HT9402-23-R-0001 Government Responses to CPD DRAFT RFP 2 030322023.pdf

Q# RFP Reference Subject Question Publishable Government Response

348 OTA What was the DHA’s rationale in procuring the contract under FAR Part 15 and not under an Other Transaction Agreement? This demonstration will be conducted under procedures outlined in the FAR under Part 15. Initially, DHA considered Other Transaction Authority (OTA) to execute the program but after discussions with Defense Acquisition University, contracting, and counsel, DHA determined the OTA construct was not a proper acquisition method to execute the CPD requirements.

350 Risk Model Will the DHA consider an alternative risk model(s) from that which is outlined in the draft RFP? DHA has considered industry feedback and believes the risk model to be published in the final RFP will be appropriate for the demonstration.

352 EEE Award Is there an anticipated AWARD DATE for the EEE contract, and does the DHA anticipate any delay with the roll‐out of the CPD program as a result of this pending solicitation/award process?

An award of the Triple E contract is anticipated in the 2nd Quarter of CY23.

353 OTA Did the DHA consider Other Transaction Authority (OTA) to govern the Competitive Plans Demonstration? If so, what was the determining reason(s) against using this authority?

Yes, the Defense Health Agency did consider this acquisition method early on during the IPT formation. This demonstration will be conducted under procedures outlined in the FAR under Part 15. Initially, DHA considered Other Transaction Authority (OTA) to execute the program but after discussions with Defense Acquisition University, contracting, and counsel, DHA determined the OTA construct was not a proper acquisition method to execute the CPD requirements.

354 CAS Cost Accounting Standards (CAS) Requirements are a considerable lift for an organization to meet for a contract of this magnitude. Will all CPD offerors be required to meet CAS, or will the DHA review this requirement?

Any cost reimbersable CLINs have been removed from the RFP, therefore CAS requirements are not applicable to this effort as written.

355 EEE Draft RFP #2 states: G.8.1. The EEE Contractor will be responsible for collecting or refunding enrollment fees for applicable CPD enrollees.

The EEE Contractor will forward the enrollment fees collected, net of any refunds, to DHA as described in the contract covering the EEE requirements.

Will DHA disburse enrollment fees to the CPD contractor? If so, will it be the full amount or partial?

No enrollment fees will be disbursed to the CPD contractor. The CPD contractor will not be at financial risk for enrollment fees and will not be responsible for administering enrollment fees.

356 Enrollment Fee How will enrollment fees impact the calculation of capitated fees, if at all? Enrollment fees will not affect the capitation rates. The CPD contractor will not be financially at risk for enrollment fees.

357 CUI Does the government intend to provide additional requirements related to protection of confidential unclassified information (CUI) at rest?

Or are CPD contractors allowed to use varying methods of protection as long as NIST SP 800‐171 standards are met?

NIST SP 800‐171 implemented safeguards for CUI in transit and at rest on non‐DoD information systems. CPD contractors may use varying methods to protect CUI as long as they can show how they can be mapped to the specific NIST SP 800‐171 requirement. For example, Appendix D in NIST SP 800‐171 publication provides an informal mapping to NIST SP 800‐53 and ISO/IEC 27001. Explanation of how each NIST SP 800‐171 is met shall be described in the CPD's System Security Plan.

358 Data sharing Will the MCSC share beneficiaries' historical medical records with the CPD contractor to facilitate continuity of care and case management? If so, will there be a standard data format for medical records?

Once the beneficiary is enrolled, the CPD will have to request the individual records from the MCSC or previous health plan. This will be discussed during the MOU development with the CPD/MCSC during the transition in.

Note: The beneficiary would need to bring their record to the new provider (or fill out a release form with their old provider to have the record sent to the new provider). The MCSC would not have the record either – they would only have claims, just like the USFHP Direct Providers. This would be a provider to provider transfer.

359 Industry Days Will the Government hold additional Industry Days for the other 21 markets included in the draft solicitation? If so, what is the expected timing of an Industry Day for other markets?

No other industry days are scheduled at this time.

360 Site Selection What is the criteria for selecting Tampa, FL and Atlanta, GA as the markets for CPD? Market research indicated a minimum 3‐5,000 enrollee threshold. DHA combined enrollment analysis with existing policies/guidance to determine the most viable sites.

364 Alternate Benefit Design What is the level of flexibility and alternative benefit designs that will be allowed under CPD? The CPD will provide the Uniform TRICARE Prime benefit. Additional services will not be provided at the expense of the DHA.

365 CUI With the understanding that any contractor personnel must be US persons to access controlled unclassified information (CUI), does that requirement apply to contractor technology personnel who maintain systems but do not have access to the data in the systems? An example might be technology help desk staff outside the United States who provide support outside of US business hours.

Unless CUI is marked as NOFORN or NF, Non‐US persons may access CUI on non‐DoD information systems if: (1) Access to such information is within the scope of their assigned duties, (2) Access to such information would help accomplish a lawful and authorized DoD mission or purpose and would not be detrimental to the interests of the DoD or the U.S. Government, (3) There are no contract restrictions prohibiting access to such information, and (4) Access to such information is in accordance with DoDIs 8500.01 and 5200.02 and export control regulations, as applicable.

