T-5 RFP Industry Questions with Government Responses Amendment 0006.pdf

T-5 Managed Care Support Services

HT9402-20-R-0005

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

L.8. Volume IV, Price/Cost Organization/In structions L.8.18

Network Discount Guarantee

We understand DHA is likely to continue the practice of reducing reimbursement for certain medical services throughout the T-5 contract as it has done historically. The T- 5 RFP indicates MCSCs will be expected to deliver a network discount guarantee even if/as DHA reduces reimbursement for discounted services, which presents a significant challenge to MCSCs in achieving the discount guarantee. Because the penalty/disincentive to MCSCs for not delivering the network discount guarantee can be significant, would the Government please provide more guidance, detail or data on reimbursement reduction practices?

GOVERNMENT REVISED RESPONSE 8/10/21: Generally the TRICARE Program follows Medicare. Where TRICARE does not follow Medicare, it continually analyzes rates to ensure reimbursement is reasonable. Historically, the Government has sought rate reductions where it was not paying reasonable charges (e.g. billed charges & non- Medicare DME). In addition, Government has a proposed rule to move from the Medicare legacy Ambulatory Surgery Centers (ASC) to the current Medicare reimbursement system.

C.2.9.

Communication s and Customer Service C.2.9.2.1. eHealth Exchange

The interoperability requirements clearly reflect the Government’s desire for network providers to be connected to a Health Information Exchange, with the capability of making CLRs electronically available to MHS GENESIS. Please confirm that the Government plans to have a process to PULL the CLRs (by submitting HIE queries) versus the network providers PUSHING the CLRs to the Government.

The Government confirms that a pull process is needed from the HIE into MHS GENESIS.

Future potential enhancements to MHS GENESIS may allow a push, but these enhancements are not yet part of the MHS GENESIS requirement.

L.8. Volume IV, Price/Cost Organization/In structions L.8.17

Attachments L-5e and L-5w Price Evaluation Templates

In previous proposals, DHA has required Not-Separately-Priced (NSP) CDRL Estimated Total Pricing to be submitted on each individual CDRL document within "18.

Estimated Total Price" as well as the "CDRLs" tab located within both L-5e and L-5w, Price Evaluation Templates East/West Region, Amendment 0001. Will DHA confirm that NSP CDRL Estimated Total Prices are to only be included on L-5 Price Evaluation Templates within the "CDRLs" tabs?

Yes, CDRLs are not separately priced. The Government only requires estimates of those CDRLs for informational only, budgetary, and planning purposes. There is no evaluated price, contractual linkage or payment tied to the estimates provided by the offeror.

TRICARE

Operations Manual (TOM)

Ch 1, Sec 3, para

5.2.2 and CDRL M030 Referral Accuracy

The Government's revisions to the referral accuracy requirements in Amendment 2 to allow a randomly-selected audit sample for Network Prime referrals is appreciated and very helpful. However, the TRICARE Policy Manual and CDRL M030 still require a 100% audit of MTF Prime referrals. Based on our estimation of MTF Prime referrals for T-5 , a monthly audit of 115,000 MTF Prime referrals will be required. This large number of audits for the 18 attributes listed in the CDRL will be costly. Would the Government be willing to reconsider this 100% audit requirement and use the same random selection audit process and precision levels required for Network Prime referrals?

To validate that the Government is aware of the volume of MTF Prime referrals and the work effort needed to audit 100% of these referrals. If the goal for this requirement is to obtain an accuracy rate, then using a statistically-valid sample would accomplish this goal without a 100% audit.

No, The Government expects 100% audit of the MTF Prime referrals.

TRICARE

Operations Manual (TOM) Ch 18, Sec 3

Autism Care Demonstration

Is the DHA seeking or will the DHA seek to extend the Autism Care Demonstration beyond its current expiration date of 12/31/23 as referenced in the T-5 TOM Chapter 18, Section 3? If yes, please clarify the specific number of Option Periods of the ACD T- 5 offerors should account for in their T-5 bids?

Due to previous legislation and litigation, DHA will likely extend the ACD past the projected expiration date. Offerors should account for all eight (8) health care delivery option periods in their proposals.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM)

Ch 18, Sec 3, para 2.0

Autism Care Demonstration

Question 452 in the Government’s Q&A response released with Amendment 2 guides offerors to price the Autism Care Demonstration (ACD) in their T-5 bid. The T-5 version of the TRICARE Operations Manual, Chapter 18, Section 3, Paragraph 2.0 communicates that the ACD “is projected to expire on December 31, 2023.” As CY 2023 is projected to be the transition year for T-5, the Q&A response conflicts with the TOM’s guidance. Given this, should offerors price the ACD-related costs only through the end of 2023 in their T-5 bid and manage future ACD program costs via the change order modification process when the program is extended past 2023? Or will DHA be issuing a revision to the T-5 draft TOM to extend the demonstration; and if so, should offerors assume ACD costs should be included in their T-5 bids through Option Periods 1 -8 of the T-5 contract?

Due to previous legislation and litigation, DHA will likely extend the ACD past the projected expiration date. Offerors should account for all eight (8) health care delivery option periods in their proposals.

