HT9402-23-R-0001 Request for Proposal (RFP) Conformed Amendment 0001 10092023.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE PAGE OF PAGES

1 2

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

10/09/2023

4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicable)

6. ISSUED BY CODE HT9402 7. ADMINISTERED BY (If other than Item 6) CODE

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code) (x) 9A. AMENDMENT OF SOLICITATION NO.

HT940223R0001

x 9B. DATED (SEE ITEM 11)

07/12/2023

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

x The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, X is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

Items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

Changes incorporated herein are described in the Summary of Changes on the continuation page of this amendment. This amendment is in response to questions submitted since issuance of the RFP and other identified administrative changes. Offerors are requested to acknowledge receipt of all amendments hereto upon submission of proposal as explained in Block 11.

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

MARCUS R. WEBB 303-676-3451

MARCUS.R.WEBB.CIV@HEALTH.MIL

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

16C. DATE SIGNED

NSN 7540-01-152-8070

Previous edition unusable

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

mailto:MARCUS.R.WEBB.CIV@HEALTH.MIL

A. Changes incorporated herein are described in the Summary of Changes on the continuation pages of this amendment. This amendment is in response to questions submitted since issuance of the RFP and other identified administrative changes. The conforming actions described in this amendment does not relieve the Offeror of the requirement to acknowledge receipt of each amendment issued in accordance with instructions in item 11 above as indicated in Block 14 of the SF 33, Solicitation, Offer and Award.

B. Summary of Changes:

Document Section/Paragraph

Change/Revision

RFP Section H Deleted Section H.1.

RFP Section J Updated title of the J-17.

CDRL A170 Revised in its entirety.

Attachments J-17 DRAFT TOM Chapter 18

Revision 1:

TRICARE Operations Manual Chapter 8 Section 2:

Added the Competitive Plans Demonstration to the parens with TPharm, TOP and TMEP in paragraph 7.1.

TRICARE Operations Manual Chapter 18 Section 10:

Added paragraph 5.7.3: Clarifies that “All other claims will be rejected by DHA by using edits in the TRICARE Encounter Data System.”

Added paragraph 5.7.4: Clarifies that “The contractor shall use HCDP XXXX for identification and jurisdiction of CPD claims.”

Updated the standard in paragraph 10.5.9.2 from 97% to 95%.

C. The solicitation is amended to reflect changes described herein; solicitation sections, attachments, CDRLs, and TRICARE Manuals are provided as reflected on beta.sam.gov. Changed areas are indicated by a vertical line in the left margin or tracked changes text, with the exception of the updated attachments and CDRLs, which were replaced in their entirety.

HT9402-23-R-0001 2 of 2 Amendment 0001

SOLICITATION, OFFER AND AWARD

1. THIS CONTRACT IS A RATED

ORDER UNDER DPAS (15 CFR 700)

RATING PAGE OF PAGES

1 128

2. CONTRACT NUMBER 3. SOLICITATION NUMBER

HT9402-23-R-0001

4. TYPE OF SOLICITATION

SEALED BID (IFB)

X NEGOTIATED (RFP)

5. DATE ISSUED

7/12/2023

6. REQUISITION/PURCHASE NUMBER

7. ISSUED BY CODE HT9402 8. ADDRESS OFFER TO (If other than Item 7)

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

SOLICITATION

9. Sealed offers in original and copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the depository located in until 1200 PM MST local time (Hour)

12/11/2023 (Date)

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

10. FOR

INFORMATION

CALL:

A. NAME

Marcus R. Webb

B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS

marcus.r.webb.civ@health.mil AREA CODE

NUMBER

676-3451

EXT.

11. TABLE OF CONTENTS

(X) SEC. DESCRIPTION PAGE(S) (X) SEC. DESCRIPTION PAGE(S)

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

A SOLICITATION/CONTRACT FORM X I CONTRACT CLAUSES

X B SUPPLIES OR SERVICES AND PRICES/COSTS PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

X C DESCRIPTION/SPECS./WORK STATEMENT X J LIST OF ATTACHMENTS

X D PACKAGING AND MARKING PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE

X K REPRESENTATIONS, CERTIFICATIONS AND

OTHER STATEMENTS OF OFFERORS X F DELIVERIES OR PERFORMANCE

X G CONTRACT ADMINISTRATION DATA L INSTRS., CONDS., AND NOTICES TO OFFERORS

H SPECIAL CONTRACT REQUIREMENTS M EVALUATION FACTORS FOR AWARD

OFFER (Must be fully completed by offeror) NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

12. In compliance with the above, the undersigned agrees, if this offer is accepted within calendar days (60 calendar days unless a different period is inserted by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the designated point(s), within the time specified in the schedule.

