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

590 L.4. Proposal Preparation

L.4.3 System Security Plan

Amendment 0001 of the final RFP added a note regarding page limitations that stated, "The System Security Plan does not count toward the Written Technical Proposal page limitation." However, the System Security Plan is not listed on the chart of proposal volume contents in the introduction to L.4. Is it the Government's intent for the offeror to include its System Security Plan as an attachment to Volume II?

GOVERNMENT REVISED RESPONSE 08/11/2021: No.

L.4. Proposal Preparation

L.8.18.4 Future Condition Risks

Can the Government confirm that Section L.8.18.4 does not limit a Contractor’s rights under the Changes clause and does not otherwise limit a Contractor’s right or ability to obtain an equitable adjustment?

The Government does not intend to alter contractor rights under the changes clause or right to request an equitable adjustment through L.8.18.4.

L.4. Proposal Preparation

L.8.18.4 Future Condition Risks

Can the Government also confirm that Section L.8.18.4 does not limit a Contractor’s right or ability to assert claims or defenses relating to the legal doctrines of (a) force majeure; (b) mistake; (c) impossibility; (d) impracticability; and (e) cardinal changes?

The Government confirms L.8.18.4 is not intended to deny the contractor's right to assert these claims or defenses in an appropriate forum

M.8. Evaluation of Factor 2, Past Performance

M.8.4.2 Past Performance Relevancy

Can the Government confirm that an offeror may receive a Very Relevant rating for Past Performance, even if the contractor does not meet all of the criteria in Table M.8.4.2?

The information in Table 8.4.2 establishes the scope, magnitude, and complexities of the T- 5 contracts for the purposes of comparing past performance references to T-5's scope, magnitude, and complexities. These are not criteria to reach any particular Relevancy rating. There is not a requirement to meet or exceed any number of entries from the table for a contract to be evaluated as Very Relevant, Relevant, or Somewhat Relevant.

771 OTHER M030 CDRL CDRL M030 states that a "100% audit of MTF Prime Referrals" is required, does that imply that a statistical sample size can be created from just this universe of MTF Prime Referrals? Or that the contractor must audit every single transaction for MTF Prime Referrals?

The Government is requiring a 100% audit of every single transaction for MTF Prime Referrals, a statistical sample size is inadequate for this requirement.

772 OTHER M030 CDRL CDRL states that for Network Prime Referrals, the margin of error for the sample should be +/- 1? From a percentage perspective, does this translate to 10% or 1%? Other CDRLs, M290 for example, provide that "A statistically valid random sampling" be implemented, can this be done for this CDRL as well?

The +/- 1 margin of error is 1%. No, "a statistically valid random sampling" is not an option for CDRL M030.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

773 TRICARE

Reimbursement Manual (TRM)

H.18.3.3 APM H.18.3.3 states that all Category 2, 3, 4 Health Care Payments are excluded from the Cap.

Is the Cap calculation limited to only incentives tied to the non-risk bearing arrangements in 2a-3a?

H.18.3.1 sets out "the Government will cap its total reimbursements to the contractor for APM Special Payment Cost Category 3 (incentive or bonus payment that are not risk-based). See Section G 14.5." Section G 14.5 identifies these incentive or bonus payments as including "all Cat. 2 APM payments and any similar payments that may be included as a supplemental feature of a Cat. 3 or Cat. 4 model (e.g., a quality incentive paid in addition to risk-sharing or capitation). For contractor-initiated APMs, reimbursement of these non-risk-based payments is subject to the Section H.18.3.1. reimbursement caps."

774 TRICARE

Reimbursement Manual (TRM)

H.18.3.3 APM H.18.3.3 states that all Category 2, 3, 4 Health Care Payments are excluded from the Cap.

If APM payment incentives remain under 100% CMAC, then how does the $30m Cap apply?

This question misstates H 18.3.3. However, DHA will pay invoices for contractor initiated APM incentives or Bonus Payments that are not risk based in accordance with Section G.14.

up to the cap established by the contract.

