Third Party Administrator Post Industry 1:1 Government Responses to Industry Questions

# Question Gov't Response

How will the Dental TPA RFP be released?

• Are there option to GSA Open, VETS 2, 8(a) STARS III?

• What is the NAICS code or other designations that our team would need to meet? Any special codes that direct the type of vendor or experience?

The government has not yet fully determined the acquisition approach; however, the government does not anticipate that the requirements will be set aside for small businesses.

Any capable company will be able to submit a proposal and compete for the requirement.

The NAICS code is 524292 -- Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds.

2 What is the current (or recent) number of enrolled beneficiaries in TDP-6? 1.9M? What is the current (or recent) number of enrolled families in TDP-6?

The number of enrolled beneficiaries fluctuates monthly. Trends between 1.7-1.8 million in multiple categories; sponsor plans for guard/reserve, sponsor guard/reserve individual plans which is a family member, guard/reserve family plans (2 or more), active duty individual plans (1st person enrolled), active duty family plans (2 or more), survivor individual plans (1st person) and survivor family plans (2 or more). The number of enrolled families will be shared with the Request for Proposal (RFP).

3 How will the initial Open Season work? The government has not yet determined how it will handle enrollment. However, there will not be an auto-enrollment.

4 Is BWE designed for TDP enrollments? Will Dental TPA have option for enrollment segment into DOES electronically vs the current manual process?

BWE is currently used to enroll in Dental.

No, DOES is an operator based application, there is no systemic interface for a contractor to perform enrollments on DEERS.

5 Are there access to care requirements? Will there be drive time waivers? This is not relevant to the TPA, only to TDP contractors.

6 Transfer allotment information

Depending on the government's selected enrollment approach, allotment information may be transferred from the TDP6 contractor to TPA contractor; however, the government will not be able to transfer any EFT or credit card information used for recurring payments due to banking laws.

7 Would the TPA be sending collected enrollment premiums to DHA or directly to the carriers? The TPA will collect premiums and remit them to the carriers.

8 What are the hours of operations for call center support for OCONUS?

The contractor will be required to provide OCONUS Customer service support continuously from 6:00 PM EST on Sundays to 10:00 PM EST on Fridays, and from 9:00 AM to 1:00 PM EST on Saturdays. The contractor will be required to make its phone Automated Response Unit (ARU) available 24/7/365.

9 What are the customer service standards for OCONUS?

Comprehensive, readily accessible customer services that include multiple avenues of access (for example, e-mail, World Wide Web, telephone, and facsimile) for TDP beneficiaries and providers, along with 24/7 ARU access. Standards will be released in the

RFP.

Will the TDP TPA act as a systems transactions "interpreter" for the TDP-7 contractors? Will the TDP-7 contractors transmit and receive HIPAA or X12 transactions through the TDP TPA? Similar to the EEE for CPD?

Yes, the TPA is the "interpreter" of DEERS information. The TPA will be required to handle standard transactions such as HIPAA and X12.

11 Will the contractors be competing against each other in CONUS and OCONUS or do we want to break into regions?

Yes, the TDP-7 carriers will all provide worldwide coverage - both CONUS and OCONUS;

no regions.

12 Would the TPA be sending the premiums to the carrier themselves? The TPA will collect premiums and remit them to the carriers.

13 Please confirm DHA remains responsible for the open enrollment announcement and marketing.

The government anticipates that both the TPA and the carriers will be required to include marketing in their communications plans.

14 Please confirm that beneficiaries will access and enroll via milConnect. Yes.

15 Please confirm that the TRICARE manuals will be updated prior to contract award. The TRICARE Manuals generally will not apply to the TPA contract.

16 Will DHA standardize an Interface Control Document (ICD) for all carriers (message formats, validations, error codes) to reduce DHA integration costs?

DHA will provide the requisite documents for TPA interfaces and data exchanged with government systems. The TPA is responsible for ICDs between the TPA and the carriers.

17 Please confirm the TPA is responsible for transferring encounter data to DHA systems. The TPA will not be responsible for encounter data.

18 After the TPA collects premiums, will those premiums go to DHA or directly to Dental Carriers? The TPA will collect premiums and remit them to the carriers.

19 What self-service and technology enhancements will be most beneficial to the Government for this program?

Offerors should submit self service and technology enhancements in their proposals.

