HCBS Request for Proposal 1145PC22R0001.pdf

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Solicitation #1145PC22R0001

Peace Corps Office of Health Services

Health Care Benefits Services

Request for

Proposal (RFP)

#1145PC22R0001

February 11, 2022

TABLE OF CONTENTS

SECTION A – SOLICITATION/CONTRACT FORM

A.1. Issuing Office

A.2. Contract Type

A.3. Term of Contract

A.4. Effective Date

A.5. Receipt of Proposals

SECTION B – SUPPLIES OR SERVICES AND COSTS/PRICES

B.1. CLIN Structure

B.2. Contract Summary

SECTION C – DESCRIPTION/SPECIFICATIONS/PERFORMANCE

WORK STATEMENT

C.1. Introduction

C.2. Technical Requirements

C.3. Transitions

C.4. Invitee Cost-Reimbursement Administrative Services (Plan 1)

C.5. Health Care Administrative Services for Peace Corps Volunteers (PCVs) (Plan 2)

C.6. Health Care Administrative Services for Returned Peace Corps Volunteers (RPCVs) (Plan 3)

C.7. Access to Short-Term Group Health Insurance (Plan 4)

C.8. Medical Claims

C.9. Automated Eligibility And Authorization System

C.10. Data and Reporting Requirements

C.11. Historical Beneficiary Demographics and Claims History

C.12. Rights Reserved for the Peace Corps

SECTION D – PACKAGING AND MARKING

D.1. Packaging

D.2. Marking

SECTION E – INSPECTION AND ACCEPTANCE

E.1. Inspection and Acceptance

E.2. Inspection Location

E.3. Quality Assurance Surveillance Plan (QASP)

E.4. Acceptance

E.5. Clauses Incorporated by Reference

SECTION F – DELIVERIES OR PERFORMANCE

F.1. Period of Performance

F.2. Delivery

F.3. Place of Performance

F.4. Notice Regarding Late Delivery

F.5. Clauses Incorporated by Reference

SECTION G – CONTRACT ADMINISTRATION DATA

G.1. Contracting Officer’s Authority

G.2. Contracting Officer’s Representative

G.3. Contractor Representative

G.4. Invoice and Payment Instructions

G.5. End of Health Care Delivery

G.6 Withholding of Contract Payments

SECTION H - SPECIAL CONTRACT REQUIREMENTS

H.1. Loss/Damages

H.2. Confidentiality

H.3. Privacy and Security of Protected Health Information

H.4. Compliance with Federal, State, Local, and Foreign Requirements

H.5. Protection of Information

H.6. Contractor Required Insurance

H.7. Advertising of Award

H.8. Use of Peace Corps Name and Logo

H.9. Small Business Subcontracting Plan Requirements

H.10. Key Personnel

H.11 Information Security

H.12 Data Rights

H.13 Nonfederal Systems and Organizations – IT Security and Privacy

Requirements H.14 PC Security Compliance Requirements H.15 Reporting and Continuous Monitoring

H.16 Deliverables to be provided Quarterly to the PC Information System

Security Officer (ISSO), Information System Security Manager (ISSM), and/or Contracting Officer (COR)

H.17 Privacy Assessment Activities and Required Documentation

H.18 Deliverables to be provided annually or when there is a major change to the PC ISSO, ISSM, and/or COR

H.19 Additional Stipulations

H.20 System Accessibility And Ease Of Use H.21 Breach Of Information Notification Requirement

H.22 Organizational Conflict Of Interest

H.23 Economic Price Adjustment (EPA) Clause

H.24 Statutory and Regulatory Authority

SECTION I - CONTRACT CLAUSES

I.1. Clauses Incorporated by Reference

I.2. Clauses Incorporated in Full Text

SECTION J - LIST OF DOCUMENTS, EXHIBITS, AND OTHER ATTACHMENTS

SECTION K – REPRESENTATIONS, CERTIFICATIONS, AND OTHER

STATEMENTS OF OFFERORS

K.1. Clauses Incorporated by Reference K.2. Clauses Incorporated In Full Text

SECTION L - INSTRUCTIONS, CONDITIONS, AND NOTICES TO

OFFERORS

L.1. Clauses Incorporated In Full Text

L.2. General Instructions

L.3. Organizational Conflict Of Interest

L.4. Inquiries Concerning This Solicitation

L.5. Proposal Preparation And Solicitation Response Requirements

L.6. Volume I – Executed Offer

L.7. Volume II – Technical Proposal

L.8. Volume III - Past Performance

L.9. Volume IV– Price Proposal

L.10. Subcontracting Plan and Small Business Participation

SECTION M EVALUATION FACTORS FOR AWARD

M.1. FAR 52.217-5 Evaluation of Options (Jul 1990)

M.2. General

M.3. Evaluation Factors And Relative Weight

M.4. Evaluation Factor 1 – Technical Approach

M.5. Evaluation Factor 2 – Past Performance

M.6. Evaluation Factor 3 – Price

M.7. Evaluation Factor 4 – Subcontracting Plan And Small Business

Participation

SECTION A – SOLICITATION/CONTRACT FORM

A.1. Issuing Office This solicitation is for Peace Corps Health Care Benefits Services and is being issued by the Peace Corps, Office of the Chief Financial Officer, Acquisition and Contract Management (ACM), hereafter referred to as ACM, on behalf of the Office of Health Services (OHS).

