HT9402-23-R-0001 Government Responses to CPD DRAFT RFP 11282022.pdf

Q# RFP Reference Subject Question Publishable Government Response 1 The draft references the Tricare reimbursement manual as a governing document for CPD participants. Is it correct to infer that contractors would be required to limit reimbursement to what is prescribed in the manual?

The Government does not intend to impose restrictions on CPD contractor use of Alternative Payment Models (APMs) for value-based care programs. The CPD contractor may consult the applicable TRICARE regulations (e.g., 32 CFR 199.14) governing TRICARE provider reimbursement methodologies and the TRICARE Reimbursement Manual (TRM) when determining how to structure reimbursements to its network providers (and non-network providers). However, the CPD contractor will have freedom to negotiate provider reimbursement rates as it deems appropriate and may freely utilize and employ APMs, as described in the Health Care Payment Learning & Action Network (HCPLAN) framework. Although the CPD contractor will not be required to consult with the Government before utilizing APMs under the CPD, the Government will require the CPD contractor to report to the Government on its use of APMs and how such use will support the types of Government objectives outlined in the TRM, Chapter 18, Section 1.

2 C.7.2 Communications We understand you require a 60 day window to review communications, would you consider a shorter window?

Yes, DHA Comms will consider it (nothing less than 30 days). Please propose your desired window in your next official communication.

3 G.2 Risk Scores If zero sum game, how do we model the market share?

Market share impacts the math on how you forecast risk transfer payments.

Risk scores will be administered similar to Medicare Advantage (MA), in that CPD risk scores will be compared to the non-CPD MCSC Prime enrollee risk scores. See Section G (G.2.2.3.5.) for details.

4 Costs The draft RFP references reimbursement for “transition in” costs. Can the agency elaborate on the kinds of costs it plans to reimburse contractors for and if these factors should also be included in the bid submission?

Reimbursement for transition-in costs would occur to the extent the offeror included such costs in the fixed-price CLIN for transition-in it proposal submission. The costs would be scrunitized using FAR Part 31, Contract Cost Principles and Procedures.

5 Information Security a.) What is the time sensitivity around information security requirements?

b.) Can we use time after the award date (i.e., during Transition In) to implement NIST required Cyber Security infrastructure?

Contractor must ensure NIST SP 800-171 is implemented at contract award. Otherwise, the contractor may not receive, transmit, process, or develop DoD CUI on their covered contractor information systems. If there are NIST SP 800-171 controls not fully implemented at contract award, the contractor must provide a Plan of Action describing mitigation and remediation plans w/remediation date(s) to be reviewed and determined if acceptable by Government.

6 Marketing and Communications

Should we be awarded the contract, when would we receive beneficiary specific data into to start marketing and communication activities?

Beneficiary specific data will be issued during transition.

7 Payment Does the Government intend to exercise flexibility to allow for provider payments above the current TRICARE Maximum Allowable Charge (TMAC) rates to attract providers to value-based arrangements and reward providers for achieving cost and quality targets tied to improving beneficiaries’ health?

The Government does not intend to impose restrictions on CPD contractor use of Alternative Payment Models (APMs) for value-based care programs. The CPD contractor may consult the applicable TRICARE regulations (e.g., 32 CFR 199.14) governing TRICARE provider reimbursement methodologies and the TRICARE Reimbursement Manual (TRM) when determining how to structure reimbursements to its network providers (and non-network providers). However, the CPD contractor will have freedom to negotiate provider reimbursement rates as it deems appropriate and may freely utilize and employ APMs, as described in the Health Care Payment Learning & Action Network (HCPLAN) framework. Although the CPD contractor will not be required to consult with the Government before utilizing APMs under the CPD, the Government will require the CPD contractor to report to the Government on its use of APMs and how such use will support the types of Government objectives outlined in the TRM, Chapter 18, Section 1.

8 Pharmacy Data Does the Government intend to provide Pharmacy data during the CPD RFP response period in order to give a holistic view of beneficiaries health and therefore inform the development of capitation rates?

Yes, pharmacy utilization data will be provided with the RFP data files.

9 Payment Per DHA's note in Section G.2, what will be the timing of capitation payments?

The timing of the capitation payments has been updated in Section G of the Draft RFP.

10 Enrollment a.) Do the 4,609 enrollees to the USFHP cited in the Draft Request for Proposal (RFP), Attachment J-1, all reside in Burlington County?

b.) If so, through what local delivery do they receive care?

a) No, the 4,609 USFHP enrollees reside within the Prime Service Area based on beneficiary reported ZIP code.

b) They receive care through Johns Hopkins.

11 Customer Service Page C9 of C19, C.7.4.9. requires the contractor to transfer phone calls on stated enrollment topics to the EEE contractor. Are those transfers to be "warm", which is to say the contractor phone agent remains on the line with the caller until a live agent from the EEE contractor answers? Are there more technical requirements related to this "transfer" process?

Yes, the transfers are to be "warm" and the contractor agent must remain on the line until the EEE system picks up.

