RFR 253933 Refugee Health Assessment Program~1.docx

The Commonwealth of Massachusetts Department of Public Health Bureau of infectious disease and Laboratory Sciences

Address: 305 South Street, Jamaica Plain, MA 02130

Contact Name: Dr. Falah Hashem

Email: falah.hashem2@mass.gov

Request for Response (RFR)

Document Title: Refugee Health Assessment Program

DPH RFR Document Number: 253933

COMMBUYS BID Number: BD-25-1031-BID00-BID02-105199

July 17, 2024 Key RFR Information All Potential Bidders Must Read

COMMBUYS REGISTRATION

It is the responsibility of the prospective Bidder and awarded Contractor to maintain an active registration in COMMBUYS and to keep current the email address of the Bidder’s contact person and prospective contract manager, if awarded a contract, and to monitor that email inbox for communications from the Purchasing Department, including requests for clarification. The Purchasing Department and the Commonwealth assume no responsibility if a prospective Bidder’s/awarded Contractor’s designated email address is not current, or if technical problems, including those with the prospective Bidder’s/awarded Contractor’s computer, network or internet service provider (ISP) cause email communications sent to/from the prospective Bidder/Awarded contractor and the Purchasing Department to be lost or rejected by any means including email or spam filtering. To register review the COMMBUYS Job Aide COMMBUYS Vendor Registration and/or go to www.COMMBUYS.com.

QUOTE SUBMISSION

This BID requires the submission of electronic quotes. All Bidders are advised to allow adequate time for submission of their quotes by considering potential online impediments like Internet traffic, Internet connection speed, file size, and file volume. DPH is not responsible for delays encountered by Bidders or their agents, or for a Bidder’s local hardware failures, such as computers or related networks, associated with bid compilation or submission. Bids submitted via COMMBUYS are time stamped by the COMMBUYS system clock which is considered the official time of record.

If you plan to submit a quote to this RFR “No Bid” should not be checked anywhere in your quote in COMMBUYS. This includes on the General Screen and the Items tab. Checking No Bid sends your quote to a different location in COMMBUYS than the rest of the quotes for that Bid and you run the risk of the Department not receiving your response. The department will not guarantee that a bid received with a “No Bid” checked will be reviewed.

Section A: Procurement Overview

A1: Procurement Description and Purpose:

The Massachusetts Department of Public Health (DPH), Division of Global Populations and Infectious Disease Prevention (Division) ((hereinafter, the “DGPIDP” or the “Division”) seeks to purchase a network of eligible, qualified healthcare providers for the Refugee Health Assessment Program (RHAP), also known as domestic Refugee Medical Screening (RMS).

Providers currently holding a valid RHAP contract with DPH are invited to submit a proposal in response to this RFR from the date of its publication until the end of March 2025 to facilitate the execution of their new contract before the start of SFY2026, which is July 1, 2025. Agencies applying for the first time should anticipate a review period of at least four months before receiving notifications about their proposals. New providers whose proposals are submitted by August 30, 2024, may anticipate a contract start date of January 2, 2025, to ensure operational readiness by the start of SFY2026.

This RFR is for direct services under the Office of the Comptroller’s object code classification MM3 or M03. To be considered eligible to apply for this RFR, a bidder must be considered an organization. Individuals are not eligible to apply.

The RHAP services provided under this RFR are available to persons eligible for Office of Refugee Resettlement (ORR) refugee benefits and services, including individuals granted immigrant status as refugees, asylees, Cuban/Haitian entrants, Immigrant visa holders from Iraq and Afghanistan, certain Amerasians, victims of a severe form of trafficking, and individuals with other status deemed eligible by ORR. RHAP services are prioritized for individuals within their first 90 days after arrival in the United States, with some flexibility for initiation supported by non-ORR funds.

Referrals to the RHAP program are made by resettlement agencies, which assist in linking refugees with RHAP services by referring eligible individuals to services and providing education about the importance of RHAP services as part of the initial orientation.

Refugees may present with various health conditions and cultural backgrounds, necessitating culturally sensitive and linguistically appropriate RHAP services. RHAP contractors are expected to provide comprehensive initial and follow-up screening, medical assessment, mental health screening, and more (as outlined in Section C and summarized in Appendices A and B), and will be reimbursed for allowable costs incurred under a cost-reimbursement structure. Eligible applicants for this procurement include licensed medical agencies with experience in providing services to RHAP priority populations or a demonstrated capacity to do so.

Refugees and other eligible ORR individuals qualify for MassHealth coverage, with most obtaining active health insurance by their second visit. Those who have not yet received their MassHealth cards should still be considered eligible, either retroactively from the application date or through a temporary number. Contracted agencies are expected to seek third-party reimbursement where possible and appropriate, as third-party revenue is a key source of budget offset revenue. Clients should never be turned away because they cannot pay for services or are “out of network."

