T-5 Draft RFP Section H v1.1.pdf

SECTION H

SPECIAL CONTRACT REQUIREMENTS

HT940220R0005 Page H1 of H11

H.16. FUTURE POTENTIAL DEMONSTRATIONS AND PRODUCT IMPROVEMENTS

H.16.1. The purpose of this section is to describe potential demonstrations and product improvements that the Government may implement during the contract’s period of performance.

When the Government implements a demonstration or product improvement, it may do so under the authority of the changes clause of the contract in addition to via changes to Chapter 18 of the

TRICARE Operations Manual and related manuals.

H.16.1.1. Advanced Primary Care:

H.16.1.1.1. The Contractor shall actively identify and include in its networks Advance Primary

Care (APC) practices that promote cost efficiency, clinical quality, improved access and beneficiary experience through practice designs including but not limited to:

H.16.1.1.1.1. Multidisciplinary teams that provide care coordination for complex patients; focus on prevention and provide patient centric resources; and support robust connections with the medical neighborhood and community-based services.

H.16.1.1.1.2. Same or next day appointments, extended appointment length, extensive use of digital health tools, embedded telehealth, chronic condition registries, medication adherence programs, collocation of behavioral health services, and management of life style risks.

H.16.1.1.1.3. Administrative infrastructure that supports value-driven care, population-based care payment and integration of DHA health and wellbeing ecosystem resources.

H.16.1.1.1.4. Timely referrals and interoperable medical record and data transfer capabilities.

H.16.1.1.1.5. RESERVED

H.16.1.1.2. The Contractor shall design and implement an APC monitoring and continuous improvement program. The Contractor shall include metrics for financial performance, beneficiary experience, and risk-adjusted clinical outcomes based on factors including Social

Determinants of Health (SDOH).

H.16.1.1.3. The Contractor shall utilize advanced analytic tools to assess APC performance, and provide continuous feedback to improve value-based care delivery.

H.16.1.1.4. The Contractor shall submit a quarterly report on the performance of APCs within its network. For reporting requirements, see DD Form 1423, Contract Data Requirements List

(CDRL), located in Section J of the applicable contract.

HT940220R0005 Page H2 of H11

H.16.1.1.5. The Contractor shall provide an outreach and education program on APC for

TRICARE-eligible beneficiaries. The program shall include education on availability, advantages and incentives to promote beneficiary use of APC providers.

H.16.1.2. Beneficiary Choice Demonstration

H.16.1.2.1. The Contractor shall offer beneficiaries a choice of enrollment options to

Accountable Care Organizations (ACOs) or other local or regional plans (these ACOs and plans are referred to as “Beneficiary Choice plans”) in areas designated in attachment J-X. A local or regional plan is a full TRICARE benefit plan that is available in the market area to beneficiaries as an alternative to TRICARE Prime and TRICARE offered by the MCSC. The intent of the demonstration is to offer beneficiaries a different TRICARE option under demonstration authority that lowers cost and increases quality, efficiency and convenience. Payments for care under this demonstration will be made on a fully capitated (fixed price) per-member-per-month basis through the MCSC to the MCS Contractor.

H.16.1.2.2. The Contractor’s network shall include Beneficiary Choice plans that have demonstrated high quality outcomes, lower cost, and reduction of waste.

H.16.1.2.3. The Contractor shall ensure that its proposed PMPM rates (inclusive of admin and health care) for the demonstration do not exceed what the Government would have paid for the same beneficiaries enrolled to the MCSC. The contractor shall include arrangements for value-based payments that motivate providers to invest in and adopt new approaches to care delivery.

The demonstration may not be implemented until the Government and Contractor reach agreement on the PMPM rates.

H.16.1.2.4. The Contractor shall design and implement an Beneficiary Choice plan monitoring and continuous improvement program. The Contractor shall use CMS guidelines for developing metrics and establishing trends in value-based care (VBC).

H.16.1.2.5. The Contractor shall use data from Beneficiary Choice plans to calculate and assess plan performance and provide continuous feedback to improve VBC delivery. Where the

Contractor relies on Accountable Care Organizations reporting, the Contractor shall validate the

Accountable Care Organizations data. The Contractor shall submit a quarterly report on beneficiary enrolment and the performance of ACOs within its network. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

H.16.1.2.6. The Contractor shall establish provider/ Accountable Care Organizations incentives and support beneficiary incentives and effective communications methods to promote enrollment in and success of the ACOs.

