Attachment 2 PSHBS SOW.docx

RFP 24322623R0004 Postal Service Health Benefits System (PSHBS) Indefinite Delivery, Indefinite Quantity (IDIQ) Contract

Office of Personnel Management (OPM) Postal Services Health Benefits System (PSHBS) Statement of Work (SOW)

1. Purpose The purpose of this single award Indefinite Delivery/Indefinite Quantity (IDIQ) Contract is to provide a vehicle for OPM to establish the Postal Service Health Benefits (PSHB) Program, that will offer health insurance coverage to an estimated 1.7 million United States Postal Service (USPS) employees, annuitants, and their eligible family members. The PSHB Program is authorized under Title I, Section 101 of The Postal Service Reform Act (PSRA, Pub. L. 117-108), which requires OPM to establish and operate the Program with a separate risk pool from the Federal Employees Health Benefits Program (FEHB).

2. Scope For this contract, OPM is seeking a contractor that can support the objectives listed below. The objectives require that the contractor provide a comprehensive suite of IT services and solutions to support the development of a scalable PSHB system using software development in a variety of environments and infrastructures. To meet PSRA statutory requirements, the contractor will work with OPM to develop and deliver a Postal Service Health Benefits System (herein referred to as PSHBS, or “the system”). Although the initial user base will include 1.7 million USPS enrollees, the system will be built using scalable, flexible technology that enables OPM to (potentially) service an additional 6.5 million federal employees, annuitants, and eligible family members enrolled in the FEHB.

Additionally, the scope and objectives of this IDIQ include a customer support center that will service PSHB employees, annuitants, and family members. Services provided include, but are not limited to, eligibility determinations, enrollment support, and enrollment and premium reconciliation.

Additional services under the scope of this contract include, but are not limited to, documentation, operations, deployment, cybersecurity, configuration management, training, commercial off-the-shelf (COTS) product management and utilization, technology refresh, data and information services, information display services and business analysis for IT programs.

3. Objectives The objectives identified within this SOW are described in general terms. Each task order will address specific requirements, project scheduling, and other related performance criteria, as applicable. The objectives will establish and sustain a scalable system to be deployed in a cloud environment. The following are key objectives for this IDIQ:

· Develop and deliver a new scalable PSHBS utilizing an agile methodology

· Sustain and maintain the newly developed PSHBS

· Stand up and operate a Customer Service Center

· Scale PSHBS to service approximately 6.5 million federal employees, annuitants, and eligible family members.

4. High-Level Technical Objectives

4.1 PSHBS Functional Objectives (Core Task Order)

PSHBS Functional Objectives include, but are not limited to:

4.1.1 Project management

4.1.2 Business Rules Management

4.1.3 Data Analytics and Reporting

4.1.4 Data Integration

4.1.5 Decision Support

4.1.6 Direct Payment

4.1.7 Eligibility Determination

4.1.8 Enrollment Management

4.1.9 Enrollment Processing

4.1.10 Enrollment Reconciliation

4.1.11 Financial Management Integration

4.1.12 Health Plan and Benefit Management

4.1.13 Premium Reconciliation

4.1.14 System Training

4.1.15 Printing and Mailing

4.1.16 Chat bot and push notification capability

4.1.17 Mobile response capability

4.1.18 Auditing Capabilities

4.1.19 Reporting functionalities and capabilities

4.1.20 Workflow and Task Management Capabilities

· Functional Objectives and associated requirements are more fully defined in the PWS and RTM.

4.2 PSHBS Non-Functional Objectives (Core Task Order)

PSHBS Non-Functional Objectives include, but are not limited to:

4.2.1 Project Management

4.2.2 Project Document Management

4.2.3 Cybersecurity compliance as defined in Section 5.

4.2.4 Systems engineering, including technical and technical management processes

4.2.5 System architecture and design documentation

4.2.6 Technical solution design, creation, and implementation using a defined business process, user stories, and/or business use cases

4.2.7 Software development using a hybrid of Enterprise Agile (e.g., Scaled Agile) and traditional program management methodologies.