However, the TPA contractor should not plan on developing any enrollment applications.

The Dental TPA Draft WBS does not mention requirements related to the Military Data Repository (MDR). Will the TDP7 Dental Carriers still have responsibility for providing dental care encounter data input to the MDR or other government repository?

No, the TPA responsibilities will not include encounter data collection or data input to the

MDR.

21 If yes to the above, does the DHA envision the TPA will perform any administrative or oversight function to ensure TDP input processing for the MDR? N/A, see above.

22 Will the TPA be required to integrate or interface with MHS GENESIS/Dentrix to validate patient dental records are current or to upload encounter data?

No, at this time, the government does not anticipate that the TPA contractor will be required to interface with MHS GENESIS/Dentrix.

23 Does the DHA envision a single carrier for OCONUS locations or is the expectation that the 2-4 carriers will have both CONUS and OCONUS networks?

The government's expectation is that all carriers will provide both CONUS and OCONUS services.

24 Will the government have multiple bidders established for TDP-7 before they issue the RFP for TPA? The TPA RFP will be issued prior to issuing the TDP-7 RFP.

25 Is it safe for the TPA to assume that all commercial dental carriers will have a standard API for interfacing with the TPA contractor? APIs between TPA and dental carriers may be industry standard.

26 Will DHA standardize APIs and data schemas for DEERS and pay centers, or allow the TPA contractor to define interfaces?

The TRICARE Systems Manual (TSM) provides the ADP/IT requirements to support APIs with DMDC/DEERS and Pay centers.

27 Would DHA consider expanding the TPA to be a marketplace for other health products (e.g., Vision)? Not at this time.

What is the TPA required security posture (e.g., FedRAMP/Impact Level, CMMC Level 2), and how will it flow down to the TDP-7 carriers? How can system controls mitigate provider impact?

DFARS clause 252.204-7012 and DFARS clause 252.204-7021 (CMMC) requirements prescribed therein apply to both TPA and TDP-7 contracts. If contractors will receive, process, transmit, or develop covered defense information (defined in DFARS 252.204- 7012), then the contractor must follow the security requirements of DFARS clause 252.204- 7012 and DFARS 252.204-7021. Cloud computing: Minimum security requirement is equivalent to FedRAMP Moderate. However, if intention is for a system interface with cloud service provider to a government system, then FedRAMP High or above is recommended.

29 For transition: How is the timing expected between TDP-TPA and TDP-Carrier? The TPA RFP will be issued prior to issuing the TDP-7 RFP. The TPA will transition in with the TDP-7 carriers over an expected 12 month transition.

30 What is DHA’s TPA-Carrier long-term strategy? Has DHA considered expanding the TDP-7 TPA role and/or capabilities be expanded to other DHA programs?

DHA is establishing the TPA requirement/contract in order to comply with the NDAA.

DHA has no current plans to expand the role/capabilities of the TPA to other DHA programs.

31 What types of performance guarantees, interoperability standards and performance incentives will DHA place on the TPA? These have yet to be established; however, DHA is open to industry input regarding these.

32 How does DHA expect to administer OCONUS dental care delivery? (single carrier v. all carriers) All carriers must deliver both CONUS and OCONUS services.

33 Is the Gov open to one organization serving as both TPA and Carrier? No.

34 What is the expected TPA and carrier procurement timeline and what is the expected duration of the TPA contract?

DHA anticipates issuing the RFP for the TPA in Q4 CY27 and the TDP7 RFP in Q1 CY28.

This timeline is subject to change. The government has not determined the duration of the contracts; however, is open to comment from industry regarding the duration.

Can DHA provide preliminary insights into the IT security posture that the TDP‑7 TPA and TDP‑7 carriers will be required to maintain? Will DHA express a preference for contractor systems operating at higher security postures, such as FedRAMP Moderate or High, or will DHA establish a single standard requirement?

DFARS clause 252.204-7012 and DFARS clause 252.204-7021 (CMMC) prescribe the standard requirements for contractors. If the contractor, and any applicable Tier 1 level subcontractor or third-party business entity that will receive, process, transmit, or develop covered defense information (defined in DFARS 252.204-7012), then the contractor must follow the security requirements of DFARS clause 252.204-7012 and DFARS 252.204- 7021. Cloud computing: Minimum security requirement is equivalent to FedRAMP Moderate. However, if intention is for a system interface with the contractor's cloud service provider to a government system, then FedRAMP High or above is recommended.

