HT9402-23-R-0001 CPD DRAFT 2 Request for Proposal (RFP).pdf

SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED

ORDER UNDER DPAS (15 CFR 700)

RATING PAGE OF PAGES

1 122

2. CONTRACT NUMBER 3. SOLICITATION NUMBER

HT9402-23-R-0001

4. TYPE OF SOLICITATION

SEALED BID (IFB)

X NEGOTIATED (RFP)

5. DATE ISSUED

3/3/2023

6. REQUISITION/PURCHASE NUMBER

7. ISSUED BY CODE HT9402 8. ADDRESS OFFER TO (If other than Item 7)

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the depository located in until 1200 MST local time (Hour)

3/20/2023 (Date)

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR

INFORMATION

CALL:

A. NAME

Marcus R. Webb

B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS

marcus.r.webb.civ@health.mil AREA CODE

NUMBER

676-3451

EXT.

11. TABLE OF CONTENTS

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM X I CONTRACT CLAUSES

X B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

X C DESCRIPTION/SPECS./WORK STATEMENT X J LIST OF ATTACHMENTS

X D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE

X K REPRESENTATIONS, CERTIFICATIONS AND

OTHER STATEMENTS OF OFFERORS X F DELIVERIES OR PERFORMANCE

X G CONTRACT ADMINISTRATION DATA L INSTRS., CONDS., AND NOTICES TO OFFERORS

H SPECIAL CONTRACT REQUIREMENTS M EVALUATION FACTORS FOR AWARD

OFFER (Must be fully completed by offeror) NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

AWARD (To be completed by government)

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

10 U.S.C. 2304 (c) ( ) 41 U.S.C. 253 (c) ( )

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTERED BY (If other than Item 7) CODE 25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

Marcus R. Webb 303-676-3451 marcus.r.webb.civ@health.mil

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97) Prescribed by GSA - FAR (48 CFR) 53.214(c)

13. DISCOUNT FOR PROMPT PAYMENT

(See Section I, Clause No. 52.232.8)

10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%)

14. ACKNOWLEDGEMENT OF AMENDMENTS

(The offeror acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated):

AMENDMENT NO. DATE AMENDMENT NO. DATE

15A. NAME

AND

ADDRESS

OF

OFFEROR

CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER

(Type or print)

15B. TELEPHONE NUMBER 15C. CHECK IF REMITTANCE ADDRESS

IS DIFFERENT FROM ABOVE - ENTER

SUCH ADDRESS IN SCHEDULE.

17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXT.

X PAGE 1

PAGES 2-6

PAGES 7-26

PAGES 29-32

PAGES 33-45

PAGES 54-69

PAGES 46-53

PAGES 71-84

PAGES 85-109

PAGES 110-122

X

X

X mailto:marcus.r.webb.civ@health.mil mailto:marcus.r.webb.civ@health.mil

NAME OF OFFEROR OR CONTRACTOR

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED

HT940223R0001

PAGE OF

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ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

AMOUNT

(F)

Delivery Location Code: HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066 USA

0001 Transition-In

0001AA Transition-In Readiness Milestone (5% of CLIN 1 EA 0001 Amount)

0001AB Pre-Startup Validation Milestone (10% of CLIN 1 EA 0001 Amount)

0001AC Pre-Open Season Milestone (40% of CLIN 0001 1 EA Amount)

0001AD Start of Health Care Delivery Milestone (45% of 1 EA CLIN 0001 Amount)

0002 Reports, Contract Data Requirements List (CDRL)

1001 RESERVED 12 MO

(Option Line Item)

1002 Performance Metric Incentives 1 LO (Option Line Item)

1003 Risk Adjusted Care Support Services (Option Line Item)

1003AA Capitated Per Member Per Month (PMPM) 1st QTR 3 MO

(Option Line Item) Continued ...

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ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

AMOUNT

(F)

1003AB Capitated Per Member Per Month (PMPM) 2ND QTR 3 MO

(Option Line Item)

1003AC Capitated Per Member Per Month (PMPM) 3RD QTR 3 MO

(Option Line Item)

1003AD Capitated Per Member Per Month (PMPM) 4th QTR 3 MO

(Option Line Item)

1004 Aggregate Fixed Price On-Going Administrative 12 MO Portion (Option Line Item)

1005 HPSA/PSA Quality 12 MO (Option Line Item)

1006 Capitalization Direct Medical Education 12 MO (Option Line Item)

1007 Reports, Contract Data Requirements List (CDRL) (Option Line Item)

2001 RESERVED 12 MO

(Option Line Item)

2002 Performance Metric Incentives 1 LO

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(A)

SUPPLIES/SERVICES

(B)

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

AMOUNT

(F)

2003 Risk Adjusted Care Support Services (Option Line Item)

2003AA Capitated Per Member Per Month (PMPM) 1st QTR 3 MO

(Option Line Item)

2003AB Capitated Per Member Per Month (PMPM) 2ND QTR 3 MO

(Option Line Item)

2003AC Capitated Per Member Per Month (PMPM) 3RD QTR 3 MO

(Option Line Item)

2003AD Capitated Per Member Per Month (PMPM) 4th QTR 3 MO

(Option Line Item)

2004 Aggregate Fixed Price On-Going Administrative 12 MO Portion (Option Line Item)

2005 HPSA/PSA Quality 12 MO (Option Line Item)

2006 Capitalization Direct Medical Education 12 MO (Option Line Item)

2007 Reports, Contract Data Requirements List (CDRL) (Option Line Item)

3001 RESERVED 12 MO

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ITEM NO.

