RFI__Medical_Claims_12.29.2016.pdf

US Peace Corps Office of Health Services (OHS)

Request for Information (RFI) Medical Claims Administration Services (MCAS)

This RFI is pursuant to federal acquisition regulation (FAR) part 10: Market Research.

This RFI is for acquisition planning purposes to inform the Peace Corps of the current status of industry sources and best practices for medical claims administrative services.

This notice is not a commitment by the Government for any actual procurement and does not constitute a solicitation or a promise of a solicitation in the future. Peace Corps is not at this time seeking proposals or quotes, and will not accept unsolicited proposals/quotes. Participation in this effort is voluntary; not responding to this RFI does not preclude participation in any future solicitation, if one is issued. The Government will not reimburse respondents for the information provided or for costs incurred in response to this RFI. Respondents are responsible for properly marking and clearly identifying any proprietary information or trade secrets contained within their response. Proprietary information received in response to this sources sought will be safeguarded and handled as marked and in accordance with applicable government regulations. The

Government will not be liable for protecting any proprietary information not properly marked and clearly identified. Responses submitted to the Peace Corps will not be returned. Any follow up communication regarding this RFI will be posted in Federal

Business Opportunities (www.fbo.gov). Please check the FBO.gov website for updates we kindly ask you to not follow up for updates via email or phone.

1. BACKGROUND

As the preeminent international service organization of the United States, the Peace

Corps sends Americans abroad to tackle the most pressing needs of people around the world. Peace Corps Volunteers work at the grassroots level toward sustainable change that lives on long after their service—at the same time becoming global citizens and serving their country. When they return home, Volunteers bring their knowledge and experiences—and a global outlook—that enriches the lives of those around them. The

Peace Corps’ mission is to promote world peace and friendship by fulfilling three goals:

- To help the people of interested countries in meeting their need for trained men and women

- To help promote a better understanding of Americans on the part of the peoples served

- To help promote a better understanding of other peoples on the part of

Americans.

Peace Corps is authorized to provide all necessary or appropriate health care to

Trainees and Volunteers, either in their country of service, in the United States, or in a third country as needed.

More information about the Peace Corps can be found on www.peacecorps.gov

2. PURPOSE OF THIS REQUEST FOR INFORMATION (RFI)

This RFI is intended to inform the Peace Corps on the current status of industry sources and best practices for medical claims administrative services.

The purpose of this notice is to obtain information regarding:

a. The availability and capability of qualified business sources; including their

DUNS, size classification relative to the North American Industry Classification

System (NAICS) code for the proposed acquisition. Whether there are other than small business; small businesses; HUBZone small businesses; service-disabled veteran-owned small businesses; 8(a) small businesses; veteran-owned small businesses; woman-owned small businesses; or small disadvantaged businesses.

b. Industries best practices for managing and administering self-insure medical claims

c. Effective cost control methods including incentives

d. Available extensive international networks that can offer quality and cost control

e. General industry feedback.

Your responses to the information requested will assist the Government in acquisition planning. The Peace Corps may utilize the responses to this RFI to conduct additional market research.

3. INFORMATION REQUESTED

The Government is requesting that all interested vendors provide information regarding their best practice experience and innovative practices to perform the types of services outlined in Section 4 of this RFI.

Questions regarding this RFI are due January 18, 2016 at 12 noon ET please use subject line “RFI Medical Claims” to ensure your questions are received. Final RFI submissions are due January 29, 2016 at 9am ET to cmejiasalamanca@peacecorps.gov please use subject line “RFI Medical Claims” to ensure your submission is received. Submission shall be limited to up to 10 pages, 12 point font. Submissions shall contain:

a) Name, ownership, and address of firm;

http://www.peacecorps.gov/ mailto:cmejiasalamanca@peacecorps.gov

b) Size of business and socioeconomic status (i.e. other than small, small, small disadvantaged business, woman owned, etc.);

c) Number of years in business;

d) Affiliate information;

e) Point of contact – address and phone number;

f) List of existing Government Wide Acquisition Contracts (GWACS) for which you are currently qualified;

g) What is your organization’s experience in performing medical claims administrative services? Describe the scope of services and the agency(ies) for which these services were performed. Include names and telephone numbers of the agency representatives with knowledge of the contract;

h) Does your company have a GSA schedule contract that includes medical claims administrative services? What Special Identification Number (SIN) are the services awarded under?;

i) Labor Categories – Please provide pricing samples for possible labor categories for services identified in the requirements section below.