TRICARE

Operations Manual (TOM)

Ch 18, Sec 3, para 6.1

Autism Care Demonstration

The draft TOM states, "The contractor shall assign an autism-specific care manager known as the Autism Services Navigator (ASN) (see paragraph 11.11) to each beneficiary participating in the ACD who will serve as the primary advocate for the beneficiary and family." Since the draft TOM indicates ASNs will have extensive responsibilities requiring significant effort related to work performed directly with each beneficiary, their families, all of their providers, and Comprehensive Care Plan (CCP) development and oversight, we request the following:

Will DHA provide the current number of beneficiaries participating in the ACD in each region? Will DHA provide the anticipated number of ASNs expected in Option Period 1-8?

The current number, and historical trends, are available in the quarterly reports to congress that are publicly available. As the current quarterly report is pending publication, the most current numbers are: West: 5,716; East: 9,979. DHA has not directed any one number of ASNs. The proposal should estimate the number of people it would take to fulfil the requirements based on the information available.

TRICARE

Operations Manual (TOM)

Ch 18, Sec 3, para 8.9.2

Autism Care Demonstration

The draft TOM states, "The contractor shall conduct, on an annual basis, an audit, which must include a minimum of 30 records for each ASCP/Sole Provider group that include a combination of administrative records (paragraph 8.9.6) and medical documentation (paragraph 8.9.7) reviews and one medical team conference session note." Will DHA provide the anticipated number of audits for Option Period 1-8 for each region?

The requirement says a minimum of 30 records for each ASCP/Sole Provider group. That should be extrapolated for the duration of the proposal.

TRICARE

Operations Manual (TOM)

Ch 27, Sec 1, para

2.1.4 and CDRL R180

Telehealth Accreditation

In the response to questions, the Government made clear that virtual-only telehealth providers will require a specific telehealth accreditation and that the Offeror's Health Network accreditation would be sufficient for providers who deliver care via physical office locations and who have integrated a HIPAA-compliant virtual care delivery option into their practices. Will the Government consider updating the current policy and CDRL requirements to reflect this telehealth accreditation clarification as the current policy and CDRL wording indicates the contractor shall obtain and maintain the telehealth accreditation?

Yes, the Government revised the requirement with Amendment 0003. No change to CDRL R180 are required.

TRICARE

Systems Manual (TSM) Ch 2, Sec 2.1 TEDS

The draft TSM deals with data structure for claims and provider editing. Did DHA intend to replace it all with a reference to provider requirements around National Provider Identifier (NPI)?

TSM Chapter 2, Sec 2.1 was updated in amendment 003.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM)

Chapter 1, Section 3, para 6.5.3

Claims Reprocessing

TOM Chapter 1, Section 3, para 6.5.3 states, "The contractor shall not exceed 2% reprocessing rate of the total monthly claims volume processed for the first two option periods. In all remaining option periods, the contractor shall not exceed 1.75% reprocessing rate of the total monthly claims volume processed."

We have reviewed the all prior questions and responses, and would like to request clarification as follows:

There are many categories of adjustments required by TRICARE Policy (as reflected in Additional Info/Rationale) that are not the result of contractor error. Will the Government clarify how it will exclude from this calculation those adjustments where the contractor is required to adjust claims for reasons other than contractor error?

The Government's previous response to Q60 of Amendment 0002 dated 5/20/21 stated, "All claims pended per Government direction are excluded from this standard. The Government will update the TRICARE Operations Manual to reflect excluded claims.

This is a new Government requirement based on the TRICARE Audit error rates (H.10.) so the Government cannot provide historical TRICARE data."

This question was in regards to claims reprocessing and not deferred claims. We assume the Government intends to exclude claims reprocessed at the Government's direction, including under those processes prescribed in the TRICARE Manuals, from this calculation.

Does the Government concur?

The Government concurs. All claims pended or reprocessed per Government direction are excluded from this standard. The contractor shall report the reprocessing rate and the Government may review any excluded claims that the contractor believes are at the Government’s direction under the Inspection of Services clause. See CDRL M090.

Exhibit A.

Contract Data Requirements List M400 CDRL Reporting

M400 IDES MOA Claims Without Authorization is an existing CDRL under T2017, however this CDRL was not included in the RFP. Please confirm this CDRL was intentionally omitted from the T-5 RFP.

This CDRL was intentionally omitted.

Exhibit A.

Contract Data Requirements List A020 CDRL Reporting

CDRL A020 Indirect Medical Education (IDME) Ratio for Children's Hospitals Report - Under T2017, DHA modified the submission due date for the A020 from September 1 of each year, to April 1 of each year. We assume the due date for A020 under T-5 is April 1 of each year.

Does the Government concur?

No. The A020 due date is September 1.

Exhibit A.

Contract Data Requirements List Q080 CDRL Reporting

Under T2017, the existing CDRL Q080 is the quarterly Capital and Direct Medical Education Report. CDRL Q080 under the T-5 RFP is now the Behavioral Health Network Status Report.

Please confirm the quarterly CDRL for Capital and Direct Medical Education Report was intentionally omitted from the T-5 RFP.

Yes. The Government intentionally omitted the quarterly CDRL for Capital and Direct Medical Education Report from T-5.

Exhibit A.

Contract Data Requirements List A070 CDRL Reporting

Under T2017, the existing CDRL A070 is the Annual Capital and Direct Medical Education Report. CDRL A070 under the T-5 RFP is now the Comprehensive Autism Care Demonstration (A) Report.

Please confirm the Annual CDRL for Capital and Direct Medical Education Report was intentionally omitted from the T-5 RFP.

