Draft_RFP_PC-16-R-007.pdf

SOLICITATION, OFFER, AND AWARD 1. THIS CONTRACT IS A RATED ORDER

UNDER DPAS (15 CFR 350)

RATING

PAGE OF PAGES

1 | 69

2. CONTRACT NUMBER

3. SOLICITATION NUMBER

PC-16-R-007

4. TYPE OF SOLICITATION

SEALED BID (IFB)

NEGOTIATED (RFP)

5. DATE ISSUED

6. REQUISITION/PURCHASE NO.

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

Peace Corps 1111 20th Street, NW.

Office of Acquisition and Contract Management, 4th Floor Washington, DC 20526

NOTE: In sealed bid solicitations “offer” and “offeror” mean “bid” and “bidder”

SOLICITATION

DRAFT

10. For A. NAME B. TELEPHONE (NO COLLECT CALLS) C. E-MAIL ADDRESS Information Email

Sonja Truehart-McKinney AREA CODE

NUMBER

692-2840

EXT.

struehartmckinney@peacecorps.gov

11. TABLE OF CONTENTS

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

PART I - THE SCHEDULE PART II - CONTRACT CLAUSES

X A SOLICITATION/CONTRACT FORM 5 I CONTRACT CLAUSES 63

X B SUPPLIES OR SERVICES AND PRICE/COST 6 PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

X C DESCRIPTION/SPECS./WORK STATEMENT 11 J LIST OF ATTACHMENTS 69

X D PACKAGING AND MARKING 41 PART IV - REPRESENTATIONS AND INSTRUCTIONS

X E INSPECTION AND ACCEPTANCE 42 K REPRESENTATIONS, CERTIFICATIONS

X F DELIVERIES OR PERFORMANCE 44 AND OTHER STATEMENTS OF OFFERORS N/A

X G CONTRACT ADMINISTRATION DATA 46 L INSTRS., CONDS., AND NOTICES TO OFFERORS N/A

X H SPECIAL CONTRACT REQUIREMENTS 52 M EVALUATION FACTORS FOR AWARD N/A

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.

13. DISCOUNT FOR PROMPT PAYMENT

10 CALENDAR DAYS

20 CALENDAR DAYS

30 CALENDAR DAYS

CALENDAR DAYS

14. ACKNOWLEDGMENT OF AMENDMENTS AMENDMENT NO. DATE AMENDMENT NO. DATE

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

15A. NAME CODE FACILITY 16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN

AND OFFER (Type or print)

ADDRESS

OF

OFFEROR

15B. TELEPHONE NUMBER 15C. CHECK IF REMITTANCE 17. SIGNATURE 18. OFFER DATE

EXT.

ADDRESS IS DIFFERENT FROM ABOVE

- ENTER SUCH ADDRESS IN

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) (1) 41 U.S.C. 253(c)( )

23. SUBMIT INVOICES TO ADDRESS

SHOWN IN (4 copies unless otherwise specified)

ITEM

See Section G

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

26. NAME OF CONTRACTING OFFICER (Type or print)

Sonja Truehart-McKinney

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.

NSN 7540-01-152-8064 STANDARD FORM 33 (Rev. 9-97) PREVIOUS EDITION NOT USABLE Prescribed by GSA – FAR (48 CFR) 53.214(c)

Solicitation PC-16-R-007

Peace Corps Office of Health Services

Health Care Benefits Services

Draft Solicitation

PC-16- R-007

July 12, 2016

TABLE OF CONTENTS

SECTION A – SOLICITATION/CONTRACT FORM

A.1. Issuing Office

A.2. Receipt of Proposals

A.3. Term of Contract

A.4 Effective Date

SECTION B – SUPPLIES OR SERVICES AND PRICES/COSTS

B.1. CLIN Structure

B.2. Contract Summary

B.3. Performance Incentive Plan

SECTION C – DESCRIPTION/SPECIFICATIONS/STATEMENT OF

WORK

C.1. Introduction

C.2. Technical Requirements

C.3. Transitions

C.4. Invitee Cost-Reimbursement Administrative Services (Plan 1)

C.5. Health Benefit Services for Peace Corps Volunteers (Plan 2)

C.6. Health Care Services for Return Peace Corps Volunteers (Plan 3)

C.7. Access to Group Health Insurance Policy (Plan 4)

C.8. Medical Claims

C.9. Data and Reporting Requirements

C.10. Historical Beneficiary Demographics and Claims History

C.11. Rights Reserved for the Peace Corps

SECTION D – PACKAGING AND MARKING

D.1. Packing

D.2. Marking

SECTION E – INSPECTION AND ACCEPTANCE

E.1. Inspection and Acceptance

E.2. Inspection Location

E.3. Quality Assurance Surveillance Plan (QASP)

