HT940221RFI00093 Concepts of Operations and Questions.docx

HT940221RFI0093

Request for Information TRICARE Dental Program 6 (TDP6) Draft Concepts of Operations and Questions

The DHA is considering two different concepts for its sixth generation TDP contract. The first concept is a traditional “winner-take-all” competition where the Agency develops requirements for TDP6 which include dental care functions (provider networks and claims processing) while also providing all program support functions including eligibility verification, enrollment, enrollee dental premium collection, refund/recovery of overpayment of premiums resulting from active duty status change, and provide related customer service functions. The TDP contractor must have the capability to interface with DHA systems, Defense Enrollment Eligibility System (DEERS), Government finance centers, and commercial banks. The TDP6 contractor would propose requirements that meet and/or exceed the Government’s minimum requirements and set premiums for single plans and family plans. Proposed premiums would be the same for each plan worldwide (i.e., a single plan would cost the same whether in Alaska or Germany). Premium amounts are subsidized by DHA. The percentage paid by the beneficiary varies from 0% to 100% depending on whether their status is an active duty family member, Reserve family member, Reserve/National Guard member, or a survivor. The TDP6 contractor is required to have a mechanism/system that allows the tracking of all premiums collected and disbursed, including retroactive payments and collections for Government audit purposes.

The second concept under consideration is a multiple award scenario where capable vendors would provide a plan meeting minimum Government requirements and agree to work with a Government intermediary contractor for enrollment and premium payment/recovery responsibilities which the Government believes would alleviate significant administrative burden and increase competition. Under this concept, the vendors would propose requirements that meet and/or exceed the Government’s minimum requirements and set premiums for single plans and family plans. Proposed premiums would be the same for each plan worldwide (i.e., a single plan would cost the same whether in Alaska or Germany). The Government intermediary contractor would be responsible for verifying beneficiary eligibility utilizing DEERS, and collecting the beneficiaries’ applicable share of the premiums via various Government finance or payroll centers, electronic fund transfers (EFTs), or credit card. The premium amounts will vary based on the vendor and the plan (i.e. single or family plan) selected by the beneficiary. As currently envisioned, the vendors will supply the Government intermediary contractor with a report of enrollments and the premium amount to be collected. Premium amounts are subsidized by DHA. The percentage paid by the beneficiary varies from 0% to 100% depending on whether their status is an active duty family member, Reserve family member, Reserve/National Guard member, or a survivor. The Government intermediary contractor will be responsible for collection of the applicable premium amount from the beneficiary and DHA for its share of the premium. The Government intermediary contractor shall have a mechanism/system that allows the tracking of all premiums collected and disbursed, including retroactive payments and collections for Government audit purposes.

For an understanding of DEERS and Government finance center requirements, industry may view current TDP requirements in the TRICARE Systems Manual (TSM) 7950.3-M, April 1, 2015 at http://manuals.health.mil. The following TSM chapters apply:

· Chapter 1, General Automated Data Processing (ADP) Requirements

· Chapter 3, Defense Enrollment Eligibility Reporting System (DEERS) (Section 5.2 does not apply to TDP) DHA is looking for innovative approaches to dental health, incorporating a variety of industry practices to improve quality, contain costs, enhance access, provide greater beneficiary satisfaction, and enable greater readiness. In the development of these proposed requirements, DHA is requesting the following information from industry.

1. To meet the objective of better price/value to the Government and beneficiaries and better service to the beneficiaries, would a single award (as done presently) or multiple award contracts allow for competition to best meet the objective?

2. What are industry concerns about operating with an intermediary contractor?

3. What are industry concerns if the intermediary contractor also provides claims processing?

4. If an intermediary contractor is utilized, would that affect your transition-in timeline? If so, would you require more than a 12-month transition-in period? What would be the obstacles in transitioning with an intermediary contractor?

5. The TDP population is very mobile due to their sponsor’s duty assignments. How would industry process retroactive changes for premiums and claims between vendors when a sponsor does not timely update their active duty status, address, or family members? Does industry follow the ‘good faith payment’ for these situations? Does industry reimburse the enrollee when the enrollee has overpaid premiums due to their own mistake?