j) Other pricing factors – please provide any other pricing factors associated with completing the requirements (cost per claim, administrative fees, IT)\

k) Peace Corps uses an electronic medical record system (EMR). Does your company have the ability to process electronic claims forms provided through Peace Corps’

EMR?

l) Do you currently have the ability to support self-insured organizations and if so, please describe the services you provide and how you control costs while ensuring quality of care.

m) What are the provider networks available to your company, both within the U.S. and internationally, and how broad is their coverage? If a provider is needed in an area where there are no network providers, how would your company determine reimbursement rates for care?

n) How would your company determine reimbursement rates for out-of-network care;

specifically, what cost-controls and incentives would you use to allow for sufficient coverage and high-quality care while complying with current allowable government contracting options?

4. REQUIREMENTS

The US Peace Corps Office of Health Services (OHS) manages the healthcare of more than 7,000 individuals in 70 countries. These individuals include: invitees, Peace Corps trainees (PCTs), Peace Corps Volunteers (PCVs), and Returned Peace Corps

Volunteers (RPCVs).

The health benefits program at the Agency is a self-insurance program and is considered primary coverage for all authorized care. The program is administered by

OHS. The current program includes three plans based on the status of the insured individual at the agency (invitee, Volunteer, etc.). The number of applicants, volunteers, and returned volunteers varies each year. However we have provided demographics and information about prior year’s medical claims processing numbers by plan.

The demographics of Peace Corps Volunteers over the four year period 2011-2014 are men 38%, women 62% and mean age 28. Demographic data and PCT/Vs on-board are as of September 30 of that calendar year. Age breakdown by fiscal year:

Fiscal Year

Age 20-29 30-39 40-49 50-59 60-69 Greater than 70

2011 Count 7565 782 156 199 348 45

2012 Count 6798 547 142 217 332 37

2013 Count 5837 694 131 173 318 56

2014 Count 5586 648 126 158 253 47

The historical numbers for volunteers, applicants, and number of claims processed by plan.

Fiscal Year Invitati ons Accept ed

PCT/V

s On-board

PCT/Vs Ending Service

Plan 1 Medical No of Claims

Plan 2 Medical No of Claims

Plan 3 Medical No of Claims

11 * 9095 4106 9861 2994 7081

12 * 7209 4924 6200 4174 7678

13 3522 7209 4089 5339 3616 5993

14 3731 6818 4132 6509 4246 6757

*Peace Corps moved to a new process in 2013, the 2011 & 2012 data is not applicable.

The historical average cost per claim per plan by Fiscal Years 11-14

Fiscal Year

Average Plan 1 Medical Claim Amount

Average Plan 2 Medical Claim Amount

Average Plan 3 Medical Claim Amount

11 62.23 620.31 173.76

12 74.59 894.41 184.08

13 84.98 957.62 237.70

14 83.63 1024.49 204.77

Plan 1 – Invitees for Peace Corps service require medical, dental, and vision examinations in order to be evaluated for health status. Invitees are reimbursed by the agency for these screening expenses up to a limited maximum amount for certain, specific services. Reimbursement is provided based on proof of out of pocket expenses.

The maximum amount of reimbursement is based on an established fee schedule. The invitee is responsible for submitting medical receipts to the medical claims administrator.

The proposed maximum allowable reimbursement for invitees will be as follows:

Invitee

Medical $290

Dental $135

Vision $290

Mental Health $280

Total $995

This requirement provides prompt payment of reimbursement to the invitee, upon proof of out-of-pocket expenses, up to the maximum allowable amount.

Plan 2 - During Peace Corps service, trainees/PCVs receive routine and emergency medical care, preventive health services, and health promotion education from their

Peace Corps Medical Officer while in-country. This care is not covered under the scope of this RFI.

However, when volunteers are away from their posts in another country or on medical leave, medical care may be required. Care under these circumstances is under the scope of this RFI.

This care is provided by physicians, surgeons, counselors, psychologists, therapists, dentists, other medical specialists and clinical providers. Primarily this care takes place in any state within the United States (U.S.) but can take place in any country, or at a

Peace Corps-authorized regional medical center (typically in Bangkok, Thailand, Pretoria, South Africa, or Rabat, Morocco, but can also be other regional centers). The providers of this care are to be compensated for services provided to PCVs within the scope of this requirement.