(A)

SUPPLIES/SERVICES

(B)

QUANTITY UNIT

(C) (D)

UNIT PRICE

(E)

AMOUNT

(F)

(Option Line Item)

3002 Performance Metric Incentives 1 LO (Option Line Item)

3003 Risk Adjusted Care Support Services (Option Line Item)

3003AA Capitated Per Member Per Month (PMPM) 1st QTR 3 MO

(Option Line Item)

3003AB Capitated Per Member Per Month (PMPM) 2ND QTR 3 MO

(Option Line Item)

3003AC Capitated Per Member Per Month (PMPM) 3RD QTR 3 MO

(Option Line Item)

3003AD Capitated Per Member Per Month (PMPM) 4th QTR 3 MO

(Option Line Item)

3004 Aggregate Fixed Price On-Going Administrative 12 MO Portion (Option Line Item)

3005 HPSA/PSA Quality 12 MO (Option Line Item)

3006 Capitalization Direct Medical Education 12 MO

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ITEM NO.

(A)

SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

(B) (C) (D) (E) (F)

3007 Reports, Contract Data Requirements List (CDRL)

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COMPETITIVE PLANS DEMONSTRATION

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1. SCOPE:

The purpose of this contract is to provide Managed Care Support (MCS) to the Department of Defense TRICARE program. The Competitive Plans Demonstration (CPD) contractor shall provide comprehensive health, medical, and administrative support services through a managed care plan (the TRICARE Prime uniform benefit) to eligible TRICARE beneficiaries.

There are two categories of outcome-based statements in this contract: Objectives and Technical Requirements (also provided in the documents). The objectives represent the overall outcomes required and are supported by the technical requirements. These requirements represent specific outcomes, tasks, and/or standards that shall be achieved.

CPD sites are listed in Section J, Attachment J-1.

C.2. DOCUMENTS

The following documents are hereby incorporated by reference and form an integral part of this contract—except to the extent that the contract elsewhere (see Attachment J-9) provides exceptions to the applicability of such documents. Documentation incorporated into this contract by reference shall have the same force and effect as if set forth in full text for those chapters and sections that are identified herein:

• Title 10, United States Code, Chapter 55

• 42 Code of Federal Regulations (CFR), Part 422, section 2430

• 32 CFR, Part 199. The following sections apply to this contract: 199.2, 199.4, 199.6, 199.7, 199.8, 199.9, 199.10, 199.11, 199.12, and 199.17

• Privacy Act of 1974, as amended, 5 U.S.C. 552a

• Health Insurance Portability and Accountability Act (HIPAA) of 1996, Pub. L. No. 104-191

• Department of Defense Instruction (DoDI) 5200.02, “DoD Personnel Security Program (PSP),”

March 21, 2014 (as amended)

• DoDI 5400.11, "DoD Privacy and Civil Liberties Program," January 29, 2018 (as amended)

• DoDI 8582.01, "Security of Non-DoD Information Systems Processing Unclassified Nonpublic

DoD Information," December 9, 201

• DoDI 8580.02, "Security of Individually Identifiable Health Information in DoD Health Care

Programs," August 12, 2015

• TRICARE Policy Manual (TPM) 6010.63-M, April 2021, Change 5001

• TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021, Change 5002

• TRICARE Systems Manual (TSM) 7950.43M, April 2021, Change 5003

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021, Change 5005

HT9402-23-R-0001 v2 Page C2 of C20

The TRICARE manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated Federal statutes and regulations and may not be interpreted in contradiction thereto. Among the manuals the TRICARE Policy Manual takes precedence over the other three TRICARE manuals. The TRICARE Reimbursement Manual takes precedence over the TRICARE Systems Manual and the TRICARE Operations Manual.

The TRICARE Systems Manual takes precedence over the TRICARE Operations Manual.

C.2.1. MANUAL UPDATES:

DHA periodically incorporates changes related to healthcare policy, systems, and operations in the corresponding manuals. The CPD contractor shall subscribe to a mailing list that provides the latest manual updates and revisions through the TRICARE manuals website:

https://manuals.health.mil.

Manual changes will be incorporated in the contract by revising paragraph 2.0 DOCUMENTS and TRICARE Manual Exceptions Table (Attachment J-9) with a supplemental (bilateral) modification, regardless of applicability. Prior to preparing the proposed modification, DHA’s TRICARE Health Plan Office will issue drafts of the proposed manual changes to the CPD contractor, identifying the applicability and allowing the CPD contractor to provide comments or questions on drafts. The Contracting Officer (CO) will provide modifications to the CPD contractor within thirty (30) days following the issuance of the manual change or changes to which it relates.

C.3. DEFINITIONS:

Definitions in manuals, attachments, and/or exhibits are incorporated by reference.

C.4. GOVERNMENT-FURNISHED PROPERTY AND SERVICES:

There is no Government-Furnished Property and Services under this contract.

C.5. CONTRACTOR-FURNISHED ITEMS:

The CPD contractor shall furnish all necessary items not provided by the Government for the satisfactory performance of this contract.