E.4. Acceptance

E.5. Clauses Incorporated by Reference

SECTION F – DELIVERIES OR PERFORMANCE

F.1. Period of Performance

F.2. Delivery

F.3. Place of Performance

F.4. Notice Regarding Late Delivery

F.5. Clauses Incorporated by Reference

SECTION G – CONTRACT ADMINISTRATION DATA

G.1. Contracting Officer’s Authority

G.2. Contracting Officer’s Representative

G.3. Invoicing and Payment Information

G.4. End of Health Care Delivery

G.5. Withholding of Contract Payments

SECTION H - SPECIAL CONTRACT REQUIREMENTS

H.1. Loss/Damages

H.2. Confidentiality

H.3. Privacy and Security of Protected Health Information

H.4. Compliance with Federal, State, Local, and Foreign Requirements

H.5. Protection of Information

H.6. Contractor Required Insurance

H.7. Advertising of Award

H.8. Use of Peace Corps Name and Logo

H.8. Personnel Security Requirements

H.9. Small Business Subcontracting Plan Requirements

H.10. Key Personnel

SECTION I - CONTRACT CLAUSES

I.1. Clauses Incorporated by Reference

I.2. Clauses Incorporated in Full Text

SECTION J - LIST OF DOCUMENTS, EXHIBITS, AND OTHER

ATTACHMENTS

J.1- Peace Corps Personnel Security Policies

J.2. - Panel Providers

J.3. - Peace Corps Standard Form (SF) 127C

J.4. - Peace Corps IT Security Policies & Procedures

J.5. - Government Transition Team

J.6. - Plan 1 Cost Reimbursement Fee Schedule

J.7. - Authorized Air Ambulance Callers

J.8.- Preferred Air Ambulance Destinations

J.9. - AfterCorps Coverage

J.10. - Contract Data Requirements List

J.11. Small Business Plan

SECTION A – SOLICITATION/CONTRACT FORM

A.1. Issuing Office This Draft Request for Proposal (RFP) is being issued by the Peace Corps, Office of Acquisition and Contract Management (OACM), on behalf of the Office of Health Services, which is the only point of contact for this procurement. Inquiries concerning this Draft solicitation must be submitted electronically via email to the following:

Sonja Truehart-McKinney struehartmckinney@peacecorps.gov

A.2. Receipt of Proposals All copies of an Offeror ‘s (or subcontractor’s) proposals must be submitted by the time and date in Block 9 of Standard Form (SF) 33. The Contractor shall forward solicitation responses to the following address:

TBD

A.3. Term of Contract This contract will be awarded to one Offeror for a one-year base Period, with four (4) one (1) year option periods.

A.4. Effective Date This contract (“Contract”) is made effective as of ___* see below___________(“Effective Date”), by and between , (to be filled in by Offeror) a (i.e. corporation)(to be filled in by Offeror ) organized and existing under the laws of the State of _____________ (to be filled in by Offeror).

*This contract shall be effective as of the date the contract is executed by the Contracting Officer (CO), at which time the Contractor shall commence work in accordance with the terms and conditions herein.

(End of Section A) mailto:struehartmckinney@peacecorps.gov

SECTION B - SUPPLIES OR SERVICES AND COSTS/PRICES

ITEM NO. SUPPLIES/SERVICES QTY UNIT

UNIT

PRICE AMOUNT

BASE

AWARD

Transition Phase-In (Firm Fixed Price (FFP)) Planning and Implementation of Transition Period In Accordance With (IAW) Statement of Work (SOW), Sections C.1, C.3 1 Lot

Invitee Cost -Reimbursement Administrative Services (Plan 1) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.4 TBD CS

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Note A) TBD MM

Health Care Administrative Services for Returned Peace Corps Volunteer- (Plan 3) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Note A) TBD MM

Access to Group Health Insurance Policy (Plan 4) (Fixed Price with Economic Price Adjustment) IAW Sections C.1, C.2 and C.7. (See Note A) TBD MM

0006 Other Direct Cost (ODC) - Medical Claims IAW Section C.8. (See Note B) 1 Lot

Ceiling Price

Performance Incentive Pool - Performance Incentives shall be IAW Section B.3. (See Note C) (see synopsis for additional information) 1 Lot

Data for Items 0001 - 0007, and (if options are exercised) 0009 through 0029 IAW Section C.9 (Not Separately Priced (NSP)) 1 Lot NSP

OPTION I

Invitee Cost -Reimbursement Administrative Services (Plan 1) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.4 (See Note D) TBD CS

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Notes A and D) TBD MM

Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Notes A and D) TBD MM

Access to Group Health Insurance Policy (Plan 4) (Fixed Price with Economic Price Adjustment) IAW Sections C.1, C.2 and C.7. (See Notes A and D) TBD MM

Other Direct Cost (ODC) - Medical Claims IAW Section C.8. (See Note B and D) 1 Lot

Ceiling Price

OPTION II

Invitee Cost -Reimbursement Administrative Services (Plan 1) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.4 (See Note D) TBD CS

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Notes A and D) TBD MM

Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Notes A and D) TBD MM

Access to Group Health Insurance Policy (Plan 4) (Fixed Price with Economic Price Adjustment) IAW Sections C.1, C.2 and C.7. (See Notes A and D) TBD MM

Other Direct Cost (ODC) - Medical Claims IAW Section

1 Lot Ceiling

C.8. (See Note B and D) Price

OPTION III

Invitee Cost -Reimbursement Administrative Services (Plan 1) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.4 (See Note D) TBD CS

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Notes A and D) TBD MM

Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Notes A and D) TBD MM

Access to Group Health Insurance Policy (Plan 4) (Fixed Price with Economic Price Adjustment) IAW Sections C.1, C.2 and C.7. (See Notes A and D) TBD MM

Other Direct Cost (ODC) - Medical Claims IAW Section C.8. (See Notes B and D) 1 Lot

Ceiling Price

OPTION IV

Invitee Cost -Reimbursement Administrative Services (Plan 1) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.4 (See Note D) TBD CS