Yes. The Government intentionally omitted the annual CDRL for Capital and Direct Medical Education Report from T-5.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM)

Chapter 11, Section 9, Para 2.7

Contractor Responsibilities - Debt Collection Assistance

Although TOM, Chapter 11, Section 9, Para 2.0 speaks to the Contractors Responsibilities – Debt Collection Assistance and the Government Debt Collection Assistance Officers (DCAO), this area of the TOM does not reference a specific CDRL to prepare and submit a monthly report per Para 2.7.

Please clarify which specific monthly CDRL is to be used to fulfill this contract requirement.

If no CDRL is to be provided, would the Government consider removing this requirement.

Debt collection reporting falls under the monthly M090 Management report CDRL.

L.6. Volume II, Technical Proposal

L.6.2.6.1.3 and L.6.2.6.9.3 as well as H.16.1.1.2 and H16.1.9.1

Metrics for Beneficiary Experience

Sections H and L require metrics for beneficiary experience in relation to Advanced Primary Care (APC) practices and Virtual Value-Based Networks (VVN). Managed care support contractors (MCSC) are prohibited from surveying beneficiaries. Currently, MHS Patient Satisfaction Surveys measure patient satisfaction at the Prime Service Area level. In order to assess patient experience at an APC or VVN level, surveys will need to be conducted at the group and individual provider level.

Will MCSCs be permitted to survey beneficiaries to meet this requirement without requiring additional OMB approval?

If proposed, the Government intends to seek this exception to policy in the development of these Demonstrations.

TRICARE

Operations Manual (TOM)

Chapter 18, Section

Autism Care Demonstration

(ACD)

The purpose of ACD is to further analyze and evaluate the appropriateness of the ABA tiered=delivery model under TRICARE. It is also assessing the feasibility and advisability of establishing a beneficiary cost-share for ABA services for ASD. The ACD is projected to expire on December 31, 2023, which is before the start of health care delivery (SHCD).

Since the program is still under evaluation and the final determination has not been made, is it the Government’s intent to have the ACD costs included in our T-5 pricing?

Yes, the Government's intent is to have the ACD costs included in T5 bids.

TRICARE

Operations Manual (TOM)

Chapter 11, Section 6, para 4.4.2

Beneficiary Welcome Packet

The Government's Response to Q495 of Amendment 0002 dated 5/20/21, did not address whether DHA will supply contractors with the Welcome Packet materials.

The TOM, Chapter 11, Section 6, para 4.4.2 reads, “The contractor shall print and mail out a Welcome Packet to each new beneficiary household. Welcome Packets will include a welcome letter, costs [and] fees sheet, wallet [card], and the appropriate plan or program handbook. DHA Communications develops the packet contents.“ We assume the contractor would ONLY be responsible for the printing of a cover letter, and the printing of the DHA-developed materials would remain the responsibility of DHA. As such, Welcome Packet materials would be provided to contractors as part of the material ordering process.

Does the Government concur?

DHA will provide the contractor with all printed materials to store and mail to beneficiaries and others as required. The contractor is responsible for postage for materials leaving their possession.

TRICARE

Operations Manual (TOM)

Chapter 11, Section 6, para 4.4.2

Beneficiary Welcome Packet

Will contractors receive the (currently excluded) PNT data for active duty family members who enroll in TRICARE Select in order for packets to be mailed to this population?

The contractors will receive a report of enrollment to TRICARE Select to complete this task.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM)

Chapter 11, Section 6, para 4.4.2

Beneficiary Welcome Packet

As the packet contents outlined in TOM, Chapter 11, Section 6, para 4.4.2 (wallet card, costs and fees sheet, handbook) are universal regardless of plan type (outside of TFL), we assume only one packet is to be mailed per household, regardless of the number of beneficiaries enrolled or whether family members enroll in different plans.

Does the Government concur?

The contractor will send one packet per plan (for example, TRICARE Prime, TRICARE Select) per household. If materials cover multiple plans such that one kit covers the household, one kit is acceptable.

684 H.5.9.5 H.5. Performance Guarantees (PGs) H.5.9.5

Regarding RFP section H.5.9.5. which states “ For calculations of the Performance Guarantees under paragraph H.5.9, an occurrence shall be considered the final result of an assessment of a minimum of 1,000 claims received during the prior quarter, beginning the second quarter after the SHCD to assess the Contractor’s claims processing system for accuracy of the claim, first pass auto-adjudication percentage, and claims reprocessing rate." a. Based on TOM Chapter 1, Section 3, paragraph 6.5.1, please confirm that the contractor’s claims payment error rate used to assess the quarterly Claims Accuracy Rate Performance Guarantee is the payment error rate determined by Quarterly Claims Processing and Payment Accuracy Compliance Review process described in RFP Section 10.1.3.

b. Based on TOM Chapter 1 Sec on 3, paragraph 6.5.2, please confirm that the contractor’s first pass auto-adjudication rate used to assess the quarterly First Pass Auto-Adjudication Performance Guarantee applies to the total volume processed during the measurement quarter and reported on CDRL M090.

c. Based on TOM Chapter 1 Sec on 3, paragraph 6.5.3, please confirm that the contractor’s claims reprocessing rate used to assess the quarterly Claims Reprocessing Rate Performance Guarantee only includes claim reprocesses due to contractor error during the measurement quarter and includes total volume processed during the measurement period and reported on CDRL M090 .

d. Alternately, is there a separate process where DHA will perform an assessment of a minimum of 1,000 claims received during the prior quarter to assess the Contractor’s claims processing system for accuracy, first pass auto adjudication percentage and claims reprocessing rate? If so, please describe the process for claim selection, the process for performing the assessment and reporting of the results for the related performance guarantees.