This requirement provides prompt payment to providers for medical services rendered to Volunteers and Trainees. The requirement also allows for high-quality, acceptable and medically appropriate services provided by the widest range of providers at the lowest cost to the agency. The agency requires the ability to send Volunteers to any choice of provider, regardless of network affiliation.

All medical care provided under plan 2 shall be authorized in advance by the Peace

Corps. Claims are paid directly to the provider or directly to the Trainee or Volunteers for out of pocket expenses.

Plan 3 – Upon completion of Peace Corps service, Returned Peace Corps Volunteers

(RPCVs) may be authorized by the Agency for evaluation (but not treatment) of certain health conditions related to Peace Corps service. The authorization for evaluation is available for up to 6 months after Close of Service (COS). All treatment for conditions proximally related to service must be provided through the Federal Employees

Compensation Act (FECA) program, administered by the Department of Labor (DoL).

The Peace Corps has been delegated a narrow authority by Department of Labor (DoL) to provide payment authorization for limited treatment. The DoL delegated authority is limited in dollar value (up to $1,500) and for specific, limited, clearly defined medical conditions. The issuance of authorization by Peace Corps for DoL delegated authority for treatment is rare and not a normal/regular occurrence under this requirement.

This requirement provides for prompt payment of authorized health care evaluations and limited DoL authorized medical treatment for RPCVs. Services should be high-quality, acceptable and medically appropriate services provided by the widest range of providers at the lowest cost to the agency.

Plan 4 – RPCVs are offered up to 3 months (1 month paid for by the agency and the option of the RPCV purchasing an additional 2 months) group medical insurance after close of service. This coverage should comply with the basic minimum requirements of the Affordable Care Act.

4.1 GENERAL / Objectives

The scope of the program is to provide medical claims administrative services to the

Peace Corps’ Office of Health Services (OHS).

4.2 Goals

The goals of this requirement are to provide commercially available off the shelf

(COTS), accurate, timely, customer focused medical claims processing services to the

Peace Corps’ Office of Health Services (OHS).

4.3 LIST OF POTENTIAL TASKS

a. Task 1 – Phase In

(1) Vendor shall ensure there is appropriate coverage as the contract starts up and transitions into full operation.

b. Task 2 – Plan Medical Claims Administration

(1) Plan I – reimburse medical claims promptly per the Peace Corps established cost-share levels

(2) Plan 2 – reimburse medical claims promptly per authorization of the

Peace Corps within a network, a wrap network, or after negotiation.

(3) Plan 3 – reimburse medical claims promptly for RPCV’s evaluation claims per authorization of the Peace Corps within a network, a wrap network, or after negotiation.

(4) Plan 4 – provide group coverage automatically for 30 days with the option of RPCV payment for 2 additional months of identical coverage.

c. Task 3 – Customer Support

(1) IT Infrastructure

a. External Web Site for all individuals to access – the general public, applicants, invitees, trainees, volunteers, and RPCVs.

b. Web site for OHS administrative staff

c. Help desk phone line/email/call center for invitees/PCVs/RPCVs, OHS staff, and providers with domestic and global capability

d. Ability to interface with Agency IT systems (Peace Corps

Electronic Health Record / invitee, Volunteer, RPCV status data).

e. Ability to access and enter on-line medical authorizations globally such that OHS authorizations can be provided and tracked electronically.

f. Ability to access an on-line claim status portal, to include the ability to view/print the original invoice.

(2) Account Manager dedicated to the Agency requirement and represent the vendor to the following: internal OHS, Agency representatives and leadership.

(3) Provide accurate information as needed to Volunteers who are

Medicare or Tricare beneficiaries with regards to maintaining coverage and premium payments during and after Peace Corps service.

d. Task 4 – Reports

(1) Quarterly Financial for all plans

(2) Bi-Annual Financial for all plans

(3) In person meeting with all of OHS at the Peace Corps HQ in

Washington, DC. (annually and as required)

(4) On demand, on line, real time data, and access to the following accurate reports

a. Top 25 diagnosis codes (by quantity)

b. Top 25 medical claims (by cost)

c. Other assorted reports as required

e. Task 5 – Financial responsibility

(1) Vendor shall provide evidence of a $2,000,000 line of credit throughout the life of the award.

f. Task 6 – Phase out

(1) Vendor shall ensure all operations are continuous and seamless as the contract phases out.

___________________________ END ____________________________