S01-VADIP-36C79122R0006-Final 06-08-22.docx

36C79122R0006

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

UEI:

EFT:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

36C79122R0006 06-08-2022 Bradley Geghan (303)-273-6214 06-22-2022 15:00

MDT

Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E) 555 Corporate Circle Golden CO 80401-5621

X

524114 $41.5 Million

N/A

Department of Veterans Affairs Commodities & Services Acquisition Svc

555 Corporate Circle Golden CO 80401-5621 Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E)

Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E)

Veterans Affairs Dental Insurance Program (VADIP)

See Section B.2 for Schedule of Premiums

06-22-2022

Bradley Geghan

VA OPAL NAC 2022 322130

Table of Contents

A.2 NOTES TO OFFERORS

1. This Request for Proposal (RFP) is a Department of Veterans Affairs (VA) action intending to contract with qualified dental insurance carriers to administer and provide insurance coverage to eligible Veterans and Civilian Health and Medical Program of VA (CHAMPVA) beneficiaries for the VA’s Dental Insurance Program (VADIP).

2. Public Law 117-42, dated September 30, 2021 amended Section 1712C of title 38, United States Code, “Dental insurance plan for veterans and survivors and dependents of veterans” (the Statute) by striking subsection (j), which stated that the Act terminates on December 31, 2021. The Statute now allows VA to offer dental insurance plans to Veterans and CHAMPVA beneficiaries beyond calendar year 2021. Eligibility for this program is defined as (1) Any Veteran who is enrolled in VA healthcare under 38 U.S.C. § 1705, in accordance with 38 CFR § 17.36 and (2) Any survivor or dependent of a Veteran who is eligible for medical care under 38 U.S.C. § 1781, which includes individuals eligible for CHAMPVA under 38 CFR § 17.271.

3. This contract will not have appropriated funding, therefore the contract type will be NO-COST with fixed premium rates for the base year. As such, this procurement is not subject to the requirements of the Federal Acquisition Regulations (FAR) or the Veterans Affairs Acquisition Regulations (VAAR); however, the language from numerous FAR and VAAR provisions and clauses, which were deemed appropriate and relevant to this solicitation and the resultant contract(s), have been utilized throughout this solicitation and will continue to be utilized in the resultant contract(s). Some of these FAR and VAAR provisions and clauses have been revised to suit this procurement. This is indicated by the word “(TAILORED)” in the provision or clause title. Other clauses in this RFP contain no FAR or VAAR citation number; these have been written solely for the resultant contract(s) of this solicitation. Provisions will not be included in the contract award document.

4. This is considered a commercial service in accordance with the definition for Commercial service at FAR 2.101.

5. Dental insurance and dental insurance providers have been determined to be Health-care Resource and Health-care Providers as defined in VAAR 873 and 38 U.S.C. 8153.

6. This is a Full and Open, Competitive RFP. The applicable NAICS code is 524114, Direct Health & Medical Insurance Carriers; with a U.S. Small Business Administration size standard of $41.5 Million.

7. The solicited base will be awarded as a No-Cost contract with four option periods. The completed Section B.2.1 Priced Schedule of Premiums shall be required in lieu of completing Blocks 19 – 24 of the SF 1449. Please refer to Section E.5 Addendum to FAR 52.212-1 – Specific Instructions to Offerors Regarding Proposal Preparation for instructions for completing the Priced Schedule of Premiums and Section E.16 Addendum to VAAR 852.273-73 – Evaluation Factors for how the Government will evaluate the price factor for this RFP.

8. All proposals submitted in response to this RFP shall be valid for a minimum of 90 calendar days from the date the RFP closes. A statement regarding the validity period must be included in the proposal.

9. Offerors should take special notice of FAR 52.212-1 Instructions to Offerors-Commercial Service and VAAR 852.273-74 Award Without Exchanges. The Government intends to award contract(s) resulting from this solicitation without exchanges with offerors. Initial proposals should contain the Offeror’s best terms. The Government reserves the right to conduct exchanges if determined necessary by the Contracting Officer.