A.2. Contract Type A Firm Fixed Price (FFP), Fixed Price Economic Price Adjustment (FP EPA), and Time and Materials (T&M), contract (hereafter referred to as contract) is expected to be awarded.

A.3. Term of Contract This contract will be awarded to one Offeror for a one-year base Period, with four (4) one (1) year option periods.

A.4. Effective Date This contract (“Contract”) is made effective as of * see below (“Effective Date”), by and between Peace Corps and , (to be filled in by Offeror) a (i.e. corporation) (to be filled in by Offeror ) organized and existing under the laws of the State of (to be filled in by Offeror).

*This contract shall be effective as of the date the contract is executed by the Contracting Officer (CO), at which time the Contractor shall commence work in accordance with the terms and conditions herein.

A.5. Receipt of Proposals All copies of an Offeror‘s (or subcontractor’s) proposal must be submitted by the time and date in Block 9 of Standard Form (SF) 33 to the email addresses below:

Noemi Edwards, Contracting Officer nedwards@peacecorps.gov and

Avery Stevenson, Contract Specialist astevenson@peacecorps.gov

(End of Section A) mailto:nedwards@peacecorps.gov mailto:astevenson@peacecorps.gov

SECTION B - SUPPLIES OR SERVICES AND COSTS/PRICES

ITEM NO.

SUPPLIES/SERVICES

QTY

UNIT

UNIT

PRICE

AMOUNT

BASE

AWARD

Transition Phase-In (FFP) Planning and Implementation of Transition Period In Accordance With (IAW) Performance Work Statement (PWS), Sections C.1, C.3.1

1 Lot

Invitee Cost -Reimbursement Administrative Services (Plan 1) (FFP (Unit Price)) IAW Sections C.1, C.2 and C.4

6,500 CL

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (FFP (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Note A)

Medical Consulting Services (Plan 2) Time and Materials(T&M)/Labor Hour (LH)

7,000

MM

0004 1 NTE

Health Care Administrative Services for Returned Peace Corps Volunteer- (Plan 3) (FFP (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Note A)

4,000 MM

Short-Term Group Health Insurance Policy (Plan 4) (FP EPA) IAW Sections C.1, C.2 and C.7. (See Notes A and B)

See Note B

4,000 MM

0007 Other Direct Cost - Medical Claims IAW Section C.8.

(See Note C)

Lot

$6,600,000

0008 Automated Eligibility and Authorization System (Option)

(FFP) IAW Section C.9 (See Note D)

Data for Items 0001 - 0008, and (if options are exercised) 0009 through 0033 IAW Section C.10 (Not Separately Priced (NSP))

1 Lot NSP

OPTION I

C.4 (See Note D)

6,825 CL

0011 Health Care Administrative Services for Peace Corps

C.2 and C.5 (See Notes A and D)

7,800 MM

0012 Medical Consulting Services (Plan 2) Time and Materials (T&M)/Labor Hour (LH)

1 NTE

0013 Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (FFP (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Notes A and D)

4,300 MM

EPA) IAW Sections C.1, C.2 and C.7. (See Notes A, B, and D)

See

B 4,200 MM

0015 Other Direct Cost - Medical Claims IAW Section C.8.

(See Notes C and D)

$6,930,000

OPTION II

7,166 CL

8,500 MM

0018 Medical Consulting Services (Plan 2) Time and Material (T&M) Labor Hour (LH)

1 NTE

4,600 MM

EPA) IAW Sections C.1, C.2 and C.7. (See Notes A, B, and D)

See

B 4,410 MM

1 Lot $7,276,500

0021 Other Direct Cost (ODC) - Medical Claims IAW Section C.8. (See Notes C and D)

OPTION III

7,524 CL

8,700 MM

0024 Medical Consulting Services (Plan 2) Time and Materials

1 NTE

4,630 MM

EPA) IAW Sections C.1, C.2 and C.7. (See Notes A, B, and D)

See

B 4,630 MM

0027 Other Direct Cost - Medical Claims IAW Section C.8.

$7,640,325

OPTION IV

7,900 CL

8,900 MM

0030 Medical Consulting Services (Plan 2) Time and Material

1 NTE

0031 Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (FFP (Unit Price)) IAW

4,700 MM

EPA) IAW Sections C.1, C.2 and C.7. (See Notes A, B, and D)

4,862 CA

Other Direct Cost - Medical Claims IAW Section C.8.

$8,022,341

0034 Transition Phase-Out (FFP) IAW Section C.3.2 (See Note D)

CL – Price per Claim

CA- Price per Case (Unit Price is based on the Peace Corps paying the first month premium)

MM – Price per Member per Month

Note A: The Government intends to procure services for 12 months from the date of award or option exercise. However, in the event the contract is terminated or the Period of Performance (PoP) is modified via a modification to the contract for a period less than 12 months, the Government will only be responsible for the monthly services provided prior to and in the month the contract was terminated or a contract modification was executed to revise the PoP. The quantity represents the maximum quantity of Volunteers under this contract for the base and each option year. This number of members per month may vary each month. The applicable CLIN is invoiced monthly for the number of members per month in accordance with the eligibility roster provided to the Contractor by Peace Corps staff on a daily and monthly basis.