4.2.8 Visual and Content Design

4.2.9 Phased Implementation and Operations

4.2.10 Data Governance

4.2.11 Data Architecture

4.2.12 Data or system migration

4.2.13 Build, testing, implementation and integration

4.2.14 Cloud hosting in OPM’s Azure cloud or a public cloud-hosted environment that is FedRAMP moderate.

4.2.15 Systems Training

4.2.16 Financial Management Integration

4.2.17 Accessibility, including Section 508 Compliance

4.2.18 System Manageability and Reporting Capabilities

4.2.19 System Scalability

4.2.20 Availability

4.2.21 Graphic User Interface

4.2.22 Supportability

4.2.23 Audit and Audit Reporting Capabilities

4.2.24 Integration Services

4.2.25 Test Management

4.2.26 Continuous Improvement Process

4.2.27 Operations and Maintenance

4.2.28 IT Service Management based on the ITIL framework

4.2.29 Decommission planning and execution

· Non-Functional Objectives and associated requirements are more fully defined in the PWS and RTM.

4.3 Customer Service Center Services (Optional Task Order)

Customer Service Center objectives include, but are not limited to:

4.3.1 Technology that integrates with the PSHB system, including a Customer Relationship Manager (CRM), Automated Call Distribution (ACD), Interactive Voice Response (IVR), call recording, call back assist, co-viewing capability, fax, email, TTY/TDD, and the ability to initiate warm transfers to external entities

4.3.2 Recruiting, training, and staffing Customer Service Representatives (CSRs)

4.3.3 Recruiting, training and staffing for enrollment support

4.3.4 Recruiting, training and staffing eligibility verifications and exception request determinations

4.3.5 Content development and management

4.3.6 Recruiting, training, and staffing for premium and enrollment reconciliation

4.3.7 Regular and ad-hoc reporting, including maintaining a real-time data dashboard

4.3.8 Service desk, field and technical support to include access management, event management, incident management, problem management, and request fulfillment

4.3.9 Customer and user training

4.3.10 Creating and updating system documentation

4.3.11 Ability to implement an integrated customer service center capability and provide trained personnel, both of which can scale to support Open Season surge requirements, supporting end user needs.

4.4 FEHB Scalability Objectives (Optional Task Order)

FEHB Scalability Objectives include, but are not limited to:

4.4.1. The PSHBS system will be built using scalable, flexible technology that enables OPM to service approximately 6.5 million additional federal employees, annuitants, and eligible family members.

5. Other Considerations

5.1 Security

The Contractor shall satisfy all applicable requirements in the appendix entitled “OPM_Cyber_Language_IT_Acquisitions_2022-11-02". All requirements shall be interpreted by the Contractor as applicable and mandatory unless stated otherwise in writing by the OPM.

5.2 Other Direct Costs (ODCs)

ODCs, if applicable, will be addressed and approved by the COR at the task order level and will be paid on a reimbursable basis.

5.3 Travel

All travel, if applicable, will be defined and priced as Not to Exceed at the task order level. Travel by air shall be negotiated at a fair and reasonable price, not to exceed coach fare. The costs for meals and incidental expenses incurred by Contractor(s) personnel shall be considered reasonable and allowable to the extent they do not exceed, on a daily basis, the per diem rates set forth in the Federal Travel Regulations (FTR). Travel by privately owned vehicle shall be at the current GSA approved mileage rate. Traveling expenses within a 50- mile radius of a selected delivery facility/location will not be reimbursed. Except as indicated above, the Contractor(s) will be reimbursed for actual travel expenses incurred, in accordance with the FTR and FAR Part 31.205-46 - Travel costs. Contractor(s) or its representatives who incur travel costs in excess of the amount negotiated and agreed upon for each activity do so at its own expense.

5.4 OPM/GAO Review

The contractor has an obligation to continue to maintain its financial resources and financial stability throughout the life of the contract. The contractor must permit OPM and the Government Accountability Office (GAO), through OPM, to examine its records to the extent necessary for OPM and GAO to carry out their functions and responsibilities. All information in the contractor’s program can be used by GAO or OPM Office of the Inspector General (OIG) to audit the program. OPM intends to use these reports for a variety of purposes, but also to determine if the contractor has met the goals and to determine if the contractor has adequate financial resources to continue to perform the contract. In the event the Government (OPM or GAO) determines, through reviews of the contractor’s financial records, that the contractor no longer has adequate financial resources or financial stability to assure future performance without increased risk or concern over the security or performance of the program or its finances, the Government reserves the right to terminate this contract for cause under FAR 52.212-4(m).