10. The Government anticipates contracts will be awarded to no more than four offerors; however, the Government reserves the right to award to more or less than four offerors if it is in the best interests of the Government. These awards will be based on a best value evaluation in accordance with (IAW) FAR 15.101-1, in conjunction with FAR Part 12 Acquisition of Commercial Service. The Offeror’s Premium Rate, Technical Approach, and Past Performance will be evaluated under this RFP. Offerors are also cautioned to pay specific attention to Section E.5 Addendum to FAR 52.212-1 – Specific Instructions to Offerors Regarding Proposal Preparation. Offerors should read Section E.15 VAAR 852.273-73 Evaluation-Health-Care Resources (Nov 2021) (Tailored) and Section E.16 Addendum to VAAR 852.273-73 – Evaluation Factors, in its entirety. Awards will be made to the Offerors whose proposals are determined to provide the best value to the Government based upon Section E.16 Addendum to VAAR 852.273-73 – Evaluation Factors, Basis for Award; therefore awards may be made to other than the lowest priced offeror.

11. FAR Clause 52.204-7 System for Award Management is included in this solicitation. Use System for Award Management (SAM) and go to the contract opportunities section to find the procurement notices for VADIP. Contractors should search for opportunities at SAM.gov | Contract Opportunities. Search for the solicitation with VA dental insurance plan (VADIP) or the solicitation number, 36C79122R0006.

12. Offerors are responsible for including sufficient details to permit a complete and accurate evaluation of the proposal. The Government will not make assumptions concerning an Offeror’s intent, capabilities, facilities or experience. Offerors are cautioned to ensure that their proposals are complete, including all fill-ins and blanks in the solicitation.

13. Definitions and Acronyms are listed in attachment VIII in part D of this solicitation.

14. This RFP shall not be discussed with any Government employee except the Contracting Officer, Mr. Bradley Geghan. Your comments and/or questions should be directed, in writing, by email, to Mr. Geghan at Bradley.geghan@va.gov. Please indicate the RFP number, 36C79122R0006, in the subject line of the email covering all correspondence pertaining to this RFP.

A.3 CONTRACT ADMINISTRATION DATA

Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C791 Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E) 555 Corporate Circle Golden CO 80401-5621

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 SCHEDULE OF PREMIUMS

The Government anticipates providing dental insurance plan options to all 50 United States, Washington D.C., and the U.S. territories of American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. The contractor shall provide schedule of premium rates for base and optional years.

The monthly premium rates shall include all associated administrative costs, including but not limited to beneficiary and enrollee services, communications and education, network building and provider services, appeals, program integrity, and all other associated costs.

Premium pricing shall have monthly premium rates for Veterans and CHAMPVA enrollees to select from when choosing a payment plan. The monthly premium rates shall be evaluated in the proposed offer.

The schedule of premiums in the tables below sets forth the amounts that enrollees will pay for dental insurance depending on the type of plan selected by enrollees. A list of the states and territories included in each of the twenty-one rating regions is provided in Section D called Attachment V – VHA Dental Network Map-Rating Regions.

Premium rates may differ for each region, but no premium rates for any of the rating regions should exceed the lowest premium rate commercially offered for the same insurance plan by the offeror for that specific rating region (Section D-Attachment I). It is only mandatory to propose monthly premium pricing for the regions where coverage is provided, but coverage must be provided to the entire region at that price.

A monthly premium rate shall be provided for every column in the table below for every rating region that is covered. No more than three plan tiers shall be proposed. One of these tiers shall include all the services identified in Section B.4 Performance Work Statement (PWS), paragraphs B.4.1.8. Additional tiers may or may not include all the services identified in PWS paragraph B.4.1.8.

The premium rate pricing tables stated in the proposal will be incorporated in the resultant contract. The base period and option premium rates shall be fixed.

The Contractor shall submit the following after 10 months in every year including the base period and options:

A. Proposed prices for services that may be performed in the next succeeding option period; and B. An estimate and breakdown of the costs of these supplies or services including:

i. Sufficient data in addition to the actual experience report as necessary to support the accuracy and reliability of this estimate; and

ii. An explanation of the differences between this estimate and the original (or last preceding) estimate for the same supplies or services.

The premium shall include all associated administrative costs, including but not limited to beneficiary and enrollee services, communications and education, network building and provider services, appeals, program integrity, and all other costs.

B.2 Schedule of Premium Rate Plans (See Attachment IX – Dental Plan Charts in Section D) The contractor shall offer at minimum a basic plan and a high plan. Pricing for Base period and Option Periods 1, 2, 3, and 4 shall be fixed price. CHAMPVA includes beneficiaries and dependents, which for this section will mean the family plan.