The procurement for RHAP services is open on a rolling basis and is set to close on 6/30/2033, with approximately 20 awards to be granted. DPH reserves the right to increase the number of awards depending on need and funding. Additionally, DPH reserves the right to close the procurement upon reaching the specified number of awards and retains the discretion to reopen it based on programmatic needs.

Section B: Procurement Information B1: Applicable Procurement Law

Executive Branch Goods and Services

B2: Whether Single or Multiple Contractors Are Required for Contract(s)

Check One (“X”):

B3: Calendar Rule Type

B4: Acquisition Method: Fee for Service:

B5: Use of a Procurement by a Single or Multiple Departments

· Identify additional Eligible Entities by name or type.

The Purchasing Department reserves the right to add or remove additional authorized users during the contract term.

B6: Expected Duration of Contract

B7: Anticipated Expenditures, Funding or Compensation for Expected Duration

Dollar Amount

Estimated annualized procurement amount $6,000,000

Check One (“X”):

Notice concerning rates of payment – implementation of Chapter 257 of the Acts of 2008: An Act Relative to Rates for Human and Social Service programs provides that the Secretary of Health and Human Services has the sole responsibility for established rates of payment for social service programs purchased by governmental units of the Executive Office. Contracted vendors will be reimbursed based on rates established by EOHHS regulation, 101 CMR 304, 101 CMR 317, 101 CMR 320, 101 CMR 318, and other applicable rate regulations as may be amended from time to time during the duration of the Contract. As a result of Chapter 257, during the life of the Contract, rates of payment and reimbursement structures may change.

Will Federal Funds be used to fund any part of Contract(s)?

*Additional information for contracts with Federal Dollars:

Sub-Recipient: Providers receiving federal grant funds will be considered sub-recipients for federal grant purposes and will be required to comply with applicable federal requirements, including but not limited to sub-recipient audit requirements under OMB Circular A-133.

Unique Entity Identifier: On April 4, 2022, the unique entity identifier used across the federal government changed from the DUNS Number to the Unique Entity ID also known as UEI or SAMS number. Any entity that wants to apply for federal contracts or wants to receive federal funds must register with SAM. Entities that use SAM include for profit businesses, nonprofits, government contractors or subcontractors, as well as state and local governments.

Registering with SAM.gov is free and is required for your organization to receive federal funds. Your organization can submit an application to this RFR without being registered on SAM, however if awarded your organization will need to have an active SAM account prior to contract execution.

Unspent Funds: Any funds from Capital, Trust and/or Federal Accounts designated in the budget that are unspent in any fiscal year will not be available for expenditure in the subsequent fiscal year.

Section C: Performance and Contract Specifications

C1: Eligibility

This RFR is for direct services under the Office of the Comptroller’s object code classification MM3 or M03. To be considered eligible to apply for this RFR, a bidder must be considered an organization. Individuals are not eligible to apply.

The procurement process for organizations will prioritize those with documented experience in providing successful services to RHAP priority populations or demonstrate the capacity to do so. Eligible applicants include licensed medical agencies such as community health centers, hospital-based clinics, or primary care physician practices. The successful bidders will be expected to work collaboratively with various community agencies and healthcare service providers, including resettlement agencies, primary care providers serving refugees, local boards of health, and regional program staff of the Division.

DPH seeks bidders who can adapt to the dynamic resettlement landscape and changing immigration pathways, such as Haitian Humanitarian Parole and private sponsorship. The contractors must be flexible to respond to the needs of changing populations, resettlement patterns, and rapid increases in new arrivals.

In case of unexpected or atypical increases in the number of individuals needing RHAP services, the sites may subcontract with other providers in the community. To meet increased demand for RHAP services, and contingent upon the availability of existing resources or new state or federal funding that may become available during the procurement period, DPH may add funds to existing or new contracts or subcontracts funded under this RFR.

C1a: Provider Qualification Requirements

To be considered eligible and prior to entering into a contract with DPH a bidder must demonstrate that it meets minimum administrative and fiscal standards established through the Executive Office of Health and Human Services (EOHHS) provider qualification policy. Your provider qualification status will be considered when making award decisions.

Provider qualification is the process used to evaluate a provider’s administrative and financial condition. The main objectives of the provider qualification process are to determine whether the provider has (a) the capabilities to comply with the numerous federal and state administrative requirements that surround the expenditures of public funds and (b) sufficient fiscal and administrative capacity to fulfill its contractual obligations.

· New Providers of Purchased Human and Social Services to Clients Bidders who do not have current contracts with the Commonwealth of Massachusetts to provide human and social services for clients must submit completed provider qualification application materials as part of the response to this RFR. The Contracting Qualification Forms and instructions can be found in the Provider Qualification Folder (QUALIFICATION) in the attachments section of COMMBUYS for this RFR.