775 TRICARE

Reimbursement Manual (TRM)

H.18.3.3 APM Please clarify that shared savings incentives that are earned by the provider are capped and that additional improvements above $30m go back to DHA (e.g., CMS’s Next Generation ACO risk corridor).

Shared savings incentives that are earned by the provider do not fall under the APM cap.

Shared savings above the approved APM arrangement will go back to the Government.

776 TRICARE

Operations Manual (TOM)

Chapter 7, Section 6, Para 3

CDRL Q280 Attachment J-8 includes a comprehensive list of Quality Metrics while J-11 includes an abreviated list of Quality Metrics. Please confirm the metrics required for the clinical quality dashboard for OP1 are listed in J-11. Please confirm these metrics are the total list of metrics required for the dashboard in OP1. Please confirm whether the "Possible Metrics" are included so that pricing can be determined.

J-8 is the list of all Clinical Quality Metrics within the T5 Solicitation and includes any relevant targets for each metric. The J-11 attachment is a list of current CQM dashboard metrics, along with metrics currently being considered (possible metrics). Per CDRL Q280 "The government will provide a list of required measures 60 days prior to the start of the option period. At the contractors' discretion, additional quality and value measures meaningful to beneficiary healthcare and readiness may be included." For the purposes of pricing, consider these lists as OP1 metrics with the understanding that a final list for OP1 will be provided 60 days prior to SHCD and may be somewhat different than what is listed.

777 TRICARE

Operations Manual (TOM)

Chapter 7, Section 6, Para 3

CDRL Q280 The Q280 CQM Data Dashboard requires that data is available and displayed for individual network providers, including specialists. If a specialist does not have a metric to display on the Dashboard (for example, a vascular surgeon) is the requirement to display them anyway? Or is the Dashboard to only display the facilities and providers for which at least one of the J-8 or J-11 metrics apply?

If specialists do not generate a particular CQM metric, that specific reporting requirement may be omitted. The contractor does not need to display providers with no outcomes for the metrics.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

779 Section H.3.2.1.7.

Assumption of Risk for Guaranteed Discount:

Per Amendment 0003, under Section L.8.18.4, DHA removed the following statement:“The Offeror shall further agree that the guaranteed network provider discount shall not be adjusted for any action by the Government, including unilateral contract changes, allowable rates, and payment methodology.” In Amendment 0003, DHA also responded to Question No. 595. This question asked about DHA’s likely continued “practice of reducing reimbursement for certain medical services” and the challenge that this presents “in achieving the discount guarantee.” DHA responded, in part, by stating that “[c]hanges affecting network discounts guarantees may be addressed during the change negotiations.”

However, the provision at Section H.3.2.1.7. remains unchanged, stating:“The guaranteed discount percentages provided in paragraph H.3.2.1.1 shall not be adjusted to account for changes to TRICARE allowable amounts, the expansion of TRICARE coverage to additional procedures and Durable Medical Equipment (DME), or for any other actions or conditions that may affect the willingness of the Contractor’s network providers to accept discounts. The Contractor assumes all risks of future conditions and changes that may affect the Contractor’s ability to achieve the guaranteed network provider discounts.”

The deletion of the above sentence from Section L.8.18.4 and DHA’s response to Question 595 have created a conflict between the language used in Sections H and L of the RFP and has introduced ambiguity for Offerors. Specifically,the deletion of this sentence from Section L.8.18.4 implies that Offerors arenot assuming the full risks set forth in Section H.3.2.1.7, to include risks for any Government-mandated actions such as unilateral contract changes to coverage or changes to allowable rates, and payment methodology. However, the corresponding provision in Section H requires Offerors to assume all risks of future conditions and changes that may affect their ability to achieve the guaranteed network provider discounts, to include “changes to TRICARE allowable amounts” and “the expansion of TRICARE coverage.” We respectfully request that DHA provide all Offerors clarity on DHA’s expectations in order to ensure that all Offerors are competing on a level playing field with the same understanding of the RFP’s requirements.

The RFP remains unchanged with regard to risk. The Government determined the sentence in L.8.18.4. was unnecessary and its removal does not change the requirement of H.3.2.1.7.

regarding risks assumed by offerors and their network discounts. Additionally, Question #595 has been edited to clarify the Government’s position.