Note B: The Contractor shall provide pricing for each sub-category of Short-Term Group Health Insurance in the table below. The total quantity of Short-Term Group Health Insurance Policy (Plan 4) shall not exceed the quantity stated in Section B above.

Contract Period Sub-Category Unit Price Base Award Volunteer

Spouse Dependent Child (18 years of age and under) Dependent Child (19 to 26 years of age) Option I Volunteer

Spouse Dependent Child (18 years of age and under) Dependent Child (19 to 26 years of age) Option II Volunteer

Spouse Dependent Child (18 years of age and under) Dependent Child (19 to 26 years of age) Option III Volunteer

Spouse Dependent Child (18 years of age and under) Dependent Child (19 to 26 years of age) Option IV Volunteer

Spouse Dependent Child (18 years of age and under) Dependent Child (19 to 26 years of age)

Note C:

The amount represents the ceiling price for actual medical claims for the base year or option period. The sum of medical claims shall not exceed this amount. The Contractor shall monitor and account for all costs of medical claims under this contract. The Contractor shall notify the Contracting Officer in writing whenever it has reason to believe that the costs it expects to incur for medical claims in the next 90 days, when added to the costs of medical claims already paid, will exceed 75 percent of the total amount so far allotted to the contract by the Government.

The ceiling price does not constitute a commitment, implied or otherwise, that the Government will expend the entire amount in the base or option period. The aggregated ceiling price for medical claims under this contract shall not exceed the base year and all option periods or

$TBD.

Note D: Option item to which the option clause in SECTION I-2 applies and which is to be supplied only if and to the extent said option is exercised.

B.2. Contract Summary

This contract includes the following Firm Fixed Price (FFP), Fixed Price Economic Price Adjustment (FP EPA), and Time and Materials (T&M) items:

Item Type

0001 – 0003, 0005, 0008 FFP

0010- 0011, 0013, 0016-0017 0019, 0022-0023, 0025, 0028-0029 0031, 0034

0006, 0014, 0020, 0026, and FP EPA

0004, 0007, 0012, 0015, 0018, 0021, 0024, 0027, 0030, and 0030 T&M, LH – ODC

0009 NSP

(End of Section B)

SECTION C –DESCRIPTION/ SPECIFICATIONS/ PERFORMANCE WORK STATEMENT

C.1. INTRODUCTION (Applicable to all Contract Line Item Numbers (CLINS)

The Performance Work Statement (PWS) (Section C) defines the technical and management requirements for the Contractor to administer a Health Care Benefits Services (HCBS) contract for the Peace Corps in an efficient and timely manner throughout the term of this contract. Section C includes two categories of outcome-based statements. The “Statement of Desired Outcomes” represents the desired outcomes for this contract. The desired outcomes are supported by “Technical Requirements.” These requirements encompass the scope of the contract and represent specific tasks, outcomes, and/or standards that, at a minimum, must be achieved.

The purpose of this contract is to provide the Peace Corps Community access to National and International Health Care Networks, claims processing, health care support services (e.g. online authorizations management, claims adjudication, access to claims data, guarantees of payment (GOPs), air ambulances, etc.) and a short term group medical insurance policy for Returned Peace Corps Volunteers (RPCVs).

C.1.1. Background. The Peace Corps is an independent executive agency of the federal government established in 1961 by President John F. Kennedy to promote world peace and friendship through the service of American Volunteers abroad. The Volunteers’ service fulfills the three primary goals established in the founding legislation:

• Improve the lives of people through grassroots assistance;

• Foster a better understanding of Americans on the part of the people served; and

• Foster a better understanding of other people on the part of Americans.

On March 15, 2020, the Peace Corps announced the temporary, global suspension of all Peace Corps Volunteer activities and the evacuation of all of Peace Corps Volunteers due to the COVID-19 pandemic.

At the time of the evacuation, the Peace Corps had 6892 Volunteers and trainees serving in foreign countries.

The Peace Corps intends to return to normal operations, with more than 7,000 Volunteers serving in posts located in approximately 65 developing countries worldwide, as soon as conditions permit a safe return.

The posts are divided into three regions:

• Africa (AF)

• Intra-America and Pacific (IAP), and

• Europe, Mediterranean and Asia (EMA).

C.1.1.2.Office of Health Services (OHS) Mission.

Peace Corps’ OHS manages healthcare services for Invitees, Peace Corps Volunteers (PCVs), and Returned Peace Corps Volunteers (RPCVs). The mission of OHS is to provide quality medical and mental health services and support to the Peace Corps community through its Office of Medical Services (OMS). The health care benefits program is comprised of both a self-insured and a commercially insured component. In order to accomplish this mission, the Health Care Benefits Services (HCBS) contract will supplement the services that are provided to the Peace Corps community via Peace Corps’ internal team of onsite doctors and other medical professionals at approximately 65 Peace Corps posts worldwide. These services will include:

• Managing financial assistance, for medical, mental health, dental, and vision examinations required of Invitees in order for OMS to evaluate their health status and required vaccinations before entering service,

• Providing access to national and international health care provider networks; and international air ambulance medevac service and consultations,

• Adjudicating authorized claims per requirements of this contract for eligible Invitees, PCVs and RPCVs, and

• Providing access to short term group health insurance for RPCVs according to the requirements of the contract.