AWARD (To be completed by government)

19. ACCEPTED AS TO ITEMS NUMBERED 20. AMOUNT 21. ACCOUNTING AND APPROPRIATION

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

10 U.S.C. 2304 (c) ( ) 41 U.S.C. 253 (c) ( )

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

(4 copies unless otherwise specified)

ITEM

24. ADMINISTERED BY (If other than Item 7) CODE 25. PAYMENT WILL BE MADE BY CODE

26. NAME OF CONTRACTING OFFICER (Type or print)

Marcus R. Webb 303-676-3451 marcus.r.webb.civ@health.mil

27. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

28. AWARD DATE

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97) Prescribed by GSA - FAR (48 CFR) 53.214(c)

13. DISCOUNT FOR PROMPT PAYMENT

(See Section I, Clause No. 52.232.8)

10 CALENDAR DAYS (%) 20 CALENDAR DAYS (%) 30 CALENDAR DAYS (%) CALENDAR DAYS (%)

14. ACKNOWLEDGEMENT OF AMENDMENTS

(The offeror acknowledges receipt of amendments to the SOLICITATION for offerors and related documents numbered and dated):

AMENDMENT NO. DATE AMENDMENT NO. DATE

15A. NAME

AND

ADDRESS

OF

OFFEROR

CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER

(Type or print)

15B. TELEPHONE NUMBER 15C. CHECK IF REMITTANCE ADDRESS

IS DIFFERENT FROM ABOVE - ENTER

SUCH ADDRESS IN SCHEDULE.

17. SIGNATURE 18. OFFER DATE

AREA CODE NUMBER EXT.

X PAGE 1

PAGES 2-6

PAGES 7-26

PAGES 29-33

PAGES 34-47

PAGES 57-72

PAGES 73-74

PAGES 48-56

PAGES 75-88

PAGES 89-115

PAGES 116-128

X

X

X mailto:marcus.r.webb.civ@health.mil mailto:marcus.r.webb.civ@health.mil

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HT9402-23-R-0001 Page C1 of C20 Section C

SECTION C

COMPETITIVE PLANS DEMONSTRATION

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

C.1. SCOPE:

The purpose of this contract is to provide Managed Care Support (MCS) to the Department of Defense TRICARE program. The Competitive Plans Demonstration (CPD) contractor shall provide comprehensive health, medical, and administrative support services through a managed care plan (the TRICARE Prime uniform benefit) to eligible TRICARE beneficiaries.

There are two categories of outcome-based statements in this contract: Objectives and Technical Requirements (also provided in the documents). The objectives represent the overall outcomes required and are supported by the technical requirements. These requirements represent specific outcomes, tasks, and/or standards that shall be achieved.

CPD sites are listed in Section J, Attachment J-2 Atlanta Heat Map, J-3 Tampa Heat Map.

C.2. DOCUMENTS

The following documents are hereby incorporated by reference and form an integral part of this contract—except to the extent that the contract elsewhere (see Attachment J-9) provides exceptions to the applicability of such documents. Documentation incorporated into this contract by reference shall have the same force and effect as if set forth in full text for those chapters and sections that are identified herein:

• Title 10, United States Code, Chapter 55

• 42 Code of Federal Regulations (CFR), Part 422, section 2430

• 32 CFR, Part 199. The following sections apply to this contract: 199.2, 199.4, 199.6, 199.7, 199.8, 199.9, 199.10, 199.11, 199.12, and 199.17

• Privacy Act of 1974, as amended, 5 U.S.C. 552a

• Health Insurance Portability and Accountability Act (HIPAA) of 1996, Pub. L. No. 104-191

• Department of Defense Instruction (DoDI) 5200.02, “DoD Personnel Security Program (PSP),”

March 21, 2014 (as amended)

• DoDI 5400.11, "DoD Privacy and Civil Liberties Program," January 29, 2018 (as amended)

• DoDI 8582.01, "Security of Non-DoD Information Systems Processing Unclassified Nonpublic

DoD Information," December 9, 201

• DoDI 8580.02, "Security of Individually Identifiable Health Information in DoD Health Care

Programs," August 12, 2015

• TRICARE Policy Manual (TPM) 6010.63-M, April 2021, Change 5001

• TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021, Change 5002

• TRICARE Systems Manual (TSM) 7950.43M, April 2021, Change 5003

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021, Change 5005

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021, Change 5005, Chapter 18, Section 10.

HT9402-23-R-0001 Page C2 of C20 Section C

The TRICARE manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated Federal statutes and regulations and may not be interpreted in contradiction thereto. Among the manuals the TRICARE Policy Manual takes precedence over the other three TRICARE manuals. The TRICARE Reimbursement Manual takes precedence over the TRICARE Systems Manual and the TRICARE Operations Manual.

The TRICARE Systems Manual takes precedence over the TRICARE Operations Manual.

C.2.1. MANUAL UPDATES:

DHA periodically incorporates changes related to healthcare policy, systems, and operations in the corresponding manuals. The CPD contractor shall subscribe to a mailing list that provides the latest manual updates and revisions through the TRICARE manuals website:

https://manuals.health.mil.