B.3 CONTRACT REQUIREMENTS

B.3.1 CONTRACT TYPE

Since there will be no appropriated funding involved in this contract, this is considered a “No-Cost” contract. Enrollees will provide payment for the premiums and the Government will provide consideration for the reporting requirements. “Consideration” for this solicitation refers to the Government marketing the contractor’s dental plans to the veterans. This contract also establishes fixed prices for the premiums at the time of the basic contract award and shall utilize fixed price premium pricing for base year and the four option periods.

This is a nonpersonal services contract to provide dental insurance services. The Government shall not exercise any supervision or control over the contract service providers performing the services herein. Such contract service providers shall be accountable solely to the Contractor who, in turn is responsible to the Government.

B.3.2 TERM OF CONTRACT

The base contract is effective from the date of award to June 30, 2023. There are also four, one-year option periods that may be exercised by the Contracting Officer. These dates are subject to change based on the award date.

The anticipated periods of performance for this contract are:

The dates above may change if the award date is delayed. This contract may be extended for six (6) months through December 31, 2027, at the discretion of the Government. If an extension is deemed necessary, the Contracting Officer will issue a unilateral modification to the Contractor for the extension no later than May 31, 2027.

B.3.3 KEY PERSONNEL AND SUBSTITUTIONS

The Contractor shall assign to this contract the following key personnel: Contract Manager or Officer (i.e. equivalent to Government’s Contracting Officer). The Government defines the role of its contracting officer as a person with the authority to enter into, administer, and/or terminate contracts and make related determinations and findings.

The Contractor shall designate its key personnel, in writing via email, to the Contracting Officer within 10 calendar days after award and notify the Contracting Officer, in writing, 10 calendar days prior to any changes or substitutions.

B.4 PERFORMANCE WORK STATEMENT (PWS)

B.4.1 Overview of PWS

B.4.1.1 Overview The Department of Veterans Affairs (VA), Health Eligibility Center (HEC), through the Denver Logistic Center (DLC) intends to contract with qualified dental insurance carriers to administer and provide insurance coverage to eligible VA beneficiaries for VA’s Dental Insurance Program (VADIP). Coverage for VADIP dental services will be provided in the United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands.

HEC serves as VA’s national service center for VA health care registration, enrollment, and eligibility activities. HEC also serves as the business owner for administrative information systems supporting the delivery of VA health benefits. HEC achieves VA’s gold standard of honoring America’s Veterans by providing accurate and timely health care eligibility and enrollment determinations and responsive and respectful customer service.

HEC supports VA’s health care delivery system by providing centralized eligibility verification and enrollment processing services. HEC determines a Veteran’s eligibility for VA health benefits and facilitates the enrollment process by providing guidance to VA field offices and facilities. HEC also collaborates with other Veteran Affairs administrative offices on the implementation of policy.

B.4.1.2 Background 38 U.S.C. § 1781 requires that VA establish and administer a dental insurance plan, hereinafter referred to as VADIP, for Veterans enrolled in VA health care and survivors and dependents of Veterans eligible for VA’s Civilian Health and Medical Program (CHAMPVA). The Department of Veterans Affairs Expiring of Authorities Act of 2021, Public Law 117-42, signed into law September 30, 2021, removed the previous termination date for VADIP of December 31, 2021 and allows VA to provide VADIP services indefinitely.

Under the statute, VA will contract with private dental insurers to administer the dental insurance plan. The contracted insurers shall also be responsible for administering various aspects of VADIP, as described in this document. VA’s primary role in VADIP is administering the contract with the private insurer and providing the private insurer with eligibility verification of individuals applying for VADIP coverage.

B.4.1.3 Objectives The statement of objectives represents the desired outcomes of this contract. These objectives are supported by technical requirements identified throughout the Performance Work Statement (PWS). Objectives are as follows:

i. Provide dental insurance plans to eligible VADIP population and administer dental insurance plans to enrolled VADIP beneficiaries.

ii. Provide desirable enrollment options and plan benefits.

iii. Maximize number of participants through marketing efforts, customer satisfaction, and versatile services.

iv. Customer Service – provides and maintains high levels of enrollee and provider satisfaction.

v. Reporting – provide reports, recommendations, and findings to VA so that VA can report on the progress of VADIP to Congress.

B.4.1.4 Scope of Work The Contractor shall provide all personnel and resources necessary to provide the services in this PWS. The Contractor shall provide and manage dental insurance plans for eligible beneficiaries while performing all administrative tasks and associated financial transactions.