HT9402-23-R-0001

OFFICIAL DHA RESPONSES TO DRAFT RFP 1 11282022

12 Eligibility Per section, C.7.3.5., Medicare-eligible beneficiaries are not eligible for the CPD. Can the government clarify the information stated in C.7.5.5.3. regarding Medicare-eligible beneficiaries with Part A who elect to enroll in CPD?

Any beneficiaries with any Medicare coverage, including Part A only, will not be elligible for CPD enrollment.

13 Payment C.7.5.5.2.2. How are MTF emergency services rates established? Is this process in place today and are MTF's trained and staffed to support this process?

The CPD will be required to reimburse the MTF at the rate separately calculated by the government. The following DHA Uniform Business Office (UBO) website contains the rates: https://health.mil/Military-Health-Topics/Access-Cost-Quality-and- Safety/Uniform-Business-Office/UBO-Rates-Overview/MHS-UBO-Rates. The MTF UBO will bill the CPD Contractor based on the Health Care Delivery Program (HCDP) code. Anticipate it will require continuing education for both the MTF and patients since this is only a 3 year demonstration.

14 Payment G.2. Capitation payments made in the month following the month of coverage, rather than in advance of the month of coverage would not pose a significant problem as CareSource adequately capitalizes the organization to ensure working capital is sufficient.

The timing of the capitation payments has been updated in Section G of the Draft RFP.

15 Payment G.2.1.2.2.3 What will the process consist of for notification and reconcilation of reimbursement?

The CPD will be required to reimburse the MTF at the rate separately calculated by the government. The following DHA Uniform Business Office (UBO) website contains the rates: https://health.mil/Military-Health-Topics/Access-Cost-Quality-and- Safety/Uniform-Business-Office/UBO-Rates-Overview/MHS-UBO-Rates. The MTF UBO will bill the CPD Contractor based on the Health Care Delivery Program (HCDP) code. Anticipate it will require continuing education for both the MTF and patients since this is only a 3 year demonstration.

Note: Outpatient pharmacy care is not subject to reimbursement 16 System Interface G.2.1.3 How will discrepancies between the EEE and the

CPD contractor systems be addressed? Will there be a reconciliation process?

DEERS is system of record for eligibility/enrollment. MOU between CPD/EEE could outline process. DHA is considering an AD HOC IPT workgroup to develop guidance on reconciliation and include this in the MOU.

17 Transition In Will all Open Enrollment and Onboarding plan materials be template-based with contractor adding details such as Disease Management, Network (telehealth, mental health) and Claims information?

DHA Comms must approve all concepts for all marketing campaigns and products. DHA Comms will provide approval of concept and provide templates as needed. DHA Comms must approve all final products.

18 Marketing and Communications

Is the contractor permitted to market directly to prospective beneficiaries? If yes, is it only utilizing DHA templates?

Yes. However, DHA Comms will need to approve in advance all concepts for all marketing campaigns and products. DHA Comms will approve marketing concepts and provide templates as needed. DHA Comms will also need to approve all final products.

Note that the requirement at paragraph C.7.2.6 of the performance work statement applies specifically to the annual TRICARE Open Season campaign.

19 Transition In May we obtain requirements documentation for the portal (pre/post enrollment) built by the CPD contractor that links to TRICARE (Similar to https://www.humanamilitary.com/)?

Please clarify your request. What specific requirements documentation are you seeking? Although perhaps not directly responsive to your question, we note that DHA Comms will provide the CPD contractors with style sheets reflecting expected "look and feel" for the online secure portal

20 Marketing and Communications

May we obtain a list showing the amount of documents used on an annual basis to receive, store, and mail TRICARE materials (content, newsletters, required notices -marketing toolkit)?

The TRICARE national suite of print products include handbooks, brochures, fact sheets, wallet cards, and newsletters. There are 22 products available for print. In typical years, TRICARE has printed over 3.3 million items and shipped to its various partners for distribution.

TRICARE publications are listed at https://tricare.mil/Publications. It is denoted which may be available for print.

21 Conferences Could further details be provided on what is expected at conferences?

For the conferences, the CPD contractor will be expected to provide a subject matter expert who is able to answer questions from beneficiaries about TRICARE, the role of the CPD contractors, the nature of the CPD health plan, and related matters. The conferences typically run for 3 calendar days, 8-10 hours per day.

22 Administrative Costs The administrative cost to serve some of the relatively small populations in CPD markets may be much higher on a per-beneficiary basis than a regional MCSC operating at scale. When evaluating the offerors' proposed ongoing administrative cost multiplier, will the Department take into consideration the higher per-beneficiary administrative costs necessary to serve these small CPD populations?

The government recognizes that the overall average administrative cost per beneficiary may be higher if enrollment is lower.

23 EEE Interface May we obtain the full technical specifications on how the CPD contractor will interface with the EEE and Tpharm (Express Scripts) contractors?

Only EEE Contractor needs technical specifications to connect to DoD/DMDC systems. CPD contractor will connect to EEE Contractor through a secure portal with CAC access.

24 Payment General: How will newborns be handled? Parents have 90 days to sign newborns up for benefits. However, claims for their hospital stays, some of them substantially high dollars, will be received and paid prior to the 90 day deadline.

If the newborn is enrolled, is their coverage retroactive to birth? Which contractor would be responsible for claims related to their birth?