Health Care Administrative Services for Peace Corps Volunteers (Plan 2) (Firm Fixed )Price (Unit Price)) IAW Sections C.1, C.2 and C.5 (See Notes A and D) TBD MM

Health Care Administrative Services for Returned Peace Corps Volunteers (Plan 3) (Firm Fixed Price (Unit Price)) IAW Sections C.1, C.2 and C.6 (See Notes A and D) TBD MM

Access to Group Health Insurance Policy (Plan 4) (Fixed Price with Economic Price Adjustment) IAW Sections C.1, C.2 and C.7. (See Notes A and D) TBD MM

Other Direct Cost (ODC) - Medical Claims IAW Section C.8. (See Notes B and D) 1 Lot

Ceiling Price

Transition Phase Out (Firm Fixed Price) IAW Section C.3.2 (See Note D) 1 Lot

CS – Price per Case/Claim MM – Price per Member per Month

Note A: The Government intends to procure services for 12 months from the date of award or option exercise. However, in the event the contract is terminated or the Period of Performance (PoP) is modified via a modification to the contract for a period less than 12 months, the Government will only be responsible for the monthly services provided prior to and in the month the contract was terminated or a contract modification was executed to revise the PoP.

Note B: The amount represents the ceiling price for actual medical claims for the base year or option period. The sum of medical claims shall not exceed this amount. The Contractor shall monitor and account for all costs of medical claims under this contract. The ceiling price does not constitute a commitment, implied or otherwise, that the Government will expend the entire amount in the base or option period. The aggregated ceiling price under this contract shall not exceed the base year and all option periods or $TBD.

Note C: The purpose of performance incentives is to incentivize the contractor for meeting/exceeding measured and evaluated performance measures as described in Section B.3.

The amount as stated herein is the maximum incentive price over the life of this contract.

Note D: Option item to which the option clause in SECTION I-2 applies and which is to be supplied only if and to the extent said option is exercised.

B.2. Contract Summary

This contract includes the following Firm Fixed Price (FFP) and Time and Material items:

Item Type 0001, 0002 – 0004, 0007 Firm Fixed Price 0009- 0011, 0014-0016 0019-0021, 0024-0026

0005, 0012, 0017, 0022, and Fixed Price with Economic Price Adjustment

0006, 0013, 0018, 0023, and Time and Material – ODC

0008 Not Separately Priced (NSP)

B.3 Performance Incentive Plan (see synopsis for more information with regards to performance incentives)

(End of Section B)

SECTION C –DESCRIPTION/ SPECIFICATIONS/WORK STATEMENT

C.1. INTRODUCTION (Applicable to all Contract Line Item Numbers (CLINS)) The Statement of Work (SOW) (Section C) defines the technical and management requirements for the Contractor to administer a Health Care Benefits Services (HCBS) contract for the Peace Corps in an efficient and timely manner throughout the term of this contract. Section C includes two categories of outcome-based statements. The “Statement of Desired Outcomes” represents the desired outcomes for this contract. The desired outcomes are supported by “Technical Requirements.” These requirements encompass the scope of the contract and represent specific tasks, outcomes, and/or standards that, at a minimum, must be achieved.

The purpose of this contract is to provide the Peace Corps Community access to National and International Health Care Networks, claims processing, health care support services (e.g. online authorizations management, claims adjudication, access to claims data, guarantees of payment (GOPs), air ambulances, etc.) and a short term group medical insurance policy for Returned Peace Corps Volunteers (RPCVs).

C.1.1. Background. The Peace Corps is an independent executive agency of the federal government established in 1961 by President John F. Kennedy to promote world peace and friendship through the service of American volunteers abroad. The volunteers’ service fulfills the three primary goals established in the founding legislation:

• Improve the lives of people through grassroots assistance;

• Foster a better understanding of Americans on the part of the people served; and

• Foster a better understanding of other people on the part of Americans.

There are currently more than 7,000 volunteers serving in posts located in approximately 65 developing countries worldwide. The posts are divided into three regions:

• Africa (AF),

• Intra-America and Pacific (IAP), and

• Europe, Mediterranean and Asia (EMA).

C.1.1.1. Office of Health Services (OHS) Mission. Peace Corps’ OHS manages healthcare services for Invitees, Peace Corps Volunteers (PCVs), and Returned Peace Corps Volunteers (RPCVs). The mission of OHS is to provide quality medical and mental health services and support to the Peace Corps community through its Office of Medical Services (OMS). The health care benefits program is comprised of both a self-insured and a commercially insured component. In order to accomplish this mission, the Health Care Benefits Services (HCBS) contract will supplement the services that are provided to the Peace Corps community via Peace Corps’ internal team of onsite doctors and other medical professionals at approximately 65 Peace Corps posts worldwide. These services will include: 1. managing cost-sharing financial assistance, and limited full reimbursement, for medical, dental, and vision examinations required of Invitees in order for OMS to evaluate their health status and required vaccinations before entering service, 2. providing access to national and international health care provider networks,

3. adjudicating authorized claims per requirements of this contract for eligible Invitees, PCVs and RPCVs, and 4. providing access to short term group health insurance for RPCVs according to the requirements of the contract.

