FINAL Request for Proposal Questions 112123 Final Approved.pdf

HT9402‐23‐R0001 CPD, Final RFP Questions Question Government Response

1 What is the anticipated contract award date? The Government expects to award 2 contracts before the end FY24.

2 CDRL File A170 ‐ Financial Incentive for Quality of Care ‐ NCQA Audited Results (CPD) appears to be missing. The document provided for A170 is the same as Value‐Added Items Services for A180. Will the government provide an updated A170?

The Government has revised A170 and is provided under Amendment 0001.

3 For Volume III: PAST PERFORMANCE INFORMATION. After review of Sections L.4.3 and L.7, for clarity, we are seeking confirmation that Volume III can include up to 62‐pages total of 'PAST PERFORMANCE INFORMATION'.

Volume III of the Request for Proposal is limited to 50 pages total including references noted at L.7.3. The information provided under L.7.7. and L.7.8. do not count towards the page count illustrated at L.4.3.

4 An inconsistency was identified between sections M.10.2 and L.5.2 regarding AbilityOne small businesses. AbilityOne is not referenced specifically in section L.5.2 and it states contractors "may use the services...for the blind", however, AbilityOne is referenced specifically in the percentage goals listed in section M.10.2. Can the government confirm that AbilityOne small businesses are required to be included in the small business plan at the prescribed percentage target?

The overall Subcontracting goal is 25% to be derived from those subcontracting categories listed at M.10.2. Potential offerors should consider and pursue those goals to the maximum extent practical. Offerors will be evaluated on their subcontracting plan considering those groups, as described in M.10.2. Offerors should explain their rationale for not including any particular small business subcategory in their subcontracting plans, as applicable.

5 03033023 Government Responses to CPD DRAFT RFP 2, #354 states that CAS requirements would not be applicable to the effort; however, it appears a number of requirements and contract clauses applicable to CAS or cost reimbursable contracts remain (see e.g.Section I reference to FAR 52.230‐2 Cost Accounting Standards (JUN 2020), FAR 32.230‐6 Administration of Cost Accounting Standards (JUN 2010)). Can you clarify if this was intentional or if these will be removed?

The Government has re‐evaluated its position for CAS applicability due to CLIN X003. Because of the capitation rate recalculation process required during performance and the flexibility of pricing, CAS is applicable to the subsequent contract. The Government may seek a CAS waiver if it is in the best interest of the Government. Firms without existing, adequate CAS Disclosure Statements are not prohibited from submitting proposals.

6 Section L.9.4.1. requires the offeror to provide adequate documentation that its accounting system is capable of tracking and segregating cost data in sufficient detail to administer the contract. IAW FAR 16.301(a)(3), cost reimbursable contracts require this limitation, not fixed price contracts. Can you clarify if this expectation remains or will be removed? If it remains, would you confirm whether information provided under financial viability Section L.9 would suffice for this requirement (i.e., no additional information required)?

The information required under Section L.9 , Volume V, Financial, requires submission of information that speaks to the financial viability of the offeror and does not address the ability of the offeror to sufficiently segregate cost data. Section L.9.4.1. states, “The Offeror shall provide documentation that its accounting system is capable of tracking and segregating cost data in sufficient detail to administer the contract.” The offeror may provide evidence from, but not limited to, the Defense Contract Management Agency, Defense Contract Audit Agency or a Certified Public Accounting firm that its accounting system is capable of tracking and segregating cost data. The annual capitated rate adjustment, as outlined in G.2.3, updating the Originally Awarded Capitation Rates, will require the availability of such cost data.

7 Section I includes FAR 52.216‐7 Allowable Cost and Payment; however, IAW FAR 16.307, our understanding is that this clause should only be included in cost reimbursable contracts. Can you clarify if this was intentional or if it will be removed?

FAR 52.216‐7 will remain in the solicitation due to the nature of recalculations described with CLIN X003. The capitated rate recalculation process required during performance and the flexibility of pricing, CAS is applicable to the subsequent contract.

8 Is there a maximum penalty they can assess for non‐performance under section H.1.3.2 in the event of repeated missed PG assessments? It indicates $20,000 per occurrence, and defines occurrence, but doesn’t indicate if there is a limit to how many occurrences they can assess or the frequency of such assessments.