C.6. OBJECTIVES:

The overarching CPD program goals are to observe the effect of competition between overlapping networks; test a risk adjusted capitation payment method; and test systems interfaces and interoperability between DoD systems, the Eligibility, Enrollment and Encounter (EEE) Pilot contractor, and the CPD contractor. The CPD contractor must provide comprehensive health care services to all eligible CPD Prime enrollees for which the CPD contractor shall receive a monthly capitation payment. Health care services for the CPD program are defined in 32 CFR 199; the services provided are known as the TRICARE Prime option. The key objectives included in this contract are as follows:

https://manuals.health.mil/

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C.6.1. SPECIFIED OBJECTIVES:

C.6.1.1. Objective 1: Manage Per Capita Cost: Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity.

C.6.1.2. Objective 2: Ensure Beneficiary Satisfaction at the highest level possible through the delivery of world-class health care as well as customer-friendly program services.

C.6.1.3. Objective 3: Implement programs that include patient safety, population management of disease and continued administration of these performance outcomes during the contract period of performance.

C.6.1.4. Objective 4: Conduct a seamless Transition--In period to ensure system interfaces and processes of care are operationalized and fully functional in a timely manner to support the 2024 Open Enrollment Season.

C.6.1.5. Objective 5: Support the Government's analysis and evaluation of this demonstration via the collection and reporting of performance, quality, cost, and beneficiary satisfaction data.

6.2. PERFORMANCE CRITERIA

The CPD contractor’s performance during the life of the resulting contract will be evaluated by criteria as follows:

C.6.2.1. Network Requirements: Maintain an adequate provider network in accordance with all contract requirements throughout the contract performance period.

C.6.2.2. Marketing: Market the CPD benefit to beneficiaries within the designated service area as stated in the contract and manuals.

C.6.2.3. Enrollment: Process enrollment actions as stated in Paragraph 7.3. Streamline enrollment processes which improve the beneficiary experience and facilitates the implementation and use of the EEE Pilot capabilities.

C.6.2.4. Customer Services: Provide highest level of beneficiary satisfaction as measured by surveys: conducted by contractors and/or Government.

C.6.2.5. Medical Management: Submit complete and accurate clinical data as required. Implement innovative performance programs during the base period and option periods of the contract, to include patient safety and population management of disease.

C.6.2.6. Clinical Quality Management: Provide clinical quality and population health management data to be measured by the annual quality site visits.

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C.6.2.7. Claims: Accurately process claims consistent with the requirements outlined in Paragraph

7.7. Claims.

C.6.2.8. Management and Administration: Provide qualified staff to meet all requirements of the contract and maintain contractor accessibility to the DHA through the CO and the Contracting Officer’s Representative (COR).

C.6.2.9. Perform Transition requirements that will be addressed in TOM Chapter 18, Section XX (pending).

C.7. TECHNICAL REQUIREMENTS:

The CPD contractor must fulfill the technical requirements listed below in accomplishing the overall objectives of this contract.

The CPD contractor shall transition-in in accordance with the terms of TOM Chapter 18, Section XX. The transition in period will occur over a nine-to-twelve-month period.

C.7.1. PROVIDER NETWORK REQUIREMENTS:

The CPD contractor shall maintain a managed, stable, high-quality preferred provider network of individual and institutional health care providers (see 32 CFR 199.17(p)) who produce high quality clinical outcomes.

C.7.1.1. The CPD contractor’s network shall be accredited by a nationally recognized accrediting organization at the start of health care delivery (SHCD) and such accreditation shall be maintained during all periods of contract performance. Network accreditation shall be from a national body that considers quality benchmarks for network management, provider credentialing, quality management and improvement, and consumer protection. When this contract and the accrediting body each have a standard for the same activity, the higher standard shall apply. For reporting requirements, see DD Form 1423-1, Contract Data Requirements List (CDRL) located in Section F of the contract.

C.7.1.1.1. The CPD contractor shall ensure that all of its network providers are Medicare participating providers (unless they are not eligible to be participating providers under Medicare).

C.7.1.1.2. The CPD contractor shall ensure that the providers in its network are sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all CPD Prime enrollees are eligible under this contract, as described in 32 CFR 199.4, 199.5, and 199.17.

C.7.1.2. The CPD contractor shall submit a network plan detailing all components of its network, including the contractor's network sizing model and the formula(s) used to derive network specialty targets, by provider specialty in its geographic area of responsibility (Attachment J-1).

For plan details see DD Form 1423-1, CDRL, located in Section F of the contract.

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C.7.1.3. The CPD contractor shall establish mechanisms to evaluate network providers using the quality metrics specified in the TOM Chapter 7, Section 6. The CPD contractor shall display meaningful quality metrics, at the individual provider and facility level, in an easily understood and accessible format on their website.

C.7.1.4. Beginning with the SHCD and throughout contract performance, the CPD contractor shall ensure that all provider networks established in the CPD contractor’s geographical service area (Attachment J-X) meet the beneficiary access standards (see 32 CFR 199.17(p)(5)).

C.7.1.5. The CPD contractor shall develop and implement a system for continuously monitoring and evaluating network adequacy and for reporting network adequacy or access issues to the Government. For reporting requirements see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.1.6. The CPD contractor shall ensure that the standards for access, measured in terms of beneficiary travel time, appointment wait time, and office wait time for various categories of services contained in 32 CFR 199.17(p)(5), are met. These standards shall be met in a manner which achieves beneficiary satisfaction with access to network providers and services as set forth in the contract.