C.1.1.2. Peace Corps titles for the stages of service. Applicant – person who applies for service, Invitee – person who is invited to serve, Trainee – entered service not yet sworn-in as Volunteer, Peace Corps Volunteer (PCV) – sworn-in to a typical two year service agreement, Returned Peace Corps Volunteer (RPCV) – ended service. For the purposes of this contract the word Volunteer will include Trainees, PCVs and RPCVs.

C.1.1.3. Health Care Benefits Program Plans 1-4

PLAN 1 - Only US citizens are invited to serve in Peace Corps. Less than 1% of applicants reside outside of the US and Puerto Rico. Peace Corps Invitees submit their medical receipts after paying out-of-pocket or in accordance with their individual insurance, for exams or immunizations required to be cleared for entry into the Peace Corps. Following the submission of payment receipts, cost-sharing financial assistance is administered and provided directly to the beneficiary. The maximum amount of cost-sharing for examinations is based on a formula that corresponds to basic medical screening requirements; required immunization cost share is based on country of assignment. A small number of invitees, normally less than 10%, are authorized additional health care related items needed for service that are not subject to cost-sharing.

PLAN 2 - Countries with a Peace Corps program maintain a Health Unit to service the health care needs of PCVs in-country. The Health Unit is staffed by a varying mix of host-country nationals, third-country nationals and/or Americans. The levels of education and training for the medical professionals in each country vary and can include one or a combination of the following: Registered Nurses (RNs), Nurse Practitioners (NPs), Physician Assistants (PAs), Peace Corps Medical Officers (PCMOs) and Medical Doctors (MDs). The Peace Corps employs Regional Medical Officers (RMOs) – all RMOs are Medical Doctors. Currently, there is an RMO at each of the following locations: Morocco, South Africa, and Thailand (subject to change). The care provided by these staff members is not covered by this contract.

PCVs overseas who require non-routine or emergency medical, mental health, or dental evaluation and treatment may be medically evacuated aka "medevaced" to the US or to regional locations worldwide. Washington, D.C. is the most common US medevac site followed by the PCV’s home of record. Abroad Peace Corps primarily medevacs PCVs to its RMO hubs but transports to other locations as needed. On occasion Guarantee of Payments (GOPs) or pre-established relationships are needed in order to accept medevacs at certain facilities. Most medevaced PCVs’ travel is arranged by Peace Corps, however, there are situations (less than 10/year, on average) when Peace Corps requires an air ambulance in order to safely medevac a volunteer. While these services could be required anywhere worldwide, the Peace Corps web site identifies in which countries Volunteers currently serve (subject to change):

http://www.peacecorps.gov/volunteer/learn/wherepc/ http://www.peacecorps.gov/volunteer/learn/wherepc/

Volunteers on leave or official travel status may utilize the National Network in all 50 states, the District of Columbia or Puerto Rico. Volunteers may require air ambulance services from their country of service or any country to which the Volunteer may travel during their Peace Corps service. Volunteer travel is not prohibited during such periods as vacation or home leave, and the Volunteer is fully covered under Plan 2 during all phases and aspects of service -- including vacation and home leave. When in the US or abroad on leave or official travel status, PCVs who require routine and non-routine medical or dental care receive health care services from providers whose costs are paid for by Peace Corps through a self-insured health benefits program. This includes all pharmacy needs. All healthcare services/needs provided to beneficiaries must be pre-authorized by Peace Corps and are reimbursed to the beneficiary or paid to the provider. Peace Corps currently issues authorizations on a case-by-case basis via a paper authorization process. Authorizations can currently be issued by any Peace Corps health care provider domestic or international (i.e. medical doctor, nurse, dentist, etc.).

Plan 3 - For six months after the end of service, the Peace Corps may authorize RPCV medical evaluations for Conditions of Coverage while Serving Abroad. Peace Corps will pay for treatment for Conditions of Coverage while Serving Abroad as defined in the Division of Federal Employee Compensation (DFEC) Procedure Manual Federal Employee Compensation Act (FECA) Part 2, Group 5, Chapter 2-1701, Peace Corps Cases, which may be found at the following link: https://www.dol.gov/owcp/dfec/regs/compliance/dfecfolio/FECA- PT2/group5.htm#217019. Otherwise RPCVs must file a FECA claim through the Department of Labor (DOL). RPCVs may be eligible for FECA benefits under DOL regulations if they meet required criteria. These services related to RPCVs are referred to as benefit PLAN 3.

Plan 4 – Peace Corps offers short term group health insurance to RPCVs (and applicable dependents) available for up to three months after End of Service (EOS). At its discretion, the Peace Corps will pay the first month’s health insurance premium for RPCVs and eligible dependents. The RPCV has the option to buy an additional two months of the same coverage at the same monthly rate the Peace Corps pays.

C.1.1.4. Peace Corps Electronic Medical Records. OHS recently launched an Electronic Health Record (EHR) system, acronym, “PCMEDICS”. PCMEDICS was deployed to all posts in the Fall of 2015. The Peace Corps has since fully transitioned all current and new volunteers from paper files to PCMEDICS as of February 2016. PCMEDICS is deployed in a hub-and-spokes configuration: the hub is a cloud instance, and it contains the complete dataset of all global records; and the spokes are discrete PCMEDICS installations on servers located at each individual post, containing only local data. The local data is automatically synchronized with the cloud data across the Peace Corps’ Virtual Private Network (VPN) on a regular basis. For more specific information about how Peace Corps PCMEDICS can integrate with outside systems see Section C.2.3.8. The other systems, acronyms used, utilized by OHS are MAXx and DOVE.