· Current Providers of Purchased Human and Social Services to Clients Bidders with current human and social services contracts (MM3/M03 contracts) must have filed their Uniform Financial Statements and Independent Auditor's Report (UFR) with the Operational Services Division (OSD) via the internet using the UFR eFiling application for the most recently completed fiscal year before a contract can be executed and services may begin unless considered exempt from filing. Other contractor qualification/risk management reporting requirements and non-filing consequences promulgated by Secretariats or Departments pursuant to 808 CMR 1.04(3) may also apply. If you have questions about your UFR contact the UFR Help Desk at ufrefilehelp@mass.gov. The following is a link to access the OSD UFR eFilling System: https://ufr.osd.state.ma.us/home.asp

C2: Intended Client Population

RHAP services procured under this RFR are available to persons eligible for Office of Refugee Resettlement (ORR) refugee benefits and services. The term “refugee” is used in this document to include individuals granted immigrant status as refugees, asylees, Cuban/Haitian entrants, Immigrant visa holders from Iraq and Afghanistan, certain Amerasians, victims of a severe form of trafficking, and individuals with other status as deemed eligible by ORR[footnoteRef:2]. DPH reserves the right to expand the definition of eligibility for RHAP services during this procurement, consistent with directives from ORR. DPH may also expand eligibility under this RFR by supporting a service expansion with other Federal or State resources. [2: For a complete list of individuals by immigration status eligible for RHAP services, please refer to the U.S. Department of Health and Human Services Office of Refugee Resettlement policy and guidance posted on their website, as it is subject to periodic amendment. ]

Most persons referred for RHAP services are within 90 days of arrival to the United States (newly arrived). Some asylees may have been in the U.S. for a significant period before being granted asylum. Other asylees arrive directly from overseas with derivative status, joining a parent or spouse granted asylum. Victims of trafficking may also have resided in the U.S. for a significant period before being granted eligible status. RHAP services should be prioritized for individuals within their first 90 days after arrival in the United States; however, initiation of RHAP services, when supported by non-ORR funds, is allowable after the 90-day post-arrival period, consistent with guidance from DPH.

Several factors can impact the well-being of refugees before they resettle in the U.S. These include their place of origin and, in some cases, living conditions in overcrowded refugee camps with limited resources. Lack of access to healthcare services overseas, exposure to contagious diseases like tuberculosis, vulnerability to poor nutrition, and chronic illnesses such as diabetes can result in acute and chronic health conditions. Furthermore, psychological distress from conflicts, displacement, and resettlement, which can lead to mental health issues such as depression or post-traumatic stress disorder, are some other psychological and physical health factors that affect their health.

Refugees may present with vastly different healthcare beliefs and cultural backgrounds. They may also communicate in a range of spoken and written languages, which may impede access to health information and utilization of health services. Through this procurement, DPH seeks to fund clinical organizations and staff teams with knowledge of the healthcare needs of refugees, and experience in providing culturally sensitive and linguistically appropriate RHAP services to immigrant and refugee populations with diverse backgrounds.

The presidential determination on refugee admissions for the federal fiscal year 2024 (October 1, 2023 – September 30, 2024) is to admit up to 125,000 refugees to the U.S. based on humanitarian concerns or the national interest. The refugee admissions numbers are determined per the following regional allocations.:

Africa . . . . . . . . . . . . . . . 30,000-50,000 East Asia . . . . . . . . . . . .. 10,000-20,000 Europe and Central Asia . . . . . .. 2,000-3,000 Latin America/Caribbean . . . . . . 35,000-50,000 Near East/South Asia . . . . . .. 30,000-45,000

During FFY2023 (October 1, 2022, through September 30, 2023), a total of 60,014 refugees arrived in the U.S. Their distribution by world region was as follows: Africa 24,481 (41%), Near East and South Asia 20,194 (34%), Latin America and Caribbean 6,312(10%), Europe and Central Asia, 2,765(5%), East Asia 6,262 (10%). Additional information is available at www.state.gov/prm or https://www.wrapsnet.org/admissions-and-arrivals.

Also, during FFY2023, the U.S. welcomed many more arrivals via the Department of Homeland Security’s Humanitarian Parole pathways for Afghan, Ukrainian, and those seeking parole at a U.S. point of entry (POE) (Note: not all persons seeking parole at POE are eligible for ORR refugee services).

In recent years, approximately 2,000 to 3,000 refugees received RHAP services annually. During FFY2022, 2,982 refugees were served through RHAP in Massachusetts, with the largest numbers from Afghanistan (67%), Ukraine (13%), Haiti (5%), and the Democratic Republic of Congo (5%). By world region, approximately 70% of resettlement was from the Near East and South Asia,13% from Europe and Central Asia, 9% from Latin America, 7% from Africa, and approximately 2% from East Asia. DPH utilizes past migration patterns and anticipated trends in new arrivals as one consideration in selecting a network of RHAP provider organizations optimally capacitated to meet the needs of newly arriving populations.

C3: Geographic Location of RHAP Services

The RHAP services shall be provided in areas of the State with the highest concentrations of newcomers. Traditionally, these areas surround resettlement hubs in Boston, Brockton, Holyoke, Lawrence, Lowell, Lynn, Springfield, West Springfield, and Worcester. Refugees may continue to resettle in areas further from resettlement agency partners; therefore, eligible organizations located in northwestern and southeastern Massachusetts regions are encouraged to also apply, though the number of new arrivals in this area may be fewer in number and less consistent compared to other areas of the Commonwealth.