Manual changes will be incorporated in the contract by revising paragraph C.2. DOCUMENTS and TRICARE Manual Exceptions Table (Attachment J-9) with a supplemental (bilateral) modification, regardless of applicability. Prior to preparing the proposed modification, DHA’s TRICARE Health Plan Office will issue drafts of the proposed manual changes to the CPD contractor, identifying the applicability and allowing the CPD contractor to provide comments or questions on drafts. The Contracting Officer (CO) will provide modifications to the CPD contractor within thirty (30) days following the issuance of the manual change or changes to which it relates.

C.3. DEFINITIONS:

Definitions in manuals, attachments, and/or exhibits are incorporated by reference.

C.4. GOVERNMENT-FURNISHED PROPERTY AND SERVICES:

There is no Government-Furnished Property and Services under this contract.

C.4.1. Government-Furnished Information

C.4.1.1. The US Family Health Plan Data Integrator Contractor will execute an optional CLIN to implement the Eligibility, Enrollment, and Encounter (EEE) Pilot. The EEE Pilot requirements are included as attachment J-15 and correlate to the conceptual workflow charts, see attachment J-16.

The Data Integrator contract data dictionary and reporting specifications are attachments J-11 and J-12, respectively. The Government is providing the CPD and EEE Pilot requirements and workflow charts in Section J for informational purposes only and may be subject to continuous change throughout the life of the contract.

C.5. CONTRACTOR-FURNISHED ITEMS:

The CPD contractor shall furnish all items necessary for the satisfactory performance of this contract.

https://manuals.health.mil/

HT9402-23-R-0001 Page C3 of C20 Section C

C.6. OBJECTIVES:

The overarching CPD program goals are to observe the effect of competition between overlapping networks; test a risk adjusted capitation payment method; and test systems interfaces and interoperability between DoD systems, the EEE Pilot contractor, and the CPD contractor. The CPD contractor shall provide comprehensive health care services to all eligible CPD enrollees for which the CPD contractor will receive a monthly capitation payment. Health care services for the CPD program are defined in 32 CFR 199; the services provided are known as the TRICARE Prime option. The key objectives included in this contract are as follows:

C.6.1. SPECIFIED OBJECTIVES:

C.6.1.1. Objective 1: Manage Per Capita Cost: Create value by focusing on quality, eliminating waste, and reducing unwarranted variation; considering the total cost of care over time, not just the cost of an individual health care activity.

C.6.1.2. Objective 2: Ensure Beneficiary Satisfaction at the highest level possible through the delivery of world-class health care as well as customer-friendly program services.

C.6.1.3. Objective 3: Implement programs that include patient safety, population management of disease and continued administration of these performance outcomes during the contract period of performance.

C.6.1.4. Objective 4: Conduct a seamless Transition--In period to ensure system interfaces and processes of care are operationalized and fully functional in a timely manner to support the 2025 Open Enrollment Season.

C.6.1.5. Objective 5: Support the Government's analysis and evaluation of this demonstration via the collection and reporting of performance, quality, cost, and beneficiary satisfaction data.

6.2. PERFORMANCE CRITERIA

The CPD contractor’s performance during the life of the resulting contract will be evaluated by criteria as follows:

C.6.2.1. Network Requirements: Maintain an adequate provider network in accordance with all contract requirements throughout the contract performance period.

C.6.2.2. Marketing: Market the CPD benefit to beneficiaries within the designated service area as stated in the contract and manuals.

C.6.2.3. Enrollment: Process enrollment actions as stated in Paragraph 7.3. Streamline enrollment processes which improve the beneficiary experience and facilitates the implementation and use of the EEE Pilot capabilities.

HT9402-23-R-0001 Page C4 of C20 Section C

C.6.2.4. Customer Services: Provide highest level of beneficiary satisfaction as measured by surveys: conducted by contractors and/or Government.

C.6.2.5. Medical Management: Submit complete and accurate clinical data as required. Implement innovative performance programs during the base period and option periods of the contract, to include patient safety and population management of disease.

C.6.2.6. Clinical Quality Management: Provide clinical quality and population health management data to be measured by the annual quality site visits.

C.6.2.7. Claims: Accurately process claims consistent with the requirements outlined in Paragraph

7.7. Claims.

C.6.2.8. Management and Administration: Provide qualified staff to meet all requirements of the contract and maintain contractor accessibility to the DHA through the CO and the Contracting Officer’s Representative (COR).

C.6.2.9. Perform Transition-in and out requirements that will be addressed in TOM Chapter 18, Section 10. For reporting requirements, see DD Form 1423-1, CDRL P110 and W040, located in Section F of the contract.

C.7. TECHNICAL REQUIREMENTS:

The CPD contractor must fulfill the technical requirements listed below in accomplishing the overall objectives of this contract.