C.7.1.6.1. The CPD contractor shall monitor, and report monthly, all complaints by beneficiaries with respect to network adequacy or the availability of health care providers. For reporting requirements see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.1.7. The CPD contractor shall provide data validating access to care for beneficiaries in their geographical area. The CPD contractor shall utilize a geo-mapping tool to demonstrate access for primary and specialty care by ZIP Code in the geographical area (Attachment J-4). For reporting requirements, see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.1.8. The CPD contractor shall submit a plan for reporting on access to care for TRICARE beneficiaries. The contractor’s plan shall explain how the contractor will report access to care data for the contractor’s geographic area of responsibility (Attachment J-1). For plan reporting requirements see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.1.9. The CPD contractor shall develop and implement a system for continuously monitoring network appointment availability for all provider and facility types. The CPD contractor shall assess appointment availability for each provider type in its network, at a minimum annually and otherwise as requested by the Government, to ensure beneficiary access to care. The CPD contractor shall report on how it measured appointment availability (e.g., by employing surveys).

For reporting requirements see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.1.10. The CPD contractor shall measure enrolled beneficiary access to telehealth services. For reporting requirements see DD Form 1423-1, CDRL, located in Section F of the contract.

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C.7.1.11. The CPD contractor shall inform the Government within 24 hours of obtaining information regarding any network inadequacy relative to its service area and shall submit a corrective action plan with each notice of an instance of network inadequacy. (Network inadequacy is defined as any failure to meet the access standards.) The CPD contractor shall respond to any inquiries from Government representatives (CO or COR) concerning network adequacy, including provider turnover information, within two business days of the day after receiving such an inquiry.

C.7.1.12. The CPD contractor shall ensure that all network providers who provide services and receive reimbursement under this contract are health plan providers in accordance with the criteria set forth in 32 CFR 199.6. The CPD contractor shall obtain and maintain documentary evidence that each such provider meets the criteria set forth in 32 CFR 199.6, subject to the exceptions identified in the TPM, Chapter 11.

C.7.1.13. The CPD contractor shall ensure that no network provider requires payment from a beneficiary for any excluded or excludable service that the beneficiary received from a network provider (i.e., the beneficiary shall be held harmless) unless the beneficiary has been properly informed in writing (in an Explanation of Benefit (EOB) or waiver of liability form), that the services are excludable, and the provider has documentation that the beneficiary agreed in advance of receiving the services to pay for such services. Any such understanding to pay must be evidenced by written records. A beneficiary who is informed that care is potentially excludable and proceeds with receiving the potentially excludable service, shall not, merely by receiving such care, be deemed to have agreed to pay for such care. General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew that specific services he or she receives were excluded or excludable.

C.7.1.14. During the contract period of performance, the CPD Contractor shall ensure that written agreements with its network providers require that such providers participate in the CPD Contractor's Clinical Quality Management Program, as outlined in TOM Chapter 7, Section 6.

C.7.1.15. The CPD contractor shall ensure that its online network provider directory is accessible to users (i.e., beneficiaries, providers, partner contractors, and government stakeholders) at the SHCD and on a continual (24 hours a day/7 days a week) basis except for during scheduled downtime for system maintenance.

C.7.1.16. CPD contractor shall not pay for non-covered services with CPD capitation dollars.

C.7.1.17. The CPD Contractor shall ensure that providers in its network do not bill enrolled beneficiaries for “activities that improve health care quality” as that term is defined in 42 CFR

422.2430 (also see Section G Paragraph 2.1.5 of this solicitation). Further, the CPD contractor shall not bill the Government for such activities.

https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-X/section-422.2430 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422/subpart-X/section-422.2430

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C.7.2. MARKETING AND BENEFICIARY EDUCATION REQUIREMENTS:

C.7.2.1. The CPD contractor shall ensure that all of its marketing materials display the TRICARE logo and are approved by the DHA Communications Division, Falls Church, Virginia before being issued. Marketing materials include all written materials used to publicize, inform, educate, or otherwise influence reliant MHS beneficiaries. If the TRICARE Communications Division does not respond to a CPD contractor’s request for a marketing materials review within 30 days of receiving the marketing materials, then the marketing materials shall be deemed approved.

C.7.2.2. The CPD contractor may market health plan services directly to eligible beneficiaries (see paragraphs C.7.3.4 – C.7.3.6 below regarding beneficiary eligibility).

C.7.2.3. The CPD contractor shall submit contractor-produced educational materials to DHA Communications at least 60 calendar days prior to publication for review and approval.

C.7.2.4. The CPD contractor shall provide to the EEE contractor the CPD website link and phone number to be included in beneficiary enrollment notifications.

C.7.2.5. The CPD contractor shall include links to TRICARE’s social media, web pages, and email subscriptions services in print and digital marketing and education materials during the annual TRICARE Open Season annual campaign that takes place from October through December each calendar year.

C.7.2.6. The CPD contractor shall use marketing toolkits provided by DHA Communications, including briefings, emails, and text messages when communication with beneficiaries during the annual TRICARE Open Season annual campaign that takes place from October through December each calendar year.

C.7.2.7. The CPD contractor shall comply with all other marketing and beneficiary education requirements as set forth in the TOM, Chapter 11, Section 6.

C.7.3. ENROLLMENT:

C.7.3.1. The CPD contractor shall provide benefit descriptions for the EEE Enrollment Exchange Portal to DHA for approval NLT 180 day prior to the SHCD.

C.7.3.1.1. The CPD contractor may provide the benefit information to the EEE contractor only after it has received approval to do so from the DHA.

