NPNConsultantRFI_20240410.docx

WTC HEALTH PROGRAM

RFI 75D301-24-RFI-NPNCons

World Trade Center Health Program Request for Information

CDC WORLD TRADE CENTER (WTC) HEALTH PROGRAM NPN STRATEGY CONSULTANT

REQUEST FOR INFORMATION 75D301-24-RFI-NPNCons

RESPONSE DUE DATE:

5:00 pm Eastern Time, April 24, 2024 Restricted Use/All CDC Staff

Title: CDC World Trade Center (WTC) Nationwide Provider Network (NPN) Strategy Consultant

This Request for Information (RFI) is issued solely for information and planning purposes and is not a solicitation for proposals, proposal abstracts, or quotations. Release of this RFI shall not be construed as a commitment to procure items or services. Responses are not offers and cannot be accepted by the Government to form a binding contract. The Government will not pay for any information or administrative cost incurred in response to this RFI; all associated costs with responding to this RFI is solely at the respondent’s expense. Respondents should indicate which information in their response they consider to be proprietary. Responses will assist the Government in the development of its acquisition strategy, including the determination of small business capabilities and interest in any possible future acquisition.

I. Purpose The purpose of this Request for Information (RFI) is to gather insights and capabilities from experts in long-term planning and strategy development for nationwide healthcare programs, with a specific focus on the evolution and enhancement of the World Trade Center (WTC) Health Program’s Nationwide Provider Network (NPN). The RFI aims to gather information on different approaches to address these goals and identify potential consultants who can provide comprehensive analyses and recommendations to support the NPN's future growth and effectiveness.

II. Background The WTC Health Program was established by Title I of the James Zadroga 9/11 Health and Compensation Act of 2010, Public Law 111–347(January 2, 2011), as amended by Public Law 114–113 (December 18, 2015) and Public Law 116–59 (September 27, 2019), adding Title XXXIII to the Public Health Service (PHS) Act (codified at 42 U.S.C. 300mm to 300mm-61). All references to the Administrator in this document mean the Director of the National Institute for Occupational Safety and Health (NIOSH) within the Centers for Disease Control and Prevention (CDC), or his or her designee. Information on the WTC Health Program is available at http://www.cdc.gov/wtc. High-level Program statistics can be found at https://www.cdc.gov/wtc/ataglance.html.

The WTC Health Program provides monitoring, screening, and treatment (medical and pharmacy) to 9/11 Responders and Survivors. Specifically, the WTC Health Program is a limited benefit health plan, meaning that treatment is covered for only specified health condition(s) resulting from exposure to airborne toxins, hazards, or other adverse conditions arising from the September 11, 2001, terrorist attacks. An internal provider enrolled with the WTC Health Program must diagnose a member with a WTC-related health condition and determine that it is related to the member’s 9/11 exposure. The determination must then be certified by the WTC Health Program for the member to receive treatment. An enrolled member must meet certain exposure, latency, and symptom-onset requirements for their health condition to be certified. A list of certifiable conditions can be found in 42 CFR § 88.15 (https://www.cdc.gov/wtc/regulations2.html)

There are currently eight (8) Clinical Centers of Excellence (CCEs) in the New York Metropolitan Area (NYMA) metropolitan area, and one (1) Nationwide Provider Network (NPN) that administers benefits to members outside of the NYMA. The CCEs are brick and mortar clinics, while the NPN manages and coordinates care remotely using providers located across the country. Currently, the majority of Program members live within or near NYMA; however, an increasing number of members are relocating outside of the NYMA, increasing demand for NPN services. The WTC Health Program also contracts with a Third-Party Administrator (TPA) that manages enrollment eligibility, provider network, and claims processing for the NYMA CCEs and contracts with a Pharmacy Benefits Manager (PBM) to administer pharmacy benefits to Program members, both of which the NPN interfaces with.

The key functional areas of the current NPN contract include:

1. Member Services (including Call Center and Member Education)

2. Member and Provider Communications

3. Clinical Diagnostic Determinations (for purposes of certifying a health condition as WTC-related)

4. Benefits Counseling

5. Case Management and Care Coordination for Monitoring, Diagnostic, and Treatment Services

6. Utilization Management (including Prior Authorizations and Referrals)

7. Provider Network Management (including Network Adequacy and Provider Education)

8. Claims Processing and Adjudication (including Coordination of Benefits for Survivors)

Some unique requirements for the NPN are mandated by the Zadroga Act, impacting all Program contractors, including:

1. Unique Monitoring Requirements: Members are entitled to an Initial Health Evaluation (IHE) and Annual Monitoring Exam (AME), the components of which are Program-specific and not an industry-standard physical. These exams include certain questionnaires, tests and diagnostics needed to diagnose WTC-related conditions.

