DoD Civilian- Japan DRAFT PWS.docx

B. DELIVERIES OR PERFORMANCE.

Base Period: XXXX (12-month period of performance) Option Periods: XXXX

C. PERFORMANCE WORK STATEMENT (PWS).

C.1. GENERAL.

C.1.1. This contract provides supplemental health care assistance for Department of Defense (DoD) Government Civilian Employees residing or working in Japan. These services are provided through a contract offered by the DoD.

C.1.2. DoD Civilian Employees must reside in Japan to be eligible for services under this contract. Civilian Employee family members are not eligible for these services.

C.1.3. The contractor will provide the following supplemental health care assistance services: health care/provider finder services; establishing direct billing agreements on behalf of certain carriers of the Federal Employees Health Benefit Plans (FEHBPs); paying host nation providers, on behalf of the FEHBPs, for health care delivered to eligible DoD Civilian Employees at the time care is rendered; and obtaining reimbursement from the FEHBPs for payments made to host nation providers for health care services. Payments for health care services will depend on medical coverage determined by the FEHBPs.

C.2. STATUTORY AND REGULATORY AUTHORITY.

· 10 USC Sec 1599b, Employees Abroad: travel expenses; health care

· Public Law 104-191, Health Insurance Portability and Accountability Act of 1996 (HIPAA)

· 5 USC 552a, Privacy Act of 1974, as amended

· 5 USC 552, Freedom of Information Act

· DOD Instruction 5200.48 Controlled Unclassified Information, March 6, 2020

C.3. CONTRACTOR/GOVERNMENT FURNISHED ITEMS. The contractor shall furnish all necessary items, e.g., facilities, labor, services, supplies, etc., for the satisfactory performance of this contract. Government furnished property, equipment, and services may be provided under this contract. However, the contractor should be prepared to execute the required services without any Government support.

C.4. TECHNICAL REQUIREMENTS. The technical requirements for the contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in paragraph C.2.

C.5. SCOPE OF SUPPLEMENTAL SERVICES.

C.5.1. AGREEMENTS WITH THE FEDERAL HEALTH BENEFIT PLAN (FEHBP) CARRIERS

C.5.1.1. The contractor shall establish agreements with each Federal Health Benefit Plan (FEHBP) that provides coverage to DoD civilian employees located in Japan to enable execution of DBAs on behalf of the FEHBP carriers. The following carriers provide coverage for civilians residing in Japan:

· Aetna – (International Traditional Choice® Indemnity Plan) Non-appropriated Funded Employees

· American Postal Workers Union (APWU) Health Plan

· Compass Rose Health Plan

· Foreign Service Benefit Plan

· GEHA Benefit Plan

· Mail Hander’s Benefit Plan

· National Association of Letter Carriers (NALC)

· National Rural Letter Carrier’s Association (NRLC)

· Special Agents Mutual Benefit Association (SAMBA)

C.5.1.2. The contractor shall establish such agreements with the FEHBP carriers during the transition period.

C.5.1.3. The contractor’s agreements with the FEHBPs shall address the following matters, at a minimum:

· Conditions under which the contractor may establish DBAs with host nation providers in Japan on behalf of the FEHBP carrier

· Conditions under which the contractor may develop a network (or supplement the FEHBPs network) of providers who agree to accept reimbursement from the contractor on behalf of the FEHBP carriers

· Conditions under which the contractor may issue a guarantee of payment (GOP) to a host nation provider on behalf of the FEHBP carrier (consistent with the terms of the applicable policy of FEHBP coverage and billing instructions for the host nation provider)

· Conditions under which the contractor may, on behalf of the FEHBP carrier, pay host nation providers for health care delivered to eligible DoD civilian employees at the time care is rendered

· The process the contractor will follow to obtain reimbursement from the FEHBP carrier for payments made to host nation providers for health care delivered to eligible DoD civilian employees

· Notification process the contractor will follow to inform the FEHBP carrier when it opens a case which may incur insured costs

· Determination process the contractor will follow to confirm FEHBP carrier policy coverage for health care services

C.5.2. DIRECT BILLING AGREEMENTS AND GUARANTEE OF PAYMENTS

C.5.2.1. The contractor shall develop a network of providers in Japan that accept direct billing agreements for the purpose of providing cashless, claimless services to DoD Civilian employees seeking care from these providers. The direct billing agreements shall ensure the provisions and conditions required per C.5.1.3 will be met.

C.5.2.2. The contract shall establish Guarantee of Payment or other business process(es) to fulfill this requirement.

C.5.3. HEALTH CARE FINDER SERVICES

C.5.3.1. The contractor shall provide health care finder services to eligible DoD Civilian Employees that are enrolled to one of the FEHBP carriers listed in C.5.1.1.

C.5.3.2. The contractor shall offer call center operations to support health care finder services via toll-free lines 24 hours per day, seven days per week, 365 days per year.

C.5.3.3. The contractor shall assist eligible DoD Civilian Employees with gaining access to host nation providers (including, but not limited to, primary care, specialty care, urgent/emergent care, mental health care, ancillary services, durable medical equipment (DME), and pharmacy services) and issue GOPs for health care services on behalf of the FEHBP carriers. Additionally, the contractor shall ensure that its health care finder service accurately informs beneficiaries about access mechanisms, referral procedures, and any applicable rules regarding health care coverage.