The CPD contractor shall perform transition-in and out activities in accordance with the terms of TOM Chapter 18, Section 10. The transition in period will occur over a (12) twelve-month period.

C.7.1. PROVIDER NETWORK REQUIREMENTS:

The CPD contractor shall maintain a pre-existing managed, stable, high-quality preferred provider network of individual and institutional health care providers (see 32 CFR 199.17(p)) who produce high quality clinical outcomes.

C.7.1.1. The CPD contractor’s network shall be accredited by a nationally recognized accrediting organization at the start of health care delivery (SHCD) and such accreditation shall be maintained during all periods of contract performance. Network accreditation shall be from a national body that considers quality benchmarks for network management, provider credentialing, quality management and improvement, and consumer protection. When this contract and the accrediting body each have a standard for the same activity, the higher standard shall apply. For reporting requirements, see DD Form 1423-1, Contract Data Requirements List (CDRL) R020 and R070, located in Section F of the contract.

C.7.1.1.1. The CPD contractor shall ensure that all its network providers are Medicare participating providers (unless they are not eligible to be participating providers under Medicare).

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C.7.1.1.2. The CPD contractor shall ensure that the providers in its network are sufficient in number, mix, and geographic distribution to provide the full scope of benefits for which all CPD enrollees are eligible under this contract, as described in 32 CFR 199.4, and 199.17.

C.7.1.2. The CPD contractor shall submit a network plan detailing all components of its network, including the contractor's network sizing model and the formula(s) used to derive network specialty targets, by provider specialty in its geographic area of responsibility (Attachment J-1).

For plan details see DD Form 1423-1, CDRL P030, located in Section F of the contract.

C.7.1.3. The CPD contractor shall establish mechanisms to evaluate network providers using the quality metrics specified in the TOM Chapter 7, Section 6. The CPD contractor shall display meaningful quality metrics, at the individual provider and facility level, in an easily understood and accessible format on their website.

C.7.1.4. Beginning with the SHCD and throughout contract performance, the CPD contractor shall ensure that all provider networks established in the CPD contractor’s geographical service area (Attachment J-2 and J-3) meet the TRICARE beneficiary access standards (see 32 CFR 199.17(p)(5)). For reporting requirements, see DD Form 1423-1, CDRL Q070, located in Section F of the contract.

C.7.1.5. The CPD contractor shall develop and implement a system for continuously monitoring and evaluating network adequacy and for reporting network adequacy or access issues to the Government. For reporting requirements see DD Form 1423-1, CDRL M020, located in Section F of the contract.

C.7.1.6. The CPD contractor shall ensure that the standards for access, measured in terms of beneficiary travel time, appointment wait time, and office wait time for various categories of services contained in 32 CFR 199.17(p)(5), are met. These standards shall be met in a manner which achieves beneficiary satisfaction with access to network providers and services as set forth in the contract.

C.7.1.6.1. The CPD contractor shall monitor, and report monthly, all complaints by beneficiaries with respect to network adequacy or the availability of health care providers. For reporting requirements see DD Form 1423-1, CDRL M120, located in Section F of the contract.

C.7.1.7. The CPD contractor shall provide data validating access to care for beneficiaries in its geographical area to the Government and the EEE contractor. The CPD contractor shall utilize a geo-mapping tool to demonstrate access for primary and specialty care by ZIP Code in the geographical area (Attachment J-4). For reporting requirements, see DD Form 1423-1, CDRL S010 and M110, located in Section F of the contract.

C.7.1.8. The CPD contractor shall submit a plan for reporting on access to care for TRICARE beneficiaries. The contractor’s plan shall explain how the contractor will report access to care data for the contractor’s geographic area of responsibility (Attachment J-4). For plan reporting requirements see DD Form 1423-1, CDRL P100, located in Section F of the contract.

C.7.1.9. The CPD contractor shall develop and implement a system for continuously monitoring network appointment availability for all provider and facility types. The CPD contractor shall

HT9402-23-R-0001 Page C6 of C20 Section C assess appointment availability for each provider type in its network, at a minimum annually and otherwise as requested by the Government, to ensure beneficiary access to care. The CPD contractor shall report on how it measured appointment availability (e.g., by employing surveys).

For reporting requirements see DD Form 1423-1, CDRL A120, located in Section F of the contract.

C.7.1.10. The CPD contractor shall measure enrolled beneficiary access to telehealth services. For reporting requirements see DD Form 1423-1, CDRL Q030, located in Section F of the contract.

C.7.1.11. The CPD contractor shall inform the Government within 24 hours of obtaining information regarding any network inadequacy relative to its service area and shall submit a corrective action plan with each notice of an instance of network inadequacy. (Network inadequacy is defined as any failure to meet the access standards.) The CPD contractor shall respond to any inquiries from Government representatives (CO or COR) concerning network adequacy, including provider turnover information, within two business days of the day after receiving such an inquiry.