C.7.3.1.2. The CPD contractor shall submit updates to its benefit information to DHA on a quarterly basis.

C.7.3.2. The CPD contractor shall immediately accept and apply enrollment information from the EEE contractor to the CPD contractor member database.

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C.7.3.3. The CPD contractors shall rely on the EEE contractor to relay eligibility and enrollment information from the Defense Enrollment Eligibility Reporting System (DEERS).

C.7.3.4. TRICARE Beneficiaries in the following categories, who reside within the designated CPD geographic boundaries, are eligible to enroll into the CPD:

• Active-Duty Family Members (ADFMs)

• ADFMs of Guard/Reserve sponsors on Active Duty

• Retirees/Retiree Family Members/Survivors who are not eligible for Medicare

• Non-TRICARE For Life (TFL)/Survivor Households

• Beneficiaries participating in the Transition Assistance Management Program (TAMP)

• Beneficiaries participating in the Transitional Compensation Program

CI.7.3.5. Active-Duty Service Members (ADSMs), Guard/Reserve Service Members, and beneficiaries who are eligible for Medicare are not eligible to enroll into the CPD. Beneficiaries participating in the following benefit programs are also not eligible to enroll into the CPD:

• TRICARE For Life (TFL)

• TRICARE Reserve Select (TRS)

• TRICARE Reserve Retired (TRR)

• TRICARE Young Adult (TYA)

CII.7.3.6. Due to CPD program design and the Government’s desire to maintain beneficiary continuity of care, beneficiaries participating in or receiving benefits under the following special programs are not eligible to enroll into the CPD:

• Autism Care Demonstration

• Extended Care Health Option (ECHO) Program

• Wounded Warrior Program

• Continued Health Care Benefits Program

CIII.7.3.7. Following a beneficiary’s enrollment in the CPD, if the CPD contractor becomes aware of a disqualifying event in the beneficiary’s life, then the CPD contractor shall investigate and determine the validity of the disqualifying event. If the disqualifying event is valid, then the CPD contractor shall report the disqualifying event to the EEE contractor to initiate appropriate enrollment actions.

Disqualifying events include:

• Loss of TRICARE Prime eligibility

• Becoming eligible for Medicare

• Enrollment into a non-eligible benefit/special program listed in paragraph 7.3.6 above.

• Change of residence outside of designated demonstration geographic boundaries

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C.7.4. CUSTOMER/MEMBER SERVICES:

C.7.4.1. The CPD contractor shall provide comprehensive readily accessible customer services for CPD enrolled beneficiaries and CPD network providers in accordance with the TOM, Chapter 11.

C.7.4.2. The CPD contractor shall provide outreach and communication consistent with those services offered to its (or its parent or affiliate organization’s) commercial customers.

Customer services shall be formatted to TRICARE specifications and include multiple, contemporary avenues of access (for example, email, World Wide Web, telephone, texting, smart phone applications, and social media) for CPD enrolled beneficiaries in accordance with the TOM, Chapter 11. Customer services shall be delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers.

C.7.4.3. The CPD contractor shall establish accessible telephone services, toll-free or without long distance charges, for enrolled beneficiaries seeking information.

C.7.4.4. The CPD contractor shall perform all customer service functions with courteous, and responsive staff knowledgeable of the TRICARE benefit that results in highly satisfied beneficiaries within timeliness and quality standards as outlined in TOM Chapter 1, Section 3.

C.7.4.5. The CPD contractor shall provide a process for responding to all types of beneficiary inquiries (both routine and priority) that meet the timeliness and quality standards outlined in TOM Chapter 1, Section 3, paragraph 3.0.

C.7.4.6. The CPD contractor shall provide the DHA multiple points of contact to address complaints and grievances received by the Government.

C.7.4.7. The CPD contractor shall encourage each health plan member and provider to use Medline Plus® a web site developed and maintained by the U.S. National Library of Medicine (NLM) and the National Institutes of Health (NIH). This site will provide health professionals and health plan members with information on diseases and conditions, clinical trials, drugs, and the latest health information. The use of this site is not intended to be a substitute for health care information provided by the plan but may be used as resource to supplement the plans health care information. See, Medline Plus® site: http://medlineplus.gov.

C.7.4.8. The CPD contractor shall comply with all requirements related to TRICARE publications, social media, beneficiary outreach, website management, TRICARE branding, and media relations as described in the TOM, Chapter 11, Section 6.

C.7.4.9. The CPD contractor shall refer eligibility, enrollment, and enrollment billing inquiries to the EEE contractor and shall transfer phone calls on these topics to the EEE call center.

C.7.4.10. The CPD contractor shall establish a process with the EEE contractor and other TRICARE contractors for coordinating customer service calls on matters outside of the CPD contractor’s area of responsibility (AOR), to include triaging and defining call levels (routine, urgent, emergent).

http://medlineplus.gov/

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C.7.5. CLINICAL MANAGEMENT:

C.7.5.1. Medical Management (MM)

C.7.5.1.1. The CPD Contractor shall develop, implement, and maintain a MM Program, that includes behavioral health, in accordance with the requirements in the TOM Chapter 7, as well as complies with the TRICARE benefits provisions of 32 CFR 199.4, 32 CFR 199.5, and the TPM in order to provide health care for eligible beneficiaries to the extent authorized by law.

C.7.5.1.2. The CPD contractor shall obtain and maintain throughout the life of the contract accreditation from a nationally recognized accrediting organization for the following MM programs: utilization management, case management, and disease management.