366 CUI Can controlled unclassified information and other contractor data co‐exist at rest within one infrastructure, or does controlled unclassified information need to be completely segregated on the front and back ends?

CUI may reside within one infrastructure but access controls and system and communication protection requirements prescribed in NIST SP 800‐171 need to be implemented to ensure confidentiality of CUI.

367 Info Security Do we need to stand up a completely firewalled technology ecosystem? To further elaborate on this question, what will the logical access control requirements be? How will data need to be segregated using those access controls?

See System and Communications Protection and Access Control family domains in NIST SP 800‐171. If nonfederal organizations entrusted with protecting CUI designate systems or components for the processing, storage, or transmission of CUI, those organizations may limit the scope of the security requirements to only those systems or components. Isolating CUI into its own security domain by applying architectural design concepts (e.g., implementing subnetworks with firewalls or other boundary protection devices) may be the most cost‐effective and efficient approach for nonfederal organizations to satisfy the security requirements and protect the confidentiality of CUI. Security domains may employ physical separation, logical separation, or a combination of both. This approach can reasonably provide adequate security for the CUI and avoid increasing the organization’s security posture to a level beyond which it typically requires for protecting its missions, operations, and assets.

Nonfederal organizations may use the same CUI infrastructure for multiple government contracts or agreements, if the CUI infrastructure meets the safeguarding requirements for the organization’s CUI‐related contracts and/or agreements including any specific safeguarding required or permitted by the authorizing law, regulation, or governmentwide policy.

368 CUI Will non‐crytpographic protections of CUI at rest be permissible? Will commercially acceptable levels of encryption of CUI be permissible? Use Federal Information Processing Standards (FIPS)‐validated cryptography and National Security Agency (NSA)‐approved cryptography to protect CUI at rest.

369 Risk Model The risk‐adjusted capitation rate will be based on the average risk score of the Prime‐enrolled population. However, those beneficiaries previously enrolled in Select will also be eligible for the CPD demonstration. Will DHA consider a separate risk adjustment for the previously Select‐enrolled beneficiaries, relative to the Prime‐enrolled average?

Former Select enrollees who enroll in CPD will receive a risk score in the same manner as former Prime enrollees.

371 Site Selection Although the current draft limits markets to Tampa and Atlanta, at Industry Day the government stated that these would be the "initial" markets. Will the Government share criteria used to limit CPD to these two locations and what additional criteria/markets would be considered in the future?

Market research indicated a minimum 3‐5,000 enrollee threshold. DHA combined enrollment analysis with existing policies/guidance to determine the most viable sites.

372 Claims Data C.7.7.2. and elsewhere throughout the RFP and specially DHA's response to question #268, it appears DHA's definition of claims encounter data is the end result of claims processing, without fee for service payments, resulting in the data represented in EDI transactions 837 and

835. In the industry, encounter data generally includes some level of medical record data in addition to claim results. Please define claims encounters as it relates to the CPD RFP and operational requirements.

A sample data dictionary and reporting specifications is included in the J attatcments.

Note: The MDR claims data elements are available on health.mil and submitted in 3 different encounter files; Medical/Clinical (MCD), Pharmacy (Rx), and Provider (PRV).

Note: Encounter data does include diagnosis and procedure information.

373 Info Security In the industry day, it was noted that users within the system that had access to aggregate data would require Tier 3 clearance. Can the Government further define who an "aggregator" is and what kind of aggregate data applies to this requirement? Previous RFPs only noted Tier 1 and Tier 2 clearance for individuals working on this program. We assume this to only apply to system administrators.

Favorable and adjudicated Tier 1 (non‐sensitive position) and initiation of Tier 2 required for Users whose access allows data entry or singular search capability to a DoD system or non‐DoD system (i.e., covered contractor ISs) with CUI (e.g., PHI). Users with Tier 1 background investigation do not have the ability to aggregate and extract data from a DoD system. "Aggregate" or "compiled" CUI has a potential to cause serious damage to national security. Tier 3 (non‐critical sensitive position) User has ability to aggregate and extract from a DoD system. Facility Security Officers (FSO) required to have Tier 3. System administrators that manage non‐DoD ISs with CUI require Tier 1 and initiation of Tier 2. No Users under this contract will have system administrator access to a DoD IS.

374 MTF ER Care When the CPD contractor pays the MTF for emergency care provided to enrolled CPD members, is the CPD contractor also required to process the data from the MTF and send the MTF encounter data to the EEE contractor or are they not required to be reported in that manner?

The CPD contractor needs to process the MTF encounter payment to account for the cost of MTF care in their Medical Loss Ratio and future capitation payment calculations. The MTF encounter data will be sent to the DHA Medical Data Respository by the MTF staff.

375 Risk Model Would DHA consider modifying Section B to allow offerors to submit PMPM rates tiered by CLIN to allow different rates based on CPD beneficiary enrollment levels? This would help protect the CPD contractor in the event that either very low or very high membership counts are realized.

DHA does not intend to establish tiered PMPM rates for different enrollment levels and believes the creation of a separate CLIN for the offeror‐proposed aggregate fixed‐price portion of the ongoing administrative price provides important financial protection for enrollment uncertainty. Offerors may also choose to obtain stop‐loss reinsurance from a commercial source to the extent they believe that is prudent regarding the financial risk in the PMPM capitation rates.