6. Place of Performance The primary place of performance shall be specified at the task order level.

7. Contract Period The contract period for this IDIQ contract is 7 years from date of contract award. The contract period is defined as the time period the overarching IDIQ contract is active.

7.1 Ordering Period

The ordering period for this IDIQ contract is 7 years. The ordering period is defined as the time period that task orders can be issued under this contract.

7.2 Period of Performance (PoP)

This contract does not have a period of performance as performance occurs at the task order level. The PoP shall be specified in each task order that is awarded under this contract. All task orders must be solicited and awarded prior to the contract ordering period expiring. The PoP under any task order issued cannot exceed five years AND cannot extend more than five years beyond the end of the ordering period.

7.3 Continuation of Task Order Performance

In accordance with FAR clause 52.216-22—Indefinite Quantity (Oct 1995), task order performance is allowed to continue up to 60 months after the ordering period and contract period has expired. The contract shall govern the Contractor’s and Government’s rights and obligations with respect to that order to the same extent as if the order were completed during the contract’s effective period; provided, that the Contractor shall not be required to make any deliveries under this contract after 84 months (7 years) of the ordering period and contract period expiring. The terms and conditions of the base contract remain valid and in full force and effect for the performance of any task order, including any exercise of options contained on the task order, during the contract's period of performance beyond the contract's effective period for placing orders.

8. Quality Assurance Surveillance Plan (QASP) This IDIQ contract will not have a QASP as performance occurs at the task order level. Each task order will have a QASP specific to the requirements issued under that task order.

9. Government Furnished Property (GFP) OPM will provide office space and reasonable accommodation, including all necessary identification to ease building access and communications, to include badges, phones, and computers. All other GFP will be documented and identified at the task order level.

10. Subcontracting ALL subcontractors proposed regardless of business size of the prime or the subcontractor, MUST:

Be actively registered in SAM, not subject to any offsets, and not have any active exclusions; AND Be a U.S. owned company, doing business physically within the 50 United States or District of Columbia, performing under this contract from within those geographic limitations, and all employees supporting the performance of this contract must be physically located within the 50 United States or District of Columbia; AND Disclose any previous company names / DUNS, parent company or subsidiary, related to the current company (including but not limited to any mergers, acquisitions, consolidations, novation, or other changes in name, DUNS number, or structure) for the past eleven (11) years, as well as any bankruptcies filed by any of those entities. Subcontractors must have had no bankruptcies under any company names or DUNS used at present or for the past eleven (11) years.

In accordance with OPM clause 1752.209-71 Contractor’s Key Personnel, any post award changes involving individual subcontractors that are deemed to be key personnel may be considered with Government approval however, in addition to the above requirements and any subcontract clauses, the contractor must be careful to ensure that the small business minimum requirements (30% of total contract value) are maintained when replacing or eliminating subcontractors.

The prime Contractor is required to submit eSRS IAW 52.219-9, to demonstrate its yearly subcontracting goals are being met.

11. Additional Potential Mandates OPM benefit programs are highly visible and receive a great deal of scrutiny from Congress, the press, employee unions, and other employee/annuitant organizations. In addition, legislative and regulatory changes to programs and executive order mandates can occur at any time, impacting services business rules, process flows, and customer service demands. Such mandates may include (but are not limited to) bringing in new populations that were previously not eligible for any of the programs administered by the contractor.

To accommodate new mandates, OPM may need to adjust the method of payment or funding source previously specified for any task order. Some new mandates may require adjustments to the funding sources and payment methods of certain task orders for compliance with regulations. The prices of the affected task orders will remain firm-fixed price and will not be subject to renegotiation should there be more than one method of payment or funding source identified by the Government as a result of these mandates.