Eligible VADIP beneficiaries include:

a. Any Veteran who is enrolled in VA healthcare under 38 U.S.C. § 1705, in accordance with 38 CFR § 17.36; and

b. Any survivor or dependent of a Veteran who is eligible for medical care under 38 U.S.C. § 1781, which includes individuals eligible for CHAMPVA under 38 CFR § 17.271.

38 U.S.C. § 1781 does not permit any other individual, including non-eligible dependents of VADIP beneficiaries, to enroll in VADIP. The Contractor must offer enrollment to all eligible beneficiaries that request enrollment. Only VADIP dental insurance plans as accepted under the contract shall be offered to VADIP beneficiaries. The Contractor shall not offer alternative dental insurance plans to VADIP eligible Veterans when contact is initiated through this program. The law mandating this program does not cover beneficiary dependents other than those eligible under CHAMPVA; however, it is the Contractor’s option to offer non-VADIP sponsored dental coverage to dependents under a separate program that is not endorsed or marketed along with VADIP.

Throughout this document the term “beneficiary” refers to a Veteran or CHAMPVA member who has successfully enrolled into the VHA Healthcare system and would be eligible to enroll in a VADIP insurance plan. The term “applicant” refers to anyone who starts the VADIP enrollment process, and the term “insured” refers to beneficiaries enrolled in a dental insurance plan through VADIP.

Total enrollment in the VA healthcare system is roughly 8.9 million. Previous independent studies estimated participation in VADIP to be between 100,000 and 300,000. Enrollment in VADIP is largely dependent on the services available through VADIP insurance plans, associated costs to the beneficiaries, and the success of the marketing and outreach programs to the beneficiaries. Successful marketing programs, quality insurance tier options, and lower costs could likely result in higher participation. Approximately 59 percent of the eligible population is over sixty years old.

Unless otherwise stated, any mention of days in this PWS shall be understood to mean consecutive calendar days.

Transition Period The Contractor shall have 90 days after contract award to begin enrollment. All awarded Contractors will commence taking enrollments on the same day, designated by VA. The Contractor will begin enrollment and allow for adequate system set up and establishment of all processes in order to meet the requirements of the PWS. The expected award date is July 1, 2022 and then 90 days to prepare for setup.

B.4.2.1 General Information Marketing VA will market VADIP through existing websites and through print media (posters and brochures at VA facilities). VA will also publish press releases and present plan information at Veteran Service Organization meetings.

The Contractor will be responsible for launching a marketing campaign which informs the eligible Veteran population of their right to voluntarily enroll in VADIP. Veteran eligibility lists will not be provided by VA, so all communications and marketing will be to the general Veteran population. The plan must include the Contractor’s approach and marketing techniques identified and accepted in its original proposal. The marketing plan shall describe the Contractor’s strategy to inform and educate VA beneficiaries and network providers on all aspects of its program. The Contractor’s accepted marketing plan shall be updated on an annual basis and provided to the Contract Officer’s Representative (COR) 10 business days after exercise of the option period. The COR will review the plan and provide concurrence or feedback for recommended changes. The Contractor shall be responsible for continued marketing efforts. VA has the right to review and request changes to marketing materials and brochures. The Contractor will capitalize the “V” in Veteran, per VA communication standards.

The Contractor shall not utilize any beneficiary Protected Health Information (PHI) or Personally Identifiable Information (PII) (including enrollees' addresses and phone numbers) for any purpose other than enrollment and administration of dental benefits. The Contractor is not restricted from marketing non-VADIP plans to individuals who do not qualify for VADIP coverage. Marketing materials for non-VADIP plans may not contain any information that alleges or could be read to imply VA endorsement of non-VADIP plans. There may not be any information about non-VADIP plans provided as a part of any VADIP communications. This includes any VADIP marketing materials, plan/benefit information and/or websites except as described below:

The Contractor may include the following or a similar statement in its eligibility and question & answer sections only: “Dependents of Veterans, except those eligible under CHAMPVA, are not authorized to enroll in VADIP. Dependents may be eligible for separate coverage offered by this company that is not affiliated with VADIP or endorsed by the VA. Contact a Customer Service Representative for additional information.” The Contractor shall obtain written approval from VA of final language used if included in any VADIP related marketing materials or websites prior to use.