780 A CLIN in the pricing template was added to account for the cap on Category 3 costs, however it does not appear in the Schedule B through Amendment 0004. Will DHA release a revised version of Schedule B that includes the new CLIN?

The Pricing Template (L-5 e/w) includes a cap for APM Special Payment Cost Category 3 payments in accordance with Section H.18.3. The cap is not a CLIN but will be added to the offeror's proposed underwritten healthcare costs in the calculation of the Total Evaluated Price in accordance with Section L.8.5.

781 Regarding the System Security Plan (SSP), in the Q&As released by DHA, there is conflicting guidance given in Q#590 and Q#614 about whether the SSP should be submitted. The RFP instructions are clear, but we want to make DHA aware should the Q&As cause confusion for Offerors.

Thank you for bringing this to our attention. Question #590 has been revised with the correct answer and guidance as stated in the RFP.

782 Accreditation C.2.3. Medical Management

C.2.3.4 According to section C.2.3.4. The Contractor shall obtain and maintain throughout the life of the contract accreditation from a nationally recognized accrediting organization for the following MM programs: utilization management, case management, and disease management. Population Health is not listed as a program needing accreditation. NCQA developed a new NCQA Population Health Program for organizations that conduct focused population health management for specific conditions or populations. According to the NCQA website, "The NCQA Disease Management Accreditation and Certification programs will transition into the new Population Health Program Accreditation and Prevalidation programs launching this December. The last day to submit applications for Disease Management Accreditation/Certification was November 26, 2019."Does the NCQA population health program accreditation meet the contract requirement for disease management accreditation?

No, the NCQA Population Health program accreditation does not meet the contract requirement for disease management accreditation at this time. 10 U.S.C Chapter 55 requires a Disease and Chronic Care Management Program that is nationally recognized and accredited.

783 Network J. List of Attachments and Exhibits

J-19 The PSA listing originally provided does not match to the PSA names in the J-19 attachement from amendment 002, rosters do not align. Can the government please provde an updated PSA listing that aligns with J-19 and/or include the DMIS on J-19.

The government can not provide DMIS IDs in Attachment J-19 because a ZIP code can align with multiple DMIS IDs.

784 Personnel Security.

TRICARE Systems Manual (TSM)

TSM Chapter 1, Section 1.1:

There is a general understanding, from a personnel security stand point, what constitutes regular access from administrative access. However in preparing to define roles within the T-5 program, we would like further definition on what is considered an “Authorized User” vice an “Enhanced User and Core User”.

Please be more specific. The Government does not see "Authorized User", "Enhanced User" or "Core User" in TSM Chapter 1, Section 1.1. For more information on Personnel Security, please see reference in TSM Chapter 1, Section 1.1: DoDD 52002.2-R, “Personnel Security Program,” January 1987, as amended, http://www.dtic.mil/whs/directives/corres/pdf/520002r.pdf.

785 APM Payments G. Contract Administration Data

G.14.4 How will APM reporting work in OP8 if a contractor has to transition out, yet the program spans across episodes of care that could span across the outgoing T-5 and incoming T-6 contractor?

APM reporting will be in accordance with the provisions and instructions in the contract and TOM Chapter 2 Transitions.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

786 Non Risk Bonus Payments

G. Contract Administration Data

L.8.5 What will happen if bidders distribute more than $30M per year of non-risk bonus payments? For example, if a bidder lists the $30M as their bonus payments, and in OP1 they distribute $50M of bonus payment which ultimately improves their actual discount because they negotiate a lower discount through the use of bonus payments

In accordance with Section H.18.3.2., the contractor is financially responsible for payments above the cap.

787 Category 2 APMs

H.18 Alternative Payment Models

How will Category 2 APMs be viewed by DHA in OP 5 and onward? Can DHA continue to use Category 2 APMs in OP 5? How will they be considered in the guaranteed discount ?

Yes, the contractor may continue to use Category 2 APMs in OP5, however, the healthcare dollars paid under these APMs will not count toward the APM goals in Section H.18.1. The healthcare claims will continue to count toward the guaranteed network discount.

