T-5 DRAFT RFP Section L v1.1.pdf
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- Attached to
- Draft RFP - TRICARE Managed Care Support (T-5) Federal contract opportunity
- Solicitation number
- HT940220R0005
- Issued by
- Defense Health Agency
About this file
This draft request for proposals (RFP) concerns the fifth-generation TRICARE Managed Care Support Contracts (T-5) to provide administrative and support services for the receipt of private sector health care and integration with the Department of Defense direct care system. Interested parties are requested to provide feedback on the draft requirements, terms, and conditions using the provided Microsoft Excel response template by September 18, 2020. The Defense Health Agency seeks to deliver medical services and associated administrative support through T-5 to support the Military Health System in providing an integrated care program that optimizes military medical force readiness and a medically ready force.
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SECTION L
INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS
HT940220R0005 Page L1 of L6
L.6.2.6. Subfactor 6 – Planned Demonstrations/Product Improvements
L.6.2.6.1. Advanced Primary Care (APC):
L.6.2.6.1.1. The Offeror’s proposal shall describe its approach to including APC practices in its provider networks including specific qualifying features, payment methodologies, recruiting plan, target ratio of APC providers to Select adult and pediatric beneficiaries (<= 5,000 eligible beneficiaries/ 1 APC provider) and provider reporting capabilities. The proposal shall include qualifying features of the APCs, payment methodology and a recruiting plan.
L.6.2.6.1.2. The Offeror’s proposal shall describe its administrative infrastructure, systems and plans to support APC practices and to promote their utilization by the TRICARE beneficiaries.
L.6.2.6.1.2.1. The Offeror’s proposal shall describe the Governance model and support infrastructure for integration of APCs.
L.6.2.6.1.2.2. The Offeror’s proposal shall describe its approach to facilitating medical record and data transfers between APCs, other providers and the contractor.
L.6.2.6.1.2.3. The Offeror’s proposal shall describe approach to measurement, continuous improvement, and provider and DHA reporting.
L.6.2.6.1.3. The Offeror’s proposal shall demonstrate its ability to improve clinical quality outcomes regarding prevention, and chronic condition management, improved service utilization rates (primary and specialty care, emergency room, inpatient hospital, diagnostics, pharmacy and behavioral health), appropriate care delivery as well as total cost of care. All on a risk adjusted basis.
L.6.2.6.1.4. The Offeror’s proposal shall demonstrate the ability to improve warfighter readiness, referral management, beneficiary experience and access.
L.6.2.6.2. Beneficiary Choice Demonstration
L.6.2.6.2.1. The Offeror’s proposal shall propose alternate health plans (to include ACOs) that will meet all TRICARE benefit requirements in areas designated in attachment J-X for beneficiary enrollment. [Note, the offeror may include a pharmacy benefit or may continue to rely on the TRICARE pharmacy benefit in its health plan design] The offeror shall propose a minimum of three (3) plans. Alternative plans may all be in one designated area or spread out over all three areas. The plans shall provide the TRICARE benefit to enrolled beneficiaries locally or regionally.
L.6.2.6.2.2. The Offeror’s proposal shall include the offeror’s criteria its choice of partner plans based on differentiation from its own local network’s quality, access, and cost.
HT940220R0005 Page L2 of L6
L.6.2.6.2.3. The Offeror’s proposal shall include monitoring, oversight and reporting of the plans to assure beneficiary satisfaction, cost control and excellent health outcomes.
L.6.2.6.2.4. The Offeror’s proposal shall include a methodology for assessing the success of the demonstration to include value based payments and incentives.
L.6.2.6.3. Advanced Care Management (ACM)
L.6.2.6.3.1. The Offeror’s proposal shall define its strategy for managing beneficiaries who may qualify for or would benefit from the services provided under more than one case management program, e.g. disease management, behavioral health. etc., including coordination between programs, avoiding duplication of assessments and contacts, integrating care plans, and staffing coordination.