C.7.5.1.2.1. The CPD contractor shall obtain accreditation no later than 12 months after the SHCD and shall maintain such accreditation throughout the life of the contract, inclusive of all exercised option periods. National certification, in lieu of accreditation, is insufficient to meet this requirement.

C.7.5.1.2.2. The CPD contractor shall submit letters of accreditation and re-accreditation and supporting documentation to the Government within 5 business days of receipt of the documents from the accrediting organization.

C.7.5.1.3. The CPD contractor shall develop, implement, and maintain an electronic MM data system that complies with the TOM, Chapter 7, Sections 1, 2 and 3.

C.7.5.1.4. The CPD contractor shall use predictive analytics in the operation of its MM program (as described in the TOM Chapter 7, Section 1, Paragraph 5), which are designed to support and manage the health care of individuals with high-cost conditions and complex medical conditions, inpatient admissions and discharges, pharmacy (specialty drugs, multiple medications, or pharmacies), and beneficiaries receiving low quality care.

C.7.5.1.5. The CPD contractor, in order to provide the operations described in paragraph C.7.5.1.4, shall establish a beneficiary-centric data warehouse (for data pertaining to CPD enrolled beneficiaries) and employ industry best practice analytic tools/systems to exhibit sophisticated data analysis techniques with evidence-based algorithms. The CPD contractor shall provide the Government with access to review all such data methods and analytical results.

C.7.5.1.5.1. The CPD contractor must determine whether algorithms it uses for case management, disease management, clinical quality management, or other decisions about which beneficiaries will receive additional services from the CPD contractor, contain or display inadvertent racial bias.

If any racial bias is identified, the CPD contractor shall take steps to eliminate that bias to the satisfaction of the Government. As part of determining whether any algorithms contain inadvertent racial bias and eliminating such bias, the CPD contractor shall work with the Government

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Designated Authority (GDA) to identify bias and the actions that can be taken to eliminate or mitigate bias.

C.7.5.1.6. The CPD contractor shall submit an annual strategy and reporting frequency to monitor Health Equity and Disparities. For reporting requirements, see DD Form 1423-1, CDRL, located in Section F.

C.7.5.2. Case Management (CM)

C.7.5.2.1. The CPD contractor shall operate programs designed to manage the health care of individuals with high-cost conditions (including but not limited to Maternity and Opioid Use Disorders) or with specific diseases for which proven clinical management programs exist. These programs shall be available to enrolled eligible beneficiaries. For reporting requirements, see DD Form 1423-1, CDRL, located in Section F of the contract.

C.7.5.2.2. The CPD contractor shall assist CPD enrolled beneficiaries who require benefits and services beyond those provided under TRICARE with accessing information about other DoD programs and applicable community/state/federal health care and related resources.

C.7.5.2.3. The CPD contractor shall ensure that case managers are trained in and demonstrate motivational interviewing skills and knowledge of trauma-informed care.

C.7.5.2.4. The CPD contractor shall provide a transfer of beneficiary enrollment to the regional MCS contractor for beneficiary services not specifically offered under the demonstration (see paragraph C.7.3.7).

C.7.5.2.4.1. The CPD contractor, within three (3) business days of a beneficiary request, shall provide enrollment handoff for beneficiaries with Autism Spectrum Disorder requesting covered benefits under the Autism Care Demonstration.

C.7.5.2.4.2. The CPD contractor, within three (3) business days of a beneficiary request, shall provide enrollment handoff for beneficiaries requiring services provided under the TRICARE Extended Care Health Option (ECHO) program.

C.7.5.2.5. The CPD contractor shall encourage case management activities, including but not limited to universal screening of Post-Traumatic Stress Disorder (PTSD), Anxiety Disorders and Depression through the use of standardized clinical tools.

C.7.5.2.6. The CPD Contractor shall develop, implement and maintain a CM program that complies with TOM Chapter 7, Section 2.

C.7.5.3. Population Health (PH)

C.7.5.3.1. The CPD contractor shall develop, implement, and maintain integrated, whole person PH care within the constraints, boundaries, and benefits of the current TRICARE program and in accordance with the TOM Chapter 7, Section 3.

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C.7.5.3.2. The CPD contractor’s data system shall have sufficient IT infrastructure and data analytics capacity to support the CPD contractor’s vision and goals for quality improvement, measurement and evaluation, including the capability to: a) Identify service access, utilization, health outcomes, intervention effectiveness, social risk factors, and survey (e.g., CAHPS) results by beneficiary characteristics including race, ethnicity and language, and disability; b) Employ advanced analytic methods such as hot spotting and predictive analytics and modeling to improve the identification of beneficiaries and their communities disproportionately impacted by, or at risk for, poor health outcomes and social risk factors; and c) Support the monitoring and comparison of process and outcome measures over time to inform disparity reduction efforts.

C.7.5.3.3. The CPD contractor shall incorporate Chronic Care/Disease Management (CC/DM) conditions into its PH care.

C.7.5.3.4. The CPD contractor shall collaborate annually with the GDA to identify targeted diseases.

C.7.5.4. Utilization Management (UM)

C.7.5.4.1. The CPD contractor shall ensure that care provided, including mental health care, is reviewed for medical necessity (if applicable), is appropriately authorized, and complies with the TRICARE benefits contained in 32 CFR 199.4 and 199.5 and the TPM.