DHA will provide the detailed specifications for newborns at a future date.

25 Payment General: Commercial insurance carriers target a MLR and, to the extent if they outperform and continue to deliver HC on time at the right time/quality, they would retain the excess. Conversely, to the extent they underperform, they are financially responsible.

Will DHA consider allowing the CPD contractor the ability to retain the excess as done in the commercial health care industry?

The MLR is projected to be 85%. DHA does not plan to adjust this based on the requestors inquiry.

26 Transition In C.6.2.9: The Government is requiring the CPD contractor to perform Transition requirements that will be addressed in the TRICARE Operations Manual (TOM) Chapter 18. Given the magnitude of the infrastructure required to fully execute the requirements of the TRICARE contract, including the large number of Performance Readiness Validation (PRV) and Performance Readiness Assessment Validation (PRAV), the Transition-In expenditures will be quite large.

Does the Government have a cap or an estimate on how much it will reimburse the CPD contractor for Transition?

There will be a CLIN allowing each offeror to bid an overall fixed-dollar amount for start-up costs. The government does not have a cap at the time of this response.

27 Payment C.7.1.17. states, "CPD contractor shall not pay for non-covered services with CPD capitation dollars." The beneficiary must be held harmless for non-covered services.

Under a capitated model, can non-covered services such as text or chat consultation with clinicians be provided at no cost to the beneficiary in the interest of improved efficiency and enhanced access to care?

Can care be provided in non-traditional ways if capitation is accepted by providers, or practices?

The Government cannot reimburse for non-covered services. That said, the CPD contractors will not be prohibited from offering value-added services or benefits that are not covered by TRICARE or "services that improve healthcare quality" as defined by 42 CFR 422.2430 (or as defined by services outlined in Sec. G.). However, any non-covered services/benefits must be provided at no cost to the Government and the costs associated with such services/benefits will not be considered when rebasing the premium in future rate settings. As provided in Section G, the CPD contractor will be subject to a Medical Loss Ration (MLR), and pursuant to the rules governing the calculation of MLRs (see 42 CFR Subpart X), "services that improve healthcare quality" will be counted in the CPD MLR calculation.

28 Payment C.7.1.18. states, "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,

2.1.5 of this solicitation). Further, the CPD contractor shall not bill the Government for such activities."

We are not sure what the Government's meaning is here. Is it possible that an example be provided for clarity?

For example, would office visits to monitor asthma not improve quality of care and would there not be cost shares for retired beneficiaries or their families?

The government will not pay for non-covered benefits often associated with "activities that improve health care quality". For a list of inclusions and exclusions for these activities, please directly reference 42 CFR 422.2430.

29 Enrollment C.7.3.: Will enrollment of a beneficiary within the CPD network to a primary care manager (PCM) be handled by the CPD contractor rather than the Eligibilty, Enrollment, and Encounter (EEE) contractor to ensure that the CPD contractor can steer to preferred providers or enroll to clinically optimal providers based on beneficiary risk and conditions?

The CPD Contractor will assign PCMs within the CPD system.

30 Payment C.7.3.2: How will the Government resolve claims paid by the CPD contractor/primary MCSC which later are found to be the responsibility of the other contractor due to a lag in or retroactive eligibilty information (address, other health insurance (OHI), participation in a special program)?

The CPD contractor will not be responsible for any costs unless the member is enrolled during the time of treatment.

This will be addressed in the MOU between the CPD and MCSC/USFHP.

31 Payment C.7.3.2: Will the CPD contractor be considered at risk from the moment eligibility is established (or specifically enrolled), even if mid-month?

Will the CPD contractor receive a partial per member per month (PMPM) or the full capitated rate for that month?

1. The CPD contractor will be at risk form the time of enrollment.

2. See Section G.2.1.3 for additional clarifcation of partial month enrollments and partial PMPM payments.

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

Does this mean the CPD can communicate/market directly to the beneficiaries and offer incentives similar to commercial health plans?

Yes. However, DHA Comms will need to approve in advance all concepts for all marketing campaigns and products. DHA Comms will approve marketing concepts and provide templates as needed. DHA Comms will also need to approve all final products.

Note that the requirement at paragraph C.7.2.6 of the performance work statement applies specifically to the annual TRICARE Open Season campaign.

33 Customer Service C.7.4.10. states, “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).”

Is it possible that the Government share the requirements of the EEE contractor with the CPD bidders?

Is there an EEE RFP available to the CPD bidders in order to identify roles & responsibilities of the EEE contractor to assist with interfaces and any possible overlaps?

DHA cannot share the EEE requirements until contract award (not awarded as of the date of this response). Any available insight about EEE will be shared at industry day.

34 Payment C.7.5.5.2.2. states, “CPD enrollee may access an MTF for emergency services, for which the CPD contractor will be responsible for reimbursing the MTF.” And …G.2.1.2.2.3.

states. “If a CPD enrollee receives emergency care at a MTF, the CPD contractor will be responsible for reimbursing the MTF.”

At what rate is the CPD contractor responsible to reimburse the Military Treatment Facility (MTF)? For example: G.2.1.2. states, “…with the MTF-delivered care valued at approximately private-sector-care (PSC) rates.”