C.5.3.4.The contractor shall establish a process that includes a covered benefit review; entering appropriate case notes into the contractor’s system; locating a qualified private care sector provider to provide the care on a cashless, claimless basis, when feasible; providing the beneficiary with a written care authorization that contains the health care coverage policy of the applicable FEHBP and the host nation provider’s information; and assisting the beneficiary with establishing an appointment with the host nation provider (upon beneficiary request).

C.6. MANAGEMENT.

C.6.1. The contractor shall establish and maintain effective internal management strategies, staff education and training programs, lines of authority, and reporting and coordination interfaces with the Government.

C.6.2. The contractor’s management structure shall respond to Government requirements/inquiries within four hours. The contractor shall work cooperatively with the Government to plan and develop solutions to high priority contract changes.

C.7. RECORDS MANAGEMENT.

C.7.1. Pursuant to FAR Part 24, Protection of Privacy and Freedom of Information, the requirements of 5 UCS 552a, Privacy Act and the DoD 5400.11-R, DoD Privacy Program, are applicable to this contract and the systems of records operated and maintained by the contractor on behalf of DHA. These systems of records are found at 5 USC 552, Freedom of Information Act (Health Benefits Authorization Files, Medical/Dental Care and Claims Inquiry Files, Medical/Dental Claim History Files); 69 Federal Register 50171 and 71 Federal Register 16127 (Military Health Information System); and 64 Federal Register 22837 (Health Affairs Survey Data Base). The records systems operated and maintained by the contractor are records systems operated and maintained by a DoD Agency (DHA). The contractor shall maintain all contractor records generated under this contract in accordance with 36 CFR 1222; 36 CFR Subchapter B, Records Management; 44 USC, Chapters 21, 29, 31, and 33, Federal Records Act; 44 USC, Chapter 35, Paperwork Reduction Act; DoDD 5015.2, DoD Records Management Program.

C.7.2. The contractor shall not disseminate or publish information developed or contained in the reports furnished to DHA pursuant to this contract without prior written approval from the Contracting Officer.

C.7.3. The contractor shall not use contract records for commercial marketing purposes or any other purpose not directly related to the contract. This does not include contractor-maintained provider records for private sector providers who are part of the contractor’s network and provide care to the contractor’s other corporate business clients.

C.7.4. Freedom of Information Act (FOIA) Requests. In the event the contractor receives a FOIA request, the contractor shall return it to the requestor and instruct the requestor to submit the request to DHA.FOIA@mail.mil, or

DHA Freedom of Information Service Center 7700 Arlington Boulevard, Suite 5101 Falls Church, Virginia 22042-5101 Phone: 1-703-275-6363 Fax: 1-703-275-6386

C.7.5. The contractor shall comply with records management requirements in attachment XX.

C.8. Government Indemnification. The contractor agrees to be liable for and expressly agrees to indemnify the Government from any liability resulting from services provided under the contract for care provided by contractor network providers, or, in the alternative, the contractor agrees that all provider agreements used by the contractor shall contain a requirement, directly or indirectly by reference to applicable regulations or DHA policies, that the provider agrees to indemnify the Government from any liabilities arising from any acts or omissions in the provision of health care services by the provider to the patients under this contract for care provided by contractor providers.

C.10. ACCESS TO DATA.

C.10.1. The contractor shall provide authorized Government personnel with unlimited access to all data maintained by the contractor pertaining to this contract. This data includes, but is not limited to, agreements with the FEHBP carriers, data concerning DBAs, GOPs, the provider network, program administration, customer services, and incurred cost data. All data must be current, accurate, complete and accessible.

C.10.2. Reporting requirements under the contract will be evolving and dynamic. The contractor shall provide the Government with all required reports in accordance with Government specifications at the prescribed frequency and within the timeframe requested.

C.11. SYSTEM SECURITY.

C.11.1. The contractor shall acquire, develop, and maintain processes for safeguarding unclassified, sensitive DoD information on all contractor/subcontractor systems/networks that store, process or access Government sensitive information (SI) in accordance with DFARS Clause 252.204-7012, Safeguarding Covered Defense Information and Cyber Incident Reporting.

C.11.2. Health Insurance Portability and Accountability Act (HIPAA Security Rule). The contractor shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requirements; specifically, the administrative simplification provisions of the law; the associated rules and regulations published by the Secretary, Health and Human Services (HHS); DoD 6025.18-R, DoD Health Information Privacy Regulation; the Health Insurance Portability and Accountability Act Security Compliance Memorandum (Office of the Secretary of Defense, Health Affairs (OSD/HA) Policy 06-010); and the Security Standards for the Protection of Electronic Protected Health Information.

C.11.3. Physical Security. The contractor shall employ physical security safeguards for information systems (IS)/networks involved in the operation of the contract systems of records to prevent the unauthorized access, disclosure, modification, destruction, or use, of sensitive information. The contractor’s safeguards shall be in accordance with DFARS Clause 252.204-7012 and DoD issuances listed in TRICARE System Manual.