If DHA decides to use standard HIPAA transactions (270/271) for enrollment and eligibility transactions, which entity will be financially responsible for the associated fees (carrier, TPA)?

These have yet to be established; however, DHA is open to industry input on this topic.

Similar to the medical industry, where health plans directly access electronic health records and patient information, the dental industry is also establishing capabilities that allow carriers to access dental offices’ electronic health records. Would DHA contemplate having the TPA serve as the conduit to collect this information from carriers and share it with (1) MTFs, (2) TRICARE MCSCs, or integrate it into DHA systems?

No, the TPA responsibilities will not include encounter data collection or data input to the

MDR.

What level of guidance will DHA provide to carriers with respect to product design? Will carriers be able to determine deductibles, co‑pays, annual maximums, and the assignment of categories of care to benefit classes (e.g., endodontics as a Class II service, periodontics as a Class III service)? Will this vary between standard and nonstandard plan designs?

The basic or standard plan is outlined within the CFR and must be followed. For the High Option, the carriers will be able to make different determinations in plan design. The TPA will provide carrier information on the website and for customer services.

What key responsibilities will the TPA assume with respect to the beneficiary, and how will these responsibilities be delineated from the carrier model? For example, what will the TPA be responsible for regarding beneficiary engagement across pre‑sale and post‑sale activities, enrollment and eligibility, and premium deficits?

The TPA will be responsible for creating a website with a comparison tool, links to the TDP- 7 insurers' pages with their network providers listed, enrollment and dis-enrollment portal activities, collecting premiums, distributing premiums to the TDP-7 insurers.

What level of credentialing, training, and certifications will be required for OCONUS dental providers, and how will the delineation of effort between the TPA and the carrier be defined for this task?

The TPA will not be responsible for anything related to dental providers.

41 What countries is DHA requiring the TPA and/or carriers to operate in for the OCONUS component of the TRICARE Dental program?

The TPA will be U.S. based, but provide customer service in other languages as needed.

There are beneficiaries all over the globe, so access to multiple translation services may be necessary.

DHA is projecting nearly 6 million Benefit redeterminations to be sent to the TPA annually.

Can DHA provide details to the retroactive nature of these redeterminations? Are carriers responsible for retroactively adjudicating premiums, claims beyond a certain date?

Anytime a record changes in DEERS, there could be a redetermination and all retroactivity will go back to day one of the contract.

43 What entity (TPA or Carrier) will receive provider enrollment and eligibility inquiries? The TPA will conduct all enrollment/disenrollment actions and establish eligibility. No provider engagement or processes will be the responsibility of the TPA.

44 Which functions in the requirement are deemed TPA-regulated? The government anticipates that the preemption of state and local laws and regulations provided under 10 USC 1103 will apply to the TDP requirement.

Please confirm that the Government expects vendors (and applicable subs) to obtain and maintain state-by-state TPA licenses/registrations for any regulated activities (e.g., claims adjudication, eligibility/enrollment, billing, benefits administration).

See response to question 44.

46 When is proof of licensure required (proposal, award, or pre–go live)? Will phased evidence be accepted? See response to question 44.

Given the multi state member footprint, What transition period does the Government anticipate for initial TPA licensing (to account for filings, background checks, bonds, state processing variability)?

See response to question 44.

Can the Government clarify which specific system interfaces (DEERS, milConnect, DMDC services, RAPIDS, other DoD identity services) the contractor will be required to integrate with for enrollment, eligibility verification, and ongoing beneficiary updates.

Interfaces/applications the TPA contractor will be required to use will be included with the

RFP.

Can the Government clarify whether the vendor will be required to maintain direct integrations with milConnect for beneficiary self-service actions, or whether those functions remain fully owned by DMDC with the vendor consuming downstream updates only?

These have yet to be established; however, DHA is open to industry input on this topic.

Does the Government expect the contractor to use existing government-owned middleware or integration layers when exchanging data with DEERS/milConnect, or may the contractor develop independent adapters and interface solutions?

The TSM provides the ADP/IT security connectivity requirements for the TPA. The TPA and TDP-7 carriers will use industry standards for data exchanges.