376 Encounter Data Is there an expectation for the contractor to be responsible for ensuring beneficiary clinical encounter information is entered into the MHS

EMR?

CPD contractor will submit encounter data (include clinical) to the EEE contractor to submit to the DHA MDR.

377 Duration We recommend DHA allow the CPD demos to run for 5 Option Years instead of 3. Three years is an inadequate amount of time to grow enrollment to the point where statistically valid results of the success of alternate payment plans can be determined. We offer as an example that CMS allows five years to test alternate treatment/payment methods in their CMMI demonstrations.

The times outlined in the RFP indicate the duration of the CPD.

378 Performance H.1.3. CUSTOMER SERVICE PERFORMANCE GUARANTEE indicates we need to meet a 97% accuracy rate. Can DHA provide additional context on what this metric means, what the criteria is in terms of how we meet this metric, and also what performance guarantees are we up against (dollars, CAP)?

Yes, additional details will be provided in the final RFP.

379 Performance Please confirm when performance criteria content will be provided. Additional details will be provided in the final RFP.

380 Eligibility Please confirm if the Custodial Care Transitional Policy (CCTP) and Individual Case Management Program For Persons With Extraordinary Conditions (ICMP‐PEC) members are eligible for the CPD program.

No, Custodial Care Transitional Policy (CCTP) and Individual Case Management Program For Persons With Extraordinary Conditions (ICMP‐PEC) members are not eligible for the CPD program..

381 Eligibility Is there a current list of targeted diseases? Targeted diseases are not specified for the CPD contract to allow the flexibility to determine programs based on disease prevalence. Targeted diseases for the current T‐2017 contract include: Cancer, Asthma, Heart Disease, Diabetes, Chronic Obstructive Pulmonary Disease, Depression, and Anxiety Disorder.

The Contractor shall collaborate annually with the Government Designated Authority (GDA) to identify targeted diseases.

Please see RFP C.7.5.3.4.

382 Disenrollment Criteria Please clarify the disenrollment criteria. Is there a particular number of violations that must occur? Disenrollment/disqualifying criteria is listed in paragraphs C.7.3.5., C.7.3.6., C.7.3.7, and C.7.5.5.3. CPD Contractor will discuss disenrollment requests, based on violations, with DHA on a case by case basis.

383 4.1.2 Preadmission/Preauth 4.1.2 indicates the CPD contract will perform preadmission and preauthorization reviews using the list in paragraph 4.2, however, J‐9 excludes paragraph 4.2. Is there a different list that should be utilized.?

Thank you for identifying this conflicting information. To clarify, TOM Ch 7, Sec 4, para 4.2 does apply to the CPD with the exception of Applied Behavioral Analysis (ABA) and Extened Care Health Option (ECHO) services.

384 C.7.7.2. and L.6.2.3.3. Pharmacy Data C.7.7.2. and L.6.2.3.3. implies that the CPD contractor will be required to ingest the pharmacy data from the pharmacy contractor and then electronically submit it along with the claims encounter data to the EEE. Presumably, pharmacy data will be sent by the pharmacy contractor.

Why would pharmacy data need to be transmitted to EEE by the CPD?

There is no requirement for pharmacy data to be submitted to the EEE. Per C.7.5.9.1.2, the TPharm contractor will be responsible for all aspects of outpatient pharmacy claims, including "Pharmacy Billing (Including TEDS)" and "Transmitting data to CPD Contractors, DHA pharmacy, and enterprise data warehouses".

385 Enrollment Attachment J‐4 provides the count of currently enrolled TRICARE beneficiaries by ZIP code in Atlanta and Tampa, which is very helpful. We request that DHA provide a similar list but with the enrollment categories delineated into three categories: 1) Prime enrolled civilian network. 2) Prime enrolled MTF providers. 3) Select enrolled beneficiaries. This is necessary as we assume Prime enrolled beneficiaries are more likely to enroll in CPD than Select enrollees.

Yes, Attachment J‐4 will be updated to include Select Enrolled Beneficiaries.

386 EEE requirements If the EEE interactions, work processes, and transactions are not able to be specifically provided with the CPD RFP, will DHA issue EEE requirements as they are developed as change orders to the CPD contractor(s)?

Anticipate EEE Contract to be awarded by release of final RFP and will share EEE requirements at that time.

387 Historical Data When DHA makes historical data pertaining to Atlanta and Tampa beneficiaries available in the RFP, we understand DHA specifically de‐ identifies PHI information. Are offerors required to perform additional sanitization/exclusion of the data, or is the data sent by DHA already de‐identified to the point that it can be fully analyzed without further de‐identification? This assumes the offeror signs a data‐sharing agreement with DHA to ensure the privacy and security of protected health information.

The explicit patient ID number in the data will be encrypted, but the data will still be sensitive and will contain PHI‐level information that will need to be protected accordingly.

388 Enrollment Processing Presumably the EEE contractor may have a backlog of CPD enrollments at month end. That backlog would probably not be included in their report to the CPD contractor of members enrolled for CPD to bill DHA the PMPM for the month. When the EEE completes the backlog enrollment entry, would they retroactively date the enrollment for when the enrollment was received? If so, how would the CPD contractor be paid for the retroactively enrolled CPD members?