A. The claims accuracy performance guarantee will be separate from the claims payment error rate determined by the quarterly claims processing and payment accuracy compliance review.

B. Concur. The first pass auto-adjudication rate will apply to the total volume processed during the measurement quarter (minimum 1,000).

C. The Government concurs that only claims reprocessed during the assessment quarter.

All claims pended or reprocessed per Government direction are excluded from this standard.

D. The claims processing health care delivery PG described in H.5.9 is separate from the quarterly claims audit described in H.10. The process of claims selection will not be described.

685 H.9.4

H.9. Performance Readiness Validation (PRV)/Performance Readiness Assessment and Verification (PRAV) H.9.4

Regarding RFP Section H.9.4 Claims Reprocessing Rate and the response to related Question 502, DHA responded that “All claims pended (emphasis added) per Government direction are excluded from this standard. The Government has amended the T-5 TRICARE Operations Manual to reflect excluded claims (6.5.2 First Pass Auto-Adjudication/6.5.3 Claims Reprocessing.)”. Since pending claims will not impact the claim reprocessing rate as it does auto-adjudication, please verify it is the government’s intent to exclude claims “adjusted/reprocessed” per government direction/requirements or outside of the contractor’s control such as adjustments/reprocesses resulting from the submission of additional or modified information or return of unsolicited checks by a provider or beneficiary.

All claims pended per Government direction are excluded from this standard.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

686 H.9.4

H.9. Performance Readiness Validation (PRV)/Performance Readiness Assessment and Verification (PRAV) H.9.4

Regarding RFP Section H.9.4 Claims Reprocessing Rate and the response to related Question 60 for the T-5 Draft RFP 3, DHA responded that “This is a new government requirement based on the TRICARE Audit error rates (H.10) so the Government cannot provide historical TRICARE data.” Section H.10 calculates payment accuracy based on dollars paid in error while the new Claims Reprocessing Rate is proposed to be calculated on the count of claim reprocesses. Since these are two different and distinct measures, there is not a direct mathematical relationship between the payment error percentage to the count of claims requiring adjustment or reprocessing – even when only claims processed as a result of contractor error are considered. Since DHA has stated there is no historical data available to establish the performance rates for the Performance Guarantee, would DHA consider using Option Period 1 to collect data and establish the baseline and then later incorporate the Performance Guarantee in subsequent Option Periods through a contract modification.

Thank you for your inquiry. The Government non-concurs.

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

Chapter 2 Section 8 Paragraph 2.0

The TRICARE Operations Manual (TOM) provided with the T-5 RFP removed the requirement to transfer ADP files in electronic format by the 15th calendar day following Trans Spec & participate in prep/testing of these files until they are fully readable by the incoming or DHA.

The timely transfer of ADP files, including preparation/testing is critical to the transitions. With the removal of this section from the T5 RFP , contractors will need defined, final authority to direct file/data transfers or path to resolution to facilitate transitions & recipients. Eliminating the 15 day requirement for transfer of ADP files & participate in preparation/testing of files until they are fully readable introduces risk.

Did the government intend to remove this requirement?

TOM Ch. 2, Sec 8, Para. 2.1 references TOM Ch. 2, Sec. 6 and TOM Ch. 9 for records requirement and transfer timelines. In addition, the Government revised the transfer timelines in Amendment 0003

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

Chapter 2 Section 8 Paragraph 2.0-2.2

The TRICARE Operations Manual (TOM) provided with the T-5 RFP removed a requirement for the outgoing contractor to start file transfers and history updates 120 prior to SHCD.

Will the government define what date in advance of SHCD the outgoing and incoming contractors are required to transfer files and history as this is critical to transition?

TOM Ch. 2, Sec 8, Para. 2.1 references TOM Ch. 2, Sec. 6 and TOM Ch. 9 for records requirement and transfer timelines. In addition, the Government will be revising the timeline to transfer the files.

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

Chapter 2 Section 8 Paragraph 4.1.6

The TRICARE Operations Manual (TOM) provided with the T-5 RFP refers to TEDS in Chapter 2 Section 10 but this section does not address the requirement to complete TEDS within 210 days following SHCD.

Did the government intend to omit the defined completion date of no later than 210 calendar days following SHCD?

The government did not intend to omit Paragraph 4.1.6. This requirement was added to T- 5 TOM, Ch. 2, Sec 8, Para. 4.0. See Amendment 0003.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

T2017 Chapter 2 Section 9 Paragraph 2.1 Paragraph 2.2 Paragraph 2.3 Paragraph 2.4

The TRICARE Operations Manual (TOM) provided with the T-5 RFP removed specifics for defining contractor responsibility for transitional cases.

Will the government provide direction for the jurisdiction for transitional cases?

Requirements regarding transfer of files/records by the outgoing contractor are located in T-5 TOM Ch. 2 Sec 6., and TOM-5 Chap. 9. Sec. 2.

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

T2017 Chapter 2 Section 10 Paragraph 4.4

The TRICARE Operations Manual (TOM) provided with the T-5 RFP removed requirements for the outgoing contractor to transfer to the incoming contractor all non-ADP files, hard copies of Bene history files transferred to incoming or Federal Records Center (FRC), and outgoing to provide samples/descriptions of files at Transition Specification.