C4: Role of Resettlement Agencies

Resettlement agencies assist in linking refugees with RHAP services by referring eligible individuals to services and providing education about the importance of RHAP services as part of the initial orientation.

Resettlement agencies facilitate MassHealth enrollment for all refugees on their caseloads. Families with dependent children are referred to the Department of Transitional Assistance (DTA) for enrollment in MassHealth Standard. Refugees without dependent children are referred to MassHealth Enrollment Centers (MECs) to complete their enrollment application to MassHealth CarePlus. A list of MECCs is available at https://www.mass.gov/info-details/masshealth-enrollment-centers-mecs or applications can be completed online at https://www.mahealthconnector.org/

Resettlement agencies also assist refugees found ineligible for MassHealth to enroll in the Refugee Medical Assistance (RMA) program. Additional information about RMA can be found here: https://www.acf.hhs.gov/orr/programs/refugees/cma

C5: Overseas Medical Examination

Before entering the U.S., refugees coming through entering the U.S. Refugee Admission Program (USRAP) complete an overseas medical examination. The overseas medical examination is an overseas medical examination that aims to identify applicants with inadmissible health-related conditions. A Class A designation indicates that the applicant has an excludable condition and has entered on an approved waiver. A Class B designation indicates the need for follow-up in the U.S. for physical or mental health conditions.

The Centers for Disease Control and Prevention (CDC) Division of Global Migration and Quarantine provides technical instructions and guidance to physicians conducting medical examinations for immigration, including but not limited to the following:

· Technical Instructions for Panel Physicians (https://www.cdc.gov/immigrantrefugeehealth/panel-physicians.html)

· Overseas Refugee Health Guidance (https://www.cdc.gov/immigrantrefugeehealth/guidelines/overseas-guidelines.html)

· Technical Instructions for Civil Surgeons (https://www.cdc.gov/immigrantrefugeehealth/civil-surgeons.html)

· Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees (https://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic-guidelines.html)

C6: Timeline of RHAP Services

In accordance with federal regulations, RHAP services are to be provided within 30 days and up to 90 days from the date of the refugee eligibility for ORR benefits to qualify for reimbursement by RHAP.

Priority for RHAP appointments is given to those persons with medical conditions identified during the overseas medical examination (Class A or Class B conditions). A refugee with a Class A condition should initiate the health assessment within seven days of U.S. entry; those with Class B conditions, within 30 days.

With an approved waiver from ORR, refugees enrolled in Refugee Medical Assistance (RMA) may receive RHAP services for up to 12 months from their date of eligibility for ORR benefits and services. Following the expansion of Medicaid on January 1, 2014, no refugees registered in RMA in Massachusetts, indicating a lower probability for ineligible individuals for Medicaid to enroll in RMA.

C7: Scope of Services

The Massachusetts RHAP was implemented in 1995 to remove barriers that prevent new arrivals from accessing timely medical services within 90 days following their entry into the U.S. Core service elements include medical assessment, mental health screening, immunization, triage, and follow-up services, referral to primary care, and specialty care if needed. Targeted tests for specific conditions complement the core service. Protocols and all elements of RHAP are defined by the Division and are provided to all contractors as outlined in this section and summarized in Appendices A and B. A comprehensive clinical guide that the Division developed for healthcare clinicians can be found online at https://www.mass.gov/lists/refugee-health-assessment-a-guide-for-health-care-clinicians

Should a newly arrived refugee have an acute or serious health condition that requires immediate care, the health insurance application may be completed at the facility providing immediate care, i.e., a hospital or acute care center. In either enrollment pathway, refugees will be eligible for MassHealth coverage should they require any medical care beyond the scope of the RHAP services.

Resettlement Agencies (RA) verify refugee eligibility for services and refer them directly to contracted providers for health assessment. In those cases where an arrival does not have a designated RA (i.e., some asylees, some Humanitarian Parolees, or Cuban/Haitian entrants), Division staff may verify eligibility and refer those individuals for services.

The RHAP service includes medical assessment, testing and treatment for specific conditions, follow-up services, triage/referral for positive findings, and linkage with primary and specialty care. See Appendices A and B for the RHAP Clinical Services protocol summary. The core service is two office or clinic visits. All services are to be delivered by physicians (MD or DO) or midlevel clinicians (NP or PA) and their appropriately supervised staff, with trained medical interpreters and in a manner that is responsive to refugees’ language, experiences, and culture. Program details are provided below.