HT940220R0005 Page H3 of H11

H.16.1.2.7. The Contractor shall offer enrollment and customer service in support of the

Accountable Care Organizations in accordance with TRICARE policies including: marketing, enrollment, beneficiary counseling, and responsiveness to beneficiary questions or concerns.

H.16.1.2.8. The Contractor may, through its agreements with the Accountable Care

Organizations, delegate accredited activities such as credentialing.

H.16.1.2.9. The Contractor may not delegate the TRICARE appeals process.

H.16.1.3. Advanced Care Management

H.16.1.3.1. The Contractor shall define and integrate all utilization management, case management, behavioral health, and population health programs for a seamless experience for the beneficiary.

H.16.1.3.2. The Contractor shall use predictive analytics, in the operation of its medical management programs, which are designed to support and manage the healthcare of all beneficiaries as described in TOM Chapter 7, Section 1.

H.16.1.3.3. The Contractor shall develop, implement, and maintain an integrated, whole person, Advanced Case Management (ACM) Program. At a minimum, Case Management in the ACM program shall meet requirements of TOM Chapter 7, Section 2.

H.16.1.3.4. The Contractor shall provide ACM services via a dedicated point of contact for beneficiaries with sensitive, rare, high profile, or high-visibility needs that are in addition to the

CM beneficiary categories identified in TOM Chapter 7, Section 2.

H.16.1.3.5. The Contractor shall offer in-home ACM services to beneficiaries who have high-need for care and are at high-risk of readmission for 30 calendar days following discharge from an inpatient setting. The first visit shall be made 48 to 72 hours post discharge.

H.16.1.3.6. The Contractor shall communicate, collaborate, and coordinate on a 24/7 basis with private sector care providers, Markets/MTFs and the Government Designated Authority (GDA) to effectively execute transfers of stabilized patients from one location to another. Transfers may occur as a result of medical, social, or financial reasons and will include moves of non-institutionalized and institutionalized patients, to include patients receiving behavioral healthcare. The Contractor shall coordinate care with the MTF clinical staff, as well as the civilian providers, when care occurs outside an MTF.

H.16.1.4. Care Collaboration Tools Requirements

H.16.1.4.1. The contractor shall provide either internally or through third party applications, an integrated care collaboration program that facilitates virtual provider-to-provider consultations

HT940220R0005 Page H4 of H11

(eConsult), which reduce costs associated with specialist referrals, reduce wait times for specialist care and produce the best quality outcomes for TRICARE-eligible beneficiaries. The contractor shall ensure the e-Consult platform supports information sharing and collaboration via synchronous and asynchronous modalities.

H.16.1.4.2. The contractor shall promote information sharing and collaboration across direct and private sector care networks to ensure coordination of care and expand medical force provider

Knowledge, Skills, and Abilities (KSAs) through access to specialist expertise. The contractor shall include e-Consult services as part of its strategy for mitigating network shortages.

H.16.1.4.3. E-Consult platforms and EHR systems shall support machine-to-machine interoperability using healthcare EDI standards (e.g. HIPAA X12 transactions and Health Level

7® (HL7) Fast Healthcare Interoperability Resources® (FHIR) between MCSCs, network providers, the Direct Care System, and other authorized contractors.

H.16.1.4.4. The contractor shall provide an outreach and education program on e-Consult capabilities, requirements and incentives for all network and TRICARE-authorized providers.

The program shall include education on the contractor’s e-Consult policies, and procedures to allow providers to carry out the requirements of this contract in an efficient and effective manner, while promoting provider information sharing and collaboration through the use of e-

Consult services.

H.16.1.4.5. The contractor shall create a billing and reimbursement methodology for e-Consults.

H.16.1.4.6. The contractor shall establish reporting and monitoring mechanisms to track and trend e-Consults by providers, measure provider satisfaction and assess impact on value. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in

Section J of the applicable contract.

H.16.1.5. Clinically Integrated Networks (CINs)

H.16.1.5.1. The Contractor’s provider network shall include Clinically Integrated Networks

(CINs) that have demonstrated high quality outcomes, lower cost and reduction of waste. CIN arrangements shall include value-based incentives that motivate providers to invest in and adopt new approaches to care delivery.

H.16.1.5.2. The Contractor shall design and implement a CIN monitoring and continuous improvement program.

H.16.1.5.3. The Contractor shall use CMS guidelines for developing quality and performance metrics and establishing trends in value-based care (VBC).

HT940220R0005 Page H5 of H11

H.16.1.5.4. The Contractor shall utilize advanced analytic tools to assess CIN performance and provide continuous feedback to improve VBC delivery.