B.4.2.2 Preemption of State Law In accordance with FAR 52.212-4(q), as a whole, does not preempt conflicting State law. However, subsections of the statute relating to the “business of insurance” and any regulations promulgated there under, preempt conflicting State law. The subsections that deal with the “business of insurance” and preempt conflicting State law include:

B.4.2.3 Eligibility, Enrollment, and Disenrollment Eligibility Verification The Contractor shall have an application process to review and accept applications from individuals interested in participating in VADIP via phone, web, mail or other means of communication. The Contractor shall start the enrollment process by querying VA’s information systems through VA’s Electronic Data Interchange (EDI) clearinghouse Contractor (Change Healthcare), to confirm the individual’s eligibility for VADIP. All costs associated with transactions between VADIP Contractor and Change Healthcare are the responsibility of the Contractor.

Change Healthcare will provide eligibility verification related to this contract. To receive eligibility information on the prospective Veteran or CHAMPVA beneficiary, the Contractor shall submit the standard formatted 270 transaction set that results in the responding 271 standard formatted transaction set being returned with eligibility status via Change Healthcare. Standard information returned by this EDI transaction includes Name, Gender, Social Security number, VA healthcare enrollment information (Enrolled or Not Enrolled), Enrollment Date, and Veteran Primary Facility. The Contractor shall notify the individuals about their VADIP eligibility status (either eligible or not eligible) within two business days of their request, either by phone, email or letter.

The Contractor shall ensure that it has the capability to manage transactions with Change Healthcare prior to the start of enrollment of applicants in VADIP. Change Healthcare may be contacted at 877.363.3666 or their website at http://www.emdeon.com/eligibility.

If VA changes its EDI clearinghouse Contractor, all VADIP Contractors will be given at least a 60 day notice. There would also be a bridge period of no more than six months for the new clearinghouse Contractor to transition with users and the Government.

Enrollment The Contractor will manage the VADIP enrollment process. The Contractor will verify a VADIP applicant’s eligibility through the eligibility verification process outlined above prior to informing the applicant about their eligibility for VADIP. The Contractor shall enroll eligible applicants within 5 calendar days from the date of receipt of a request to enroll. The Contractor shall establish effective date of coverage rules, but the effective date shall not exceed 31 calendar days from date of enrollment. The Contractor shall provide each enrolled applicant a written explanation of their effective date of coverage via email or letter as part of their enrollment package.

The initial enrollment period will be at least 12 calendar months. Following the initial 12-month period, VADIP beneficiaries shall be given an option to renew their enrollment for another 12-month period or remain covered by month-to-month enrollment, as long as the participant remains eligible for coverage and VA continues to authorize VADIP.

The Contractor shall provide coverage to an insured that ceases to be eligible for at least 30 calendar days after eligibility ceased. The insured must pay any premiums due during this 30-day period. This 30day coverage period does not apply to an insured who is disenrolled under any of the scenarios outlined in the disenrollment section below.

Disenrollment VADIP beneficiaries may be involuntarily disenrolled at any time for failure to make premium payments. Prior to such disenrollment, the Contractor shall provide no less than 15 days written notice to the VADIP beneficiary to allow the beneficiary time to make premium payments. If State law imposes additional restrictions on insurers who wish to involuntarily disenroll policyholders, then State law would govern. Likewise, State law would also govern any applicable appeals procedures or policyholder rights relating to involuntary disenrollment.

VADIP beneficiaries may ask to be voluntarily disenrolled, and will not be required to continue payment of any premiums, under the following circumstances:

i. For any reason, during the first 30 days that the beneficiary is covered by the plan, if no claims for dental services or benefits were filed by the insured.

ii. If the insured relocates to an area outside the jurisdiction of the plan that prevents the use of the benefits under the plan.

iii. If the insured asserts that he or she is prevented by serious medical condition from being able to obtain benefits under the plan, or that he or she would suffer severe financial hardship by continuing in VADIP.

iv. For any reason during the month-to-month coverage period, after the initial 12 month enrollment period.

v. At the discretion of the insurer, a 12-month lock-out period from re-enrollment is permitted upon disenrollment.

Requests for Disenrollment All insured requests for disenrollment will be submitted to the Contractor for determination of whether the insured qualifies for disenrollment. Requests for disenrollment due to financial hardship or serious medical condition must include submission of written documentation that verifies the existence of a serious medical condition or financial hardship. The written documentation submitted to the insurer must show that circumstances leading to a serious medical condition or financial hardship originated after the effective date of coverage began. A verified hardship will allow the Veteran/CHAMPVA to break 12 month lock-in period early.