L.6.2.6.3.2. The Offeror’s proposal shall define predictive analytic tools it will use to identify, support and manage the healthcare of beneficiaries through risk stratification and enrollment in the appropriate programs. The Offeror will describe other processes it will utilize for identifying, risk-stratifying, and referring beneficiaries to the appropriate programs and resources based on identified needs.
L.6.2.6.3.3. The Offeror’s proposal shall demonstrate how its advanced care management program will support and manage the healthcare of individuals with high-cost conditions, high complexity cases, or with specific diseases for which evidence-based clinical management programs exist. Descriptions of such programs should include enrollment, assessments, care planning and evaluation. The Offeror will describe how its ACM program adopts an integrated whole person approach.
L.6.2.6.3.4. The Offeror’s proposal shall describe its staffing plan, case assignment and caseload methodology employed to support the ACM program for the ACM beneficiary categories as well as beneficiaries with sensitive, rare, high profile, or high-visibility needs.
L.6.2.6.3.5. The Offeror’s proposal shall describe assessments and tools that it will use to identify beneficiaries in need (high-need and at risk for readmission) of in-home services;
processes it will use to offer in-home ACM services with first visit within 48 to 72 hours post discharge; and tools it will use to evaluate need for continued in-home visits.
L.6.2.6.3.6. The Offeror’s proposal shall depict its strategy to communicate, collaborate, and coordinate with purchased care providers, Markets/MTFs and the Government Designated
Authority (GDA) as well as define and implement care coordination for beneficiaries.
HT940220R0005 Page L3 of L6
L.6.2.6.4. Care Collaboration Tools Requirements
L.6.2.6.4.1. The Offeror’s proposal shall describe its policies, processes and systems for supporting an integrated care collaboration program that facilitates virtual provider-to-provider consultations (e-Consult) while reducing costs associated with specialist referrals and wait times for specialist care, and producing the best quality outcomes for TRICARE-eligible beneficiaries.
L.6.2.6.4.2. The offeror’s proposal shall describe how the e-Consult platform supports information sharing and collaboration via synchronous and asynchronous modalities.
L.6.2.6.4.3. The offeror’s proposal shall describe how the e-Consult platform will promote information sharing and collaboration across direct and private sector care networks.
L.6.2.6.4.4. The offeror’s proposal shall describe how e-Consult platforms and EHR systems shall support machine-to-machine interoperability between the Direct Care System, and other authorized contractors.
L.6.2.6.4.5. The offeror’s proposal shall describe how it will provide an outreach and education program on e-Consult capabilities, requirements and incentives for all network and TRICARE-authorized providers.
L.6.2.6.5. Clinically Integrated Networks (CINs)
L.6.2.6.5.1. The Offeror’s proposal shall describe its approach to including Clinically Integrated
Networks (CINs) into its provider network, including communication methods that promote member enrollment in CINs. The Offeror’s response will include the process for evaluating: (1) effectiveness, (2) stability, (3) governance, (4) financial models and, (5) the integration of provider organizations within the CIN.
L.6.2.6.5.2. The Offeror’s proposal shall define data management, reporting and accountability processes.
L.6.2.6.5.3.3. The Offeror’s response shall include a description of the approach to design value-based incentives that motivate providers to adopt effective approaches to care delivery.
L.6.2.6.5.4. The Offeror’s proposal shall describe its continuous improvement methodology to monitor and improve CIN performance.
L.6.2.6.5.5. The Offeror’s proposal shall describe how it will use provider/CIN incentives without exposing providers to extensive financial and clinical risk.
HT940220R0005 Page L4 of L6
L.6.2.6.6. Provider Recognition and Reward
L.6.2.6.6.1. The Offeror’s proposal shall describe its approach for implementing a Provider
Recognition and Reward (PRR) program for TRICARE-eligible beneficiaries in accordance with
H.16.1.6. and explain how its methodology for provider performance measurement and subsequent recognition and reward drives improved warfighter readiness, cost efficiency and clinical quality.
L.6.2.6.7. Targeted Utilization Management (UM)
L.6.2.6.7.1. The Offeror’s proposal shall demonstrate how the design, implementation, and use of its Targeted UM program will deliver on the quadruple aim of the program; increase readiness, increase consistency of care, improve clinical quality outcomes and deliver financial savings.