2. Limited Health Benefits: Members are only entitled to medically necessary treatment or diagnostic services for their certified condition(s), which is unique for each individual. The claims processing system must be set up to manage a limited health plan where members are entitled to treatment or diagnostic benefits for a certified condition(s) that are unique for each individual.

3. Unique Payment Terms: The Program must pay all claims at or below Federal Employees' Compensation Act (FECA) rates, reducing the flexibility of Program contractors to utilize existing negotiated prices. Furthermore, these rates are not used often across the industry, and some providers have indicated unwillingness to be paid under these rates.

4. Unique Billing Requirements: The Program is required to collect and maintain Other Health Insurance (OHI) for all members and facilitate COB for Survivors, as the Program is the payer of last resort for treatment claims. For effective COB, the provider needs to comply with the primary insurance’s billing requirements, as well as the Program’s. This can be challenging, particularly for providers unfamiliar with the COB process.

Additional unique challenges for the NPN in benefit administration are:

1. Members are distributed widely, across all 50 states plus all US territories, requiring familiarity with a patchwork of state and local regulations and laws (e.g., licensure).

2. Benefits counseling, a required service under the WTC Health Program, requires providing resources to members to obtain WTC-related and non-WTC-related benefits. Often, these resources are unique to a state or region.

3. Many enrolled providers may only see 1-2 members each year or never see a Program member, due to member distribution nationwide. Because of this, providers may not be as familiar with the Program and its unique requirements.

4. Care coordination tasks require the NPN contractor to establish multiple touchpoints with members across the nation. The Program has generally relied on care coordination typically through phone or mail, which can be challenging.

5. The NPN Contractor coordinates benefits for both the Responder and Survivor populations, which have different requirements. For example, only Responders can be certified for musculoskeletal disorders and only Survivor claims require coordination of benefits.

For more background on the NPN, you may refer to the previous NPN solicitation, found at https://sam.gov/opp/10d83b1d5da84a418b37c8f7ffe9e556/view. Current high-level statistics on the NPN population size, member distribution, and pace of growth is attached.

III. Information Requested The WTC Health Program is gathering information and identifying potential sources who have extensive industry knowledge and resources to perform an analysis of alternatives for the key functional areas impacting NPN members, noted in the Background. Analysis should result in targeted recommendations for the WTC Health Program to guide requirement development. Program priorities include:

A. Identifying alternatives for contract structure, set-up, and design, that will optimize:

i. Timely access to high-quality care;

ii. Consistent and positive member and provider experience; and

iii. Efficiency in processes and communications B. Increasing competition in acquisitions by optimizing alignment of required functions and services with industry capabilities C. Optimizing feasibility and success of future contracts

In response to this Request for Information, please:

1. Describe your company’s approach to conducting comprehensive analyses of long-term planning for nationwide healthcare programs, including recommendations. Describe how this approach would be tailored to the Program and specifically, the NPN’s needs.

2. Detail your company’s specific capabilities in delivering consulting services related to long-term planning and strategy development for delivering healthcare services nationwide, and how you determine “successful delivery” of these services.

3. Provide examples of your company’s past performance in delivering consulting services similar to those requested in this RFI (long-term planning and strategy development, ideally in the listed functional areas). Please include descriptions of final deliverables and how they were utilized by the client.

4. Detail the specific information/resources your company anticipates will be needed from the Program (and/or existing vendors) to ensure that the recommendations are sufficiently informed and tailored to the Program’s needs.

5. Detail the resources (labor categories and hours) your company anticipates will be needed to develop the requested analysis of alternatives/recommendations.

6. Based on your company’s expertise and the scope of work outlined in this RFI, provide an estimated timeline for completing the requested analysis.

IV. Instructions for Submission

1. Page Limit: ten (10) single-spaced pages with a minimum 10-point Times New Roman font. (Note: any pictorial examples or attachments provided in support of descriptive responses do not count towards this page limit.)

2. Questions Due By: April 16, 2024 at 12pm Eastern

3. Responses (white paper) Due By: April 24, 2024 at 5pm Eastern. Send responses to Michael Baron at lpc0@cdc.gov. Please include “WTC Health Program | RFI 75D301-24-RFI-NPNCons” in the subject line.

4. Page 1 of the white paper shall include the chart below, completed by your organization:

Company Name

Company Address

Unique Entity ID (UEI)

Primary Point of Contact Name

Primary Point of Contact Email

Primary Point of Contact Phone Number

Business Type (large business, small business, nonprofit, minority- or woman-owned, etc.)

GSA or other Federal Schedule Awards

The World Trade Center Health Program is administered by the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention image1.jpeg image2.jpeg