Did the government intend, based on TOM Chapter 9, to eliminate the requirement for the outgoing contractor to transfer non-Automated Data Processing (ADP) files (e.g., authorization files, clinic billing authorizations, and tapes/CDs, which identify Prime Service Areas (PSAs), Congressional, and DHA completed correspondence files, appeals files, TRICARE medical utilization, and administration files)?

The government did not eliminate the requirement for the outgoing contractor to transfer non-ADP files. Requirements regarding transfer of files/records by the outgoing contractor are located in T-5 TOM Ch. 2 Sec 6., and TOM-5 Ch. 9.

TRICARE

Operations Manual (TOM)

TRICARE

Operations Manual

(TOM)

T2017 Chapter 2 Section 2 Paragraph 2.9.1

The TRICARE Operations Manual (TOM) provided with the T-5 RFP removed a requirement to provide within 3 days of award or Contracting Officer direction;

electronic copies of records layout with specifications, / formats & definitions of fields & data elements, access keys & sort orders for:

- Beneficiary history files

- Claims history files

- TEPRVs

- Enrolled Bene & PCM Assignment files

- Mental Health Provider Files

The incoming must have file specs for the transition files. It is critical for incoming to receive file specifications & documentation necessary for interpretation the files.

Eliminating 3 day requirement for transfer of electronic file specifications introduces risk.

Did the government intend to remove this requirement?

Requirements regarding transfer of files/records by the outgoing contractor are located in T-5 TOM Ch. 2 Sec 6., and TOM-5 Chap. 9, Sec. 2. In addition, the government revised the transfer of record timeline found in T-5 TOM, Ch. 2, Sec. 6, Para. 2.3. in Amendment 0003.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

H.16. Future Potential Demonstrations H.16.1.9.1

Virtual Value Network

Our interpretation of the Virtual Value Network demonstration (H.16.1.9.1) is that the demonstration expands on the Value Based Steerage requirements (L.6.2.1.6) by not only identifying high quality and low waste providers but by specifically communicating this subset of high performing providers to beneficiaries and continuously developing high quality and low waste providers. We respectfully ask if this interpretation of the Virtual Value Network demonstration (H.16.1.9.1) is accurate representation of the DHA's request?

Yes. VVN allows provider value to be incorporated into designs to steer beneficiaries to higher value providers thru communications, embedded referral patterns and other means. Virtual value networks give beneficiaries and caregivers detailed and transparent actionable information on provider quality, cost and value which can be used to encourage use of these providers.

H.16. Future Potential Demonstrations L.6.2.6.4.3 & M.7.2.6.4.3Care Collaboration

L.6.2.6.4.3 and M.7.2.6.4.3 requests that the offeror shall describe its communication and education program related to e-consult capabilities, requirements and incentives. We respectfully ask DHA to provide clarity on what is meant by incentives?

Examples of potential incentives are included 2017 NDAA Section 729.

TRICARE

Operations Manual (TOM) Chapter 11 Section 7 P5.1

Telephone Appraisal System

5.1 The contractor shall provide real-time remote and on-site call monitoring capabilities to DHA Government staff identified by the applicable GDA and designated by the Contracting Officer (CO). Please confirm that call recordings being available immediately after the call ends satisfies the requirement to provide real-time remote call monitoring capabilities.

The Government will accept call recordings if available for all calls and available immediately after the call ends.

G.2. PMPM

Military Health System (MHS) Eligible Beneficiaries G.2

Changes to Beneficiary Counts

During the industry day, DHA indicated they could make unilateral changes to the number of beneficiaries in a Region. As the administrative price is composed of fixed and variable cost, if DHA makes unilateral changes to the beneficiary counts, will the administrative PMPM be adjusted to reflect the change?

As the price is calculated the fixed cost is allocated across all beneficiaries. A reduction to the beneficiaries would result in an upward price adjustment as the fixed cost would then be allocated across a smaller population

Yes, the Government has added language to specifically address this concern in G.2.2.1.1.

Should the total number of beneficiaries change by more than 10% of the awarded amount, an equitable adjustment may be requested by either party.

G.2. PMPM

Military Health System (MHS) Eligible Beneficiaries G.2

Changes to Beneficiary Counts

During the industry day, DHA indicated they could make unilateral changes to the number of beneficiaries in a Region. What is the amount (percent or number) that would need to be changed to allow bidders to alter their pricing ?

See the question 696 response.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

H.3. Healthcare Underwriting Incentives H.3.2.1.1.

Changes to Beneficiary Counts

A guaranteed discount is being calculated and proposed on the current footprint. In the event a sizable amount of beneficiaries are moved into a demonstration, or other products this could have be a detriment to our discount, especially if those members are in geographies where the bidder has more advantageous discounts. In the event beneficiaries are moved from the program into a new program would bidders be allowed to update their discount?

The guaranteed network provider discount is a fixed percentage of health care costs during contract performance and is not subject to change based on beneficiary enrollment. The Government has provided the potential competitive demonstration areas where beneficiaries may choose to enroll in a competitive plan in Attachment J-9, and Offerors should prepare their proposals accordingly.