DOVE is the system in which US Citizens apply for Peace Corps Service. MAXx is the medical module of DOVE a system in which applicants submit medical forms/information used by the Pre Service Unit nurses who are able to access these files. In addition the Agency relies on other systems, which track the official service computation dates (i.e. EOS dates), country of service

DRAFT

https://www.dol.gov/owcp/dfec/regs/compliance/dfecfolio/FECA-PT2/group5.htm#217019 and home of record for all volunteers. OHS utilizes the data in DOVE and these other systems to “feed” the OHS systems or provide data to outside sources.

C.1.2. Reserved

C.1.3. Statement of Desired Outcomes (SDO). The primary outcomes of the Health Care Benefits Services (HCBS) contract are as follows:

C.1.3.1. Objective 1 – Claims Processing. Prompt, efficient and accurate processing and adjudication of all claims that fall within the scope of the contract, to include development, coding, processing, medical/dental review, authorization, and data record submission and sustainment.

C.1.3.2. Objective 2 –Customer Satisfaction. Customer satisfaction at the highest level, to include: accurate, timely, and efficient health care claims processing services; polite, friendly, responsive customer support; user-friendly online portals and chat mechanisms; easy provider searches; benefits questions; air ambulance /Guarantee of Payment (GOPs) requests; and claims information.

C.1.3.3. Objective 3 - Management. Provision of efficient and effective management processes which will ensure the successful delivery of health care support as required by the contract (including, but not limited to, appropriate staffing levels, staff education and training, internal quality management/quality improvement program, lines of authority, and reporting and coordination interfaces with the Government).

C1.3.4. Objective 4 - Provider Networks. Availability and management of high quality, expansive health care provider networks, both nationally and internationally (to include credentialed hospitals, physicians, ancillary service providers, mental health professionals, dentists, pharmacies, diagnostic and treatment facilities, and air ambulance services), in accordance with the contract requirements.

C.1.3.5. Objective 5 – Short Term Group Health Insurance. Provide an affordable short term health insurance policy that meets the minimum requirements requested by this contract.

C.1.3.6. Objective 6 – Transition. Fully operational systems and processes at the start of health care delivery with minimal disruption and seamless transfer of services from and to a new contract.

C.1.4. Government Furnished Information The Government will provide the Contractor Government Furnished Information (GFI) necessary to effectively perform under this contract. GFI is described below:

C.1.4.1. Medical Information. Peace Corps will provide to the Contractor pertinent medical information, on a case by case basis. The Contractor shall protect the confidentiality of protected health information received from the Peace Corps in accordance with Peace Corps policy and all applicable laws and regulations (including Health Insurance Portability and Accountability Act (HIPAA) of 1996 requirements and the Privacy Act).

C.1.4.2. Eligibility Rosters - Peace Corps’ eligibility rosters will be provided on a daily basis, Monday through Friday on Federal workdays. These reports identify an individual’s eligibility at that time, as well as their Personally Identifying Information (PII). The eligibility file currently contains the following data elements: Volunteer ID , Social Security Number (SSN) , medical plan status (pre-service, in-service, post-service), Plan Number (1,2 or 3), Effective Date (eligibility start date), Termination Date, Last Name, first name, middle name, birth date, gender, marital status, telephone number, e-mail, Country Code (code used by Peace Corps to identify country of service), Type of Service (PCV or PC Response(PC response is short-term, high impact service assignments)), street , city, state, zip, foreign care of address (if exists). Currently, this information is provided through Secure File Transfer Protocol (SFTP). However, the contractor may propose an automated healthcare eligibility roster receipt process. Please see Section C.2.3.8 for more information regarding health care authorization data integration.

C.1.4.3. Health Care Authorizations – A Peace Corps authorization for medical services, also referred to internally as form 127C or 209B (See Attachment J.3) may be issued by any medically licensed Peace Corps health care clinician domestic or abroad. On the form the clinician describes in detail the services that are authorized to be paid by Peace Corps. The authorization document contains the following types of information: Volunteer’s name, Volunteer’s Social Security Number or Volunteer ID, Volunteer’s country, authorization’s expiration date, medical plan status (pre-service, in-service, post-service), End of Service (EOS) date (if applicable), provider’s name (if applicable), specialty (if applicable), problems/symptoms/ History (HX) services authorized, authorizer, authorization date. The form also provides billing instructions for the provider or beneficiary. Peace Corps currently sends a copy of the completed authorization form to the Contractor, via mail, facsimile (fax) or Secure File Transfer Protocol (SFTP). An additional copy is provided to the beneficiary to use for reimbursement or to submit to the provider for their payment processing needs. Currently, the authorization process is paper-based; however, the contractor may propose an automated healthcare authorization process. Please see Section C.2.3.8 for more information regarding health care authorization data integration.

C.1.5. Contractor Furnished Items. The Contractor shall furnish all necessary items (e.g., facilities, labor, services, supplies, etc.) for the satisfactory performance of this contract, unless the contract specifically states that the Government will be providing such items (as identified in “C.1.4. Government Furnished Information” or elsewhere within the contract).