The Government has decided to remove the Customer Service performance guarantee from the RFP. Though there will not be a financial penalty associated with this area, the contractor is still expected to meet the 95% accuracy score before SHCD.

Assessments will begin 60 days before SHCD (during the PRAV) and will continue until the contractor achieves the 95% accuracy score. Once the 95% score is achieved, assessments will be performed periodically to ensure this level is maintained and the Customer Service specifications outlined in the TRICARE Operations Manual (TOM) and the Quality Assurance Surveillance Plan (QASP) are adhered to.

9 For the TOM, as it relates to CPDs, in Section 1, 6.0 “Finality of Initial Determination”. Please provide clarification on this term. The initial determination is final and binding unless the initial determination is reopened by the contractor or revised upon appeal.

This means the original initial determination is the end of the process unless the contractor independently reopens the claim (as in the discovery of an error after issuing the initial determination), or if the initial determination is changed during the appeals review process which can occur at the reconsideration level with the contractor, or as a result of DHA appeals issuing a Formal Review Decision which overturns the initial determination and reconsideration determination made by the contractor.

10 For the TOM, as it relates to CPDs, in Section 3, please clarify the highlight, is this referring to a par‐provider appealing on behalf of an enrollee? A participating provider may appeal on behalf of a beneficiary when there has been an appointment of representative form completed, which is where the beneficiary designates the participating provider as their representative. The rest of the section is to clarify that non‐network non‐participating providers may not utilize the appeals process, and that issues involving waiver of liability for non‐network non‐participating providers are treated as allowable charge reviews which are not subject to the appeals process.

11 We appreciate the detail provided in Attachments J‐9 and J‐17 relative to how the TRICARE manuals apply or do not apply to the delivery of the TRICARE benefit under CPD. We acknowledge these documents are currently in draft form. We respectfully request that DHA allow offerors to propose additional recommended changes to the manuals that would allow for a more cost‐effective and progressive CPD model designed to meet contract objectives.

DHA is open to receiving recommendations promoting cost savings, standardization, and efficiencies resulting in positive healthcare outcomes. Implementation of such recommendations must follow the current DHA internal processes which may not afford activation in this wave of the CPD effort.

12 As the annual premium is calculated inclusive of the variable administrative cost only, can DHA confirm that the 85% MLR is based on the premium that includes variable cost only (i.e., the fixed administrative cost is excluded from the MLR calculation)?

Both variable and fixed admin components of the premium would be included in the denominator used in the MLR calculation.

Attachments J‐13 and J‐13a specify that the ongoing fixed administrative costs (CLINs 1001, 2001, and 3001, and CLIN 9001 in the event of a contract extension) are included in the MLR calculation.

13 How will retroactive terminations that span multiple months be handled financially (where CPD was making claim payments)? This is an eligibility and enrollment issue related to capitated funds. There are a few different things that occur with terminations:

14 Who will the CPD contractor be transitioning to, and what information / data will be transitioned? Upon completion of the CPD contract requirements; Transition Out activities for the respective market will be yielded back to the cognizant TRICARE Managed Care Support Contract in that market. (i.e., East Region). Transition Out Activities are referenced in the TRICARE Operations Manual, Chapters 2 and 18.

HT9402-23-R-0001 CPD

15 Can DHA provide additional insights into how private sector care rates were identified/aggregated/calculated? Tab 1 in each of Exhibits L‐1A (Atlanta) and L‐2T (Tampa) presents the detailed steps and data values used to calculate the Government‐provided inputs to the preliminary capitation rates. With the exception of the two percentage "load" factors for Health Professional Shortage Area (HPSA) payments and for DRG capital and direct medical education (DME) costs (neither of which is present on TED claims data), all of the other private sector care data (and the direct care data) presented in steps 1 and 2 of the build‐up in these exhibits were tabulated from the RFP's historical data files that are available to offerors. Offerors can review the historical data package's documentation files (the MS Word files) that describe each of the data types (TEDs, direct care, etc.) and the specific fields that are provided in each data file. In the case of the private sector care TED costs and utilization used in steps 1 and 2 of the capitation build‐ups, Government‐estimated TED completion factors for incurred but not reported (IBNR) claims were applied to the raw TED tabulations to account for the estimated value of outstanding TED claims; these IBNR factors are also available in the RFP's historical data package. For the two percentage load factors for HPSA and DRG capital/DME, as noted in the exhibit the government calculated these two percentages using its available national data for these expenditures as a percentage of the relevant national TED costs described in the exhibit notes for the respective loading percentages.