TRICARE

Reimbursement Manual (TRM) 4.6

APM Approval Process

The TRM states "The contractor is required to obtain approval for the implementation of any new APMs that are not pre-approved." - does this apply to new types of APMs involving care delivery or when the contractor enters into an APM with a provider?

TRM Ch. 18, Paragraph 4.6.5 - "Once an APM is approved it may be expanded to other providers without additional DHA approval". The requirement applies to any new APMs involving care delivery (not when a contractor enters into an APM with a provider) that are not pre-approved and draft APM proposals must be submitted to DHA for approval for the next plan year. See TRM Ch. 18, Paragraph 4.6 for sequential steps and timelines for the APM approval process.

L.9. Volume V, Financial L.9.2.4

Department of Insurance Audits

Please confirm that this requirement applies to the bidding entity? Yes, the requirement in L.9.2.4. applies to bidding entities. The Offeror shall submit copies of adverse financial items uncovered in any of the last 3 years’ State Insurance Department audits, as of RFP release date, if applicable. Offerors shall provide a supporting narrative, including a brief description of anomalies in the submitted financial data and a brief description of any projected increases and decreases in the Offeror’s business base.

TRICARE

Operations Manual (TOM)

TOM C7 S3, 2.2;

TOM C7 S3, 3.0;

CDRL M100 HEDIS Reporting

In reference to CDRL M100 Medical Management Programs Report. Can you clarify:

1. Is the expectation to report all required HEDIS measures for all TRICARE eligible beneficiaries and Active Duty Service Members by Branch of Service/Defense Medical Information System (DMIS) and geographic area of responsibility in the CM and PH programs (item 3h) in the summary report (item 3)? Clarification is needed because item 3 is a summary report of CM and PH activity.

2. Are HEDIS outcomes for beneficiaries in PH programs (item 4g) to be included in the detailed report (item 4)?

3. Summary report of Case Management (CM) and Population Health (PH) activity provided to all TRICARE eligible beneficiaries and Active Duty Service Members by Branch of Service/Defense Medical Information System (DMIS) and geographic area of responsibility will:

h. Collect, trend, and report all required HEDIS measures to include baseline metrics, target goal metrics and actual outcomes.

4. Detailed reports for CM and PH by Branch of Service and DMIS

g. For PH only, report preliminary and outcome metrics for each disease state.

1. Yes

2. Yes M100 was revised under Amendment 0003 to clarify expectations.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Operations Manual (TOM) TOM C4 Sec 1 Network

Please clarify if/how Chapter 4, Sec 1, P 7.2, which explicitly states “The contractor may not accept background checks completed by other agencies” applies to Chapter 18 Sec 3 P.8.2.3.2 which seems to suggest the contractor may rely on a Criminal History Background Check (CHBC) conducted by an authorized ABA supervisor and provided to the contractor. Are CHBC results provided by an authorized ABA supervisor acceptable or must the contractor perform an independent CHBC on all assistant behavioral analysts (ABA’s) and behavioral therapists (BT’s)?

Yes. CHBC results provided by an authorized ABA supervisor are accetable. Because the ACD is a demonstration, the TOM Ch 18, Sec 3 is the primary source for guidance, no other section applies unless specified in TOM Ch 18, Sec 3..

C.2.11.

Management C.2.12.2.1 QM/QI

C.2.12.2.1 states “The Contractor shall establish and operate a QM/QI program in accordance with the TOM Chapter 7, Section 6.”; where the previous draft RFP version stated “The Contractor shall establish and operate a QM/QI program and have in place at the start of health care delivery.” Requesting verification that the language change in the final RFP is correct, directing the QM/QI program be established and operated per TOM C7, S6 the Clinical Quality Management Program section.

See Amendment 0005 removing the reference to TOM Chapter 7, Sec 6.

C.2.8. Clinical Quality Management Attachment J-8 CQM

In relation to Attachment J-8 – Clinical Quality Metrics Updated, would DHA provide the current performance rate for the metrics that have Performance Targets identified by Health Plan level and for each region?

Please reference the Annual Evaluation of the TRICARE Program Report to Congress on Heatlh.mil. The information can be found on page 13 of the 2020 report on the table titled "TRICARE Health Plan Enterprise Support Activity- Purchased Care Dashboard. Follow here: https://www.health.mil/Military-Health- Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual- Evaluation-of-the-TRICARE-Program

705 OTHER Systems Testing

During Award-SHCD IT Systems Testing, will the Government provide testing data to be used to test systems or will we need to create our own dummy data?

The contractor shall develop all initial testing data. The Government may provide baseline or additional initial testing data to be used. The Government will provide final test data after the contractor notifies the government that a particular system has been validated and ready for testing.

L.6. Volume II, Technical Proposal Attachment L-9 Network

Please clarify how the groupings in L-9 are defined and what providers should be captured in each (Primary Care, Specialty, Behavioral health, etc..). Would like to ensure the right provider specialties are captured in the right grouping.

For example in the Behavioral Health Providers, should it include substance abuse as well as Psychiatrist or would Psychiatry go into Specialists (all types)?

See attachment J-22 Crosswalk, in Amendment 002 for the list of what should be included in each provider category.