Anticipate certain processes will have to be finalized once both the EEE and CPD Contractors are in place as outlined in C.7.9.1.:

"The CPD contractor shall participate as requested by the CO or COR in quarterly round table meetings with the Government, all other Managed Care Support Contractors, and any other participants the Government determines is necessary. The CPD contractor will arrange for high‐level managerial participation in the round table (CEO, Medical Director, etc.) as well as participation, as appropriate based on the agenda, by the CPD contractor’s technical and financial experts."

The contractor will follow the processing timelines in the manuals.

389 EEE requirements Please provide a complete EEE Statement of Work as an attachment to the next sam.gov posting for CPD. Without that, the CPD bidders will not fully understand the cost or processes needed to interact with EEE contractor.

The EEE statement of work will be provided at the earliest opportunity.

390 Eligibility Inquiries For the CPD contractor(s), will the EEE contractor be responsible for all incoming 270 eligibility queries from external parties and respond with the 271 response?

All eligibility queries will be handled by the EEE contractor.

391 Data Elements and Formats The EEE contractor will submit paid/processed encounter data to DHA based on the CPD contractor's claims processing, What data elements and in what format is the EEE required to submit data to DHA? We ask this because some specific TRICARE data elements such as the HCDP code are not part of the EDI 837/835 transactions so the data sent by the CPDs must be a proprietary format that needs to be created. Please include the field elements, definitions and requirements with which the EEE must comply in sending claims encounter data to DHA so the CPD contractor understands exactly what claims data needs to be submitted to the EEE.

A sample data dictionary and reporting specifications is included in the J attachments.

392 Data Elements and Formats Please provide the data elements, formats and requirements for the enrollment data the EEE contractor will send to the CPD contractor(s). A sample data dictionary and reporting specifications is included in the J attachments.

393 Eligibility Inquiries What responses will the EEE contractor return to the CPD contractor for eligibility queries when DEERS is slow to respond or not online for a period of time?

The EEE contractor will return eligibility queries to the CPD contractor for eligibility queries once received from DEERS. Since DEERS is the sole repository for eligibility, the EEE contractor can only return eligibility queries to the CPD contractor once they are received from DEERS.

394 Claims Processing Will the EEE contractor conduct editing on claims encounter data submitted by the CPD and return encounters that do not meet editing requirements? If so what are the specifics about this process?

The Triple EEE contractor will perform a QA process on all claims before they are uploaded to the MDR. Any claims that do not meet the requirements will be returned to the CPD contractor for correction.

395 Claims Processing For claims processing, will the EEE contractor provide to the CPD contractor(s) the beneficiary's current contributions toward the annual deductible and catastrophic cap with the eligibility query response?

Yes, the CATCAP data will be included with the claims processing information.

396 NAL Is the Nurse Advice Line limited to RN’s, RN’s or higher Nursing Education Level, and/or would Licensed Practical Nurses be allowed to fill this role?

The Nurse Advice Line is limited to RNs to provide evidence‐based health care advice and recommend the most appropriate level of care. Unlicensed personnel may assist with locator services when necessary.

397 PMPM PMPM approach proposes to use three year intervals of data including FY 2020 and FY2021. We know that utilization was much lower during these years due to the COVID 19 pandemic, as many people stayed away from healthcare unless they felt there was a bona fid need. As a result, the industry generally considers FY 2020 as an outlier, with unusually low use rates among membership pools similar to those of TRICARE. With an understanding that utilization is increasing from 2022 to 2023, there should be consideration that the broader population may not be reflective of those members eligible for the pilot and a methodology to adjust via risk adjustment or risk corridor should be employed continuously throughout the demonstration.

The NHE trends applied to the FY20‐FY22 data are anticipated to account for general effects of the COVID‐19 pandemic in those years. Further, the capitation rates will be re‐based post‐award using more recent FYs, as described in Section G.

399 Section M.7.2.5 Evaluation Section M.7.2.5 defines the evaluation for Subfactor 5 ‐ Provide the TRICARE Benefit. The government list of approaches that will be evaluated for Subfactor 5 ‐ Provide the TRICARE Benefit does not include the non‐excluded TRICARE Manual Requirements that are not separately identified in Section M.7.2.5. How will the government evaluate the offeror's approach for non‐excluded TRICARE Manual requirements that are not separately identified in Section M.2.2.5?

The Government intends to evaluate TRICARE Manual requirements during the source selection that the Government determined are the highest risk to new entrants’ understanding of the TRICARE program. These requirements will be identifed in Sections L and M of the final RFP. Non‐excluded, non‐excepted TRICARE Manual requirements will be performance requirements for the CPD awardees even if not evaluated during the competition.

402 Section C 7.7.8 Claims Processing It is our understanding that DHA will pay providers on a risk‐adjusted capitated basis. In a true capitated model providers would not submit CMS 1500 or UB92 claim forms to the contractor for payment. During the Industry Day LT Akill Lett informed industry that "contractors will not submit claims to DHA, CPDs will be reimbursed directly by DHA on a risk‐adjusted capitation basis." Please define "claims" as referenced in Section C.7.7.8. Will this necessitate the submission of CMS 1500s and UB92s to capture encounter and historical data?