C.2. TECHNICAL REQUIREMENTS (Applicable to CLINS 0002, 0003, 0004, and 0005 (and if options are exercised) 0009 through 0012, 0014 through 0017, 0019 through 0022 and 0024 through 0027)

The technical requirements for the HCBS contract are identified below. These requirements are augmented by the statutes, regulations, and other operating guidelines and instructions incorporated by reference as noted in Section H.17. Statutory and Regulatory Authority. Peace Corps is especially committed to doing no harm, to acting in good faith, and to preserving its reputation as an agent of goodwill in the eyes of beneficiaries of its Health Care Benefits Program and of the American public. The Contractor, therefore, shall provide access to high quality, responsive, timely healthcare and administrative services in a manner that preserves Peace Corps’ good working relationship with beneficiaries of its Health Care Benefits Program.

The Contractor shall provide:

C.2.1. Customer Service. The Contractor shall provide comprehensive, readily accessible customer services that include multiple, contemporary avenues of access (i.e., e-mail, World Wide Web, self-service options, telephone, and facsimile) for Volunteers and Providers.

Customer service shall be delivered in a manner that achieves the objectives of this contract without charge to Volunteers or Providers. The Contractor shall perform all customer service functions with knowledgeable, courteous, responsive staff.

C.2.1.1. Call Center Service. The Contractor shall establish telephone Call Center service. The Call Center shall have a tracking and/or ticketing system to manage calls and inquiries, ensuring all calls are logged within three hours and responded to within three business days. It is the Contractor’s responsibility to ensure adequate, trained Call Center staff is always on duty. A toll-free number for Volunteers and Providers to call into shall be available (along with phone and email access for the hearing impaired). A collect telephone number or telephone number without long distance charges to call into shall be available for Volunteers and Providers calling outside the fifty United States (U.S.) and District of Columbia (D.C.) and/or unable to access the Call Center Service via the toll-free number. Customer service representatives shall be available per commercially standard days and times (minimum 8:00 am to 9:00 pm Eastern Standard Time (EST) Monday-Friday) to Volunteers, Providers and Peace Corps Staff seeking case-specific and general information (i.e. pharmacy authorization, assistance in locating a provider) or other inquires relevant to the services provided under this contract. At least one Customer Service Representative shall be available 24 hours a day, 365 days a year to respond to emergencies, requests for GOPs and air ambulance services.

C.2.1.2. Web Portal Service. The vendor shall stand-up and maintain a web portal with a mobile platform accessible 24 hours per day, 365 days a year (unless down for planned scheduled maintenance) to Peace Corps staff, Volunteers and Providers for claims information, Volunteer eligibility information, provider information, pharmacy network information, details about the group insurance coverage (i.e. coordination of benefits with both Peace Corps post-service evaluation and FECA medical benefits), access to necessary paperwork and forms, links to the customer support unit and any other additional information relevant to Peace Corps’ Health Care Benefits Services. The Web portal shall be user friendly (easy to navigate) to ensure Peace Corps staff, Volunteers, and Providers can quickly find information. The Contractor shall use Federal Government-approved security such as Hypertext Transfer Protocol Secure (HTTPS) to secure the transfer of information over the portal. The Contractor shall maintain an accurate, readily accessible, up-to-date searchable list identifying all network providers. This list must be user-friendly and readily searchable by provider or facility name, specialty or type of facility, subspecialty, gender (for individual providers), service area, work address, work fax number, work telephone number, any limitations of service, and whether the provider is accepting new Peace Corps (PC) patients. The information contained in an electronic list shall be current within the last 30 calendar days. In the event a Provider loses its accreditation, certification and/or state or foreign licensing (if applicable), the Contractor shall update the provider network list within 24 hours.

C.2.1.3. Data Access. The Contractor shall provide a minimum of two licenses or authorizations (whichever is applicable) to Office of Health Services (OHS) and up to four additional licenses or authorizations to be assigned at the discretion of the Government to authorized Government personnel (as determined by the CO) providing unlimited off-site electronic access to all data maintained by the Contractor pertaining to the HCBS contract. This data shall include, but is not limited to, data concerning provider network(s), out-of-network providers, referrals, health care authorizations, claims processing, Volunteer and Provider satisfaction and services. All data must be current, accurate, complete and accessible in real time. “Real time” is defined as data that is refreshed at least once every 24 hours. The Contractor shall also provide read-only access to claims and enrollment data to Volunteers via web portal and any additional information agreed to by the parties.

C.2.2. Claims Processing.

The Contractor shall establish, maintain, and monitor an automated HIPAA compliant claims processing information system to ensure that claims (including adjustments) are processed in an accurate and timely manner, and meet the functional system requirements as set forth in Section H.11. Information Security.

C.2.2.1. Procedures for Processing Claims. The Contractor shall develop and deliver one hard copy Claims Processing Procedures manual (Contract Data Requirement ((CDR) A005) 30 days after contract award in accordance with Section F, and maintain an ongoing electronic Claims Processing Procedures manual accessible online to the Peace Corps. The electronic online procedures manual shall be available within 30 days after contract award in a format mutually agreed by the Contractor and the Government. The manual shall include procedures for reviewing, resolving and following up on claims pended or denied due to: lack of authorization, questions regarding participant eligibility, incomplete itemization, non-standard claims information, balance billing, excess charges, procedural errors on the part of the Volunteer or Provider and questions regarding whether services are allowable under Peace Corps’ Health Benefit Program. The manual shall provide procedures which allow claims requiring additional information to be returned for the missing information. The manual shall ensure that all required information is requested with the initial return and that no claim is returned for information that could have been obtained internally or from information provided from the Peace Corps. The manual shall include language advising beneficiaries that claims for payments submitted beyond one year from the original date of service will be rejected. Additional areas to address, although not comprehensive are:

• Points of Contact for the Claims Department or equivalent (allowing Peace Corps staff to speak directly to claims processers regarding specific cases) and other key Contract personnel, their phone and fax numbers, e-mail address and mailing addresses;

• Appeals procedure consistent with the requirements set forth under the Affordable Care Act (details can be found at: http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html);

• Procedure for resolving complaints between Peace Corps personnel or Peace Corps’ Health Care Benefits Program members and the Claims Contractor's healthcare claims processing system personnel or customer service agents regarding authorizations or claims inquiries;

• Business rules used to program the healthcare claims processing system logic for eligibility, allowable benefits, and reimbursement/payment rates for claims made under the four benefit PLANs (CLINS 0002, 0003, 0004 and 0005 (and if options are exercised) 0009 through 0012, 0014 through 0017, 0019 through 0022 and 0024 through 0027);

• Examples of the Explanation of Benefits used for Peace Corps’ health benefit plans;

• Procedure and medium to be used by Peace Corps to transmit eligibility information to, authorize services, and obtain information from the healthcare claims processing system;

• Procedure to be used by Peace Corps to access health plan information via electronic interface;

• Procedures to be undertaken in the event of electronic interface failure or healthcare claims processing system shut-down.

C.2.2.2. Claim Processing Timeliness and Quality Standards. The Contractor shall ensure that claims (including adjustments) are timely and accurately processed and adjudicated for all care provided to Volunteers in accordance with the Peace Corps’ timeliness and quality standards provided below:

• Claims and supporting documentation shall be accurately entered into the Contractor’s claims processing system within 24 hours after receipt;

• Claims shall be adjudicated within 20 business days for claims inside the fifty United States (U.S.), Puerto Rico, and District of Columbia (D.C.);

• Claims shall be adjudicated within 30 business days for claims originated outside the fifty U.S. States, Puerto Rico, and D.C.;

• Clean claims shall be paid to third party Providers within 20 business days of receipt.

For the purposes of this Contract, a “clean” claim is defined as one submitted on behalf of an eligible Volunteer for authorized, allowable healthcare services that were provided in the U.S. and are appropriately documented;

http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html

• Claims for payment that are submitted beyond one year from the original date of service shall be rejected; and

• Guarantee of Payments issued to international providers shall be available 24 hours a day, 365 days a year per request of Peace Corps staff.

C.2.2.3. Medical Coding. The Contractor shall utilize and report for each claim the most current National Uniform Billing Committee (NUBC) hospital revenue codes, Center for Medicare Services (CMS) revenue codes, CMS Healthcare Common Procedure Coding System (HCPCS) Level II codes, Current Procedural Terminology (CPT), International Classification of Diseases (ICD) diagnosis and procedure codes, Diagnostic and Statistical Manual (DSM) and American Dental Association (ADA) codes for all health services referenced in the claim.

C.2.2.4. Explanation of Benefits. The Contractor shall provide each beneficiary and provider an appropriate Explanation of Benefits (EOB) i.e. beneficiary name, provider name, date processed, date of service, information regarding appeal rights, including instructions for filing an appeal.

The EOB shall also include notice that reimbursement/payment was made in accordance with Peace Corps’ Health Benefits Program policies; (1) that reimbursement/payment for claims made under PLAN 1 (CLIN 0002) are in accordance with Peace Corps fee schedule; and (2) that reimbursement/payment made under PLAN 2 and PLAN 3 (CLINs 0003 and 0004) are considered payment in full. In no case should the PCV or RPCV under PLANs 2 and 3 (CLINs 0003 and 0004) be billed for authorized health care services. The Peace Corps’ Health Benefit Program prohibits billing beneficiaries for authorized health care services or differences between claims made and claims paid. The processing date of the oldest claim for the summary EOB shall not be greater than 31 calendar days.

C.2.2.5. Financial Administration. The Contractor shall provide financial administration as follows:

• Conduct internal audits for all claims greater than $20,000 (twenty thousand dollars) made for services provided to a single payee on behalf of a single beneficiary for a single incident;

• Have the ability to track total costs paid (and costs denied) by fiscal year and segregated by Invitee, PCV and RPCV;

• Have the capability of making Electronic Funds Transfers (EFTs) for both domestic beneficiaries/providers and international bank transfer payments via correspondent U.S.

financial institutions;

• Report all costs in U.S. currency;

• Coordinate payment related service including a Guarantee Payment Letter, if needed and when medically necessary or upon request of the CO;

• The Contractor is not required to pay any interest payments on claims paid later than 20 business days; and

• Recommend measures to control or reduce costs for the medical treatment services provided to Volunteers.

C.2.2.6. Flagged Claims Processing. The Contractor’s claim processing system shall have the capacity to flag claims that are potentially fraudulent, abusive or wasteful. In order to flag potentially fraudulent claims, the contractor’s claim processing system at a minimum shall:

• verify individual eligibility for benefits;

• ensure only claims for allowable services are reimbursed/paid;

• ensure reimbursements/payments do not exceed established schedules;

• eliminate reimbursement/payment of duplicate claims;

• compare claims made to claims reimbursed/paid;

• reconcile diagnosis codes to procedure and gender codes;

• compare the number of inpatient facility days on each claim against admission and discharge dates; and

• have the capacity to process claims under subrogation and claims involving no-fault.