C.7.1.12. The CPD contractor shall ensure that all network providers who provide services and receive reimbursement under or in connection with this contract are authorized providers in accordance with the criteria set forth in 32 CFR 199.6. The CPD contractor shall obtain and maintain documentary evidence that each such provider meets the criteria set forth in 32 CFR 199.6, subject to the exceptions identified in the TPM, Chapter 11.

C.7.1.13. The CPD contractor shall ensure that no network provider requires payment from a beneficiary for any excluded or excludable service that the beneficiary received from a network provider (i.e., the beneficiary shall be held harmless) unless the beneficiary has been properly informed in writing (in an Explanation of Benefit (EOB) or waiver of liability form), that the services are excludable, and the provider has documentation that the beneficiary agreed in advance of receiving the services to pay for such services. Any such understanding to pay must be evidenced by written records. A beneficiary who is informed that care is potentially excludable and proceeds with receiving the potentially excludable service, shall not, merely by receiving such care, be deemed to have agreed to pay for such care. General agreements to pay, such as those signed by the beneficiary at the time of admission, are not evidence that the beneficiary knew that specific services he or she receives were excluded or excludable.

C.7.1.14. During the contract period of performance, the CPD Contractor shall ensure that written agreements with its network providers require that such providers participate in the CPD Contractor's Clinical Quality Management Program, as outlined in TOM Chapter 7, Section 6.

C.7.1.15. The CPD contractor shall ensure that its online network provider directory is accessible to users (i.e., beneficiaries, providers, partner contractors, and government stakeholders) at the SHCD and on a continual (24 hours a day/7 days a week) basis except for during scheduled downtime for system maintenance.

C.7.1.16. The CPD contractor shall not pay for non-covered services and supplies with CPD capitation dollars. Non-covered services and supplies include those that are not medically or

HT9402-23-R-0001 Page C7 of C20 Section C psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-childcare. Non-covered services also include those services that are specifically excluded from coverage by law or regulation. The CPD contractor shall ensure that both it and its network providers are familiar with the TRICARE coverage rules. See also Section H.10 on Value-Added Items and Services.

C.7.1.17. The CPD Contractor shall ensure that providers in its network do not bill enrolled beneficiaries for “activities that improve health care quality” as that term is defined in 42 CFR

422.2430 (also see Section G Paragraph 2.1.5 of this solicitation). Further, the CPD contractor shall not bill the Government for such activities.

C.7.2. MARKETING AND BENEFICIARY EDUCATION REQUIREMENTS:

C.7.2.1. The CPD contractor shall ensure that all of its marketing materials display the TRICARE logo and are approved by the DHA Communications Division, Falls Church, Virginia before being issued. Marketing materials include all written materials used to publicize, inform, educate, or otherwise influence reliant MHS beneficiaries. If the DHA Communications Division does not respond to a CPD contractor’s request for a marketing materials review within 30 days of receiving the marketing materials, then the marketing materials shall be deemed approved. This process will be coordinated with the assigned Contracting Officer Representative (COR).

C.7.2.2. The CPD contractor may market health plan services directly to eligible beneficiaries (see paragraphs C.7.3.4 – C.7.3.6 below regarding beneficiary eligibility).

C.7.2.3. The CPD contractor shall submit contractor-produced educational materials to DHA Communications at least 60 calendar days prior to publication for review and approval.

C.7.2.4. The CPD contractor shall provide to the EEE contractor the CPD website link and phone number to be included in beneficiary enrollment notifications.

C.7.2.5. The CPD contractor shall include links to TRICARE’s social media, web pages, and email subscriptions services in print and digital marketing and education materials during the annual TRICARE Open Season annual campaign that takes place from October through December each calendar year.

C.7.2.6. The CPD contractor shall use marketing toolkits provided by DHA Communications, including briefings, emails, and text messages when communication with beneficiaries during the annual TRICARE Open Season annual campaign that takes place from October through December each calendar year.

C.7.2.7. The CPD contractor shall comply with all other marketing and beneficiary education requirements as set forth in the TOM, Chapter 11, Section 6. For reporting requirements, see DD Form 1423-1, CDRL Q040, located in Section F of the contract.

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C.7.3. ENROLLMENT:

C.7.3.1. The CPD contractor shall provide benefit descriptions for the EEE Enrollment Exchange Portal to DHA for approval NLT 180 day prior to the SHCD. The CPD contractor shall comply with all other marketing and beneficiary education requirements as set forth in the TOM, Chapter 11, Section 6.

C.7.3.1.1. The CPD contractor may provide the benefit description information to the EEE contractor only after it has received approval to do so from the Government.

C.7.3.1.2. The CPD contractor shall submit updates to its benefit information to the Government on a quarterly basis.

C.7.3.2. The CPD contractor shall immediately accept and apply enrollment information from the EEE contractor to the CPD contractor beneficiary database.