C.1.1.3 Peace Corps titles for the stages of service.

• Applicant – person who applies for service,

• Invitee – person who is invited to serve,

• Trainee – entered service not yet sworn-in as Volunteer,

• Peace Corps Volunteer (PCV) – sworn-in to a typical two year service agreement,

• Peace Corps Response (PCR) Volunteer – sworn-in for the same or a shorter service agreement,

• Returned Peace Corps Volunteer (RPCV) – ended service.

For the purposes of this contract the word Volunteer will include Trainees, PCVs, PCR, and RPCVs. The majority of Volunteers serve overseas; however, there are rare occasions when a U.S domestic program may be established.

C.1.1.4 Health Care Benefits Program Plans 1-4.

PLAN 1 (Invitee Cost -Reimbursement Administrative Services) - Only US citizens are invited to serve in Peace Corps. Less than 1% of applicants reside outside of the US and Puerto Rico. Peace Corps Invitees submit their medical receipts after paying out-of-pocket or in accordance with their individual insurance, for exams or immunizations required to be cleared for entry into the Peace Corps. Following the submission of payment receipts, financial assistance is administered and provided directly to the beneficiary. The maximum amount of financial assistance for examinations corresponds to basic medical screening requirements; required immunization cost share is based on country of assignment. A small number of invitees are authorized additional health care related items needed for service that are not subject to out of pocket cost. The Peace Corps will cover 100% of the cost. Any items subject to full reimbursement are identified in Attachment J.6.Plan 1 Cost Reimbursement Fee Schedule.

PLAN 2 (Health Care Administrative Services for Peace Corps Volunteers ) - Countries with a Peace Corps program maintain a Health Unit to service the health care needs of PCVs in-country. The Health Unit is staffed by a varying mix of host-country nationals, third-country nationals and/or Americans. The levels of education and training for the medical professionals in each country vary and can include one or a combination of the following: Registered Nurses (RNs), Nurse Practitioners (NPs), and Medical Doctors (MDs). The Peace Corps employs Regional Medical Officers (RMOs) – all RMOs are Medical Doctors.

Currently, there is an RMO at each of the following locations, referred to as Medical Hubs: Morocco, South Africa, and Thailand (subject to change). The care provided by these staff members and the majority of routine care coordinated and provided at Post is not covered by this contract.

PCVs overseas who require non-routine or emergency medical, mental health, or dental evaluation and treatment may be medically evacuated aka "medevaced" to the US or to regional locations worldwide.

Washington, D.C. is the most common US medevac site followed by the PCV’s home of record. Abroad Peace Corps primarily medevacs PCVs to its Medical Hubs but transports to other locations as needed.

On occasion Guarantee of Payments (GOPs) or pre- established relationships are needed in order to accept medevacs at certain facilities. Most medevaced PCVs’ travel is arranged by Peace Corps, however, there are situations (approximately 10/year on average) when Peace Corps requires an air ambulance in order to safely medevac a Volunteer. While these services could be required anywhere worldwide, the Peace Corps web site identifies in which countries Volunteers currently serve (subject to change):

http://www.peacecorps.gov/volunteer/learn/wherepc/

Volunteers on leave and official travel status may utilize the National Network in all 50 states, the District of Columbia or Puerto Rico. Volunteers may require air ambulance services from their country of service or any country to which the Volunteer may travel during their Peace Corps service. Volunteer travel is not prohibited during such periods as vacation or home leave, and the Volunteer is fully covered under Plan 2 during all phases and aspects of service -- including vacation and home leave. When in the US or abroad on leave or official travel status, PCVs who require routine and non-routine medical or dental care receive health care services from providers whose costs are paid for by Peace Corps through a self-insured health benefits program. This includes all pharmacy needs. All healthcare services/needs provided to beneficiaries must be pre-authorized by Peace Corps and are reimbursed to the beneficiary or paid to the provider. Peace Corps currently issues authorizations on a case-by-case basis via a paper or electronic authorization process. Authorizations can currently be issued by any Peace Corps health care provider domestic or international (i.e. medical doctor, nurse, dentist, etc).

PLAN 3 (Health Care Administrative Services for Returned Peace Corps Volunteers) - For six months after the end of service, the Peace Corps may authorize RPCV medical evaluations only for conditions resulting from or exacerbated by Peace Corps Service. Exceptions will be allowed for mental health counseling/treatment for RPCVs on a case by case basis; and for three (3) optional readjustment mental health counseling sessions upon close of their Volunteer service. Peace Corps will inform the contractor what types of counseling sessions/conditions are authorized under plan 3 at the time of award.

Otherwise RPCVs must file a Federal Employees’ Compensation Act (FECA) claim through the Department of Labor (DOL). RPCVs may be eligible for FECA benefits under DOL regulations if they meet required criteria. These services related to RPCVs are referred to as benefit PLAN 3.