H.16.1.5.5. The Contractor shall submit a quarterly report on the performance of CINs within its network. For reporting requirements, see DD Form 1423, Contract Data Requirements List

(CDRL), located in Section J of the applicable contract.

H.16.1.5.6. The Contractor shall establish provider/CIN incentives and support beneficiary incentives and effective communications methods to promote enrollment in and success of the

CINs.

H.16.1.6. Provider Recognition and Reward

H.16.1.6.1. The Contractor shall develop, implement, and maintain a Provider Recognition and

Reward (PRR) Program. The program shall align with the Clinical Quality Management and

Patient Safety Program as outlined in C.2.8.1.

H.16.1.6.1.1. The Contractor shall develop and implement written policies and procedures to measure provider performance, educate providers on the program and steps they can take to improve or maintain performance.

H.16.1.6.1.2. The Contractor shall track provider performance at the individual provider level

(where possible and at the practice or department level if not possible) via Provider Performance

Scorecards. Scorecards shall be updated at least quarterly.

H.16.1.6.1.3. The Contractor and DHA will mutually agree upon metrics and methodology to be included in the provider performance scorecards annually.

H.16.1.6.1.4. The Contractor shall measure providers on a risk adjusted basis to ensure providers are not penalized for serving a sicker population.

H.16.1.6.1.5. The Contractor shall provide the Government Designated Authority with training and real time access to the provider performance scorecards.

H.16.1.6.1.6. The Contractor shall report Provider Performance Scorecard results to providers at the individual and system level to promote individual accountability and performance improvement. Scorecards will include an individual score as well as the individual’s score as ranked against all other providers in the same specialty.

H.16.1.6.1.7. The Contractor shall assign levels of provider recognition based on results of provider performance scorecards.

HT940220R0005 Page H6 of H11

H.16.1.6.1.8. The Contractor shall incentivize providers at the individual level based on performance as measured in the Provider Performance Scorecard. Incentives may be positive or negative as indicated by performance.

H.16.1.6.1.9. If a monetary incentive is used, the Contractor shall pay out earned incentives on the same basis of measurement i.e., monthly, quarterly and annual. In addition, the provider’s total reimbursement may not exceed the TRICARE maximum allowable amounts. Payments outside of claims shall include attribution to individual TRICARE beneficiaries and associated health care claims.

H.16.1.6.2. The Contractor shall ensure no payment be made directly or indirectly under provider incentive program to a physician/group as an inducement to reduce or limit medically necessary services furnished to an individual.

H.16.1.6.3. The Contractor shall develop and submit a Provider Recognition and Reward Plan identifying how they will measure their effectiveness at achieving: (1) MTF optimization/readiness, (2) cost efficiency and (3) high quality. Weighting of these measures for the purpose of provider reporting and provider incentives payments requires approval of DHA.

For plan reporting requirements see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

H.16.1.7. Targeted Utilization Management (UM)

H.16.1.7.1. The Contractor shall develop, implement, and maintain a targeted UM program that evaluates the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures and facilities.

H.16.1.7.2. The Contractor’s Targeted UM program shall include the following components:

H.16.1.7.2.1. Service request (prior authorization, concurrent review, retrospective review) submitted by provider or beneficiary.

H.16.1.7.2.2. Benefit review to determine if requested service is covered.

H.16.1.7.2.3. Clinical review using Medical Necessity Criteria typically completed by clinicians with relevant experience.

H.16.1.7.2.4. Physician review by health plan with relevant specialty/experience if criteria not met or additional clinical discussion needed.

H.16.1.7.2.5. Approvals, denials and/or partial denials

HT940220R0005 Page H7 of H11

H.16.1.7.3. The Contractor shall design the targeted UM process such that medical necessity criteria is applied consistently with the intent to ensure that beneficiaries receive the correct services for their conditions, at the necessary frequency and for the necessary duration. The purpose is to ensure that medically necessary services are provided, to reduce unnecessary procedures, and to ensure members receive care from the highest quality provider available to provide the service. The UM processes are subject to strict timelines as outlined in TOM Chapter

7, Section 4. The UM program shall demonstrate integration and collaboration with other

Contractor medical management programs, including, but not limited to, case management and quality management.

H.16.1.7.4. The Contractor shall administer the targeted UM program with a collaborative approach to care, focused on promoting beneficiary health and safety in addition to fiscal stewardship.

H.16.1.7.5. The Contractor shall select services, providers, or cases subject to the targeted UM authorization requirements based on evidence based practices with transparency to providers in the services that require authorization. This process should be described in the annual plan, and results reported quarterly throughout the year.

