75D301-25-R-73216 Amend 0009.pdf

CODE FACILITY CODE

X

CODE

4. REQUISITION/PURCHASE REQ. NO.

Centers for Disease Control and Prevention

Chamblee Campus Building 102, MS S102-4

4770 Buford Hwy

Atlanta, GA 30341-3717

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

3. EFFECTIVE DATE

05/20/2025

1. CONTRACT ID CODE

9A. AMENDMENT OF SOLICITATION NO.

75D301-25-R-73216

9B. DATED (See Item 11)

01/16/2025

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (See Item 13)

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

PAGE OF PAGES

1 296

2. AMENDMENT/MODIFICATION NO.

6. ISSUED BY

CODE

7. ADMINISTERED BY (If other than Item 6)

5. PROJECT NO. (If applicable)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, X is not extended. Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing Items 8 and 15, and returning _1_ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or

(c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEGMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION

OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

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

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

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN

ITEM 10A.

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

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

D. OTHER (Specify type of modification and authority)

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

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

See page 2 for description of the amendment.

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

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

BY

(Signature of Contracting Officer)

16C. DATE SIGNED

NSN 7540-01-152-8070

PREVIOUS EDITION UNUSABLE 30-105

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

75D301-25-R-73216 Amendment 0009

Block 14 continuation page.

The purpose of this amendment is to:

(a) Revise the Performance Work Statement (PWS).

(1) Section 4.4.3 – Provider Enrollment and Credentialing. Clarify that Medicare enrollment may be a requirement for certain Providers, and that the TPA Contractor is responsible for confirming that such providers are both enrolled and in good standing with Medicare.

(2) Section 4.6.4 – Medical Claims Submission and Processing, Incomplete or Inaccurate EFT Information. Clarify that the TPA Contractor is responsible for obtaining complete and accurate EFT information from providers, and that EFT information is required for issuance of medical claim reimbursement payments subject to limited exceptions requiring the approval of the Program.

(b) Revise Section D

(1) Attachment ATT016_TPA_WTCHP Provider Terms and Conditions is revised in version 4 to clarify that payment of medical claims shall be made via EFT unless an exception has been granted by WTC Health Program. Please note: This attachment will be provided to each prospective offeror that has already completed and returned to CDC Attachment ATT104, Offeror Non-Disclosure Agreement (NDA). See footnote #83 regarding the process for obtaining non-public attachments.

(2) Attachment ATT110_TPA_Questions and Answers is revised.

All other terms and conditions remain unchanged.

Written proposals remain due by May 30, 2025, at 4:30pm ET.

SECTION B - CONTINUATION OF SF1449

Base/Transition-In Period (10/30/2025 – 10/29/2026) Items:

ITEM SUPPLIES / SERVICES QTY / UNIT UNIT

PRICE

EXTENDED

PRICE

0001 Transition-In related services

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: 10/30/2025 – 10/29/2026.

1 Job

0002 Travel

Description: Travel in support of contractually required meetings and events in the Base/Transition-In Period and all other travel in support of Transition-In activities.

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: 10/30/2025 – 10/29/2026.

1 Job

1 This contract line item number (CLIN 0001) 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 (10/30/2026 – 10/29/2027) Items:

ITEM SUPPLIES / SERVICES QTY / UNIT UNIT

PRICE

EXTENDED

PRICE

1001 Contract management and regulatory compliance

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 10/30/2026, except ad hoc all-member and targeted letters under Section 4.2.5 which are included under CLIN 1011. 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: 10/30/2026 – 10/29/2027.

12 Months

1002 Member services: enrollment application processing

Contractor beginning work.

Description: Includes Section 4.3.1 upon SHCD on 10/30/2026. 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

EXTENDED

1003 Member services: existing members

Contractor beginning work.

Description: Includes all tasks in Section 4.3 upon SHCD on 10/30/2026, 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

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

1004 Provider network management

Contractor beginning work.

Description: Includes all tasks in Section 4.4 upon SHCD on 10/30/2026, 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

EXTENDED

1005 Medical benefits administration and policy

Contractor beginning work.

Description: Includes all tasks in Section 4.5 upon SHCD on 10/30/2026, 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

1006 Utilization management

Contractor beginning work.