L.6. Volume II, Technical Proposal Attachment L-3 Network

In reference to the list of Allied Health Professionals provided with Amendment 0001, it is our understanding that for (Homemaker/Home Health Aide/Nurses( LPN/RN) all work done by them is billed by a contracted company as these allied health professionals are not a contracted specialty. Please confirm as a result the expectation is at an individual level they will have a 0:0 ratio on attachment L-3

Allied Health Professionals were removed from L-3 in Amendment 002.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

708 l.6. Volume II, Technical ProposalAttachment L-3 Network

In reference to the list of Allied Health Professionals provided with Amendment 0001, it is our understanding that Advanced Registered Nurse Practitioners/ Certified Registered Nurse Anesthetist and Physician Assistants are usually an extension of targeted physician groups and are a natural inclusion in the network and do not have associated ratios. Please confirm that meets DHA's expectations for inclusion of these specialties in the network.

Allied Health Professionals were removed from L-3 in Amendment 002.

709 L.6. Volume II, Technical ProposalAttachment L-3 Network

In reference to the list of Allied Health Professionals provided with Amendment 0001, it is our understanding that for (certified orthotist/prosthetics) all work done by them is billed by a contracted company as these are not a contracted specialty. Please confirm as a result the expectation is at an individual level they will have a 0:0 ratio on attachment L-3

Allied Health Professionals were removed from L-3 in Amendment 002.

Tricare Operations Manual (TOM)

Chapter 11, Section 6: 4:3 Ordering & Storage

This section shares information where contractor is responsible for all storage/handling/distribution of Government supplied printed materials. Please provide information on the following: types of printed materials furnished, volume of material received, frequency of receiving and any historical metrics of daily, monthly or annual distribution of these items broken down by East vs West regions.

East Region Quarterly Quantities TRICARE Plans Overview Brochure -100,000 TRICARE Choices for National Guard and Reserve Handbook- 50,000 TRICARE Choices in the United States Handbook-25,000 TRICARE Overseas Program Handbook - 25,000 TRICARE Maternity Care Brochure-20,000 TRICARE Costs and Fees Sheet – Brochure - 150,000 TRICARE Retiring from Active Duty Brochure - 100,000 TRICARE Retiring from National Guard - Brochure- 100,000 TRICARE and Medicare: Turning Age 65 Brochure - 75,000 TRICARE and Medicare: Under Age 65 Brochure - 20,000 TRICARE Contact Wallet Card - 200,000 TRICARE Health Matters Newsletter Issue 3 (East Edition) - 710,000

West Region Quarterly Quantities TRICARE Plans Overview - 10,000 TRICARE Choices for National Guard and Reserve Handbook- 25,000 TRICARE Choices in the United States Handbook- 10,000 TRICARE Overseas Program Handbook- 10,000 TRICARE Maternity Care Brochure- 10,000 TRICARE Costs and Fees Sheet Brochure - 100,000 TRICARE Retiring from Active Duty Brochure - 10,000 TRICARE Retiring from National Guard Brochure - 20,000 TRICARE and Medicare: Turning Age 65 Brochure- 30,000 TRICARE and Medicare: Under Age 65 Brochure- 10,000 TRICARE Contact Wallet Card - 75,000 TRICARE Health Matters Newsletter Issue 3 (West Edition) Newsletter -320,000

L.6. Volume II, Technical Proposal L.6.2, L.6.2.3.7.

Beneficiary Website

What are the browser types and versions that will be used for user acceptance testing?

We would like to understand expectations for testing so development work can be done to meet those standards.

DHA does quality assurance on the following: 1) Chrome (latest version not a beta version), 2) Firefox (latest version not a beta version), 3) Safari (latest version not a beta version), 4) Edge (PWA only), 5) Internet Explorer.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Reimbursement Manual (TRM) Ch 18 Sec 1 P 4.4

Alternative Payment Models

In paragraph 4.4 it states "These percentages will not include DHA initiatives (e.g.

HBVP). Can you please clarify " these percentages"? Is this referencing discount percentages or the percentage of in- network health care expenditures covered by APMs? Can contractors include DHA initiatives like HVBP in the numerator when calculating the percentage of in network healthcare expenditures covered by APMs?

Section 4.4 The Government further classifies the contractor’s proposed APMs as ones that require approval and ones that do not require approval ‘pre-approved’. The approval process is defined in paragraph 4.5. These percentages will not include DHA initiatives (e.g., HVBP).

"These percentages" refers to APM discounts and payments under DHA initiatives which may be different from the examples in Section 4.5. It is referencing discount percentages.

Contractors may include DHA initiatives in the numerator when calculating the percentage of health care spending under APMs.

TRICARE

Reimbursement Manual (TRM) Ch 18 Sec 1 P 4.3.2

Alternative Payment Models

In reference to P 4.3.2 is it a correct assumption that Contractors may aggregate in-network spend at hospitals with contracts subject to HVBP and other DHA initiatives to the numerator when calculating the percentage of in-network health care expenditures covered by APMs.

Section 4.3.2 indicates "When measuring the percent of network expenditures covered by APMs, the contractor will receive credit for APMs whether they were initiated by the contractor or the government." However there is conflicting information in P 4.4

Yes, it is a correct assumption.

Tricare Operations Manual (TOM)

TOM C7, S3, 6.1;

6.1.4; 6.1.5.; 6.2.1

Substance Use Disorders (SUD)

6.1 Includes MH and SUD; 6.1.1 states the Contractor shall require preauthorization for all non-emergency inpatient MH services. It is followed by bullets including Acute inpatient psychiatric care, RTC, SUD Inpatient and Residential:

6.1.4 The contractor shall issue an authorization for acute inpatient MH care for no more than seven calendar days at a time.