6. As DHA strives for better health, what incentives could be provided to the beneficiaries to exhibit favorable behaviors?

7. One idea to incentivize enrollees to receive preventive services (which is offered at no cost share to the enrollee) is to reduce all cost shares by 10% for other dental care when the enrollee has visited a dentist for cleanings once or twice a year. What impact would this initiative have on your dental programs and/or premiums?

8. One goal of a new TDP contract would be better outcomes. How would you identify higher quality providers (i.e. better outcomes, high-value dental care) to the beneficiaries?

9. One concern of beneficiaries is access to care. Some military bases are in remote locations with limited dental access, what could you offer to help these beneficiaries receive dental care?

10. Presently the Code of Federal Regulation (CFR) states for dental plan contractor liability that “When more than 25% or more than 200 enrollees in a specific 5 digit zip code are unable to obtain a periodic or initial (non-emergency) dentistry appointment within 35 miles of the enrollee’s place of residence, then will designate the area as ‘non-compliant.’” If CFR changes lower the dental plan contractor liability to improve access such that when more than 25 percent or more than 100 enrollees in specific 5 digit zip code are unable to obtain periodic or initial (non-emergency) dentistry appointment with a network provider within 21 calendar days and within 20 miles of enrollee’s place of residence, that area deemed non-compliant, would this increase premiums cost?

11. Another request of TDP beneficiaries is to lower costs, one option is to consider changing cost shares. How do the cost shares stated in table below compare with your other product lines (Government and commercial)? Do you recommend changing any of these costs? If so, please explain why.

12. DHA is considering a tiered approach for different size families. What differences would be in pricing between the present two-tiered (i.e. self and family) versus three-tiered of self, two family members (i.e. self+one), and three or more family members?

13. What flexibility in the plan requirements does industry require to keep the enrollee costs down?

14. DHA is considering offering Standard and High option plans. What methods does industry utilize for averaging a maximum amount the company/employer is responsible for? Explain the methodology. Are there other methods that may be viable for a Government program?

15. Presently TDP does not have open enrollment season like other TRICARE Medical contracts, how beneficial is it to have an open enrollment season? Is there a cost saving for enrollment any time versus an open enrollment season that allows for qualifying life event enrollments outside of open season?

16. DHA is interested in ways to improve access. Provider network adequacy is of paramount importance, not only to allow access to care, but to ensure better quality and improved beneficiary satisfaction. What network adequacy standards would industry propose to improve beneficiary satisfaction? What is the connection between network adequacy and quality?

17. Costs continue to rise in healthcare, and dental care is one area where there are greater potential controls on costs (starting with a very low maximum benefit relative to medical insurance). How effective are your utilization management services, and how would you suggest these services could benefit DHA? What kind of cost containment activities would industry recommend in addition to utilization management? What kind of new technologies has industry put into production that have given greater cost containment?

18. Dental plans are now competing more on cost and value, rather than network size, and DHA is interested in understanding the value a dental plan brings to our beneficiaries and to the DHA. How does industry define a high value dental plan product? Is ‘net effective discount” the best measure of value, or is there another metric industry recommends?

19. Customer experience has become paramount, as the consumer retail revolution is fueled by greater availability of data and information, proliferation of digital natives, and DHA is interested in capitalizing on these trends to improve beneficiary experience. How does industry measure and improve beneficiary satisfaction? What new tools or techniques do you use to improve customer experience, and how would you propose to not only measure but also manage and improve customer experience?

20. Customer experience has been shown to improve when dental care is easily accessible and timely, and DHA is interested in ways to improve access to care. How do you personalize oral health interventions? How have you incorporated telehealth into your dental plan, and what evidence do you have for improved customer experience, quality, or cost containment?

21. How do you measure dental quality? How do you demonstrate improvements in quality? What value-based programs have you launched?

22. How have you incorporated predictive analytics and/or artificial intelligence into your administrative or clinical services? What improvements have you seen from analytics and what is your analytics roadmap?

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HT9402-21-RFI-0093