The contractor must always be prepared to operate with transparency, be accountable to a wide variety of stakeholders, and accommodate legislative and/or executive order mandates within the timeframes specified and without any additional cost to the Government or participants.

12. Prevention and Reporting of Fraud, Waste, and Abuse Definitions and Examples: For the purposes of this Contract:

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud the Postal Service Health Benefits Program (PSHB) or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any of the aforementioned programs. Acts of fraud might be committed by a contractor, a subcontractor, a provider, and/or a beneficiary/enrollee in any of the programs administered by the contractor, including PSHB. It includes any act that constitutes fraud under applicable Federal law.

Examples include but are not limited to the following:

· Enrolling dependents who are not the enrollee’s legal dependents.

· Falsifying enrollment or eligibility information

· Falsifying enrollment data

· Unauthorized access to, removal of, or use of enrollee Personally Identifiable Information (PII) by prime, subcontractor or employee of either.

· Diverting funds for personal use.

· Purposefully misrepresenting or altering enrollee data

· Providing bank account information not belonging to the enrollee for the purpose of enrollee’s premium payment or deduction.

Waste is the expenditure, consumption, mismanagement, use of resources, practice of inefficient or ineffective procedures, systems, and/or controls to the detriment or potential detriment of entities. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources. Waste might be committed by a contractor, a subcontractor, a provider, and/or a beneficiary/enrollee in any of the programs administered by the contractor including PSHB.

Examples include but are not limited to the following:

· Using government or contractor time, money, or resources for personal matters.

· Failing to implement standard industry waste prevention measures.

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the contractor or any programs administered by the contractor, improper billing/deductions from payroll or bank accounts. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors. Abuse might be committed by a contractor, a subcontractor, a provider, and/or a beneficiary/enrollee in any of the programs administered by the contractor including the PSHB.

Examples include but are not limited to the following:

· Overbilling an enrollee

· Deducting premiums beyond date of death for a deceased enrollee

· Willfully embedding ransomware, malware etc. on the contractor’s website by a contractor or subcontractor, or an employee of either.

12.1 Prevention, Detection, Investigation, and Reporting Requirements The contractor must perform the following activities to prevent, detect, investigate, and report FWA related to the contract, the services it monitors and comes in contact with:

1. Develop programs to prevent, detect, and identify persons and organizations involved in suspicious claim activity.

· Programs should identify potential FWA issues, identify program vulnerabilities, initiate action to deny or suspend payments where there is potential FWA, develop and refer cases to OPM’s Office of Inspector General (OIG) for consideration of civil and criminal prosecution and/or application of administrative sanctions, and provide outreach to providers and beneficiaries.

· Conduct investigations of FWA allegations referred by internal plan sources or external sources

· Internal: customer service, claims, underwriting, internal audit, utilization/medical review, etc.

· External: fraud hotlines, health care task forces, law enforcement liaison, OPM referrals, OIG data requests, etc.

· Maintain a database(s) or case tracking system of all FWA cases opened, active, pending, and closed

· Containing, at a minimum, the case name, the case number, subject names, addresses, basic identifiers (SSN, if available; Tax Identification Numbers; NPI’s), specific allegations, investigative activity, case status and disposition, the contractor’s exposure, funds identified as a loss, funds recovered, funds saved as a result of cancellations, referral agency, date of referral, disposition of referral, and how the case was detected.

· The contractor must perform tracking for all cases/investigations from all sources – both internal and external.

· Upon request, the contractor must also establish a process to enable OPM- OIG access to this FWA information, database(s), or case tracking system.

2. Provide claims data upon request from OPM-OIG in the required format per these guidelines and track all data requests separately.

3. Provide liaison and investigative support to OPM-OIG, other law enforcement agencies, and personnel upon request.

· Investigative support may include but is not limited to the following: providing claims data analysis, appropriate professional review, policy guidelines, provider contracting agreements, hard copy claims, explanation of benefits, and copies of cashed checks (considered substantial support for the Fraud and Abuse Annual Report, item: OPM-OIG Reported Recoveries - Substantial Support).