6.1.5 The contractor shall follow up within two business days of a MH inpatient discharge to ensure the beneficiary has a follow up appointment secured within seven calendar days of discharge.

6.2.1 However, if the non-office based, Outpatient MH provider is a network provider, a request for preauthorization from the network provider to the contractor may be accepted in lieu of the PCM referral.

Question: 6.1.4 , 6.1.5 and 6.2.1 only specify MH, not SUD. Is SUD intended to be included w/ MH, or intended to be excluded?

SUD is included with MH. As stated in the TRICARE Program Manuals definitions, a Mental Disorder includes SUD.

715 R230 B2B Gateway QuestionnaireNA Devices

In R230 B2B Gateway Questionnaire, DHA indicated that CSR 1000v is on the list of approved devices with a note of based on license and availability.

Please clarify conditions for use of CSR 1000v?

Please identify which environment(s) (e.g. on-premise and/or cloud) the CSR 1000v can be hosted?

1. Please clarify conditions for use of CSR 1000v.

RESPONSE: Usually selected when vendor’s intended source “Data Center” is located at a cloud access providers (CAP’s) environment with current and active licenses, covered by active maintenance contracts and added to DHA’s Smart licensing portfolio with Cisco (so DHA can open tickets with TAC directly). The vendors are required to purchase a license to support LISP/GetVPN. (appX and Security license packages, the AX license has all of them including the HSEC and PERF features) .

2. Please identify which environment(s) (e.g. on-premise and/or cloud) the CSR 1000v can be hosted?

RESPONSE: CSR 1000v is for cloud environment as physical hardware cannot be placed at CAPs.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

TRICARE

Systems Manual (TSM) Ch 1 S 1.1

Gov't furnished systems

What are the contractual requirements for the contractor's use of the Assistance Reporting Tool (ART)? Please provide complete details on work procedures, system requirements, security protocols for the contractor's employee use of ART.

Individuals request an ART by completing an online form and providing a copy of Operational Security (OPSEC) training. Individuals must have a Common Access Card (CAC) and be in a customer service role within the Military Health System (MHS). ART uses .NET and is supported by most web browsers. Government furnished equipment is not required.

H.3. Healthcare Underwriting Incentives H.3.2.2. - H.3.2.2.3.

Network Usage (Negative) Incentive

H.3.2.2.2. states "For example, in month 2 of Option Period 2, if the actual percent of claims with a network provider is 74%, then a negative incentive equal to 4% of the claims will be assessed against the Contractor (4% represents the difference between the actual number of claims for care provided by a network provider and the standard). If 4% equates to 200 claims not meeting the standard, the negative incentive assessment for that month will be $2,800 or 200 claims times $14."

DHA provides an unrealistic representation of the potential penalties associated with the Network Usage Incentives (Negative Incentives). It is expected that the T-5 East or West Region will process approximately 30 million claims a year. The Option 2 network usage standard is 78% which would be 23,400,000 claims. The example of a 74% network usage would equate 22,200,000 claims. The 4% difference represents 1,200,000 claims (not 200 claims as in the example provided). A $14 penalty on each of those claims would be a $16,800,000 penalty. Just a 1% failure to meet the 78% standard would equate to a $2,100,000 penalty ($7 X 300,000 claims).

Please provide a realistic projection of the potentially significant penalties associated with Network Utilization. DHA should also reassess the extent of these penalties since they are clearly excessive.

The Government will not reassess this negative incentive. This negative incentive is designed to ensure the contractor meets required minimums due to the importance of beneficiaries having access to in-network providers. The use of out-of-network providers is incredibly detrimental to the Government and results in significantly increased costs to the Government and the beneficiary, increased beneficiary dissatisfaction, and increased potential for claims errors.

718 OTHER CDRL P060 Provider Education

We note that in the Content Details for CDRL P060 Education Plan it states: "The plan shall identify the contractors strategies and tactics to educate TRICARE beneficiaries, TRICARE and MHS staff, Reserve Component (RC) units, and providers on all aspects of TRICARE programs, including education for beneficiaries about accessing their health care benefit." Please confirm that "education" for non-network providers means information posted on the contractor's website. If DHA intends for contractors to conduct specific non-network provider education, please provide workload data or estimated volumes to facilitate the administrative price required to undertake such an effort.

There is not a contractual relationship between non-network providers and the Contractor so a plan to educate them is challenging.

The Government confirms that education for non-network providers is supported by information posted on the contractor's website and assess to call center staff to respond to provider questions (general call center line). The Government agrees and accepts that there is no contractual requirement to establish a relationship with non-network providers.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

719 Ch 11 S 7 P 1.6 Telephone Inquiries

The last sentence of TOM Chapter 11, Section 7 P 1.6 states: "...personnel shall be able to enter authorizations for urgent care for beneficiaries traveling outside of their Prime Service Area (PSA)."

Only Active Duty Service Members (ADSM) are required to have authorizations for Urgent Care. MTFs, DHA Great Lakes, or the Nurse Advice Line contractor (after hours) issue those authorizations.

Since Urgent Care services are available to all non-ADSM beneficiaries without requiring a referral or authorization from either Regional T-5 contractor, the last sentence in TOM Chapter 11, Section 7 Paragraph 1.6 should be deleted.

Neither T-5 contractor should have a responsibility for issuing urgent care authorizations for beneficiaries traveling outside of their Prime…