DHA will not be paying "providers" on a risk‐adjusted capitation basis; DHA will be paying the CPD contractor on a risk‐adjusted capitation basis and the CPD contractor will be responsible for paying providers. The CPD contractor will submit all encounters for services delivered by their providers to the EEE contractor who will forward them to DHA. All transactions will be transmitted using HIPAA compliant forms and data fields. The specific details will be provided in the final RFP (see J11/Data Dictionary & J12/Reporting Specifications).

403 Enrollment Enrollment Processing Will the EEE Contractor have access to the Beneficiary Web Enrollment (BWE) functionality (i.e.‐ API) for new enrollments into the CPD plans? Under the T2017 MCSC contracts this functionality resides with the DOES system.

The EEE Contractor will process enrollment requests submitted via the Beneficiary Web Enrollment (BWE) portal using the WebDOES application.

404 Enrollment Data Sharing Will the EEE contractor’s portal integrate with DEERS and the BWE? Or will the BWE pass information (PNTs, fees, etc.) to the EEE contractor through DEERS?

The EEE contractor’s portal will fully integrate with DEERS and process all transactions received from DEERS, and pass all required information to the CPD contractor.

405 Enrollment Enrollment Processing How will beneficiaries access the BWE Portal to enroll in the CPD after reviewing the plans options on the EEE Portal? Beneficiaries will access the BWE application via the MilConnect portal to enroll in the CPD after reviewing the plans options on the EEE website.

406 Premium billing Will the CPDs be doing their own billing for the premiums? Or will they submit them to DMDC so the EEE can perform the billing based on the data they submitted to DMDC?

The EEE contractor will conduct billing operations for the collection of premiums (enrollment fees) for beneficiaries enrolled to the CPD and report them to DMDC.

407 C.7.3 Provider networks Per C.7.3.: How will providers who participate in both the Managed Care Support Contractor's (MCSC's) Region network and in the CPD's Market network be made aware of and understand which "TRICARE" contract a beneficiary is enrolled in order to avoid any errors in quality reporting, billing appeals, and other processes?

Beneficiaries enrolled in the CPD will show which health plan they are enrolled to when an eligibility query is submitted to

DEERS.

408 CIII.7.3.7 Care Coordination Per CIII.7.3.7: When a patient is transferred out of a demo program to a MCSC due to a new disqualification (ECHO, ACD, etc) will there be a requirement to coordinate transfer and authorizations as there is with transfer between regions. The PMPM for the patient does not change from the CPD to an administrative PMPM for the MCSC until the end of the month of the disenrollment.

Yes there be a requirement to coordinate transfer and authorizations, see C.7.5.2.4.1. and C.7.5.2.4.2.

Coordination of transfer and authorizations is expected when a beneficiary is transferred from the CPD Contractor to the MCSC due to a disqualifying condition.

409 C.7.1.7 Metrics C.7.1.7 indicates the contractor will provide data validating access to care for beneficiaries in their geographic area. Does this metric apply only to beneficiaries enrolled to the CPD contractor in the designated geographic area? Or is it to include beneficiaries enrolled to the overlapping MCSC?

The metrics only apply to CPD enrollees.

410 C.7.5.1 CUI Per C.7.5.1.: Can the beneficiary‐centric warehouse be the CDP contractor's enterprise data warehouse including data for all IDS patients regardless of payer or must it be segregated containing TRICARE beneficiary data only?

CUI may reside within one infrastructure but access controls and system and communication protection requirements prescribed in NIST SP 800‐171 need to be implemented to ensure confidentiality of CUI.

Additionally, the beneficiary‐centric warehouse may be the CPD contractor's enterprise data warehouse including data for all IDS patients regardless of payer, however, the CPD contractor must be able to demonstrate that the data utilized effectively captures the needs of the CPD beneficiaries.

411 C.7.5.1.5.1. and C.7.5.1.6

Race/Ethnicity data Per C.7.5.1.5.1. and C.7.5.1.6: Will the government provide the contractor with beneficiary race or ethnicity information? When available through the EEE Contractor, and a sample data dictionary and reporting specifications is included in the J attachments.

412 C.7.5.10.1 NAL Per C.7.5.10.1.: Can the Nurse Advice Line (NAL) provided to TRICARE beneficiaries be the Integrated Delivery System's NAL available to all IDS users regardless of payer or does the NAL need to be TRICARE specific?

NAL needs to be able to support CPD enrollees with CPD TRICARE benefit information.

The NAL can be the Integrated Delivery System's as long as pertinent TRICARE information is relayed to CPD enrollees when accessing the NAL.

413 C.7.7.1 OHI data Per C.7.7.1.: The CPD contractor shall coordinate with the EEE contractor for updated catastrophic cap/deductible information. During the Industry Day call held on 3/9/23, presenter stated that the CPD contractor will be required to obtain Other Health Insurance information from the EEE contractor. Can DHA please confirm that is the case, and if so recommend adding language to Section C.7.7.

The EEE contractor will collect OHI information from CPD enrollees and maintain an OHI repository. The EEE contractor will share this information with the CPD Contractor when queried. C.7.12.2 addresses requirement for MOUs with other TRICARE Contractors to include OHI information.