PLAN 4 (Short-Term Group Health Insurance Policy) – Peace Corps offers short term group health insurance to RPCVs (and applicable dependents) available for up to three months after Close of Service (COS). At its discretion, the Peace Corps will pay the first month’s health insurance premium for RPCVs.

At its discretion, Peace Corps may also decide to pay for the second months’ premium. Peace Corps will notify the contractor of this change if/when warranted. The RPCV has the option to buy an additional two months of the same coverage at the same monthly rate the Peace Corps pays. A total of three months of coverage will be available under this plan.

C.1.1.5 Peace Corps Electronic Medical Records. In October 2015, OHS globally deployed an Electronic Health Record (EHR) system, called PCMEDICS to 70+ Peace Corps countries. By February 2016, the Peace Corps had fully transitioned all currently-serving Volunteers’ records at that time from http://www.peacecorps.gov/volunteer/learn/wherepc/ paper to electronic files in PCMEDICS. Electronically-generated Volunteer medical records commenced in early 2016. PCMEDICS is deployed in a hub-and-spokes configuration: the hub is hosted on a Federal Risk and Authorization Management Program (FedRAMP) certified, Health Insurance Portability and Accountability Act (HIPAA) and Federal Information Management Security Act (FISMA) compliant cloud instance, and it contains the complete dataset of all global records; and the spokes are discrete PCMEDICS installations on Agency-owned servers located at each individual post, containing only local data. The local data is automatically synchronized with the cloud data across the Peace Corps’ Virtual Private Network (VPN) on a regular basis. For more specific information about how Peace Corps PCMEDICS can integrate with outside systems see Section C.2.3.8. The other systems utilized by OHS are MAXx and DOVE. DOVE is the system in which US Citizens apply for Peace Corps service. MAXx is the medical module of DOVE in which applicants submit medical forms/information to be reviewed by Pre-Service Unit staff who determine medical eligibility for Peace Corps service. In addition, the Agency relies on other systems which track the official service computation dates (i.e. Enter on Duty (EOD) and End of Service dates), country of service and home of record for all Volunteers. PCMEDICS integrates with these systems of record (DOVE, MAXx, Odyssey, etc.) to maintain accurate data and to provide data to outside sources.

C.1.2. Reserved

C.1.3. Statement of Desired Outcomes (SDO). The primary outcomes of the Health Care Benefits Services (HCBS) contract are as follows:

C.1.3.1. Objective 1 – Claims Processing. Prompt, efficient and accurate processing and adjudication of all claims that fall within the scope of the contract, to include development, coding, processing, medical/dental review, accepting Peace Corps authorizations and verifying for accuracy and completeness and data record submission and sustainment.

C.1.3.2. Objective 2 –Customer Satisfaction. Customer satisfaction at the highest level, to include:

accurate, timely, and efficient health care claims processing services; polite, friendly, responsive customer support; user-friendly online portals and chat mechanisms; easy provider searches; benefits questions; air ambulance /Guarantee of Payment (GOP) requests; and claims information.

C.1.3.3. Objective 3 - Management. Provision of efficient and effective management processes which will ensure the successful delivery of health care benefits support as required by the contract (including, but not limited to, appropriate staffing levels, staff education and training, internal quality management/quality improvement program, lines of authority, reporting, coordinating interfaces with the Government) and timely invoicing.

C1.3.4. Objective 4 - Provider Networks. Availability and management of high quality, expansive health care provider networks, both nationally and internationally to include credentialed hospitals, physicians, ancillary service providers, mental health professionals, dentists, pharmacies, diagnostic and treatment facilities, air ambulance services, and telemedicine/telehealth services where available in accordance with the contract requirements.

C.1.3.5. Objective 5 – Short Term Group Health Insurance. Provide an affordable short term health insurance policy that meets the minimum requirements established by this contract.

C.1.3.6. Objective 6 – Transition. Fully operational systems and processes at the start of health care delivery with minimal disruption and seamless transfer of services from and to a new contract.

C.1.4. Government Furnished Information

The Government will provide the Contractor Government Furnished Information (GFI) necessary to effectively perform under this contract. GFI is described below:

C.1.4.1. Medical Information. Peace Corps will provide to the Contractor pertinent medical information, on a case by case basis. The Contractor shall protect the confidentiality of protected health information received from the Peace Corps in accordance with Peace Corps policy and all applicable laws and regulations (including ( HIPAA of 1996 requirements and the Privacy Act).

C.1.4.2. Eligibility Rosters - Peace Corps’ eligibility rosters will be provided on a daily basis, Monday through Friday on Federal workdays. Peace Corps may also send a weekly or monthly file that provides updates/corrections to previously provided data. These reports identify an individual’s eligibility at that time, as well as their Personally Identifiable Information (PII). The eligibility file currently contains the following data elements:

• Volunteer ID (this number can vary in length, it currently doesn’t exceed 9 digits),

• Social Security Number (SSN),

• medical plan status (pre-service, in-service, post-service),

• Plan Number,

• Effective Date (eligibility start date),

• Termination Date,

• Last Name, first name, middle name,

• birth date,

• gender,

• marital status,

• telephone number,

• e-mail,

• Country Code (code used by Peace Corps to identify country of service),

• Type of Service (PCV or PC Response (PCR)[PC Response is short-term, high impact service assignments]),

• Address: street, city, state, zip, foreign care of address/home of record (if exists).