51 What security protocols (e.g., CAC/PKI, EDI PI mapping, IL4/5/6 hosting) and cross domain requirements will govern the vendor’s integrations with DEERS and other DMDC systems?

The TSM provides the ADP/IT security connectivity requirements to support contractor system interface with DEERS and other DMDC system applications. The contractor shall comply with the DoD guidance regarding directed Ports, Protocols, and Services (PPS).

Please clarify whether enrollment and eligibility verification must occur in real-time with DEERS/milConnect or whether batch processing windows (e.g., daily/weekly file exchanges) are acceptable for certain transactions.

Yes, the verifications will happen in real-time as the TPA data links to DEERS and as the TPA and TDP-7 carriers exchange eligibility data. Batch reporting may be available for other transactions.

53 Are people that enroll active immediately, regardless of time of the month that enrollment happens?

We anticipate maintaining the current "20th of the month" rule, whereby if the premium is paid by the 20th of the month, the beneficiary will have access by the 1st of the following month, as long as the beneficiary pays via credit card or EFT.

Given the complexity of transitioning to a multi-carrier dental program and the need for real-time interoperability between the TPA and multiple TDP plans, how does the Government plan to mitigate risks associated with procurement delays and potential overlap in benefit periods? Would a parallel award or phased transition approach be considered to reduce disruption to beneficiaries?

We anticipate that the TPA contract and the 1-year transition-in period will take place prior to the transition-in period of the new TDP-7 contracts, giving the TPA the ample time for hiring and systems testing.

With the long acquisition timeline and rapidly evolving technical and regulatory landscape, how is the Government planning to build flexibility into the TPA and TDP-7 contracts to accommodate future changes? Is the Government open to industry recommendations on emerging technologies or capabilities that may mature prior to the anticipated 2028 implementation?

Yes, we are open to recommendations on emerging technologies and how they could be incorporated into the contract over time. However, all vendors are required to meet the DHA/DOW cyber security requirements as established in the TRICARE Operations Manual, TRICARE Systems Manual, and related federal statutes.

Considering that dental plans operate on annual benefit maximums, has the Government evaluated how transition timing may impact beneficiaries who have already utilized benefits within a plan year? Would aligning implementation with benefit cycles or using a phased approach be considered to minimize disruption?

The government intends to have dental care begin on January 1.

57 Will the Government provide centralized data infrastructure, or will this be vendor-driven? The vendor will be responsible for determining their data infrastructure; however, that infrastructure must be capable of interfacing with government systems.

58 Are there baseline volume assumptions the Government will provide to support staffing and pricing models?

Yes, the government will provide baseline volume assumptions such as beneficiary enrollment and eligible numbers, call volumes, email inquiries, self-service inquiries, etc.

59 Will the Government consider implementing performance metrics on an IOC-to-FOC basis following the transition-in vs. fully enforced at go-live? These have yet to be established; however, DHA is open to industry input on this topic.

60 Is the Government considering fixed vs. variable pricing models based on volume or performance? The government has not yet determined how it will handle the pricing structure.

61 What lessons learned from the current TDP/TPA structure is the Government looking to address in this next iteration? The TDP/TPA structure is new to the government.

62 Are there specific gaps or challenges the Government is prioritizing for improvement in this RFP? The TDP/TPA structure is new to the government.

63 Is an annual Open Season (OS) enrollment period contemplated? The government has not yet determined how it will handle enrollment.

64 The WBS stipulated credit card methodology. However, it did not clearly specify how credit-card interchange fees would be paid, whether by DHA, the carriers, or the TPA? These have yet to be established; however, DHA is open to industry input on this topic.

65 The WBS did not reference DHA’s beneficiary counseling and assistance coordinators. Could DHA clarify the expected level of collaboration? Currently, BCACs are rarely involved in dental program matters.

66 The WBS did not indicate whether DHA intends to establish rating regions for carriers or use a national flat rate. Could DHA please clarify its intended approach? Standard plans will use a flat premium rate and high plan premiums may differ by carrier.

67 The WBS did not specify who is responsible for certain enrollment and eligibility commercial print costs – whether the TPA or DHA/BWE. Could DHA clarify?

The government intent is for enrollment to be as paperless as possible (via portal or telephone).