414 C.7.7.2 OHI Per C.7.7.2: The CPD contractor shall accurately submit all medical and pharmacy encounters, provider, and beneficiary copay, cost share, and deductible data to the EEE contractor. Recommend this requirement be expanded to include Other Health Insurance (OHI) information as the CPD contractor can discover new potential OHI during the course of processing claims.

The Government concurs and will modify requirements.

415 G.2.2.1.2 Pharmacy Per G.2.2.1.2.: Will the CPD contractor be required to use the TRICARE Pharmacy (Tpharm) contractor for home infusion drugs when available per the TRICARE Policy Manual (TPM) Chapter 8, Sec 20.1?

If so, will such drugs be excluded in determining the capitation (PMPM) rate?

The CPD contractor will be required to follow the TPM regarding use of the TRICARE Pharmacy (Tpharm) contractor for home infusion drugs. Drugs that are obtained through the T‐Pharm benefit will not be included in the CPD capitation rate.

416 G.2.2.1.2 Pharmacy Per G.2.2.1.2: Some new medical benefit drugs are prohibitively high in cost (e.g., up to $3.5M/dose). Will there be any carve out for very high cost Medical Benefit drugs?

There will not be a carve‐out for very high cost Medical Benefit drugs. Offerors may choose to obtain stop‐loss reinsurance from a commercial source to the extent they believe that is prudent regarding the financial risk in the PMPM capitation rates.

417 L.2.1 MCSC exclusion L.2.1 states, "Current (i.e., T‐2017 contracts) or future (i.e., T‐5 contracts) TRICARE Managed Care Support contractors (or their parent companies, affiliates (as defined in FAR 2.101), or subsidiaries), may not bid as prime contractors for this requirement or participate in the performance of the requirement as subcontractors, partners, or team members of the prime contractor."

Please confirm why the Government considers CPD to be a financially viable opportunity for potential bidders after excluding current and future MCSCs (or their parent companies, affiliates, or subsidiaries) from bidding as a prime or subcontractor.

The CPD is designed to address certain requirements of NDAA FY17, Section 705, including the requirement (in paragraph 705(c)(3)), to "ensure that local, regional, and national health plans have an opportunity to participate in the competition for MCSCs under the TRICARE program." DHA understands Congress' intent here to be to open opportunities for new entrant health plans to support the TRICARE program, provide alternative networks, and so forth. In light of this consideration and other considerations, DHA has decided to exclude certain sources from this competing for the CPD requirement.

418 TRICARE

REIMBURSEMENT

MANUAL (TRM)

Chapter 12 & TRM Chapter 7 Sec 3

Reimbursement Method Per TRICARE REIMBURSEMENT MANUAL (TRM) Chapter 12 & TRM Chapter 7 Sec 3: Under the capitation model, will the CPD contractor be able to deviate from TRICARE/Medicare reimbursement methodology for services such as home health care and Inpatient/Residential Substance Use Disorder Rehabilitation Facilities (SUDRF)?

The Government does not intend to impose restrictions on CPD contractor use of Alternative Payment Models (APMs) for value‐ based care programs‐‐‐keeping in mind, of course, that the CPD contractor will deliver the TRICARE Prime Uniform benefit as defined in law and regulation. 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.

None of the TRM Chapters are exempt.

419 General Beneficiary Incentives General: Can beneficiaries be paid incentives or receive non‐monetary incentives or enhanced benefits for using high value providers within the CPD contractor’s network or for participating in population health programs?

If so, will there be a waiver granted for regulatory gift limitations?

Any incentives provided to beneficiaries must be provided at no cost to the Government. The CPD contractor will deliver the TRICARE Prime Uniform benefit as defined in law and regulation. 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. However, any non‐covered services/benefits must be provided at no cost to the Government.

420 General Participation Rate General: The choice comes down to quality of care and convenience (location, appt availability, one‐stop‐shop, etc.). As we saw in the Atlanta pilot, only approximately 1,400 participants out of 41,000 Prime beneficiaries (or 3.4%) chose to participate. Using this ratio would severely limit viable pilot sites due to adequate participation.

Does DHA feel this is a realistic participation rate to use to develop the discount and administrative multipliers?

DHA's enrollment threshold is 3,000 to 5,000 based on market research and internal analysis. The Offerors will be asked to bid administrative costs in two components – a flat dollar amount and a PMPM amount. This should alleviate a significant portion of concern about the level of enrollment. Offerors could also be concerned about the volatility of claims for a small covered population and its effect on financial results and the MLR premium rebate. The MLR formula includes adjustments to recognize the number of covered lives, which can reduce the premium rebate. But the MLR calculation does not reduce CPD losses from experience that is more than expected and not consistent with your assessment.

421 General Capitation Duplicate Payments

General: It is important to ensure that there is a reconciliation of enrollees for which the MCSC is paid PMPM and the CPD contractor is paid the full‐risk capitated rate for beneficiaries that enroll mid‐month. For example, if a beneficiary moves mid‐month from the MCSC to the CPD contractor and the CPD contractor receives a month of full‐risk capitated rate for that enrollee, then all health care costs (HCCs) incurred in that particular month must be paid by the CPD contractor.