Are these rates regionally adjusted for specific CPD locations?

Will participants be able to use MTFs for Knowledge, Skills, and Abilities (KSA)-related care and will reimbursement rates be valued at approximately PSC rates for that location?

The MTF will bill at the CMAC (CHAMPUS Maximum Allowable Charge) or comparable TRICARE maximum allowable charge.

KSA Care will not be a reason to access MTF care; CPD enrollees are locked out of the MTF except for pharmacy and emergancy services.

35 Payment G.2.2.3.4: Not all administrative tasks are driven by claim dollars or volumes. Variable and fixed costs will be specific to a given business model and operation. For example, if claims cost per capita decline, it does not always mean that administrative costs will decline.

Will the CPD contractor have an opportunity to rebid their administrative fee percentages if the costs move materially?

DHA is considering a revision for administrative pricing that would separate fixed versus variable administrative costs. The final RFP will reflect any such revision.

36 Payment G.2.2.5.1: If CPD contractors will be held “at risk” for proposed health care cost (HCC) multiplier values (the amount of health care savings below the MCSC-based costs), will EEE contractor bear a portion of that risk, as they will control enrollment steerage to high quality/properly priced providers?

Or will discount rate modifications (lack of enrollment steerage) need to be considered in the multiplier values for the proposal?

The EEE will not share any risk with the CPD. The EEE is responsible for enrolling the beneficiary in the plan. It is then the plan's responsibility to do PCM assignments.

38 Payment General: Will the CPD contractor be able to use an Alternative Payment Model (APM) with its providers, reimbursing them using the capitated dollars?

Are there any limitation on the type of APMs that can be used, bonuses that can be paid for performance or in shared savings with network providers?

The Government does not intend to impose restrictions on CPD contractor use of Alternative Payment Models (APMs) for value-based care programs. The CPD contractor may consult the applicable TRICARE regulations (e.g., 32 CFR 199.14) governing TRICARE provider reimbursement methodologies and the TRICARE Reimbursement Manual (TRM) when determining how to structure reimbursements to its network providers (and non-network providers). However, the CPD contractor will have freedom to negotiate provider reimbursement rates as it deems appropriate and may freely utilize and employ APMs, as described in the Health Care Payment Learning & Action Network (HCPLAN) framework. Although the CPD contractor will not be required to consult with the Government before utilizing APMs under the CPD, the Government will require the CPD contractor to report to the Government on its use of APMs and how such use will support the types of Government objectives outlined in the TRM, Chapter 18, Section 1.

39 C.1. General Markets DHA requested our feedback on all 23 markets, and in particular, the 6 "high interest" markets.

We believe beneficiaries most likely to enroll in a CPD are Prime enrolled beneficiaries. In the 23 markets, the total number of beneficiaries enrolled in Prime is ~450K, with enrollment ranging from ~3K (Oakland/San Jose) to ~133K (San Diego). A challenge we see with the 23 markets is that most are likely too small to yield high enough enrollment in the CPD to justify the investment and resources necessary to maintain this government program and achieve true value-based care benefits. Only 3 markets have more than 25K enrolled Prime beneficiaries - San Diego, Atlanta and the 3 combined Florida service areas. KP recommends DHA reconsider it's market strategy to include populations large enough to maximize ACO participation and their ability to deliver their full value to DHA.

The 6 "high interest" markets present the same volume challenge referenced above. The only site listed in Kaiser Permanente’s service area is Atlanta, GA. We have provided comments regarding this market in our Overall Assessment document.

Thank you for your input. The site selection is dependent on external factors and must be congruent with the overall DHA mission and priorities.

42 C.7.1.3. Network Requirements

Network Requirements When does the network plan need to be submitted (i.e., prior to SHCD, within XX months of the SHCD, etc.)?

The network plan needs to be submitted 240 calendar days prior to the SHCD.

43 C.7.1.6. Network Requirements

Network Requirements In a closed integrated health system with higher quality standards, individual providers are not hired or contracted into the CPD network if they do not meet quality standards.

KP strongly recommends CPD contractors who demonstrate overall high-quality outcomes (i.e., HEDIS scores, Medicare Star Rating) be allowed the option of limiting the display of quality metrics to the facility and organizational level.

The government will maintain this requirement as is.

See below:

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

45 C.7.3. Enrollment Marketing and Communications

This requirement implies CPD contractors can begin marketing on October 1st for Open Season (which we understand starts in early-November). We recommend CPD contractors be allowed to begin marketing as early as September 1st given the short timeframe for Open Season and the significant level of communication required to educate beneficiaries about new health plan options.

Yes, the CPD contractors will be able to begin marketing to beneficiaries before the open season begins. However, as indicated in responses to other questions, in all cases, DHA Communications will need to review CPD contractor marketing materials before they are released

46 C.7.3.5. Enrollment Benefits Please clarify what benefit descriptions CPD contractors should provide to the EEE Enrollment Exchange Portal. Our understanding is that the benefits will be administered in accordance with the defined TRICARE benefit sets so our perspective would be to leverage the existing TRICARE language to ensure consistency.