C.1.4.3. Currently serving Volunteers in Plan 2 can reapply and be invited to serve an additional term. As a result there are cases in which an individual may be in several Plans concurrently. Some examples of these phenomena are listed as scenarios below:

1) PCV Plan 2 – reapplies and is invited – No COS. Individual would be Plans 1 and 2 eligible concurrently.

2) PCV Plan 2 – reapplies and is invited – COS date established. Individual would be Plans 1 and 3 eligible, and enrolled in Plan 4 concurrently.

Currently, this information is provided through a Secure File Transfer Protocol (SFTP). Under this contract, the Peace Corps may exercise option CLIN 0008, which will facilitate the eligibility and authorization process through automation (see Section C.9.).

C.1.4.4. Health Care Authorizations – A Peace Corps authorization for medical services, also referred to internally as form 127C or 209B (See Attachment J.3) may be issued by any medically licensed Peace Corps health care clinician domestic or abroad. On the form the clinician describes in detail the services that are authorized to be paid by Peace Corps. The authorization PDF document contains the following types of information:

• Authorization ID # (reference number generated by the system)

• Volunteer’s name,

• Volunteer’s Volunteer ID,

• Volunteer’s country of service,

• Close of Service (COS) date (if applicable),

• Authorization’s effective date,

• Authorization’s expiration date,

• Provider’s name (if applicable),

• Specialty (if applicable),

• Problems/symptoms/ History (HX),

• Services authorized,

• Authorizing clinician,

• Authorization date.

The form also provides billing instructions for the provider or beneficiary. Peace Corps currently sends a copy of the completed authorization form to the Contractor, via mail, facsimile (fax) or Secure File Transfer Protocol (SFTP). The possibility of on-demand querying as an alternate mechanism for SFTP (commonly known as API) exists. An additional copy is provided to the beneficiary to use for reimbursement or to submit to the provider for their payment processing needs. Please see Section C.2.3.8 for more information regarding health care authorization data integration.

C.1.5 Contractor Furnished Items. The Contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) for the satisfactory performance of this contract, unless the contract specifically states that the Government will be providing such items (as identified in “C.1.4. Government Furnished Information” or elsewhere within the contract).

C.2. TECHNICAL REQUIREMENTS (Applicable to CLINS 0002, 0003 0005 and 0006 (and if options are exercised) 0010 through 0014, 0016 through 0020, 0022 through 0026 and 0028 through 0032)

The technical requirements for the HCBS contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in Section H.24 Statutory and Regulatory Authority. Peace Corps is especially committed to doing no harm, to acting in good faith, and to preserving its reputation as an agent of goodwill in the eyes of beneficiaries of its Health Care Benefits Program and of the American public. The Contractor, therefore, shall provide access to high quality, responsive, timely healthcare and administrative services in a manner that preserves Peace Corps’ good working relationship with beneficiaries of its Health Care Benefits Program. The Contractor shall provide:

C.2.1. Customer Service. The Contractor shall provide comprehensive, readily accessible customer services that include multiple, contemporary avenues of access (i.e., e-mail, World Wide Web, self-service options, telephone, and facsimile) for Volunteers and Providers. Customer service shall be delivered in a manner that achieves the objectives of this contract without charge to Volunteers or Providers. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff.

C.2.1.1. Call Center Service. The Contractor shall establish telephone Call Center service. The Call Center shall have a tracking and/or ticketing system to manage calls and inquiries, ensuring all calls are logged within three hours and responded to within three business days. It is the Contractor’s responsibility to ensure adequate, trained Call Center staff is always on duty. A toll- free number for Volunteers and Providers to call into shall be available (along with phone and email access for the hearing impaired). A collect telephone number or telephone number without long distance charges to call into shall be available for Volunteers and Providers calling outside the fifty United States (U.S.) and District of Columbia (D.C.)

and/or unable to access the Call Center Service via the toll-free number. Customer service representatives shall be available per commercially standard days and times (minimum 8:00 am to 9:00 pm Eastern Time (ET) Monday-Friday) to Volunteers, Providers and Peace Corps Staff seeking case-specific and general information (i.e. pharmacy authorization, assistance in locating a provider) or other inquires relevant to the services provided under this contract. At least one Customer Service Representative shall be available 24 hours a day, 365 days a year to respond to emergencies, requests for GOPs and air ambulance services.

C.2.1.2.Web Portal Service The vendor shall stand-up and maintain a web portal with a mobile platform accessible 24 hours per day, 365 days a year (unless down for planned scheduled maintenance) to Peace Corps staff, Volunteers and Providers for claims information, Volunteer eligibility information, provider information, pharmacy network information, details about the group insurance coverage, access to necessary paperwork and forms, links to the customer support unit and any other additional information relevant to Peace Corps’ Health Care Benefits Services.