All RHAP service providers must have the capacity to assure the following program components, at a minimum:

I. Two full clinic visits for the health assessment: The first visit, whenever possible, should be initiated within 30 days of refugee entry into the U.S. or asylum date, but no later than 90 days after this date. The second visit must be within 90 days of U.S. entry. Initial and follow-up visits should be 28 days apart whenever possible. Visits primarily to read a Tuberculosis Skin Test and/or drop stool specimens do not constitute a follow-up visit and may not be counted as such. During the initial visit, the provider will:

1. Review medical documents and X-rays [DS-2054 Medical Examination, DS-3025 Vaccination, DS-3026 Medical History, DS-3030 Chest X-ray and TB Classification, Pre-Departure Medical Screening findings, and other records such as the Significant Medical Conditions form, as available] for individuals completing overseas medical examination. Overseas medical records are shared with the refugee health assessment site before the appointment whenever possible.

· In the case of persons granted asylum in the U.S. (asylees), review the history of medical care utilization in the U.S.

· Review medical screening documents as available for eligible humanitarian parolees or other persons who have not completed an overseas medical examination.

2. Perform a complete medical history and physical examination, including vital signs, standard anthropometric measurements, visual acuity screen, and gross dental and hearing examinations. Clinicians are expected to assess tobacco use (packs per day) and alcohol consumption (drinks per day) of all adolescent and adult refugees. Clinicians should also document migration history, with particular attention to trauma, including psychological trauma.

3. Test all refugees for tuberculosis (TB) as described in Section B below.

4. Evaluate and treat for intestinal and invasive helminths/parasites based on a review of presumptive pre-departure treatment and the patient’s history and physical exam findings. Clinicians are expected to follow RHAP protocols derived from CDC guidelines for domestic assessment of refugees for intestinal parasites. See Appendices A and B.

5. Conduct the following core screening tests:

a) All refugees:

· Complete blood counts (CBC) with a five-cell line white blood cell differential to evaluate absolute eosinophil count.

· Provide a stool collection kit for a single sample that will be sent for Giardia antigen testing.

· Review pre-arrival hepatitis B screening and vaccination. Screen for hepatitis B infection if not completed pre-arrival, and for those who are unvaccinated, screen for immunity with Anti-HBs and Anti-HBc. Additional targeted tests are available for further evaluation of refugees with positive HBsAg or signs or symptoms suggestive of liver disease, including elevated transaminases (part of the Comprehensive Metabolic Panel, part of the RHAP targeted test panel).

· Urinalysis (UA) dipstick is for refugees who are urine continent.

b) Age-specific testing:

· Order serum IgG levels against varicella zoster virus (chicken pox) for refugees five years and older.

· Test for venous blood lead level for refugees under 16 years of age and pregnant or lactating persons of any age. Plan and schedule follow-up testing at 3-6 months post-placement in permanent housing for all refugees aged six years and younger and those aged 7 to under 18 years with prior BLL ≥3.5 μg/dL (including pregnant or lactating adolescents) or risk factors including sibling with prior BLL ≥3.5 μg/dL or known environmental exposures.

· Test for HIV antigen and/or antibodies (4th generation antigen-antibody test is preferred) for refugees 14-64 years of age. Screening refugees under 14 years old or over 64 years of age is encouraged.

· Test for Hepatitis C virus antibodies for refugees aged 18 years and older.

· Review pre-arrival screening for syphilis and gonorrhea. If not completed pre-arrival, screen for syphilis in all refugees aged 18- 45 years and gonorrhea in refugees aged 18-24 years or who have risk factors and those who are pregnant.

· Test for Chlamydia in refugees aged 18-24 years or present with associated risk factors.

6. Evaluate immunization status and initiate any needed age-appropriate vaccines. Clinicians are required to follow ACIP guidelines:

https://www.cdc.gov/vaccines/hcp/acip-recs/index.html

7. Treat other acute conditions as specified in RHAP clinical protocols. See Appendices A and B.

8. Triage or initiate care for urgent matters beyond the scope of the health assessment protocol, as appropriate. (Patients should be registered for a separate office visit with MassHealth as the payor if testing beyond that of the RHAP protocols is anticipated.)

9. If the urine pregnancy test yields a positive result, the refugee should be directed to a clinician specializing in obstetric care for proper management of the pregnancy. For patients who are pregnant or attempting to conceive, the initial screening visit presents an excellent opportunity to have conversations about the significance of preconception care, prenatal vitamins, suitable gestational weight gain, vaccinations, and addressing underlying medical conditions, tobacco and alcohol use, as well as mental health concerns. Screening clinicians should also highlight the importance of establishing a medical home for continuous health-related screening and vaccination, treating acute or chronic health conditions, and promoting health.

10. Begin basic health education on immunization, primary care, primary care clinician choice, mental health wellness, oral health, emergency services, insurance, and access to health services.

11. Provide all refugees with an age-appropriate multivitamin with iron that is roughly sufficient to last one month, as indicated and per RHAP protocol. See Appendices A and B.

12. Complete school health forms for children, personal vaccine records for adults and children, and WIC medical referral forms for pregnant women and young children.

13. In coordination with the division's regionally based staff, arrange TB clinic referrals for all refugees with confirmed TB classifications identified during the overseas medical examination (Class A/B1/B2/B3 TB).