C.2.2.7. Subrogation Services. The contractor shall perform subrogation services on all claims that indicate potential liability by other parties. All funds received by the contractor for subrogation services shall be returned to the Peace Corps. The contractor will reflect these funds in the vouchers for reimbursement.

C.2.2.8. Claims for Pharmaceuticals. Claims for pharmaceuticals paid under this contract shall meet US equivalent or international standards. Medications that are considered over-the-counter by U.S. standards are not authorized for reimbursement.

C.2.2.9. End of Health Care Delivery. Claims received by the Contractor during its period of services delivery are required to be processed to completion within 180 calendar days following the end of health care delivery. There will be no medical claims processing fee paid to the Contractor if the 180 calendar day requirement is not met.

C.2.2.10. Appeal Process. A claim dispute is a disagreement regarding a claim or utilization review decision. The Contractor shall manage an internal appeal process to resolve claim disputes, whereby eligible members may submit an appeal in writing by mail or through a web portal or a phone call, to a toll-free number, or number that accepts collect calls from international members, to the Contractor. The Contractor shall administer claims appeal procedures consistent with the requirements set forth under the Affordable Care Act (see http://www.hhs.gov/healthcare/about-the-law/cancellations-and-appeals/appealing-health-plan-decisions/index.html

C.2.3. Management.

The Contractor shall establish and maintain a single management focal point to accomplish effective management strategies, lines of authority, and reporting and interfacing with Government. The Contractor shall organize, coordinate, control, and report the status of activities, including those activities assigned to subcontractors, to ensure correct and timely delivery of services specified in this contract in accordance with Section C.9. Data and Reporting Requirements. The management focal point at a minimum is required to ensure the following:

C.2.3.1. Certification/Recertification. The Contractor shall establish and operate a provider certification/recertification program to ensure that all Providers who provide services to Volunteers are qualified to provide high quality care that is commensurate with the HCBS contract and local requirements. During the certification/recertification process, the Contractor shall check the U.S. Department of Health and Human Services (DHHS) List of Excluded Individuals and Entities (LEIE) (http://exclusions.oig.hhs.gov/) for all providers. Providers listed on the DHHS LEIE are excluded from providing services under all federal programs. This restriction remains in place even if a provider begins practicing in another country. Credentials for network providers shall be verified during the network development/network agreement process. The Contractor shall verify credentials for non-network providers upon receipt of the first Peace Corps medical claim and prior to payment of the medical claim, unless specifically waived by the CO.

C.2.3.2.Accreditation. The Contractor shall ensure that network hospitals and other places of institutional care shall meet accreditation standards of the specific host nation or U.S.

commonwealth/territory.

C.2.3.3. Quality, Safety, and Compliance Evaluations. The Contractor shall establish processes to evaluate the quality, safety, and compliance with licensure/certification and malpractice insurance requirements of network medical institutions and maintain such evaluations for inspection by the Government. Evaluations shall be updated every three years at a minimum unless specifically waived by the CO.

C.2.3.4. Medical Malpractice Coverage. The Contractor is responsible for determining the medical malpractice coverage required in the country, province, state, commonwealth/territory, etc. for each network provider (both professional and institutional) and ensuring that each network provider is in compliance with this standard. In the absence of any country, province, state, commonwealth/territory, etc., legal requirement for medical malpractice insurance coverage, the Contractor is responsible for determining the local community standard for medical malpractice coverage, and the Contractor must maintain documentation evidencing both the standard and compliance by network providers. Each network provider agreement must indicate the required malpractice coverage. Evidence documenting the required coverage of each network provider under the contract shall be provided to the CO upon request. Network providers that are country, province, state, commonwealth/territory, etc., entities and are self-insured by the country, province, state, commonwealth/territory, etc. are not required to have medical malpractice insurance. The CO retains the authority to determine whether country, province, state, commonwealth/territory, etc., and/or local requirements and/or community standards for medical malpractice coverage have been met by a network provider and whether the Contractor has documented the required coverage. The Contractor shall verify medical malpractice coverage of non-network providers upon receipt of the first Peace Corps medical claim and prior to payment of the medical claim, unless specifically waived by the CO.

C.2.3.5. Financial Rating. The Contractor shall maintain a current minimum financial strength rating of A- (excellent) as assigned by the A.M. Best Company (A.M. Best) and/or Standard and Poor’s current minimum rating of AA (very strong). The Contractor shall provide satisfactory assurances , via the Annual Contract Activity Report, (CDR A006), that the Contractor and all subcontractors, insurers, claims and program administrators maintain acceptable financial stability, required licensing and service ratings from rating organizations such as A. M. Best and/or Standard and Poor’s.

C.2.3.6. Contracting Officer Representative (COR). The Contractor shall keep the COR apprised of incidents, situations, and circumstances that affect the administration, management, financial viability or costs associated with its health insurance program and recommend action to resolve those issues.

C.2.3.7. Records Management. The Contractor shall maintain copies of all financial transaction records (including but not limited to purchase orders, paying bills, collecting debts and invoices) generated during implementation of this contract. At the end of the contract’s final period of performance, the Contractor shall deliver to Peace Corps all records, in accordance with Section F.2. CDR A010 “Financial Transaction Records”.

C.2.3.8. Standard Services. Peace Corps has the following standard services in place for hosted solutions and/or…