Proposed Response: DHA will meet internally to determine benefit description the CPD contractors should provide to the EEE Enrollment Exchange Portal. It is our intention to provide the successful offeror with this information during the transition period.

47 C.7.3.5. Enrollment Beneficiary Exclusions Will the government provide an explanation for excluding the following beneficiaries from eligibility?

• TRICARE Prime Remote (TPR)

• TRICARE For Life (TFL)

• TRICARE Reserve Select (TRS)

• TRICARE Reserve Retired (TRR)

• TRICARE Young Adult (TYA)

KP recommends all the above beneficiaries be eligible to enroll in the CPD.

TFL is excluded because DHA does not wish to incur full capitation costs for beneficiaries for whom Medicare would otherwise be first-payer. TRS and TRR are excluded because they are not eligible for the Prime benefit, and also because their inclusion in a capitation arrangement would complicate DHA's process for setting annual enrollment fees in these programs. TYA is excluded because inclusion in a temporary capitated arrangement would complicate DHA's process for setting annual TYA enrollment fees and they represent a very small population that would not materially increase enrollment in the demonstration.

48 C.7.3.6. Enrollment EFMP Exclusion Regarding:

• Exceptional Family Member Program (EFMP)

How will the CPD contractor know when a beneficiary is enrolled in the EFMP, and therefore disqualified from the

CPD?

DHA is currently re-valuating whether EFMP should remain on the exclusion list. We will provide an update before publication of a final CPD RFP."

49 C.7.5.1.3. Medical Management

MOU KP recommends DHA create a customer service MOU between the local MTF and the CPD contractor to develop a process and information guide to route misdirected calls from beneficiaries appropriately. This guide would assist with routing both administrative calls as well as medical calls such as telehealth.

DHA is assessing whether there will be a need for such an MOU

50 C.7.5.3.1. Population Health ACD Will the government allow CPD enrollees with Autism to remain enrolled in CPD if they elect to not receive services under Autism Care Demonstration (ACD)?

The beneficiary can remain in the CPD if they choose not to receive care under the ACD.

As stated in C.7.3.6, beneficiaries participating in or receiving benefits under ACD are not eligible to enroll.

And C.7.5.2.4.1 requires the CPD contractor "provide enrollment handoff for beneficiaries with Autism Spectrum Disorder requesting covered benefits under the Autism Care Demonstration."

51 C.5.5.2.2. Referral Management

MTF ED Care (Urgent Care) Confirm that MTF Urgent care services are also locked out. Yes, MTF Urgent Care is locked out.

52 C.5.5.2.2. Referral Management

Need to verify this with OGC.?

Also, I would assume Ms.

Julian would want to keep the bene at the MTF.

If a member is admitted from ER, will CPD be permitted to repatriate back to the CPD?

Yes, once a beneficary is clinical stable and able to transfer, the CPD contractor may repatriate CPD enrollees. Currently, CPDs will not be in areas where MTFs have available specialty care so this is expected to occur on a rare occasion. The CPD will be responsible for the repatriation transportation.

53 C.7.10.1.1. Information Systems/Network Security

Personnel Security Requirements

Regarding TSM Chapter 1, Section 1.1:

4.0 PERSONNEL SECURITY ADP/IT REQUIREMENTS – Please

confirm there would be no other scenarios where a CPD contractor will likely require an “ADP/IT-I (critical sensitive) or ADP/IT-II (non-critical sensitive)” with the exception of a Facility Security Officer.

There are scenarios.

TIER 2 (non-sensitive/public trust) for contractor personnel that will have access to DoD CUI (i.e., PII or PHI) on a DoD system or non-DoD system.

FSOs should be TIER 3 (non-critical sensitive).

54 G.2.1.2.2.3 Capitation Methodology

Billing/Reimbursement At what rate will Emergency Care received in MTFs be billed?

The CPD will be required to reimburse the MTF at the rate separately calculated by the government. The following DHA Uniform Business Office (UBO) website contains the rates: https://health.mil/Military-Health-Topics/Access-Cost-Quality-and- Safety/Uniform-Business-Office/UBO-Rates-Overview/MHS-UBO-Rates. The MTF UBO will bill the CPD Contractor based on the Health Care Delivery Program (HCDP) code. Anticipate it will require continuing education for both the MTF and patients since this is only a 3 year demonstration.

55 G.2.1.2.2.3 Capitation Methodology

Billing/Reimbursement Will the MTF bill the CPD contractor in accordance with the CPD contractor’s processes currently set up for invoicing? If no, please clarify the reimbursement process.

The CPD contractor will create a one off agreements with the MTFs and will typically pay the MTF the TRICARE allowable amounts.

56 G.2.1.3. Capitation Methodology

Billing/Reimbursement Will the same reimbursement process apply to MTFs outside the CPD service area, including OCONUS MTFs?

The CPD contractor will create a one off agreements with the MTFs and will typically pay the MTF the TRICARE allowable amounts.

57 G.2.1.3. Capitation Methodology

Billing/Reimbursement KP recommends:

• To support industry standard prepayment practices, on a monthly basis the EEE contractor and the CPD contractor should reconcile enrollment and capitation payments to reflect enrollment changes made in the course of the month.