14. Conduct targeted testing, as appropriate, per RHAP protocols.

15. Additional testing may be conducted as required by the Division in the future to respond to the changing health needs of refugee populations.

Between the initial visit (#1) and follow-up visit (#2), the provider will:

1. Conduct Giardia antigen testing on the returned stool specimen.

2. Measure the Tuberculin Skin Test (TST) at 48-72 hours after administration and record the results in millimeters of induration.

3. Review TB test results (IGRA or TST) and refer individuals with positive results for evaluation at a TB clinic or assessment within the facility.

4. Fill prescriptions for anti-parasitic medications and multivitamins with iron and have them ready for patients at the #2 visit. Other prescriptions may be provided on paper or sent electronically to the site’s affiliated pharmacy. If RHAP reimbursement is needed, sites should preferentially use 340B pharmacies. If MassHealth coverage is in place, sites should use it and may prescribe to the patient’s preferred pharmacy regardless of its 340B status.

During the follow-up (#2) visit, the provider will:

1. Discuss clinical findings and test results with the patient.

2. Administer additional vaccine doses as needed.

3. Initiate treatment, as needed, for parasites and other acute conditions as specified in the RHAP protocol (appendices A and B).

4. Conduct targeted testing, as appropriate, following RHAP protocols. See Appendices A and B.

5. Review primary care options and schedule an appointment. Identify current barriers to primary care access.

6. Schedule sub-specialty referrals for urgent conditions as needed.

7. Update the personal vaccine record. Complete other forms, such as the DTA Immunization Certificate, as needed.

At either the initial (#1) or follow-up (#2) visit, the provider will:

1. Conduct mental health screening using the RHS-15 instrument (see below) for all refugees 14 years and older.

II. Tuberculosis Screening and Referral: The RHAP clinical sites will collaborate with the Division to develop specific procedures for TB testing and referral for that site. Unless contraindicated, TB testing should be by IGRA; TST is the alternate method. All refugees with an overseas diagnosis of tuberculosis (latent or active), a positive TB infection resulting from RHAP testing, or symptoms consistent with tuberculosis should be referred to a state TB clinic or approved alternative for further evaluation.

TB testing using IGRA: Interferon Gamma Release Assay (IGRA) is the preferred test for refugees, with some exceptions. Children aged less than two years and individuals with chronic diseases such as diabetes mellitus, chronic renal failure, hematologic malignancy, and other specific malignancies should have a TST administered. IGRA interpretations are based on the amount of IFN-g released or the number of cells that release IFN-g. Both follow the standard qualitative test interpretation:

· Positive – suggests that M. tuberculosis infection is likely.

· Negative – suggests that infection is unlikely.

· Indeterminate – indicates an uncertain likelihood of M. tuberculosis infection.

Based on the 2024 guidance from the CDC, if the Interferon Gamma Release Assay (IGRA) is negative overseas (within the last six months), and there are no signs or symptoms of TB disease upon physical examination, no further domestic evaluation is needed. Repeat IGRA if the overseas IGRA was negative but performed ≥6 months before the domestic examination.

Refugees with indeterminate IGRA testing results, including when documented on the overseas medical examination, should have a repeat IGRA or a TST test administered per the regular protocol.

Live viral vaccine can be administered on the same day as a TST or IGRA test. If a live viral vaccine was administered overseas or before the first refugee health assessment appointment, the TST or IGRA test should be postponed for at least 28 days after the vaccination.

TB testing using TST: The TST is preferred for refugees under two years of age and those with medical conditions specified above. The TST can be administered for children six weeks and older. 5 T.U. of PPD is injected intradermally via the Mantoux technique and read by qualified personnel 48-72 hours after administration. Refugees with documentation of a positive TST from overseas should not be re-tested using TST. A positive TST result is transverse induration >10 mm (>5mm if the patient meets specific high-risk criteria).

For all refugees: For the persons noted below, arrange an appointment for evaluation at a state-supported TB clinic or other approved site. This should be done in coordination with the Division’s regionally based staff and/or the local health department.

· Refugees arriving on treatment for active TB disease (Class A TB) or latent TB infection (Class B2).

· Refugees with an abnormal overseas chest X-ray consistent with TB (Class B1 TB) regardless of TB test (IGRA or TST) result.

· Refugees with a positive TB test (IGRA or TST) overseas and diagnosis of latent TB infection (Class B2 TB).

· Refugees with a positive TB test (IGRA or TST).

· Asylees with a documented history of a positive TB test (IGRA or TST), but no documented history of treatment.

III. Immunization Assessment and Administration: Immunization assessment and administration includes review of available immunization documents; serological testing for evidence of immunity to specific vaccine-preventable diseases and review of test results; and vaccination of individuals in accordance with the vaccine schedules of the CDC Advisory Committee on Immunization Practices (ACIP) and the DPH Immunization Program. The RHAP requires clinicians to follow the most recent ACIP schedules for routine and catch-up schedules for both children and adults. These schedules are posted on the CDC website: http://www.cdc.gov/vaccines/schedules/index.html. In addition, detailed guidance from ACIP about each vaccine can be found on the web at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Massachusetts school entry vaccine requirements are available on the DPH Immunization Program website www.mass.gov/info-details/school-immunizations.