The Web portal shall be user friendly (easy to navigate) to ensure Peace Corps staff, Volunteers, and Providers can quickly find information. The Contractor shall use Federal Government-approved security such as Hypertext Transfer Protocol Secure (HTTPS) to secure the transfer of information over the portal.

The Contractor must guarantee that data stored and queried through this portal is encrypted at-rest using approved standards as defined by the National Institute of Standards and Technology (NIST) under the Federal Information Security Management Act (FISMA) and aligned with approved Peace Corps Information Security policies.

The Contractor shall maintain an accurate, readily accessible, up-to-date searchable list identifying all network providers. This list must be user- friendly and readily searchable by provider or facility name, specialty or type of facility, subspecialty,), service area, work address, work fax number, work telephone number, any limitations of service, and whether the provider is accepting new Peace Corps (PC) patients.

The information contained in an electronic list shall be current within the last 30 calendar days. In the event a Provider loses its accreditation, certification and/or state or foreign licensing (if applicable), the Contractor shall update the provider network list within 24 hours of receiving the information.

C.2.1.3 Data Access. The Contractor shall provide a minimum of two licenses or authorizations (whichever is applicable) to Office of Health Services (OHS) and up to four additional licenses or authorizations to be assigned at the discretion of the Government to authorized Government personnel (as determined by the CO) providing unlimited off-site electronic access to all data maintained by the Contractor pertaining to the HCBS contract. This data shall include, but is not limited to:

• Network(s) usage,

• Out-of-network provider usage,

• Health care authorizations,

• Claims details and status, and

• Volunteer satisfaction information

All data must be current, accurate, complete and accessible in real time. “Real time” is defined as data that is refreshed at least once every 24 hours. The Contractor shall also provide read-only access to claims and enrollment data to Volunteers via web portal and any additional information agreed to by the parties.

C.2.2. Claims Processing.

The Contractor shall establish, maintain, and monitor an automated HIPAA compliant claims processing information system to ensure that claims (including adjustments) are processed in an accurate and timely manner, and meet functional system requirements.

C.2.2.1. Procedures for Processing Claims. The Contractor shall develop and deliver one hard copy Claims Processing Procedures Manual (Contract Data Requirement ((CDR) A005) 30 days after contract award in accordance with Section F, and maintain an ongoing electronic Claims Processing Procedures Manual accessible online to the Peace Corps. The electronic online procedures manual shall be available within 30 days after contract award in a format mutually agreed by the Contractor and the Government.

The manual shall include procedures for reviewing, resolving and following up on claims pended or denied due to: lack of authorization, questions regarding participant eligibility, incomplete itemization, non-standard claims information, balance billing, excess charges, procedural errors on the part of the Volunteer or Provider and questions regarding whether services are allowable under Peace Corps’ Health Benefit Program. The manual shall provide procedures which allow claims requiring additional information to be returned for the missing information. The manual shall ensure that all required information is requested with the initial return and that no claim is returned for information that could have been obtained internally or from information provided from the Peace Corps. The manual shall include language advising beneficiaries that claims for payments submitted beyond one year from the original date of service will be rejected. Additional areas to address, although not comprehensive are:

• Points of Contact for the Claims Department or equivalent (allowing Peace Corps staff to speak directly to claims processers regarding specific cases) and other key Contract personnel, their phone and fax numbers, e-mail address and mailing addresses;

• Appeals procedure consistent with the requirements set forth under the Affordable Care Act.

Details can be found at the Department of Health and Human Services website:

http://www.hhs.gov/healthcare/about-the-law/cancellations- and-appeals/appealing-health-plan-decisions/index.html. (The term “Third Party,” referenced in the ACA procedures means Peace Corps for the purposes of this contract.);

• Procedure for resolving complaints between Peace Corps personnel or Peace Corps’ Health Care

Benefits Program members and the Claims Contractor's healthcare claims processing system personnel or customer service agents regarding authorizations or claims inquiries;

• Business rules used to program the healthcare claims processing system logic for eligibility, allowable benefits, and reimbursement/payment rates for claims made under the four benefit PLANs (CLINS 0002, 0003, 0005 and 0006(and if options are exercised) 0010 through 0014, 0016 through 0020, 0022 through 0026 and 0028 through 0032);

http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html

• Examples of the Explanation of Benefits used for Peace Corps’ health benefit plans;

• Procedure and medium to be used by Peace Corps to transmit eligibility information to, authorize services, and obtain information from the healthcare claims processing system;

• Procedure to be used by Peace Corps to access health plan information via electronic interface;

• Procedures to be undertaken in the event of electronic interface failure or healthcare claims processing system shut-down.

C.2.2.2. Claim Processing Timeliness and Quality Standards. The Contractor shall ensure that claims (including adjustments) are timely and accurately processed and adjudicated for all care provided to Volunteers in accordance with the Peace Corps’ timeliness and quality standards provided below:

• Claims and supporting documentation shall be accurately entered into the Contractor’s claims processing system within 24 hours after receipt;

• Claims shall be adjudicated within 20 business days for claims inside the fifty United States

(U.S.), Puerto Rico, and District of Columbia (D.C.);

• Claims shall be adjudicated within 30 business days for claims originated outside the fifty U.S.