• For a member enrolled after the 15th of each month, the CPD contractor should be entitled to 50% of the applicable capitation payment for that member for the month.

• Capitation payments should be supported by enrollment data, not claims data.

• Invoices for capitation should follow industry standard formats and submission practices for premium billing;

therefore the CPD contractor should not be required to follow the format required for CMS 1500, UB-04, or EDI claims submissions.

DHA will consider this input regarding capitation payments for mid-month enrollments when developing final RFP language for timing and reconciliation of enrollment and capitation. Claims data will not be used for purposes of enrollment, but DHA is requiring submission of encounter records for other purposes such as program oversight and evaluation.

58 G.2.1.4.1.1. Risk Reserves and Reinsurance

Capitation Payments Payment of capitation in the month following the month of coverage does not align with industry practice, especially for prepaid integrated health care systems, and would require significant investment in system modifications. KP recommends DHA provide capitation payments by the 1st day of coverage month.

DHA cannot prospectively reimburse for healthcare services.

59 G.2.1.4.1.2. Risk Reserves and Reinsurance

Financial Condition Statements

KP recommends, in lieu of submitting statements of current financial condition under this section G.2.1.4.1.1, if the CPD contractor is currently licensed to offer coverage in the large group commercial market in the state in which the CPD will be offered, and currently covers more than 50,000 enrollees in that state, the CDP contractor must only comply with the requirements of section G.2.1.4.1.3.

If the CPD contractor is currently licensed to offer large group coverage in the commercial market at a selected site and currently covers more than 50,000 enrollees at that site for the combination of Comprehensive Medical, Medicare Risk, and Medicaid Risk, then the CPD contractor does not need to submit the 3-year pro forma (G.2.1.4.1.1.), but must comply with the requirements of section G.2.1.4.3.

60 G.2.1.5. Medical Loss Ratio Reserves and Deposits Requirements

KP recommends, in lieu of demonstrating compliance with the required reserves and deposits requirements under this section G.2.1.4.1.2, if the CPD contractor is currently licensed to offer coverage in the large group commercial market in the state in which the CPD will be offered, and currently covers more than 50,000 enrollees in that state, the CDP contractor must only comply with the requirements of section G.2.1.4.1.3 .

If the CPD contractor is currently licensed to offer large group coverage in the commercial market at a selected site and currently covers more than 50,000 enrollees at that site for the combination of Comprehensive Medical, Medicare Risk, and Medicaid Risk, then the CPD contractor does not need to submit the 3-year pro forma (G.2.1.4.1.1.), but must comply with the requirements of section G.2.1.4.3.

61 G.2.2.1. Description of Methodology used by Government to Develop Initial Capitation Rates

MLR Requirements Because the CPD is intended to reflect coverage offered in the commercial marketplace, the use of the Medicare Advantage MLR requirements is not appropriate. KP recommends DHA instead require compliance with the MLR provisions found in 45 CFR, Subtitle A, Subchapter B, Part 158, Subparts A and B.

The CPD medical coverage is most similar to commercial comprehensive medical coverage, with the provider allowable charges being the Medicare allowable amount.

The MLR premium based rebatepayments go to DHA.

62 G.2.2.3.4. Updating the Originally Awarded Capitation Rates

Capitation Rates This implies that there will only be two capitation rates (one for ADFM and one for non-ADFM). KP recommends creating age/gender-based capitation rates (and adjusting the subsequent risk adjustment calculation similar to the ACA formula) given the significant variation in costs by age/gender for these populations. This would help minimize retrospective risk adjustment payments.

Age and gender will be accounted for in the risk scores. Therefore the capitation rates will remain at the beneficiary category level.

63 G.2.2.4. Risk Adjustment for

CY26/CY27

Risk Adjustments KP recommends the Cotiviti DxCG Intelligence model over other models such as the John Hopkins ACG System. The DxCG model allows organizations to make fair comparisons of healthcare delivery and payment systems, and in so doing, identifies opportunities for improvement. The John Hopkins ACG System is more valuable as a population health analytics tool than establishing payment methodologies.

The final RFP will specify which risk adjustment model will be used for CPD. DHA does not agree with the question's premise that the ACG model is not an appropriate option for risk-adjusting capitation payment rates.

64 G.4.3.1.1. WAWF Invoices and Payments

Administrative Changes KP suggests DHA also consider adjustments for administrative changes.

DHA will meet internally to determine how to handle change orders and administrative charges.

65 G.9. Enrollment Fees DME/GME Payments Limiting payment for DME/GME to medical schools could negatively impact a CPD contractor’s ability to contract with critical providers in a service area and could be confusing to providers, as these elements would be payable under the MCSC agreements. Would DHA reconsider excluding DME/GME from provider payments?

Thank you for your comment. DHA now intends to include DME/GME in the contractors capitation risk.

66 H.4. Post-Award Organizational Conflicts of Interest/Impaired Objectivity

Beneficiary Incentives Would DHA consider options to incentivize new enrollment in the CPD, such as waiving the enrollment fee for the first year for beneficiaries who elect this option?