Description: Includes Section 4.5.2 upon SHCD on 10/30/2026. 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

1,044,000 on active members only)

EXTENDED

1007 Claims processing

Contractor beginning work.

Description: Includes all tasks in Section 4.6 upon SHCD on 10/30/2026. 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

1008 Data and business information management

Contractor beginning work.

Description: Includes all tasks in Section 4.7 upon SHCD on 10/30/2026, 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

EXTENDED

PRICE

1009 Data and information exchanges, integrity, and governance

Contractor beginning work.

Description: Includes Sections 4.7.5 and 4.7.6 upon SHCD on 10/30/2026. 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.

1010 Travel

Contractor beginning work.

Description: Travel in support of contractually required meetings and events in 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.

EXTENDED

PRICE

1011 Ad hoc all-member and targeted letters

This is an optional CLIN. This CLIN must be

Contractor beginning work.

Description: Mail merge, printing, and mailing of ad hoc letters for all members or a targeted subset of the member population under Section 4.2.5. The Government will provide the content of these letters. This CLIN applies to the ad hoc letters described on page 1 of Attachment ATT008 (“the Communications and External Affairs Team [CEAT] estimates that approximately 5 all-member letters and 5 targeted member letters are sent out annually”). This CLIN does not include any of the enrollment letters, certification letters, or other letters, as described in Attachment ATT008.

Additionally, this CLIN includes the task to mail Member Handbooks to members upon request under Section 4.3.6. The Government will provide printed copies of the Member Handbooks to the

TPA.

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, 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-

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 (10/30/2027 – 10/29/2028) Items:

EXTENDED

PRICE

2001 Contract management and regulatory

Contractor beginning work.

Description: Includes all tasks in Sections 4.2 and

4.8 during the Sustainment phase, except ad hoc all-member and targeted letters under Section 4.2.5 which are included under CLIN 2011.

Severability: Severable line item.

Contract type: Firm-fixed-price. To be invoiced in

Period of performance: 10/30/2027 – 10/29/2028.

2002 Member services: enrollment application

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

EXTENDED

2003 Member services: existing members

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

1,918,800 on members

2004 Provider network management

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

EXTENDED

2005 Medical benefits administration and policy

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

2006 Utilization management

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

1,094,400 on active

2007 Claims processing

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

EXTENDED

2008 Data and business information management

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

2009 Data and information exchanges, integrity, and

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, EXTENDED

2010 Travel

Contractor beginning work.

Description: Travel in support of contractually required meetings and events in 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

EXTENDED

PRICE

2011 Ad hoc all-member and targeted letters

This is an optional CLIN. This CLIN must be of the member population under Section 4.2.5. The Government will provide the content of these letters. This CLIN applies to the ad hoc letters described on page 1 of Attachment ATT008 (“the Communications and External Affairs Team [CEAT] estimates that approximately 5 all-member letters and 5 targeted member letters are sent out annually”). This CLIN does not include any of the enrollment letters, certification letters, or other letters, as described in Attachment ATT008.

Additionally, this CLIN includes the task to mail Member Handbooks to members upon request under Section 4.3.6. The Government will provide printed copies of the Member Handbooks to the

TPA.

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, 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

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 applications, or $1,500.00. The Contractor’s total compensation for this line item would be $31,500.00

Additionally, see the clause in Section C24, Changes in the maximum quantity or minimum guarantee for firm-fixed-

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. The minimum guarantee of 1,653,600 units has not been met.

The Contractor is entitled to submit an invoice for an additional 53,600 units to meet the 1,653,600 unit minimum guarantee. At the end of the 12-month period of performance, the Contractor would submit an invoice for 53,600 additional units and be paid $107,200.00, for a total compensation of $3,307,200.00 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-

9 To develop the maximum quantity of 1,094,400 units for the year, the Government multiplied the estimated average number of active members anticipated during this option period by 12 months (91,200 members * 12 months = 1,094,400 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 1,094,400 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 930,240 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 788,400 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 (65,700 members * 12 months = 788,400 PMPM units). To the extent that fewer than 788,400 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 788,400 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 788,400 units has not been met. The Contractor is entitled to submit an invoice for an additional 88,400 units to meet the 788,400 unit minimum guarantee. At the end of the 12-month period of performance, the Contractor would submit an invoice for 88,400 additional units and be paid $176,800.00, for a total compensation of $1,576,800.00 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…