States, Puerto Rico, and D.C.;

• Clean claims shall be paid to third party Providers within 20 business days of receipt. For the purposes of this Contract, a “clean” claim is defined as one submitted on behalf of an eligible Volunteer for authorized, allowable healthcare services that were provided in the U.S. and internationally and are appropriately documented;

• Clean claims shall be paid to beneficiaries within 20 business days of receipt.

• Claims for payment that are submitted beyond one year from the original date of service shall be rejected; and

• Guarantee of Payments issued to international providers shall be available 24 hours a day, 365 days a year per request of Peace Corps staff.

C.2.2.3. Medical Coding. The Contractor shall utilize and report for each claim the most current National Uniform Billing Committee (NUBC) hospital revenue codes, Centers for Medicare & Medicaid Services (CMS) revenue codes, CMS Healthcare Common Procedure Coding System (HCPCS) Level II codes, Current Procedural Terminology (CPT), International Classification of Diseases (ICD) diagnosis and procedure codes, Diagnostic and Statistical Manual (DSM) and American Dental Association (ADA) codes for all health services referenced in the claim.

C.2.2.4. Explanation of Benefits. The Contractor shall provide each beneficiary and provider an appropriate Explanation of Benefits (EOB) i.e. beneficiary name, provider name, date processed, date of service, and information regarding appeal rights, including instructions for filing an appeal. The EOB shall also include notice that reimbursement/payment was made in accordance with Peace Corps’ Health Benefits Program policies; (1) that reimbursement/payment for claims made under PLAN 1 (CLIN 0002) are in accordance with Peace Corps Plan 1 Cost Reimbursement Fee Schedule (see Attachment J.6); and

(2) that reimbursement/payment made under PLAN 2 and PLAN 3 (CLINs 0003 and 0005) are considered payment in full. In no case should the PCV or RPCV under PLANs 2 and 3 (CLINs 0003 and 0005) be billed for authorized health care services. The Peace Corps’ Health Benefit Program prohibits billing beneficiaries for authorized health care services or differences between claims made and claims paid. The processing date of the oldest claim for the summary EOB shall not be greater than 31 calendar days. It is preferable that a Peace Corps representative will have the ability to download or print an EOB during and after the end of the enrollment period.

C.2.2.5. Financial Administration. The Contractor shall provide financial administration as follows:

• Conduct internal audits for all claims greater than $20,000 (twenty thousand dollars) made for services provided to a single payee on behalf of a single beneficiary for a single incident;

• Have the ability to track total costs paid (and costs denied) by fiscal year and segregated by

Invitee, PCV and RPCV;

• Have the capability of making Electronic Funds Transfers (EFTs) for both domestic beneficiaries/providers and international bank transfer payments via correspondent U.S. financial institutions;

• Report all costs in U.S. currency;

• Coordinate payment related service including a Guarantee Payment Letter, if needed and when medically necessary or upon request of the CO;

• The Contractor is not required to pay any interest payments on claims paid later than 20 business days;

• Recommend measures to control or reduce costs for the medical treatment services provided to

Volunteers; and

• Have a processing system and business rules that will identify billing that is substantially in excess of reasonable and customary charges for the provider’s locality.

C.2.2.6. Flagged Claims Processing. The Contractor’s claim processing system shall have the capacity to flag claims that are potentially fraudulent, abusive or wasteful. In order to flag potentially fraudulent claims, the contractor’s claim processing system at a minimum shall:

• Verify individual eligibility for benefits;

• Ensure only claims for allowable services are reimbursed/paid;

• Ensure reimbursements/payments do not exceed established schedules;

• Eliminate reimbursement/payment of duplicate claims;

• Compare claims made to claims reimbursed/paid;

• Reconcile diagnosis codes to procedure and gender codes;

• Compare the number of inpatient facility days on each claim against admission and discharge dates; and

• Have the capacity to process claims under subrogation and claims involving no-fault.

The contractor shall provide a copy of the providers claim, electronically if requested.

C.2.2.7. Subrogation Services. The contractor shall perform subrogation services on all claims that indicate potential liability by other parties. All funds received by the contractor for subrogation services shall be returned to the Peace Corps. The contractor will reflect these funds in the vouchers for reimbursement.

C.2.2.8. Claims for Pharmaceuticals. Claims for pharmaceuticals paid under this contract shall meet US equivalent or international standards. The Peace Corps will notify the contractor of any pharmaceuticals not covered by this plan. Medications that are considered over-the-counter by U.S. standards are not authorized for reimbursement.

C.2.2.9. End of Health Care Benefits. Plans 1-3 claims received by the Contractor during its period of service delivery are required to be processed to completion within 180 calendar days following the end of the contract Period of Performance (POP). There will be no medical claims processing fee paid to the Contractor if the 180 calendar day requirement is not met.

C.2.2.10. Appeal Process. A claim dispute is a disagreement regarding a claim or utilization review decision. The Contractor shall manage an internal appeal process to resolve claim disputes, whereby eligible members may submit an appeal in writing by mail or through a web portal or a phone call, to a toll-free number, or number that accepts collect calls from international members, to the Contractor.