Yes, refer to Section G when the final RFP is published.

68 Insurance Liability Requirements

KP recommends that DHA include provisions that enable CPD contractors to satisfy the insurance liability coverage requirements through a program of self-insurance.

Unless the CPD contractor intends to have a full-time presence on the military installation (such as liaison at an MTF or TRICARE office), the FAR Clause 52.228-5 will not be included in this solicitation.

69 Capitation Rates Per G.2.2.2.1, the Prime TED costs per enrollee for the initial historical base year will be provided as a part of the formal RFP.

1 - We request that DHA also provide the projected costs per enrollee by rate cell, including methodology and assumptions regarding all adjustments (e.g., trend, civilian/MTF blend, etc.).

2 - Additionally, we request DHA provide the average risk adjustment score (by rate cell) for the underlying base population.

The final RFP will include an exhibit that builds up the portion of the capitation rates prior to application of the two multipliers that will be bid by each offeror. DHA's current intent is that the historical data files that will be provided with the RFP will include historical data on risk scores.

70 Capitation Rates Is this to say that pre-award capitation rates will be used until Q1 when they are rebased off of FY24 data? Will there be a retroactive true-up?

The originally awarded capitation rates will be used during the first few months of the first year of healthcare delivery, until the re-basing and risk-adjustment results are executed, at which point a reconciliation amount will be calculated to adjust prior capitation payments.

71 Risk Adjustments Please share where we can get details of the DoD risk-adjustment model for TriCare. Specifically, we would like to know more about how data is collected, what systems are used, and timeframes involved.

The final RFP will include additional details on the risk adjustment process. Regarding the risk adjustment model, DHA is still reviewing which model will be used for CPD and this decision will be reflected in the final RFP.

72 Risk Adjustments Section G.2.2.3.5.2 notes that the capitation rates in all proposed years (CY25, CY26, and CY27) will be based on FY24 data for both base capitation rate development along with risk score adjustments. We recognize that this methodology may be sufficient in early years of the demonstration, barring any large acuity shifts of CPD members compared to the full eligible population.

However, we are concerned with the longevity of this methodology past the demonstration timeline. If participating in the demonstration, we aim to provide consistent and quality care for our members, and want to ensure that the rate methodology (or changes in the methodology) in future years is sufficient for us to operate the program.

DHA is reviewed the risk adjustment process for CPD and updates will be reflected the 2nd Draft RFP.

73 Risk Adjustments Could DHA expand on this statement? We would like to reserve the right to negotiate any material changes in the rate methodology that were not presented as a part of the RFP draft capitation rates.

DHA is reviewed the risk adjustment process for CPD and updates will be reflected the 2nd Draft RFP.

74 C.

Description/Specifications/W ork Statement

Beneficiary Exclusions The Draft RFP, includes the following section:

C.7.3.5. Active-Duty Service Members (ADSMs), Guard/Reserve Service Members, and beneficiaries who have Other Health Insurance (OHI) or are eligible for Medicare or Medicaid coverage are not eligible to enroll into the CPD. Further, beneficiaries participating in the following benefit programs are also not eligible to enroll into the CPD:

Question: The above exclusions may significantly decrease the number of beneficiaries and may make some of the 23 geographic locations less attractive to the health plans.

Will DHA consider removing some of these exclusions to ensure maximum participation by the health plans if needed?

The second draft RFP will reflect that beneficiaries with OHI will be eligible to enroll in the CPD. The other exclusions will remain as DHA has determined that the reasons supporting the exclusions outweigh any negative impact they may have on demonstration enrollment levels.

75 C.

Description/Specifications/W ork Statement

Eligibility (271 data) Submissions

The Draft RFP states:

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

Question: Is there an expectation that elig. data is included in the TED/encounter submission? Should the 271 data be required as part of a successful submission when the CPD submits the 835 and 837 to the EEE contractor?

Example: The HCDP is returned in the 271 and is required in a TED and isn't found in the other two transactions. The EEE Contractor is expecting all three (270 request, 835 and

837) in order to create a TED. However if CPD doesn't send a 270 but does send 835 and 837 then this encounter would returned to the CPD in the monthly Error report.

270/271 transactions will not be required when submitting claims data to EEE.

76 C.1. General Claims Processing 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.

Comment: We recommend DHA leverage the EEE contract to deliver this functionality to the CPD contractors. If not provided by the EEE, each CPD contractor would be required to have a DHA compliant claims processing system.

The CPD contractor will know beneficiary eligibility information from the EEE contractor. The EEE contractor will provide the correct deductible, and catastophic cap information so that the CPD contractor can process claims. The CPD contractor will be responsible for processing and paying claims and submitting copay, cost share information to the EEE contractor so that they cAn be updated in DEERS.

77 C.1. General Conflict of Interest As the CPD pilot health plans will be supporting beneficiaries currently under the Managed Care Support Contractors, will the Government confirm the organizational conflict of interest (OCI) between the MCSCs and the CPD program?

Please restate the question, providing more context and describing more fully the nature of the referenced OCI and the nature of your concern.