C.7.5.4.1.1. The CPD contractor shall use best practices in reviewing and approving care and establishing medical management programs to carry out this activity to the extent authorized by law.

C.7.5.4.1.2. The CPD contractor shall comply with the provisions of 32 CFR 199.4 and the TPM regarding review and approval of mental health services, notwithstanding the CPD contractor’s authority to utilize its best practices in managing, reviewing and authorizing health care services.

C.7.5.4.2. The CPD contractor shall apply its UM practices for all eligible enrolled beneficiaries in a manner consistent with TOM Chapter 7, Section 4.

C.7.5.5. Referral Management (RM)

C.7.5.5.1 The CPD contractor shall develop, implement, and maintain a RM Program in accordance with TOM, Chapter 7, Section 5, with exception to the exceptions listed in the exception table.

C.7.5.5.2. Except as provided below, CPD Prime enrollees are locked out of the direct care (military medical treatment facilities (MTFs)) system for health care services.

C.7.5.5.2.1. Under the TRICARE Pharmacy (TPharm) contract, CPD enrollees are authorized to access the pharmacy benefit through an MTF.

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C.7.5.5.2.2. CPD enrollees may access MTFs for emergency services, for which the CPD contractor will be responsible for reimbursing the MTF.

C.7.5.5.3. An enrollee’s violation of the direct care system/MTF lockouts could result in disenrollment of such enrollee.

C.7.5.6. Clinical Quality Management (CQM)

C.7.5.6.1. The CPD contractor shall develop, implement, and maintain a CQM and Patient Safety Program in accordance with the TOM, Chapter 7, Section 6.

C.7.5.6.2. The CPD contractor shall have a provider credentialing program that complies with the requirements in the TOM Chapter 4, Section 1. When this contract and the accrediting organization have differing credentialing standards for the same activity, the CPD contractor shall use the higher standard in performance of this contract.

C.7.5.6.3. The CPD contractor shall develop a data management strategy under which it shall collect and process all data necessary to produce the metrics identified in Attachment J-5, Clinical Quality Metrics, in accordance with the requirements of the TOM, Chapter 7, Section 3, Para 2.2.1 and the CPDs PH care strategy. The Government reserves the right to update Attachment J-5 in accordance with FAR 52.243-1, Alternate 1.

C.7.5.7. Coordination with the TRICARE Quality Monitoring Contract (TQMC) Contractor

C.7.5.7.1. The CPD contractor shall comply with the provisions of the TOM, Chapter 7, Section 7 regarding coordination and interaction with the TQMC contractor(s).

C.7.5.8. Telehealth

C.7.5.8.1. The CPD contractor shall develop a telehealth program that maximizes the availability of telehealth throughout its provider networks and facilitates delivery of telehealth services in accordance with the TOM, Chapter 27 and TPM, Chapter 7, Section 22.1. The CPD contractor may request exceptions to TRICARE telehealth requirements (in order to maintain its current operating models and utilize existing procedures and workflows) if these exceptions are expected to result in improved outcomes and/or lower cost to the Government. The contractor shall identify and fully justify such requests via the Telehealth Network Implementation Plan (CPD). For plan requirements, see DD Form 1423-1, CDRL P080, located in Section F of the contract.

C.7.5.9. Pharmacy Benefit

C.7.5.9.1. Beneficiaries who are enrolled in the CPD may fill their prescriptions through the TRICARE Pharmacy Program managed by the TRICARE Pharmacy (TPharm) contractor.

C.7.5.9.1.1. The TPharm contractor will dispense prescriptions in accordance with the TRICARE Uniform Formulary (UF).

https://manuals.health.mil/pages/DisplayManualHtmlFile/2022-12-05/AsOf/TOT5/C7S3.html

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C.7.5.9.1.2. The TPharm contractor will be responsible for all aspects of outpatient pharmacy claims, including:

• Claims adjudication

• Validating eligibility with DEERS

• Provision and management of a retail pharmacy network and Mail Order Pharmacy

• Pharmacy billing (including TEDS)

• Processing all Prior Authorization and Medical Necessity determinations

• Providing customer service to assist beneficiaries on pharmacy issues

• Supporting electronic pharmacy tools (e-prescribing, e-Prior Authorization, the Formulary

Search tool, etc.)

• Transmitting data to CPD Contractors, DHA pharmacy and enterprise data warehouses

C.7.5.9.2. The CPD contractor shall receive pharmacy claims from the TPharm contractor for patients enrolled in a health plan.

C.7.5.9.3. The CPD contractor shall provide a data feed identifying CPD enrolled beneficiaries to the TPharm contractor, and the TPharm contractor will return a file containing all prescriptions dispensed to those beneficiaries. The CPD contractor shall exchange these files no less than weekly, with frequency to be mutually agreed with the TPharm Contractor. The format of these files will be based on the CPD TPharm File Exchange document and may be revised by mutual agreement (Attachment J-10).

C.7.5.10 Nurse Advice Line (NAL)

C.7.5.10.1. The CPD contractor shall provide a Nurse Advice Line (NAL) for TRICARE enrolled beneficiaries that is available by phone 24 hours a day/7 days a week.

C.7.5.10.2. The CPD’s NAL shall provide evidence-based health care advice from a registered nurse that includes recommendations for the most appropriate level of care, as well as assist beneficiaries with locating an urgent care or emergency care facility, when applicable.

C.7.5.10.3. The CPD’s NAL shall assist TRICARE enrolled beneficiaries to find local care services as necessary when traveling.