L.6.2.6.7.2. The Offeror’s proposal shall detail a robust reporting package, including a set of metrics that will be able to measure the performance of the Targeted UM program and present a monthly, quarterly and annual reporting format. The Offeror may submit blinded examples of current work.
L.6.2.6.7.3. The Offeror’s proposal shall detail a Targeted UM work plan, program description and evaluation program protocol.
L.6.2.6.7.4. The Offeror’s proposal shall include processes to identify and reward high performing providers with Targeted UM or Value Based Payment incentives.
L.6.2.6.7.5. The proposal shall provide proof of nationally recognized Utilization Management accreditation in good standing or a documented plan to obtain accreditation within 18 months after contract initiation date.
L.6.2.6.8. Advanced Telehealth
L.6.2.6.8.1. The Offeror’s proposal shall describe how it will create and administer payment incentives, value based care, or risk sharing mechanisms for providers and beneficiaries to utilize telehealth services.
L.6.2.6.8.2. The Offeror’s proposal include its approach to paying providers for telehealth encounters (e.g. PMPM, FFS), including required CPT codes, allowed amounts for common
CPT codes (E&M, and sample of others), allowed amounts for in-person care for the same codes and required documentation.
HT940220R0005 Page L5 of L6
L.6.2.6.9. Virtual Value Network (VVN)
L.6.2.6.9.1. The Offeror’s proposal shall describe (a) its approach to developing a VVN, including (b) third-party tools, provider selection criteria, and key performance indicators (KPIs).
L.6.2.6.9.2. The Offeror shall describe how it will collect, manage, and distribute provider data to key stakeholders, including beneficiaries, providers, navigators, call centers and others that steer patients. The Offeror’s proposal shall describe its engagement and communication strategy to maximize beneficiary awareness and use of VVN providers, including any financial incentives.
L.6.2.6.10. Wellness and Disease Management (Population Health)
L.6.2.6.10.1. The Offeror’s proposal shall describe its approach to designing and implementing wellness and disease management programs, including data analytics, targeted incentives and behavior design. The Offeror shall discuss how it will develop metrics and monitoring protocols using recognized national clinical indicator scores such as Healthcare Effectiveness Data and
Information Set (HEDIS) and Centers for Medicare & Medicaid Services (CMS) Core measures.
The Offeror shall describe how it will identify and support financial and non-financial (intrinsic) incentives, including, but not limited to, in-year enrollment fee adjustments, real-time rewards, reductions in co-pays and co-insurances.
L.6.2.6.10.2. The Offeror’s proposal shall describe its beneficiary engagement strategy, including communication channels, approach to targeted personal communications, and plan for embedded marketing through touchpoints with provider organizations, including PCMH, MTF and other MCSC.
L.6.2.6.10.3. The Offeror’s proposal shall describe the tools and technology platforms that will support the wellness and disease management program(s), including data management, analytics and reporting.
L.6.2.6.10.4. The Offeror’s proposal shall describe how it will monitor and evaluate associated program outcomes, including metrics for determining successful program intervention, how beneficiary feedback will be obtained and incorporated into the evaluation process and how enhancements will be incorporated into the program design.
L.6.2.6.11. Centers of Excellence
L.6.2.6.11.1. The Offeror’s proposal shall describe its design and approach for developing and maintaining an integrated CCoE network for all TRICARE-eligible beneficiaries. The Offeror will provide the necessary criteria to be considered a CCoE provider and facility, the specialties and procedures with corresponding CCoEs and the number of in-network CCoE providers and
HT940220R0005 Page L6 of L6 facilities. This description will also include how beneficiaries are directed to and educated about the program.
L.6.2.6.11.2.The Offeror’s proposal shall describe its methodology for measuring cost efficiency, quality outcomes and patient experience for designated CCoEs.
L.6.2.6.11.3.The Offeror’s proposal shall describe the type and prevalence of financial arrangements, which currently exist between the Offeror and CCoEs. The description will include the Offeror’s approach and experience with value-based payment of CCoE providers and facilities.
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