· The contractor is required to report the receipt of subpoenas that relate to FWA to OPM-OIG. The contractor must notify OPM-OIG upon receipt of a subpoena or request from an office of inspector general other than OPM-OIG prior to responding.

4. Track all provider and member case notifications sent to OPM-OIG and all other law enforcement agencies and provide an annual report of such activity to OPM and OPM-OIG.

5. Provide annual FWA reports using the FWA Report Template, due April 15th of each year, to the program POC and COR.

12.2 Additional Industry Standards

The contractor must have at minimum, the following commercial industry-based program standards to prevent, detect, investigate, and report all related FWA. The contractor is encouraged to continue with and share additional practices and procedures with OPM.

a. FWA Hotlines: Establish and maintain a fraud hotline for reporting allegations of FWA, both internally and externally, via telephone and/or computer base, and track all reports. Hotlines should be available to providers, enrollees, employees, and others. Compliance programs should prohibit retaliation against whistleblowers.

b. Formal Employee Training: Ensure FWA awareness training is conducted for all employees, underwriting departments, and subcontractors engaged in the contract.

· Training should consist of an overview of specific FWA reporting requirements, debarment policies, and procedures to enable personnel to identify and handle potentially fraudulent claims submitted. The training shall include, but not be limited to, the following areas as appropriate and related to the contract: Overcharging and overpayment detection, duplicate billing, enrollment discrepancy, and the requirements related to notifying and referring potential fraud cases to OPM and OPM-OIG.

· Training should include a review of the contractor’s FWA Manual.

· Training should include all relevant Federal criminal and civil statutes and laws related to healthcare FWA.

· Instruction format may be classroom instruction, self-guided instruction, videotape, seminar, conference, computer based or by any other means available.

· The contractor must maintain records of training for all personnel working on the Contract and employed by the contractor or any of its subcontractors.

· The contractor employees must obtain annual training from an external organization such as the National Healthcare Anti-Fraud Association (NHCAA), the Association of Certified Fraud Examiners (ACFE), America’s Health Insurance Plans (AHIP), etc.

c. Enrollee Education: Inform enrollees about FWA practices via newsletters, web sites, or other means.

d. Fraud Protection/Detection Software: Use Fraud Protection Software to analyze claims data. Software should evaluate on a prospective claim-by-claim basis and through the retrospective analysis of claim trends from either providers and/or members.

e. Private Information Security: Implement safeguards to protect claims, member, and provider information from unauthorized use or access.

f. FWA Manual: Publish a FWA prevention, detection, investigation, and reporting manual. The manual must include all plans, policies, and procedures involved in the contractor’s fraud, waste, and abuse program. The manual must be provided (either electronically or hard copy) to all contractor personnel, and a copy to OPM by June 1, 2025. It should include the following, at minimum:

· An anti-fraud policy statement providing your corporate strategy to address FWA

· Written policies and procedures, followed by all personnel, for the prevention, detection, and identification of FWA

· Information for anti-fraud personnel and subcontractors regarding general investigation guidelines, investigative planning, retrospective claims analysis, interview procedures, prospective claims, review, report writing, information disclosure, law enforcement relations, and all contractor FWA related reporting requirements

· The composition, structure, duties, and functions of anti-fraud personnel and subcontractors, including names, titles, and contact information

· Procedures for referral of potential FWA issues to the contractor anti-fraud personnel

· An overview and listing of all relevant Federal laws that pertain to healthcare billing violations, including all relevant criminal and civil laws

· Formal FWA training requirements for all anti-fraud personnel

· Information about fraud hotlines as related to the PSHBS, the phone number, email address, and on-line module or web-based method for submitting a complaint or referral

· Established security safeguards to protect claims, member, and provider information from unauthorized use or access

· Information related to the education of enrollees and contracted providers about FWA issues via newsletters, websites, and/or other means of education

· An Appendix page listing all minimum requirements herein, along with all other plan items included by the contractor

Manuals must be routinely updated, kept current, and list all revisions and dates of revision.

13. Deliverables The following deliverables are specific to the IDIQ. Each task order will identify all required deliverables specific to the task order.

FWA Manual Yearly Subcontracting Goals Report

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