5 during the Sustainment phase, except Section 4.5.2.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Section 4.5.2 during the Sustainment phase.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.9

Period of performance: 9/15/2027 – 9/14/2028.

1,094,400

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.6 during the Sustainment phase.

Severability: Severable line item.

Contract type: Firm-fixed-unit-price, to be invoiced monthly in arrears.10

814,500 Medical Claims

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes all tasks in Section 4.7 during the Sustainment phase, except Sections 4.7.5 and 4.7.6.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in arrears monthly in twelve equal installments.

12 Months

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Includes Sections 4.7.5 and 4.7.6 during the Sustainment phase.

Severability: Severable line item.

Contract type: Time-and-materials line item.11 Labor to be invoiced in accordance with the labor categories and labor rates in the labor rates table, below.

1 Job

This is an optional CLIN. This CLIN must be exercised by the Government prior to the TPA Contractor beginning work.

Description: Travel in support of Option Period 2.

Severability: Severable line item.

Contract type: Cost-only. All travel will be reimbursed at-cost in accordance with the Federal Travel Regulation, 41 C.F.R. Subtitle F.

The Contractor shall obtain written approval from the COR prior to undertaking any travel.

1 Job

7 To develop the maximum quantity of 9,500 enrollment applications, the Government used its projection for the estimated number of enrollment applications anticipated during this option period. This line item is to be invoiced monthly in arrears for the number of enrollment applications finalized in a given month as of the last day of such month. A finalized enrollment application is defined as an enrollment application submitted by the Contractor to the Program that has sufficient information for the Program to make an enrollment eligibility decision (e.g., Enroll, Deny, Defer). The determination of whether there is sufficient information is made by the Program and is based on the enrollment eligibility criteria described in the Program Administrative Manual, which is incorporated by reference herein as if fully set forth herein. The Program Administrative Manual is available at https://www.cdc.gov/wtc/ppm.html or any successor website. Enrollment applications that are determined by the Program to be incomplete (i.e., placed on Suspend) or duplicates of another enrollment application for the same unique individual are not considered finalized.

The Contractor is required to finalize up to the maximum quantity of 9,500 enrollment applications during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of enrollment applications that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 8,075 enrollment applications. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 6,500 enrollment applications. The minimum guarantee is defined both by the number of finalized enrollment applications (as such term is defined above) and the number of enrollment applications received by the Contractor but not yet finalized during the 12-month period of performance of this line item. An enrollment application that is received by the Contractor but not yet finalized means (1) an application submitted online and received in the Centralized Accessible Real-time Enterprise (CARE) Portal but does not have sufficient information for the Program to make an enrollment eligibility decision or has not yet been submitted to the Program, or (2) an application submitted through the Mail/Document Center that the Contractor has entered into the CARE Portal but does not have sufficient information for the Program to make an enrollment eligibility decision or has not yet been submitted to the Program. The Contractor is not paid for enrollment applications that are received by the Contractor but not yet finalized. Whether the minimum guarantee has been met will be determined, by the Program, using the following two-step procedure:

1. If the Contractor has finalized 6,500 or more enrollment applications during the 12-month period of performance of this line item, the minimum guarantee has been met.

2. If the Contractor has finalized fewer than 6,500 enrollment applications during the 12-month period of performance of this line item, the number of enrollment applications received by the Contractor but not yet finalized during the 12-month period of performance of this line item will then be added to the number of finalized enrollment applications during the 12-month period of performance of this line item.

a. If the total of finalized enrollment applications plus received-but-not-yet-finalized enrollment applications is 6,500 or more enrollment applications during the 12-month period of performance of this line item, the minimum guarantee has been met.

b. If the total of finalized enrollment applications plus received-but-not-yet-finalized enrollment applications is fewer than 6,500 enrollment applications during the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units (enrollment applications) adding up to the minimum guarantee of 6,500 enrollment applications.

Any invoice for additional units the Contractor is entitled to submit to meet the minimum guarantee, if any, shall be determined by the Program and submitted by the Contractor after the 12-month period of performance of this line item is complete.