All RHAP sites must be enrolled and participate in the Vaccines for Children Program/DPH Immunization Program.

The RHAP requires the following of providers:

1. Review overseas immunization documentation, including pre-departure documents. Pre-departure refugee vaccination programs have expanded to cover many US-bound refugees. Some refugee documents may need to be translated. Incomplete documentation of overseas vaccines may not be considered adequate for withholding vaccination.

2. Assess immunization status. Refugees with documentation of partial immunization should receive necessary vaccines according to the ACIP catch-up schedule. Those refugees, including adults, with no documentation of prior vaccination should start the primary vaccination series. Administer all vaccinations needed to comply with age-specific adult and pediatric guidelines of the ACIP. ACIP guidelines are summarized below in the context of RHAP serologic testing for immunity to vaccine-preventable diseases. Subsequent doses should be given at the second visit, if indicated, based on prior documentation, results of serologic testing, and age-specific ACIP guidelines. Vaccination should begin at the first visit for all patients without specific contraindications. While not recommended, urine pregnancy testing may be conducted at each visit, if needed, before administering live viral vaccines to persons of reproductive potential.

3. Specific serologic testing and vaccination requirements include:

· Hepatitis B: Draw blood for HBsAg testing as needed based on the review of overseas screening results. Whenever possible, this should be done before or essentially concurrently with administering the hepatitis B vaccine, as rare false-positive tests for HBsAg in Massachusetts have been attributed to receipt of the vaccine within a few days prior to serologic testing. The first dose of hepatitis B vaccine can be given at the first health assessment visit.

· Refugees who test positive for either anti-HBs or HBsAg in the absence of previous vaccination do not require vaccination (or further doses if one was administered at the first visit).

· Refugees who test positive for anti-HBs after receiving only 1 or 2 doses of the 3-dose vaccine series [prior to the health assessment] should always complete the full series.

· Varicella: Assess all children less than five years of age for a history of chickenpox.

· Administer varicella vaccine to all children between 1 and 5 years of age who have no history of chickenpox or physical findings on examination consistent with chickenpox scars.

· History of chickenpox or physical findings on examination consistent with chickenpox scars are considered sufficient evidence of immunity and should be documented on the RHAP reporting form and personal vaccine record.

· Assess anti-varicella IgG status in adults and children five years of age and older.

· Individuals with negative results require two doses of the varicella vaccine, given at least four weeks apart. The first dose should be initiated at the second RHAP visit. School-aged children can receive one dose of varicella vaccine at the first visit, pending the serology results to facilitate school entry, and then receive the second dose at the second visit if needed.

4. Educate refugees about vaccine follow-up needs.

5. Complete a childhood or adult vaccination personal record with documentation of overseas and RHAP vaccination for all refugees.

IV. Protocols for Targeted Tests / Treatment: The RHAP protocol includes targeted testing and treatment for specific conditions in addition to the core assessment components. Providers must follow protocols outlined in the RHAP clinical manual for testing and treatment. See Appendices A and B. The targeted tests are for:

· Sexually transmitted diseases (urine amplified DNA testing for gonorrhea and Chlamydia; RPR/VDRL for syphilis)

· Parasitic infections (stool ova & parasites microscopy for helminths; IgG serology for strongyloidiasis, schistosomiasis, and filariasis; thick blood smear for malaria; CBC with differential for eosinophilia)

· Hepatitis (serologic testing for HAV, HBV, HCV, and HDV)

· Other acute infections (rapid strep testing and culture for streptococcal tonsillopharyngitis; urine culture for urinary tract infections)

· Measles, mumps, rubella antibodies

· HIV (HIV genotype, viral load, CD4 counts)

· Pregnancy (urine HCG)

· Metabolic and endocrine disorders (screening for dyslipidemia, thyroid disease, diabetes mellitus with TSH, comprehensive metabolic panel, lipid panel, and HbA1c)

· Elevated blood lead level (venous lead level)

· Nutritional issues (vitamin B12 level), and

· Congenital disorders (newborn screening profile for <6 months of age)

· Chest radiograph(s)

Pharmaceutical services authorized under this contract include prescribing of contraception, treatment of parasitic infections, and additional conditions diagnosed clinically that include the following. In all cases for RHAP clients presenting with MassHealth or other insurance, billing of insurance for these and other services must be optimized, and contractors may not bill DPH for services fully covered by insurance:

· Acute otitis media

· Acute otitis externa

· Chlamydia infection

· Gonorrhea

· Syphilis

· Anemia and iron deficiency

· Scabies and lice

· Streptococcal pharyngitis

· Tinea capitis

· Tinea corporis

· Tinea versicolor

· Urinary tract infection

· Pregnancy Prevention

V. Additional [Optional] Services Prior to the First Health Assessment Visit: The RHAP sites may provide accelerated children’s vaccination services prior to the first health assessment visit. The purpose of this early visit is to facilitate children’s entry into school, camp, or childcare, particularly when the standard first health assessment visit may be delayed to beyond the child’s first 30 days in the U.S. Sites that provide these services as part of the RHAP contract should:

· Evaluate immunization history, review overseas documentation, and record valid doses.