C.7.3.3. The CPD contractors shall rely on the EEE contractor to relay eligibility and enrollment information from the Defense Enrollment Eligibility Reporting System (DEERS).

C.7.3.4. TRICARE Beneficiaries in the following categories, who reside within the designated CPD geographic boundaries, are eligible to enroll into the CPD:

• Active-Duty Family Members (ADFMs)

• ADFMs of Guard/Reserve sponsors on Active Duty

• Retirees/Retiree Family Members/Survivors who are not eligible for Medicare

• Non-TRICARE For Life (TFL)/Survivor Households

• Beneficiaries participating in the Transition Assistance Management Program (TAMP)

• Beneficiaries participating in the Transitional Compensation Program

C.7.3.5. Active-Duty Service Members (ADSMs), Guard/Reserve Service Members, and beneficiaries who are eligible for Medicare are not eligible to enroll into the CPD.

Beneficiaries participating in the following benefit programs are also not eligible to enroll into the CPD:

• TRICARE For Life (TFL)

• TRICARE Reserve Select (TRS)

• TRICARE Reserve Retired (TRR)

• TRICARE Young Adult (TYA)

C.7.3.6. Due to CPD program design and the Government’s desire to maintain beneficiary continuity of care, beneficiaries participating in or receiving benefits under the following special programs are not eligible to enroll into the CPD:

• Autism Care Demonstration (ACD)

• Extended Care Health Option (ECHO) Program

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• Wounded Warrior Program

• Continued Health Care Benefits Program

C.7.3.7. Following a beneficiary’s enrollment in the CPD, if the CPD contractor becomes aware of a disqualifying event in the beneficiary’s life (which may also constitute a Qualifying Life Event (QLE) (see TPM Chapter 10, Section 2.1, paragraph 2.5.2)), then the CPD contractor shall investigate and determine the validity of the disqualifying event. If the disqualifying event is valid, then the CPD contractor shall report the disqualifying event to the EEE contractor to initiate appropriate enrollment actions.

Disqualifying events include:

• Loss of TRICARE Prime eligibility

• Becoming eligible for Medicare

• Enrollment into a non-eligible benefit/special program listed in paragraph 7.3.6 above.

• Change of residence outside of designated demonstration geographic boundaries

C.7.4. CUSTOMER/MEMBER SERVICES:

C.7.4.1. The CPD contractor shall provide comprehensive readily accessible customer services for CPD enrolled beneficiaries and CPD network providers in accordance with the TOM, Chapter 11.

C.7.4.2. The CPD contractor shall provide outreach and communication consistent with those services offered to its (or its parent or affiliate organization’s) commercial customers.

Customer services shall be formatted to TRICARE specifications and include multiple, contemporary avenues of access (for example, email, World Wide Web, telephone, texting, smart phone applications, and social media) for CPD enrolled beneficiaries in accordance with the TOM, Chapter 11. Customer services shall be delivered in a manner that achieves the objectives of this contract without charge to beneficiaries or providers.

C.7.4.3. The CPD contractor shall establish accessible telephone services, toll-free or without long distance charges, for enrolled beneficiaries seeking information.

C.7.4.4. The CPD contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff that results in highly satisfied beneficiaries.

C.7.4.5. The CPD contractor shall provide a process for responding to all types of beneficiary inquiries (both routine and priority) that meets the timeliness and quality standards outlined in TOM Chapter 1, Section 3, paragraph 3.0.

C.7.4.6. The CPD contractor shall provide the Government multiple points of contact to address complaints and grievances received by the Government.

C.7.4.7. The CPD contractor shall encourage each health plan member and network providers to use Medline Plus® a web site developed and maintained by the U.S. National Library of Medicine (NLM) and the National Institutes of Health (NIH). This site provides health professionals and health plan members with information on diseases and conditions, clinical

HT9402-23-R-0001 Page C10 of C20 Section C trials, drugs, and the latest health information. The use of this site is not intended to be a substitute for health care information provided by the plan but may be used as resource to supplement the plan’s health care information. See, Medline Plus® site: http://medlineplus.gov.

C.7.4.8. The CPD contractor shall comply with all requirements related to TRICARE publications, social media, beneficiary outreach, website management, TRICARE branding, and media relations as described in the TOM, Chapter 11, Section 6.

C.7.4.9. The CPD contractor shall refer eligibility, enrollment, and enrollment billing inquiries to the EEE contractor and shall transfer phone calls on these topics to the EEE call center. For reporting requirements, see DD Form 1423-1, CDRL M130, located in Section F of the contract.

C.7.4.10. The CPD contractor shall establish a process with the EEE contractor and other TRICARE contractors for coordinating customer service calls on matters outside of the CPD contractor’s area of responsibility, to include triaging and defining call levels (routine, urgent, emergent).