For example, assuming that the unit price per enrollment application is $5.00:

· If the Contractor finalizes 8,000 enrollment applications during the 12-month period of performance of this line item, the minimum guarantee of 6,500 enrollment applications has been met and the Contractor is not entitled to any further compensation. The Contractor would be paid the unit price of $5.00 multiplied by 8,000 finalized enrollment applications, or $40,000.00.

· If the Contractor finalizes 6,000 enrollment applications during the 12-month period of performance of this line item, the Contractor would be paid the unit price of $5.00 multiplied by the 6,000 finalized enrollment applications, or $30,000.00. Assume further that 1,000 enrollment applications were received by the Contractor but not yet finalized during the 12-month period of performance of this line item. The total of finalized (6,000) plus received-but-not-yet-finalized (1,000) enrollment applications is 7,000. The minimum guarantee of 6,500 enrollment applications has been met and the Contractor is not entitled to any further compensation beyond the $30,000.00.

· If the Contractor finalizes 6,000 enrollment applications during the 12-month period of performance of this line item, the Contractor would be paid the unit price of $5.00 multiplied by the 6,000 finalized enrollment applications, or $30,000.00. Assume further that 200 enrollment applications were received by the Contractor but not yet finalized during the 12-month period of performance of this line item. The total of finalized (6,000) plus received-but-not-yet-finalized (200) enrollment applications is 6,200. The minimum guarantee of 6,500 enrollment applications has not been met. The Contractor is entitled to submit an invoice for 300 additional units (enrollment applications) to meet the 6,500 minimum guarantee (6,500 – 6,200). At the end of the 12-month period of performance, the Contractor would submit an invoice for 300 additional enrollment applications and be paid the unit price of $5.00 multiplied by 300 enrollment applications, or $1,500.00. The Contractor’s total compensation for this line item would be $31,500.00 ($30,000.00 for the 6,000 finalized enrollment applications plus the additional $1,500.00).

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services, regarding changes to the minimum guarantee.

8 To develop the maximum quantity of 1,918,800 units for the year, the Government multiplied the estimated average number of members anticipated to be eligible for benefits during this option period by 12 months (159,900 members * 12 months = 1,918,800 PMPM units). This PMPM compensation arrangement establishes a fixed unit price to be invoiced monthly in arrears for each member eligible for benefits as of the close of business on the last day of the month. The number of members eligible for benefits is defined as the number of unique individuals who are currently enrolled in the Program, meaning that they have not disenrolled from the Program and are not deceased. For example, if the number of members eligible for benefits as of the close of business on the last day of the month is 150,000 members, the Contractor would submit an invoice for 150,000 units for that month. If the number of members eligible for benefits as of the close of business on the last day of the month remained at 150,000 members for each month of the year, the Contractor would have cumulatively billed for 1,800,000 units for the year (150,000 members * 12 months = 1,800,000 PMPM units).

The Contractor is required to perform up to the maximum quantity of 1,918,800 units during the 12-month period of performance of this line item. The Contractor shall not perform above this maximum quantity. The Contractor shall notify the Government if and once it has reason to believe that the total number of units that are to be invoiced under this line item in the next succeeding 30 days is expected to exceed 85 percent of the maximum quantity of this line item, or 1,630,980 units. Any increase in the maximum quantity shall only be by mutual written agreement of the Contractor and Government Contracting Officer. See the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-unit-price services.

The minimum guarantee is 1,653,600 units during the 12-month period of performance of this line item. This minimum guarantee was developed by multiplying the estimated minimum average number of members anticipated to be eligible for benefits during this option period by 12 months (137,800 members * 12 months = 1,653,600 PMPM units). To the extent that fewer than 1,653,600 units have been invoiced at the end of the 12-month period of performance of this line item, the Contractor is entitled to submit an invoice for any additional units adding up to the minimum guarantee.

For example, assuming that the unit price is $2.00 PMPM:

· At the end of the 12-month period of performance of this line item, there were 1,700,000 units invoiced, and the Contractor was paid $3,400,000.00. The minimum guarantee of 1,653,600 units has been met and the Contractor is not entitled to any further compensation beyond the $3,400,000.00.

· At the end of the 12-month period of performance of this line item, there were 1,600,000 units invoiced, and the Contractor was paid $3,200,000.00.