H.16.1.7.6. The Contractor shall implement a UM evaluation process to identify services that should not require authorization. The evaluation should target specific diagnoses, levels of care, case complexity and provider types to identify procedures and services that are low cost, have high approval rates, or that have low denial rates where eliminating authorizations provides efficiency in the UM process or reduces unnecessary provider burden.

H.16.1.7.7. The Contractor shall implement a targeted UM design that identifies high performing providers with consistently very low denial rates for a status (e.g. “Gold Card” or similar) that eliminates the requirement for utilization review. Providers must be in good standing and meet all applicable DHA requirements (e.g., accurate provider directory information) to achieve and maintain “Gold Card” status. The Contractor shall monitor these providers to ensure continued performance and Gold Card status.

H.16.1.7.8. The Contractor shall obtain and maintain Health Plan accreditation from a nationally recognized accrediting organization for the following medical management programs: utilization management, case management, and population health.

H.16.1.8. Advanced Telehealth

H.16.1.8.1. The contractor shall enhance its comprehensive, integrated telehealth services, which reduce costs and produce the best quality outcomes for TRICARE-eligible beneficiaries, in accordance with TOM, Chapter 27 and TPM, Chapter 7 through Value Based Payments for outcomes in distance specialty care, hub and spoke telehealth in rural and remote areas and through remote telehealth monitoring.

HT940220R0005 Page H8 of H11

H.16.1.8.2. The contractor shall develop and implement an equitable provider coding and payment model for telehealth care encounters to promote provider adoption and use of secure, HIPAA compliant telehealth platforms. The Contractor’s payment model shall not exceed the maximum price that the Government would have paid for the “in person” service, H.16.1.9. Virtual Value Network (VVN)

H.16.1.9.1. The Contractor shall create a Virtual Value Network (VVN) inclusive of a subset of high–value, low waste providers, to be identified using consistent, validated third-party metrics for appropriateness of care, clinical outcomes, beneficiary experience and cost. This requirement is not intended to be a narrow network but a beneficiary-facing guide to support choices of high value, low waste providers.

H.16.1.9.2. The Contractor shall use claims data to develop and maintain quarterly provider scorecards and submit monthly reports on performance metrics to the Government. For reporting requirements, see DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.

H.16.1.9.3. The Contractor shall provide web and app based tools and call center services to be utilized by beneficiaries to perform provider queries that take quality outcomes and beneficiary cost into account.

H.16.1.9.4. The Contractor shall make provider value rating tools and metrics available 24/7 through secure, HIPAA compliant technology platforms so that beneficiaries are able to make informed decisions and seek the highest quality care when needed.

H.16.1.9.5. The Contractor shall design and implement an engagement and communication strategy to maximize beneficiary awareness and use of VVN providers.

H.16.1.10. Wellness and Disease Management (Population Health)

H.16.1.10.1. The Contractor shall design and implement wellness and disease management program(s) that address the full spectrum of lifestyle risks and promote healthy behaviors, including healthy lifestyle choices (e.g., smoking cessation, weight loss, exercise, weight management, sleep hygiene) and management of chronic conditions. The disease management program will address at least the following chronic conditions: asthma, COPD, atherosclerotic vascular disease, heart failure, diabetes and cancer.

H.16.1.10.1.1. The Contractor shall develop a defined list of programs and opportunities to improve healthy behaviors, with requirements for participation and completion, and an assigned reward incentive value. The programs shall be multi-channel including at least phone/video

HT940220R0005 Page H9 of H11 based coaching, computer and mobile phone apps and biometric and activity trackers using multi-channel modes of interaction.

H.16.1.10.1.2. The contractor shall make a variety of financial and non-financial (intrinsic) incentives that best fit beneficiary lifestyles available for the beneficiaries to earn based on completion of healthily lifestyle changes resulting in measurable outcomes (e.g. weight loss).

H.16.1.10.2. The Contractor shall develop a beneficiary engagement plan that includes digital multichannel communication strategies, targeted personal communications, and embedded marketing through touchpoints directly with beneficiaries, Contractor call centers, navigation services and with provider organizations, including Patient-Centered Medical Homes (PCMH), Military Treatment Facilities (MTF) and other Managed Care Support Contractors (MCSC). This engagement plan shall educate and motivate beneficiaries about the program(s), healthy behaviors, the importance of completing activities, and promote enrollment in these programs.

Regular beneficiary touchpoints shall be implemented to assess progress towards obtaining goals.