C.7.5. CLINICAL MANAGEMENT:

C.7.5.1. Medical Management (MM)

C.7.5.1.1. The CPD Contractor shall develop, implement, and maintain a MM Program, that includes behavioral health, in accordance with the requirements in the TOM Chapter 7, as well as complies with the TRICARE benefits provisions of 32 CFR 199.4, and the TPM in order to provide health care for eligible beneficiaries to the extent authorized by law.

C.7.5.1.2. The CPD 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.

C.7.5.1.2.1. The CPD contractor shall obtain accreditation no later than 12 months after the SHCD and shall maintain such accreditation throughout the life of the contract, inclusive of all exercised option periods. National certification, in lieu of accreditation, is insufficient to meet this requirement.

C.7.5.1.2.2. The CPD contractor shall submit letters of accreditation and re-accreditation and supporting documentation to the Government within 5 business days of receipt of the documents from the accrediting organization.

C.7.5.1.3. The CPD contractor shall develop, implement, and maintain an electronic MM data system that complies with the TOM, Chapter 7, Sections 1, 2 and 3.

C.7.5.1.4. The CPD contractor shall use predictive analytics in the operation of its MM program (as described in the TOM Chapter 7, Section 1, Paragraph 5), which are designed to support and http://medlineplus.gov/

HT9402-23-R-0001 Page C11 of C20 Section C manage the health care of individuals with high-cost conditions and complex medical conditions, inpatient admissions and discharges, pharmacy (specialty drugs, multiple medications, or pharmacies), and beneficiaries receiving low quality care. For reporting requirements, see DD Form 1423-1, CDRL M070, located in Section F of the contract.

C.7.5.1.5. The CPD contractor, in order to provide the operations described in paragraph C.7.5.1.4, shall establish a beneficiary-centric data warehouse (for data pertaining to CPD enrolled beneficiaries) and employ industry best practice analytic tools/systems to exhibit sophisticated data analysis techniques with evidence-based algorithms. The CPD contractor shall provide the Government with access to review all such data methods and analytical results.

C.7.5.1.5.1. The CPD contractor must determine whether algorithms it uses for case management, disease management, clinical quality management, or other decisions about which beneficiaries will receive additional services from the CPD contractor, contain or display inadvertent racial bias.

If any racial bias is identified, the CPD contractor shall take steps to eliminate that bias to the satisfaction of the Government. As part of determining whether any algorithms contain inadvertent racial bias and eliminating such bias, the CPD contractor shall work with the Government Designated Authority (GDA) to identify bias and the actions that can be taken to eliminate or mitigate bias.

C.7.5.1.6. The CPD contractor shall submit an annual strategy and reporting frequency to monitor Health Equity and Disparities. For reporting requirements, see DD Form 1423-1, CDRL P010, located in Section F.

C.7.5.2. Case Management (CM)

C.7.5.2.1. The CPD contractor shall operate programs designed to manage the health care of individuals with high-cost conditions (including but not limited to Maternity and Opioid Use Disorders) or with specific diseases for which proven clinical management programs exist. These programs shall be available to enrolled eligible beneficiaries. For reporting requirements, see DD Form 1423-1, CDRL P010, located in Section F of the contract.

C.7.5.2.2. The CPD contractor shall assist CPD enrolled beneficiaries who require benefits and services beyond those provided under TRICARE with accessing information about other DoD programs and applicable community/state/federal health care and related resources.

C.7.5.2.3. The CPD contractor shall ensure that case managers are trained in and demonstrate motivational interviewing skills and knowledge of trauma-informed care.

C.7.5.2.4. The CPD contractor shall provide a transfer of beneficiary enrollment to the regional MCS contractor for beneficiary services not specifically offered under the demonstration (see paragraph C.7.3.7).

C.7.5.2.4.1. The CPD contractor, within three (3) business days of a beneficiary request, shall notify the EEE contractor of the beneficiary’s request to participate in the ACD, for enrollment processing. A CPD enrollee’s enrollment in the ACD will be considered a QLE (as of the ACD

HT9402-23-R-0001 Page C12 of C20 Section C enrollment date), and family members of the beneficiary enrolling in the ACD may also at that time choose to disenroll from the CPD and enroll in any other TRICARE health plan for which they are otherwise eligible.

C.7.5.2.4.2. The CPD contractor, within three (3) business days of a beneficiary request to receive services under the TRICARE ECHO program, shall provide enrollment handoff for that beneficiary.

C.7.5.2.5. The CPD contractor shall encourage its network providers to deliver case management activities, including but not limited to universal screening of Post-Traumatic Stress Disorder (PTSD), Anxiety Disorders, and Depression through the use of standardized clinical tools.

C.7.5.2.6. The CPD Contractor shall develop, implement, and maintain a CM program that complies with TOM Chapter 7, Section 2.