C.7.6. Quality Management (QM)/Quality Improvement (QI) Program (QM/QI):

C.7.6.1. The CPD contractors shall have an established internal QM/QI program covering every aspect of the CPD contractor’s operation, both clinically and administratively. The CPD contractor shall provide a plan describing the internal QM/QI program to the CO within 30 days of contract award. The CPD Contractor shall provide the CO a report listing problems identified by its internal QM/QI program and the corrective actions planned/initiated within 10 days following the end of the month in which the problem was identified. For QM/QI plan/reporting requirements, see DD Form 1423-1, CDRL P040, located in Section J-X.

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C.7.6.2. The CPD contractor's QM processes shall focus on outcomes, program processes and procedures, standardization, identifying and resolving access to care problems, and fostering a consistent, efficient, and effective TRICARE program for beneficiaries.

C.7.6.3. The CPD contractor's QM/QI processes shall focus on process improvements and shall foster innovation by incorporating health care best business practices and health care industry standards that lead to quality health care access, quality health care rendered, and quality health care outcomes.

C.7.6.4. The CPD contractor’s QM/QI program shall be comprehensive and coordinated, covering all aspects of the TRICARE program, with oversight by CPD contractor senior leadership, ensuring that QM/QI information and processes are incorporated and communicated across its entire enterprise.

C.7.6.5. The CPD contractor shall provide visibility of QM/QI processes and reports to the Government on a routine basis. The Government will determine the reporting frequency and may adjust the frequency as it deems necessary.

C.7.6.6. The CPD contractor shall initiate and conduct monthly operational and assessment reviews for the Government during which the CPD contractor will present its performance against all quality standards. The venue and manner of presentation will be determined by the Government.

C.7.7. CLAIMS:

The CPD contractor’s claims processing/encounter system shall correctly apply deductible, copay, cost shares, and catastrophic cap in accordance with the TRICARE benefit policy as delineated in 32 CFR Part 199.4, 199.17, 199.18, as well as all applicable sections of the TPM, TOM and TRM.

Point-of-Service (POS) provisions do apply to this program.

C.7.7.1. The CPD contractor shall coordinate with the EEE contractor for updated catastrophic cap/deductible information as available and receive an X12 271 Health Care Eligibility Benefit response transaction from the EEE contractor.

C.7.7.2. The CPD contractor shall send X12 835 (claim and advice) and X12 837 (remittance) transactions to the EEE contractor. The CPD contractor shall accurately submit all medical and pharmacy encounters, provider, and beneficiary copay, cost share, and deductible data to the EEE contractor by a date to be specified. The CPD contractor shall receive summary and error reports for its monthly submissions by a date to be specified.

C.7.7.3. The CPD contractor shall ensure the data integrity of all data received, stored, and transmitted in accordance with information systems/network security requirements prescribed in paragraph C.7.10 below.

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C.7.7.4. The CPD contractor shall comply with all requirements regarding adjustments/recovery of underpayments, overpayments, recoupments, Third Party Liability (TPL), and collections in accordance with the TOM, Chapter 10.

C.7.7.5. The CPD contractor shall ensure that CPD enrollees have no liability for amounts billed, except for the appropriate co-payment, for referred care that constitutes covered services, including ancillary services from a non-network provider as a result of a medical emergency or as a result of the CPD enrollee being referred to a non-network provider by the CPD or CPD’s network provider.

C.7.7.6. The CPD contractor's claims processing/encounter system shall interface with the EEE and accurately confirm eligibility and enrollment status.

C.7.7.7. The CPD contractor shall comply with TOM Chapter 18, Section X, exceptions to this chapter are defined in the exceptions table.

C.7.7.8. The CPD contractor shall only pay the claim if the beneficiary is enrolled to the CPD.

C.7.7.9. The CPD contractor shall not be responsible for claims for dates of service prior to beneficiary enrollment in the Demonstration.

C.7.7.10. The CPD contractor shall be responsible for claims with dates of service through the last day of the month in which the beneficiary disenrolls from the Demonstration.

C.7.7.11. The CPD contractor shall provide to each beneficiary and each non-network participating provider an EOB that describes the action taken when care is denied or partially denied. If the denied care is related to a covered benefit, the EOB must provide the CPD enrollee with his or her appeal rights. The CPD contractor may issue EOBs to network providers, as stipulated in the network provider agreement, provided an EOB is issued when care is denied or partially denied. The EOB must clearly describe the action taken, provide information regarding appeal rights, including the address for filing an appeal, information on the deductible and catastrophic cap status. The CPD contractor shall mail a requested EOB, without charge to the beneficiary, within 5 calendar days of receiving a request (written, verbal, and/or electronic) for an EOB from a beneficiary, regardless of his or her status. At the option of the providers, HIPAA-compliant electronic remittance advice shall be provided.

C.7.7.12. The CPD contractor shall ensure that beneficiaries who are traveling outside of the CPD area are covered under the point of service option for non-emergency and non-urgent care visits.

C.7.7.13. The CPD Contractor shall ensure that providers in its network bill enrolled beneficiaries only for applicable copayments for services provided. The CPD Contractor also shall ensure that enrolled beneficiaries are held harmless for amounts billed, except for the appropriate copayments, for referred care that constitutes covered services, including ancillary services from non-network providers, as a result of a medical emergency or as a result of the enrollee being referred to a non-network provider by the CPD Contractor or one of its network providers.

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C.7.8. RECORDS…