How will DHA ensure the CPD contractor is receiving capitation payments for the same beneficiaries they are paying claims for?

How will DHA reconcile duplicative payments to the MCSC and CPD contractor in the above example?

Question 1.: G.2.1.3. For beneficiaries whose CPD enrollment status changes in the middle of a given month, the contractor will be paid a full‐month’s PMPM rate if the beneficiary is enrolled in CPD for at least 15 days of the month and will be paid no PMPM if the beneficiary is enrolled in CPD for less than 15 days of the month.

Question 2.: See TOM Chapter 8, Section 9 on Duplicative Payment Prevention.

423 C.7.2. Marketing and Beneficiary Education Requirements

Marketing/Education What is DHA’s role in educating the beneficiaries about the CPD option? How does DHA plan to market the CPD? See C.7.2. Marketing and Beneficiary Education Requirements.

DHA Communications Division will develop a localized communications plan to inform/educate eligible beneficiares in the geographic area eligible to enroll in the CPD.

424 C.7.2. Marketing and Beneficiary Education Requirements

Marketing/Education Re: C.7.2.3: Would the Government consider using the 30 day review and approval timeline for all marketing and educational materials, as well as provide definitions for marketing and educational materials?

A 30 day approval process is appropriate for communications products intended to attract eligible beneficiaries to sign up for CPD (Marketing). Educational materials tend to have a longer shelf life and are designed to provide audience understanding of CPD as a separate demonstration from the T5 managed care and since they are rarely required for immediate implementation (vice Marketing materials) a longer review and approval timeline provided the government appropriate time to review/approval these 'evergreen' (long term) materials.

425 C.7.5. Clinical Management

Clinical Management Re: C7.5.2.1 ‐ We recommend that DHA allow the CPD Contractor to define clinical management program structure and criteria required to manage the health care costs of CPD enrollee populations to include but not limited to populations specifically identified by DHA.

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.

The CPD Contractor has flexibility in designing its clinical program structure and criteria, however they shall do so in compliance with the requirements and include but not limited to populations identified by DHA.

426 C.7.5. Clinical Management

Marketing/ Education Re: C7.5.2.2 ‐ We recommend that DHA provide CPD Contractors with a minimal list of DoD programs and information that beneficiaries should have access to.

427 C.7.5. Clinical Management

Motivational Interviewing/ Trauma Informed Care Re: C7.5.2.3 ‐ We recommend that DHA allow the CPD Contractor to define motivational interviewing skills and trauma‐informed care training and competency requirements to satisfy this requirement.

The RFP directs the CPD Contractor to ensure case managers are trained in and demonstrate motivational interviewing skills and have knowledge of trauma‐informed care, it does not direct the CPD Contractor as to how the CMs are to be trained or educated in either motivational interviewing or trauma‐informed care. The CPD Contractor may consider utilizing The National Child Traumatic Stress Network for free training courses for trauma‐informed care which includes modules specific for military families, natural disasters, suicide and Psychological First Aid.

Note:

The National Child Traumatic Stress Network (nctsn.org)

The National Child Traumatic Stress Network (NCTSN) was created by Congress in 2000 as part of the Children’s Health Act to raise the standard of care and increase access to services for children and families who experience or witness traumatic events.

This unique network of frontline providers, family members, researchers, and national partners is committed to changing the course of children’s lives by improving their care and moving scientific gains quickly into practice across the U.S. The NCTSN is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and coordinated by the UCLA‐Duke University National Center for Child Traumatic Stress (NCCTS).

Training | The National Child Traumatic Stress Network (nctsn.org) Online Training The Learning Center for Child and Adolescent Trauma is an online resource for professionals and families who want to learn more about child traumatic stress. The primary sections of the Learning Center include: Continuing Education, Military Families, Psychological First Aid, Service Systems, Special Populations, and Clinical Training. The courses available in these sections include webinars, e‐learning courses, and training curricula, descriptions of which can be accessed below. In addition, many of the courses on the Learning Center provide professionals with continuing education (CE) credit.

428 C.7.5. Clinical Management

ECHO Re: C.7.5.2.4.2 ‐ Who is responsible for counseling the member on what ECHO services are offered or available? 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.

When a CPD enrolled beneficiary is newly eligible for ECHO services as outlined in TRICARE Policy Manual, Chapter 9, the CPD Contractor is responsible for informing the beneficiary they may be eligible for ECHO benefits under the Regional Managed Care Support Contractor.

429 C.7.5. Clinical Management

MH Screening Re: C.7.5.2.5 ‐ We recommend that the selection criteria for beneficiaries that require universal screening of PTSD, anxiety, and depression are defined by the CPD.

TRICARE beneficiaries are a unique population and universal screening of PTSD, anxiety, and depression are required for all CPD enrolled beneficiaries screened for, or receiving, case management services.

430 C.7.5. Clinical Management

Case Management Re: C.7.5.2.6 ‐ We recommend that DHA contain CPD Case Management requirements solely within CPD requirements without defaulting to TOM Chap 7, Section 2 for operational or CDRL requirements.

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

The Government has provided the Manual Exemptions determined to be appropriate for the CPD in Attachment J‐9 of the RFP.