788 APM Reporting G. Contract Administration Data

G.14.4 RFP states "To the extent payments attributable to one arrangement category overlap with other categories, the Contractor may use its discretion to decide which arrangement the payments are reported” – Has DHA considered that this lack of guidance will result in inconsistent results both within a contractor and between contracts?

The Government's intent is not to be overly prescriptive and the T-5 contractor should include specifics of payment arrangements in its proposals as outlined in TRM Chapter 18.

789 APM Reporting G. Contract Administration Data

G.14.4 Do payers need to report APM payments by G.14.4 and G.14.5?

Yes Sections G.14.4. and G14.5. are referenced in Section G.14.6.

790 APM Reporting G. Contract Administration Data

G.14.2 RFP States that "The Contractor shall, on a monthly basis, submit the APM non-TED voucher, and supporting documentation electronically, citing the current fiscal year CLIN/ASAP ID." What will happen when APMs span over multiple months and fiscal years – how should the APM be booked, invoiced to DHA? Especially in a disease related status or final outcome which could span months

The invoice shall cite the current fiscal year/CLIN in accordance with Section G.14.2. If the APM spans multiple months or fiscal years, the contractor shall plan for the payments to be paid such that they do not exceed the established cap in the fiscal year of payment

791 APM Reporting G. Contract Administration Data

G.14.4 G.14.4. The Contractor shall break APMs into categories for the purposes of invoicing by individual provider. - What happens if there is a group of doctors providing care? For example, in a multi-specialty practice where the PCP is directing care across the group. How would you share the savings generated by the group, versus the individual provider?

The contractor may treat a group of providers with one tax ID is an individual provider for the purposes of APM payment and invoicing. The contractor would address the APM payment in its APM proposal in accordance with TRM Chapter 18, Section 1.

792 Special Cost Categories

G. Contract Administration Data

G.14.5 There are certain APM arrangements that would include risk and are aligned to administrative activities (i.e. follow up appointment PGs, return of clinical data, member satisifaction) . If a provider is unsuccessful in meeting the administrative requirement, they would not receive a bonus payment and therefore incur risk. In this section, should a 4th category be contemplated for this type of arrangement?

No. These would be APM Special Payment Cost Category 3, Non-risk based payments.

793 Non Risk Bonus Payments

G. Contract Administration Data

L.8.5 DHA is requesting bidders to submit what they anticipate for level of bonus payments they intend to distribute / incur. As bidders have not engaged with TRICARE providers to vet the various APMs, bidders would need to provide a best estimate / guess on the bonus dollars - especially in OP5 and beyond when a higher level of APM dollars are required. How will DHA balance the situation where a bidder could submit $0 bonus payments to receive a more favorable TEP versus those providers who bid the $30M and negatively impact their TEP?

The Government will assess the offeror's strategy to meet the requirements of Section H.18. under paragraph Section M.7.2.4.7. The relative importance of the Technical/Risk factor as compared to the Price/Cost factor is addressed in Section M.4.

794 Non Risk Bonus Payments

L.8. Volume IV, Price/Cost Organization/Instru ctions

L.8.5 Non-risk Bonus payments can be used to help providers enter into risk sharing arrangements by offering them dollars to invest in the required infrastructure. DHA offsetting the guaranteed discount with bonus payments will dissuade bidders to work with certain provider categories and help them enter into APMs such as a shared savings arrangement. Please note this approach could have unintended consequences

DHA understands the risk, however, the offset is intended to evaluate the price of the proposal fairly.

795 Category 2 APMs

H.18 Alternative Payment Models

In certain payer-provider APMs (Medicare Advantage), the product is designed specifically to address local providers. As the amount of APMs is intended to increase, would DHA consider additional TRICARE plan designs intended for APMs?

TRICARE plan designs are statutory. However, DHA may consider future demonstrations that may be pursued under statutory constraints.

796 PPQs L.7. Volume III, Past Performance Information

L.7.6 Please confirm that an offeror's reference needs only to submit a single copy of a PPQ and that PPQ will apply to the evaluation of both the East and West region proposals.