Lock-in and Lock-out Periods A 12-month lock-in period is permitted on initial enrollment. Thereafter, participants may be allowed to enter into another 12-month period or remain covered by month-to-month enrollment. At the discretion of the Contractor, a 12-month lock-out period from the date of disenrollment is allowed upon voluntary disenrollment or a failure to make payment. Each new subscriber must fulfill an initial 12-month enrollment period. After the initial 12-month period, they can continue on a month-to-month basis as long as they remain eligible and pay their monthly premium.

Waiting Periods Additional waiting times for high cost procedures shall be reasonable and based upon generally accepted dental practice standards.

B.4.2.4 Plan Requirements The Contractor may have up to a maximum of three plan tiers (e.g. Base, Standard, High) At a minimum, the high tier should include most of the services identified in section i through vii. Other Services, below. Additional tiers may or may not include all services identified in this section. The overall plan must provide beneficiaries with tier selection options that offer comprehensive, cost-effective services, and are comparable to other commercially-available dental insurance plan options.

i. Diagnostic services (Basic tiers)

· Clinical oral examinations

· Radiographs and diagnostic imaging

· Tests and laboratory examinations

ii. Preventive services (Basic tiers)

· Dental prophylaxis

· Topical fluoride treatment (office procedure)

· Sealants

· Space maintenance

iii. Restorative services (Standard tiers)

· Amalgam restorations

· Resin-based composite restorations

iv. Endodontic services (Standard or High tiers)

· Pulp capping

· Pulpotomy and pulpectomy

· Root canal therapy

· Apexification and recalcification procedures

· Apicoectomy and periradicular services

v. Periodontic services (Standard or High tiers)

· Surgical services

· Periodontal services

vi. Oral surgery (Standard or High tiers)

· Extractions

· Surgical extractions

· Alveoloplasty

· Biopsy

vii. Other Services (Standard or High tiers)

· Palliative (emergency) treatment of dental pain

· Therapeutic drug injection

· Other drugs and/or medications

· Treatment of postsurgical complications

· Crowns

· Bridges

· Dentures

Alternative benefit provision Plans must offer an alternate benefit provision when more than one dental procedure could provide suitable treatment based on common dental standards.

Benefit Plan Designs To be completed by offeror with proposal submission that meets the requirements specified in Plan Requirements in this section i-vii above. Accepted benefit plan designs will be incorporated into resultant contract.

Premiums There are no Government funds involved in this contract and services provided under this contract are totally funded through premiums paid by enrollees. The Contractor shall collect premiums directly from enrollees. The Contractor shall allow for payment by enrollees on a monthly basis (with the exception of the initial premium payment due upon enrollment based on the selected insurance plan tier). With the exception of the initial enrollment, enrollees shall not be required to pay more than one month’s premium in a single payment, unless the enrollee selects that option. The Contractor shall employ its standard business practices for the collection of past due premiums and provide proper notification as required in PWS Section B.4.2.3 disenrollment. The Contractor shall refund any overpayments within 30 calendar days of identifying the overpayment.

Contract premiums will be a fixed amount for the base period of performance and the four option periods.

Premiums for each rating regions shall be structured on the plan tiers (see Section D for Attachment V VHA Dental Network Map-Rating Regions). The Offeror may offer different premiums rates by zip code, which could be considered “rating zones” within a region. Premiums may vary based on geographic location of the enrollee (his or her residence address). The Contractor shall provide coverage for as broad of national coverage as licensed. National Coverage includes the United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands. During enrollment, a Veteran or CHAMPVA beneficiary can enroll in a plan only if he or she lives in a ZIP code serviced by the plan. If the enrollee moves during the plan year, there may be a change in premium due to a change in the rating zone.

The Contractor shall provide a Microsoft (MS) Excel file that maps the zip codes to the rating zones and rating zone premiums. The Contractor shall provide any updates to the zip codes and/or premiums 15 business days prior to the beginning of the next option period.