H.16.1.10.3. The Contractor shall provide beneficiary access to a secure, HIPAA compliant technology platform that assists in identifying risks, selecting health goals and supports integrated tracking of progress toward goals through self-report and encounter data, which can also be shared with the PCMH/Provider, MCSC, and incentive distributor. Beneficiaries shall have 24/7 access to information about the program, enrollment, status, and the ability to select and use incentives.

H.16.1.10.4. The Contractor shall identify metrics measuring the performance of the program to include at least measures of engagement, clinical status, and financial impact, to be agreed upon with DHA. Contractor shall submit reports on wellness and disease management program performance to the government quarterly and annually.

H.16.1.11 Centers of Excellence (CCoE)

H.16.1.11.1. The contractor shall identify and partner with high-performing, high-value providers and facilities outside of the MHS (Military Health System) to be used as Clinical

Centers of Excellence (CCoEs) when evaluating locations for referring all TRICARE beneficiaries. In order to minimize beneficiary travel, CCoEs shall be available within a 100 mile radius of designated MTF/Markets.

H.16.1.11.2. The contractor shall develop, implement and maintain a CCoE optimization plan that includes all TRICARE enrolled beneficiaries, integrating care delivered by MTFs, DoD

MHS (Military Health System) centers of excellence and purchased care network providers, to include steerage toward CCoEs incorporated into their network when clinically appropriate. For reporting requirements, see CDRL, DD Form 1423, located in Section J of the applicable contract.

HT940220R0005 Page H10 of H11

H.16.1.11.3. The contractor shall implement a process to maximize medically necessary referrals and authorizations to CCoEs as appropriate to enhance a medically ready force and the quality of care for beneficiaries as described in TOM, Chapter 7, Section 5.

H.16.1.11.4. The contractor shall reimburse CCoEs through CMS HCP-LAN APM Categories

2c through 4b. (see Section H.9.4 above).

H.16.1.11.5. The contractor shall establish qualification criteria for CCoEs that considers quality outcomes and savings to the Department.

H.16.1.11.6. Where available, the contractor shall recruit CCoEs to the network to provide care for beneficiaries with conditions and procedures that are high mortality, high cost, or have highly variable health outcomes. CCoE providers shall be mutually agreed upon between the

GDA and MCSC.

H.16.1.11.7. The contractor shall establish network agreements with TRICARE authorized providers and publish information informing TRICARE beneficiaries of the availability and access to network CCoEs.

H.16.1.11.8. The contractor may include opportunities for the MHS medical providers to receive training at the CCoEs to maintain and enhance their knowledge, skills and ability

(KSAs) to maximize medical force readiness.

H.16.1.11.9. The contractor shall inform the Government of any instances of facilities or providers losing CCoE designation and remove them from the CCoE network.

H.16.1.11.10. The contractor shall refer beneficiaries to the preferred list of designated CCoE providers for the medical conditions outlined in the annual MOU and IAW DoD condition-specific policy, in addition to the identified CCoEs outlined in the annual CCoE optimization plan. The contractor shall meet with the DHA on at least a quarterly basis to identify additional methods to promote utilization of the CCoEs.

H.16.1.11.11. The contractor shall create and maintain an on-line list of all network providers.

The list shall include provider specialty, sub-specialty, gender, work address, work fax number, and work telephone number for each service area, and whether or not they are a PCM, CCoE, leapfrog scores and an indicator if the provider offers telehealth (TH).

H.17. Competitive Demonstrations

H.17.1. The purpose of this section is to notify Contractor that the Government intends, during the period of this contract, to conduct demonstrations that open certain markets to local and regional providers other than the Contractor for enrollment through contracts other than T-5.

Evaluation criteria for the future competitions will be developed and published separately for the local and regional competitions.

H.17.2. The Government intends to acquire an Eligibility, Enrollment and Encounter (EEE)

Contractor to manage the enrollment of beneficiaries into the competitive demonstration

HT940220R0005 Page H11 of H11 contracts. The T-5 Contractor will interact with the Government’s future EEE contractor for the purposes of enrollment and jurisdiction of claims.

H.17.3. Under these demonstrations, beneficiaries will no longer be enrolled to the MCSC or receive services from the MCSC. The Contractor’s administrative PMPM will be reduced for each beneficiary who disenrolls into a competitive local or regional demonstration provider during in accordance with Section B., CLIN X003 and paragraph G.2.

H.17.4. The markets where the Government will consider the competitive demonstration are identified in attachment J-X.