A reference may submit a single copy of a PPQ as long as the narrative of each proposal (Section L.7.3.) provides the Government information to the same PPQ.

Final RFP Questions and Government Responses

Question Number Reference

Contract/Manual Location Subsection

Question Rationale Government Response

797 Non Risk Bonus Payments

L.8. Volume IV, Price/Cost Organization/Instru ctions

L.8.5 The application of the $30M non-bonus cap, forces bidders to select between maintaining their guaranteed discount or entering into APMs, especially category 2 APMs (as all category 2 bonus payments are considered a non-risk payment). This trade-off in conjunction with uncertainty of provider's entering into APMs could skew bidder's thinking and consistency on how to populate the non-bonus cap. Would DHA consider a Government plug-in figure that all bidders must populate their L-5 template to level the TEP evaluation?

Post award, DHA can issue a change order annually that provides guidance on the amount of non-bonus payments that can be leveraged; this change order would reflect the known and actual amount of APMs and which category the APMs should be considered .

The contract does not require bidders to enter into APM non-risk bonus payment arrangements. The TEP was updated to include the cap in order to ensure that the APM non-risk bonus payments plus healthcare would not exceed CMAC in the aggregate.

798 Category 2 APMs

H.18 Alternative Payment Models

The current application of the non-bonus payment dissuades bidders from entering into category 2 APMs (as all payments would decay the guaranteed discount). What would be DHA's perspective on bidders who do not propose nor enter into category 2 APMs?

Offerors are not required to propose Category 2 APMs to meet the RFP's Section H.18 requirements. The Offeror's approach to APM's will be evaluated pursuant to Section M,

7.2.4.6 and 7.2.4.7.

799 Government Directed APMs

H.18 Alternative Payment Models

What is the current amount of non-risk bonus payments involving Government Directed APMs? What is projected in the life of the contract?

The non-risk bonus payments involving Government Directed APMs are limited to demonstration projects. At this time the total amount of non-risk bonus payments is $1.16 million for PBMP incentives in the current option periods of T-2017. No non-risk-based payments for HVBP have been paid.

800 Government Directed APMs

H.18 Alternative Payment Models

In a previous Q&A, DHA indicated there is no penalty / reduced award fee if the amount of APMs were not achieved. If that is the case, and now that non-risk bonus payments increases the bidder's price and decays the guaranteed discount, then under limited circumstances would a bidder ever use category 2 APMs and more generally non-risk bonus payments. This unintended action could reduce the introduction of the new types of providers into TRICARE-based APMs, as for some practices category 2 is the starting point to allow providers to get a sense of the population, care delivery trends and reimbursement risk.

The combination of these factors could impair the APM strategies DHA is undertaking, and as a result would DHA consider eliminating the cap, or providing the bidders a plug-in figure?

Question 88: With the removal of the award fee being linked to the percentage of APMs, is there any remaining positive incentive for achieving the targets listed in table H.18? Additionally, can the Government confirm if the "Acceptable Quality Level" column in this table refers to the minimum APM percentages required, or something else?

No, there is no positive incentive for achieving targets listed. Yes, the acceptable quality level column threshold is the minimum acceptable.

No, DHA is concerned that some bidders may not want a plug in figure that would require network discount guarantees. DHA entered the $30M cap into the spreadsheet and afforded the opportunity for bidders to propose a lesser amount at their discretion.

801 Attachment L- 5w

Price Evaluation Template West Region

T-5 RFP Attachment L-5w (Excel doc.) Price Evaluation Template West Region – Amendment 0003, tab Section B was not updated to include the Total APM Payment Cap. As a result, the values for the APM Payment Cap are input solely on the tab Total Evaluated Price (TEP) and results in a mathematical variance between:

• cell L29 titled Total Evaluated Price as it appears on tab differs between tab Total Evaluated Price (TEP) and

• cell G151 on tab Section B which is also titled Total Evaluated Price

Please confirm this is correct

As stated in Section L.8.5., the proposed cap will be added to the Offeror's proposed Underwritten Healthcare Cost in the calculation of the Total Evaluated Price. The cap is not a CLIN and therefore not aligned to Section B. See Question #780.