C.7.5.3. Population Health (PH)

C.7.5.3.1. The CPD contractor shall develop, implement, and maintain integrated, whole person PH care within the constraints (relating to TRICARE coverage and payment rules), boundaries, and benefits of the current TRICARE program and in accordance with the TOM Chapter 7, Section 3. For reporting requirements, see DD Form 1423-1, CDRL A080, located in Section F of the contract.

C.7.5.3.2. The CPD contractor’s data system shall have sufficient IT infrastructure and data analytics capacity to support the CPD contractor’s vision and goals for providing quality improvement, measurement, and evaluation, including the capability to: a) Identify service access, utilization, health outcomes, intervention effectiveness, social risk factors, and survey (e.g., CAHPS) results by beneficiary characteristics including race, ethnicity and language, and disability; b) Employ advanced analytic methods such as hot spotting and predictive analytics and modeling to improve the identification of beneficiaries and their communities disproportionately impacted by, or at risk for, poor health outcomes and social risk factors; and c) Support the monitoring and comparison of process and outcome measures over time to inform disparity reduction efforts.

C.7.5.3.3. The CPD contractor shall incorporate Chronic Care/Disease Management (CC/DM) conditions into its PH care.

C.7.5.3.4. The CPD contractor shall collaborate annually with the GDA to identify targeted diseases.

C.7.5.4. Utilization Management (UM)

C.7.5.4.1. The CPD contractor shall ensure that care provided, including mental health care, is reviewed for medical necessity (if applicable), is appropriately authorized, and complies with the TRICARE benefits contained in 32 CFR 199.4 and the TPM.

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C.7.5.4.1.1. The CPD contractor shall use best practices in reviewing and approving care and establishing medical management programs to carry out this activity to the extent authorized by law.

C.7.5.4.1.2. The CPD contractor shall comply with the provisions of 32 CFR 199.4 and the TPM regarding review and approval of mental health services, notwithstanding the CPD contractor’s authority to utilize its best practices in managing, reviewing and authorizing health care services.

C.7.5.4.2. The CPD contractor shall apply its UM practices for all eligible enrolled beneficiaries in a manner consistent with TOM Chapter 7, Section 4. For reporting requirements, see DD Form 1423-1, CDRL M080, located in Section F of the contract.

C.7.5.5. Referral Management (RM)

C.7.5.5.1. The CPD contractor shall maintain a RM Program in accordance with TOM, Chapter 7, Section 5, subject to the exceptions listed in the CPD Manuals Exception Table (TOM Chapter 18, Section 10, Addendum E). For reporting requirements, see DD Form 1423-1, CDRL Q020 and M060, located in Section F of the contract.

C.7.5.5.2. Except as provided below, CPD enrollees are locked out of the direct care (military medical treatment facilities (MTFs)) system for health care services.

C.7.5.5.2.1. Under the TRICARE Pharmacy (TPharm) contract, CPD enrollees are authorized to access the pharmacy benefit through an MTF.

C.7.5.5.2.2. CPD enrollees may access MTFs for emergency services, for which the CPD contractor will be responsible for reimbursing the MTF.

C.7.5.5.3. An enrollee’s violation of the direct care system/MTF lockouts could result in disenrollment of such enrollee.

C.7.5.6. Clinical Quality Management (CQM)

C.7.5.6.1. The CPD contractor shall develop, implement, and maintain a CQM and Patient Safety Program in accordance with the TOM, Chapter 7, Section 6. For reporting requirements, see DD Form 1423-1, CDRL A010, M040, P020, R010 and S030, located in Section F of the contract.

C.7.5.6.2. The CPD contractor shall have a provider credentialing program that complies with the requirements in the TOM Chapter 4, Section 1. When this contract and the accrediting organization have differing credentialing standards for the same activity, the CPD contractor shall use the higher standard in performance of this contract.

C.7.5.6.3. The CPD contractor shall develop a data management strategy under which it shall collect and process all data necessary to produce the metrics identified in Attachment J-5, Clinical Quality Metrics, in accordance with the requirements of the TOM, Chapter 7, Section 3, Para 2.2.1 and the CPDs PH care strategy. The Government reserves the right to update Attachment J-5 in

HT9402-23-R-0001 Page C14 of C20 Section C accordance with FAR 52.243-1, Alternate 1. For reporting requirements, see DD Form 1423-1, CDRL Q010, Q050 and S020 located in Section F of the contract.

C.7.5.7. Coordination with the TRICARE Quality Monitoring Contract (TQMC) Contractor

C.7.5.7.1. The CPD contractor shall comply with the provisions of the TOM, Chapter 7, Section 7 regarding coordination and interaction with the TQMC contractor(s). For reporting requirements, see DD Form 1423-1, CDRL Q060 and M050, located in Section F of the contract.

C.7.5.8. Telehealth

C.7.5.8.1. The CPD contractor shall develop a telehealth program that maximizes the availability of telehealth throughout its provider networks and facilitates…