16 Can DHA confirm MCSC discounts are factored into the capitation rates? Can DHA provide a range of the discounts for actuarial purposes? The government‐paid amounts for the historical TED data used in step 1 of the capitation build‐up do reflect the savings from any discounts achieved by the MCSC for those claims. DHA will not provide the range of such discounts. Offerors are free to use the TED‐level data provided in the historical data files to develop their own assessment of MCSC discounts reflected in the data.

17 When does the CPD bidder invoice DHA for the fixed price administrative cost? In Schedule B it shows it is monthly, but Section G does not confirm the payments / invoicing cyclle

The ongoing fixed‐price portion of administrative cost for CLINs 1001, 2001, 3001 (and 9001 in the event of a contract extension) shall be invoiced monthly.

18 Is the 85% MLR inclusive of risk adjustment payments? The risk‐adjusted capitation payments, including any catch‐up payments in either direction for the early incurred months of an option period, are included in the MLR calculation. Yes, the premium payment is risk‐adjusted; therefore, the 85% is inclusive of risk‐adjusted payments.

19 Knowing claim run will occur during transition out, should bidders include the cost of claim run out (claim, calls) in the transition out CLIN? An offeror should consider the extent to which its administrative expenses during the transition‐out period will have already been priced on an incurred basis in the offeror's proposed capitation rate and/or its proposed fixed‐price portion of ongoing administration costs (CLINs, 1001, 2001, 3001, 9001). To the extent an offeror anticipates transition‐out expenses that are not priced on an incurred basis in those other prices, then the offeror should include those other transition‐out expenses in its proposed price for transition‐out.

20 Medical history is important in the provision of high quality healthcare and required to properly execute the medical management requirements.

What medical history data will the awarded contractor receive on patients that enroll in CPD?

Attachment J‐18 List of Data Files Available for Atlanta, Tampa 06082023.

21 C.4.1.1 As written the RFP includes references to the TRICARE manuals including the claims processing, policy and reimbursement requirements which will require the CPD contractor to build and deploy a claims processing solution that is fully compliant with all TRICARE rules, regulations, and security requirements. One of the initial objectives behind the development and deployment of the EEE concept was to enable the EEE contractor to perform the functions that fall outside of commercial best practices and solutions so to minimize the cost, time for implementation. The requirements of the current RFP will result in redundant functionality between the CPD and EEE contractors. We encourage DHA to clarify CPD requirements to allow CPD contractors to deploy commercial best practices.

The EEE contractor will not be adjudicating or paying claims on behalf of the CPD contractor. The CPD contractor will be responsible for adjudicating and paying the claims for care provided to CPD enrollees. Recommendation acknowledged.

22 C.4.1.1. What company administers the EEE contract? MicroHealth LLC (Vienna, VA) was awarded the Data Integrator contract in August 2023. The EEE effort is an optional CLIN on that contract and will be administered by MicroHealth. The EEE effort has not been exercised yet.

23 We understand the adjudication of an encounter should result in no ($0.00) payment made to a provider who is under an Alternate Payment Method (APM). When processing such encounters, does the total Allowed Amount need to be calculated to determine what would have been paid if not for the APM? We assume the Paid Amount should be zero ($0.00) in the data sent to the EEE contractor, but should the total Allowed Amount be submitted as well?

There are different categories of alternative payment models that are possible under the CPD. Not all of these models will result in $0.00 payments. Depending on the type of APM and the specific provisions of that APM, an encounter record for care from an APM provider could include a real‐time payment based on that claim.

11/21/2023 Any questions regarding the information herein should be referred to the Contracting Officer, Marcus R. Webb @303‐676‐3451

HT9402-23-R-0001 CPD