· Order serum IgG levels against Varicella (chicken pox) for all refugee children aged 5 and older.

· Order Anti-HBs, HBsAg, and Anti-HBc testing as needed for refugee children based on the review of overseas screening and vaccine records.

· Assess for a reliable history of chickenpox disease and document a positive history on the childhood vaccination record.

· School districts may require the first dose of varicella vaccine for those children without a history of chickenpox disease while serologic test results are pending. In such cases, RHAP providers should vaccinate and review the need for the second dose after results are available.

· Initiate all necessary age-appropriate vaccines per ACIP childhood vaccine schedules following a review of overseas vaccination documents.

· Conduct TB test by IGRA or TST; if TST, schedule the TST reading for 48-72 hours later.

· Give all refugees a childhood vaccination booklet, or equivalent record, that provides documentation of valid vaccine doses administered pre-arrival or at the RHAP site as well as the history of chickenpox disease, as appropriate. [Update the record at the second health assessment visit.]

Sites should continue to schedule the first health assessment visit as usual, with the goal of this visit being within 30 days of U.S. entry. The next doses in the vaccine series will be given at the second health assessment appointment.

VI. Additional [Optional] Services Prior to and Subsequent to Health Assessment Visits: RHAP sites have the option to deliver monthly wellness and integration services. The goal of the RHAP Wellness and Integration encounters is to strengthen the capacity for regular check-ins with newly arrived refugees. These check-ins aim to review their engagement in care, address feelings of isolation or distress, and provide support to help them access necessary services. These encounters, in conjunction with health center screening systems for addressing social determinants of health (SDoH), are designed to pinpoint newly arrived refugees who may be at higher risk of distress, isolation, disengagement from care, or challenges in navigating our health systems and community resources. They serve as a tool for engagement and relationship-building to support newly arrived refugees. By creating stronger connections to RHAP sites, these encounters can also help minimize the risk of refugees being lost to follow-up after their RHAP visits.

These services are available to RHAP clients before and after their health assessment visits for up to one year after their arrival or RHAP eligibility date. The coverage of Wellness and Integration services is provided through state funds. Therefore, contractors must establish a distinct budget and tracking plan to clearly separate activities related to RHAP and Wellness and Integration based on the funding source.

VII. Additional [Optional] Services After the Second Health Assessment Visit: The RHAP sites have the option of providing additional adult vaccination services to eligible individuals after the two-visit health assessment. These services can be provided for RHAP-eligible individuals aged 19 or older during the first year following entry into the U.S. The services include:

· Assessment of immunization status.

· Vaccination to complete series (i.e., Td, hepatitis B, varicella) and/or influenza.

· Assessment of engagement with primary care services and referral as appropriate.

VIII. Primary Care Linkage: The RHAP services include linking refugees with primary care and assuring that findings and recommendations from the health assessment are forwarded to the designated primary care provider. Refugees are not obligated or required in any way to continue their primary care at the same site (or with the same clinician) where they received their health assessments. Providers must have services that address linkage, including:

· Assessment—for primary care options, including refugee needs related to language, geographic location, and preference.

· Referral – for primary care, including scheduling of appointments and documentation for follow-up.

· Transfer of medical record/RHAP form – to primary care, with findings from the health assessment and recommendations for follow-up.

IX. Refugee Health Education: Refugee health education is an important component of the health assessment as these are the first encounters a refugee has with the U.S. healthcare system. Health education may include topics such as immunization, primary care, mental health and wellness, oral health, emergency services, insurance, and general access to health services.

X. Language Access: Language access is critical to the delivery of health assessment services, and sites are required to have systems in place that facilitate the identification and use of trained medical interpreters, including those provided through telephone, web-based, or other emerging technologies.

· Services must be delivered with trained medical interpreters or bilingual clinical staff.

· Providers must have the capacity to provide health assessment services to diverse refugee groups, including new and changing populations.

XI. Transportation Access: Refugees receiving health assessment services are newly arrived in the U.S. and have limited options for transportation. Although public transportation or assistance from the sponsor is preferred, in some situations, refugees may need assistance with transportation, and contracted providers under this RFR are expected to facilitate access to medical transportation to attend medical visits, obtain prescribed medications from a pharmacy, or participate in prescribed therapeutic programs.

· The health assessment site should be accessible by public transportation. Parking facilities should be available.

Contractors may include transportation support costs in their budget justifications for cases where RAs are unable to accompany patients home after their appointments. While reimbursement for transportation assistance may be available, it is important to note that this resource is very limited, and specific reimbursement criteria will be determined after the award is granted.

XII. Documentation Procedures: Provider sites must ensure that documentation relative to the RHAP is complete.