See J‐9, Manuals Exceptions Table, TOM Chapter 7, Section 2. It has the following exceptions in paragraphs: 1.4, 1.6, 2.4.1 and

2.5.5 bullets 1, 2, 3 and 5 are not applicable.

431 C.7.5. Clinical Management

Pop health requirements Re: C.7.5.3.1 ‐ Similar to how each individual USFHP medical management requirements are individually negotiated, we recommend DHA allow CPD contractors to request an exemption to population health requirements that do not add value to their established care delivery model. "The CPD contractor may request exceptions to TRICARE population health care 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 P010 Medical Management Program Plan."

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.

For further consideration, the Government would require clarification on the specific population health requirements which should be exempted for this Demonstration along with justification as to why.

432 C.7.5. Clinical Management

Pop health Requirements Re: C.7.5.3.1 ‐ We recommend that DHA contain CPD Population Health requirements solely within CPD requirements without defaulting to TOM Chap 7, Section 3 for operational or CDRL requirements.

The Government has provided the Manual Exemptions determined to be appropriate for the CPD in Attachment J‐9 of the RFP.

433 C.7.5. Clinical Management

Utilization Management Re: C.7.5.4.2 ‐ We recommend that DHA contain CPD Utilization Management requirements solely within CPD requirements without defaulting to TOM Chap 7, Section 4 for operational or CDRL requirements.

The Government has provided the Manual Exemptions determined to be appropriate for the CPD in Attachment J‐9 of the RFP.

434 C.7.5. Clinical Management

Preventive and non‐referred care Re: C.7.5.5 ‐ For CPD enrollees, will DHA confirm that preventative and other services for that do not require a referral stay in the CPD network?

The CPD contractor shall ensure that beneficiaries who receive care outside of the CPD area (without a referral) are covered under the point of service option for non‐emergency and non‐urgent care visits.

All care (primary, specialty, preventive) is required to be within the CPD, unless the beneficiary is using the TRICARE Prime point‐ of‐service benefit.

CPD Contractor should have their own provider networks that meet TRICARE standards.

435 C.7.5. Clinical Management

Clinical Quality Management Re: C.7.5.6.1 ‐ We recommend that DHA contain CPD Clinical Quality Management requirements solely within CPD requirements without defaulting to TOM Chap 7, Section 6 for operational or CDRL requirements.

The Government has provided the Manual Exemptions determined to be appropriate for the CPD in Attachment J‐9 of the RFP.

436 C.7.5.9 Pharmacy Benefit

Pharmacy Re: C.7.5.9.3. ‐ Under what timeframe (24/48/72 hours, etc) must the TPharm contractor return the file of prescriptions for enrollees to the CPD Contractor?

Per C.7.5.9.3, “The CPD contractor shall exchange these files no less than weekly, with frequency to be mutually agreed with the TPharm Contractor.” Regarding processing time, the file containing pharmacy data is generally returned within 6 hours of receiving the request file in the evening. This timing will need to be agreed upon with the TPharm contractor during transition‐ in.

437 C.7.5.10. Nurse Advice Line (NAL)

Virtual Care/NAL Re: C.7.5.10 ‐ We recommend that the CPD’s existing virtual care programs, including nurse advice and triage capabilities will satisfy this requirement.

The CPD Contractor's existing virtual care program is acceptable as long as long as it satisfies the Nurse Advice Line requirements identified in the RFP (C.7.5.10)

438 C.7.5.10. Nurse Advice Line (NAL)

NAL Re: C.7.5.10 ‐ Will DHA confirm that the MHS Nurse Advice Line can support CPD enrollees when traveling outside of the CPD Service area and internationally?

Currently the MHS Global NAL contract does not support the CPD, refer to C.7.5.10.3. for beneficiaries while traveling outside of the CPD service area and internationally.

439 C7.7. Claims Travel ‐ ATC Re: C.7.7.12 ‐ Will DHA confirm that beneficiaries will have access to the TRICARE network when traveling outside of the covered CPD area?

We request that this information be included within the final RFP.

The CPD contractor shall ensure that beneficiaries who receive care outside of the CPD area (without a referral) are covered under the point of service option for non‐emergency and non‐urgent care visits.

All care (primary, specialty, preventive) is required to be within the CPD, unless the beneficiary is using the TRICARE Prime point‐ of‐service benefit.

CPD Contractor should have their own provider networks that meet TRICARE standards.

440 C7.7. Claims ATC ‐ provider network overlap Re: C.7.7.12 ‐ Will DHA confirm that within the CPD Service Area, the CPD Contractor can limit beneficiary access to the broader MCSC provider network based on internal workflows for referral and non‐referral‐based visits (such as preventive services)? We request that this information be included within the final RFP.

The CPD contractor shall ensure that beneficiaries who receive care outside of the CPD area (without a referral) are covered under the point of service option for non‐emergency and non‐urgent care visits.

All care (primary, specialty, preventive) is required to be within the CPD, unless the beneficiary is using the TRICARE Prime point‐ of‐service benefit.

CPD Contractor should have their own provider networks that meet TRICARE standards.

441 C7.12. Memorandums of Understanding (MOUs)

Re: C.7.12.3 ‐ We recommend that the DHA require CPDs to develop a MOU with the TRICARE Overseas Contractor to document responsibilities when…