79 Risk Adjustments The Risk Adjustment approach, as presented in the TRICARE proposal, employs limited member history (FY’24) in capitation rate setting and risk score calculation. We recommend the DHA consider expanding the data collection period to allow for a more complete understanding of the health risk level associated with the underlying Prime population.

DHA is reviewing the details of the risk adjustment process and will reflect any revisions in the final RFP.

80 Newsletter Will DHA consider the CPD contractor conducting a test to determine if mailing a printed version of the newsletter one time per year is the most effective approach? Costs may be saved and engagement may be higher if a proportion of recipients who opt in to digital-only communications do not receive a printed version.

No. DHA Comms will not consider the CPD contractor conducting a test. We request data and input from the contractors regarding materials and product data which may be used to inform increased use of electronic vs. print. We are always open to data to inform our decisions.

81 Ad-hoc Meetings Do these ad-hoc meetings require in person participation, or is teleconference acceptable?

Teleconference is acceptable for adhoc meetings.

82 Enrollment Estimates A contractor's administrative cost ratio could vary based upon the amount of eligibles who opt into the CPD program. Could DHA please provide a CPD enrollment range or minimum beneficiary count contractors should assume? A bidder could achieve a competitive advantage by assuming a high level of eligible conversion in their proposal, then negotiate post award a administrative rate that is based upon actuals.

DHA anticipates that the RFP will include government-estimated enrollment counts for purposes of consistently evaluating the total cost of each offeror, although DHA makes no guarantee regarding actual or minimum enrollment. DHA is also considering possible RFP revisions for pricing of ongoing administrative costs to address uncertainty regarding enrollment levels.

84 Quality Measures Will DHA dictate the quality measures that the CPD contractor will need to publish on its website? Which quality measures will be required?

The DHA outlines required Clinical Quality Metrics in TOM, Chapter 7, Section 6, and Attachment J-5. Clinical Quality Metric CDRLs will also be released with RFP draft 2.

85 Capitation Rates In G.2.1.2.1. the RFP states that "separate rates will be developed for two broad categories..." When reviewing Schedule B, should Section B be updated to have sub-CLINs associated with CLIN xxx3 to reflect two sets of capitated rates?

The Section B CLIN structure will be finalized in the final RFP.

87 Enrollment/Disenrollment Processing

Assuming the EEE contractor will manage beneficiary CPD enrollment, would the assignment of a primary care manager (PCM) to the enrolled CPD beneficiary be managed by the EEE contractor (during the enrollment activity) or by the CPD contractor (after the EEE contractor notifies the CPD contractor of a newly enrolled beneficiary)?

The EEE contractor is responsible for determining eligibility of the beneficiary, and processing enrollment requests to the CPD.

88 Population Data Are beneficiaries with OHI excluded in the J-1 population counts?

No, OHI is not excluded since this population has the option to switch to CPD during open enrollment.

89 C.7.11 Benefits With respect to coverage and benefits requirements, does the CPD contractor follow Tricare guidelines alone or is there an expectation to also adhere to state level mandates and requirements?

Please provide specific examples of the referenced state level mandates and requirements.

Note: As a general rule, the Department of Defense has determined that "in the administration of 10 U.S.C. chapter 55, preemption of State and local laws relating to health insurance, prepaid health plans, or other health care delivery or financing methods is necessary to achieve important Federal interests, including but not limited to the assurance of uniform national health programs for military families and the operation of such programs at the lowest possible cost to the Department of Defense, that have a direct and substantial effect on the conduct of military affairs and national security policy of the United States." Please see 32 CFR 199.17(a)(7) for a full explanation of the scope and extent of the federal preemption in this area.

Potential CPD vendors should consullt their legal counsel for help in interpreting this regulatory language.

90 G.2 Risk Scores It looks like during the duration of the contract risk scores are invariant. This is similar to the recent Medicare ACO models that don’t permit changes during the contract year. What that means is that we adopt the risk score from the incumbent payer and can’t increase revenue via increased documentation, and our incentive is to really focus in on the base year for the next wave of the contract. The incumbents are working hard next year to drive coding completeness, which we may benefit from.

The outgoing T-17 and incoming T-5 MCS contracts do not include risk scores for payment of the MCS contractor. CPD risk scores will be adjusted annually over the life of the contract. Offerors will be provided 4 years of historical data to assess their risk on submitting proposals.

91 G.2 Risk Scores To incentivize robust participation, several government health programs cap downside risk. For example, the Medicare Advantage has a permanent risk corridor program as did the individual market for the first few years following passage of the Affordable Care Act. Given the similarities in design, will there be a similar program for this demonstration?

DHA will not be capping the contractor's downside risk (risk for losses), but DHA assumes the CPD contractor may opt to obtain reinsurance itself.

92 Enrollees If an enrollee moves out of the CPD region in the middle of a plan year, will they remain on the same plan or be transitioned into a new plan midyear? If so, how will the program facilitate that transition with the EEE?

If an enrollee moves out of the CPD region in the middle of a plan year, it would be considered a "Qualifying Life Event - (Relocation to a new country, and/or city (OCONUS), region or ZIP +4 code (date received or date specified by the beneficiary in the future) (self-attestation)) in accordance with TRICARE Policy Manual, Chapte 10, Section 3.1.