68 Will DHA require background checks and CACs and if so at what level of staffing will that apply?

TSM requirements will be followed. Government background checks and CAC cards are necessary so that contractor personnel can access government information systems and the controlled unclassified information that resides therein. Company background checks (equivalent to NACI) will be required for personnel with access to covered defense information that resides on covered contractor information systems.

69 Is CMMC compliance required, and if so at what level? CMMC compliance will be required and level will be provided in the RFP. Expect CMMC Level 2 C3PAO.

70 Please confirm DHA will evaluate past performance based on the prime contractor and key subcontractors.

It is anticipated that past performance for the prime contractor will be evaluated. Details regarding potential evaluation of past performance of key subcontractors has not been determined. The final RFP will include all of the appropriate information.

71 We realize the required level of CMMC is not known at this time, however will an update on the required level be provided once determined?

CMMC compliance will be required and level will be provided in the RFP. Expect CMMC Level 2 C3PAO.

72 Are we looking to have the TPA monitor fraud, waste, and abuse? No. This is for care related items and will be the responsivity of the dental carriers.

73 Do we have initial year and long-term performance metrics for the TPA? For KPIs and SLAs or is it still evolving? These are being developed and will be included in the RFP.

74 Do we have innovations we are seeking from industry? Or would we be accepting of innovation suggestions from industry? Yes, we are accepting of innovation suggestions from industry.

75 With the RFP, do we plan to put out call volumes, beneficiary stats in different areas to help with the pricing? Yes.

76 Are there any operational insights from the current model the government would like to see carried over to the new model?

Time to answer calls, process enrollments, process refunds, provide the premiums to the TDP vendors, will be forthcoming.

77 Which DEERS interfaces and integration mechanisms are anticipated? Interfaces/applications the TPA contractor will be required to use will be included with the

RFP.

78 Will the TPA calculate the Paid Through Date (PTD), or will PTD determinations be performed by DMDC, similar to the medical benefit construct?

PTD will be calculated by DMDC as premiums are updated by the TPA contractor similar to the current medical/dental benefit construct.

79 How does DHA envision separating enrollment records for multiple dental carriers within DEERS (e.g., separate contractor codes within a single region or another model)? These have yet to be established; however, DHA is open to industry input on this topic.

80 What is considered a complex billing scenario?

Guard/Reserve members being called to active duty and their payments convert to ADFMs and then revert back once orders are canceled. A member divorces, but the Military Department doesn't notify DMDC for a long period of time, resulting in retroactivity and claims changes (relating to the former spouse) that then fall onto the prime carriers.

81 Will enrollment fees be considered government funds collected and remitted by the TPA, or carrier-owned premium funds? The TPA will collect premiums and remit them to the carriers.

82 If fees are remitted to carriers, may carriers exercise discretion to waive enrollment fees? Enrollment fee waivers are not anticipated at this time. The government pays their monthly portion. As a result, the bene premium cannot be waived.

83 What reconciliation, reporting, and oversight controls are envisioned between DHA, the TPA, and carriers?

The government will provide more information in the RFP and anticipates working out certain details during the transition period(s).

84 What are the customer service ownership boundaries between DHA, carriers, TPA – who owns what? The government has not yet determined its approach in this area.

The WBS requires the TPA to identify and resolve missing payroll remittances and reconcile complex billing scenarios. Where payroll allotments are requested but not remitted:

• Is the TPA expected to assume interim cash-flow exposure?

• Will DHA define aged receivable thresholds before government escalation?

• Are there statutory or regulatory constraints governing recovery actions for delinquent beneficiaries?

If allotments aren't passing through, the members would know that already since the pay centers would notify them that they've maxed out their allotment numbers, or for whatever reason, they didn't have enough pay to cover. In that case, the TPA would reach out to the member for CC or EFT payments. Or, the TPA could wait another pay cycle or another month and wait to see if allotment is now working. At that time, the TPA would request a higher total for the services to pay. Again if allotment will no longer work, then TPA will establish another means for monthly payments. DHA will define thresholds and its typically set to 60 or 90d. Yes, there are some regulations, i.e. if costs exceed 60 or 90d, then TPA may have to take a shorter period of time (perhaps 45d), so as to not exceed a certain dollar threshold. That will be covered more in the RFP. The duration of 60-90d have been increased due to government shutdowns.