General Policies All covered dental services are subject to the following general policies:

i. Services must be necessary and meet accepted standards of dental practice. Services determined to be unnecessary or which do not meet accepted standards of practice are not billable to the insured by a participating dentist unless the dentist notifies the patient of their liability prior to treatment and the insured chooses to receive the treatment. Participating dentists shall document such notification in their records.

ii. An appeal is not available when the services are determined to be unnecessary or do not meet accepted standards of dental practice unless the Dental Provider notifies the insured of his/her liability prior to treatment and the insured makes the decision to receive the treatment. This is because such services are not billable to the insured under the VADIP insurance plan(s), and there would be no amount in dispute to consider at appeal.

iii. Procedures must be reported using the American Dental Association’s (ADA) current dental procedure codes and terminology (CDT).

iv. Covered services will include only those which have an associated CDT code. Adjunctive services are not covered under this contract.

v. Services, including evaluations, which are routinely performed in conjunction with or as part of another service, are considered integral. Participating dentists may not bill members for services denied by the insurer if they are considered integral to another service.

vi. Charges for the completion of claim forms and submission of required information for determination of benefits are not payable to participating dentists by either the Contractor or the enrollee.

vii. All plan deductibles shall be reasonable in comparison to the plan tier for which it applies to and the applicable monthly premium and co-payments.

B.4.2.5 Network Requirements The Contractor must provide a stable, high-quality network or networks of general dental care participating providers that are available to all VADIP beneficiaries. The network must include appropriate specialty care providers such as oral surgeons and endodontists. Please see minimum network standards below and reference Attachment IV for Veteran population density per zip code, which will allow for pricing high density, rural and highly rural areas to be within a network region.

The Contractor must provide a robust network of dental providers in order to ensure adequate access to VADIP beneficiaries. The network must be portable across state lines and provide the insured with provider selection within a reasonable distance from their homes, as defined in minimum network standards below and must ensure that enrollees are able to obtain an appointment within a 14 days in an urban area and 30 days within a rural area. The Contractor must provide and maintain adequate networks for the delivery of dental services. The Contractor must provide provisions for coverage for eligible beneficiaries who are on travel outside of their home area or live in a different area for part of the year, if the transient area is within the contract network (i.e. eligible beneficiaries who temporarily move to warmer locations for the winter.)

The VA requires a network of providers to cover the United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands.

Minimum Network Standards for access to a general dentist are as follows:

a. 98% of urban enrollees shall have access to a general dentistry network provider within 10 driving miles of their primary residence.

b. 90% of rural enrollees shall have access to a general dentistry network provider within 50 driving miles of their primary residence.

c. 90% of highly rural enrollees shall have access to a general dentistry network provider within 150 driving miles of their primary residence.

d. Network access standards are based on maximum driving distances to network providers based on the following population density.

Out-Of-Network Allowed charges for out-of-network providers will be 100 percent of the usual, customary, and reasonable charges for the area (50th percentile charged in the region according to the Fair Health Data). The Contractor shall have processes to reimburse VADIP beneficiaries for non-compliant network areas seeking treatment from non-network providers. The approved reimbursement process will be incorporated into resultant contract.

Billing The Contractor’s network providers cannot bill the patient for covered services provided during a period for which premiums have been paid for other than the stated patient cost sharing amount.

Claims Prior to the payment of any claim for dental services, the Contractor shall ensure the provider has complied with the licensure requirements established by the state in which the services were rendered. Claims for services rendered by providers who do not meet applicable licensure requirements shall be denied.

B.4.3.1 Administration The Contractor shall provide VADIP beneficiaries a full suite of integrated benefit and financial tools that can provide individualized help in selecting the right type of benefits and level of coverage for each unique circumstance. At a minimum, a comparison chart for each tier shall clearly inform VADIP beneficiaries about the benefits, costs, co-pays, deductibles, and restrictions each service or tier has.

Information Technology The Contractor shall provide VADIP beneficiaries with information about available dental plans and allow applicants to select the plan that best meets his or her needs. The Contractor shall establish a website for the VADIP to allow public access to check for eligibility and to compare available plans to facilitate a decision by eligible participants on selecting a dental plan. Minimum features shall include:

a. A tool that will allow an individual accessing the site to self-determine if they would be eligible for benefits.

b. A dynamic side-by-side comparison table of features (coverage, copays, deductibles, exclusions, inclusions, special notes and premiums as a minimum).

c. A tool to determine cost by zip code.

d. Online application process that allows potential eligible veterans and CHAMPVA to apply online with the application forwarded to the selected insurance carrier upon completion.

e. Contact information page for insurance carriers, VHA, and the customer service center. Clear guidance shall be provided on which number to dial based on caller needs.

f. The Contractor shall maintain a VADIP website for interested VADIP participants and provide for content management updates to reflect changes made to the program. The COR will consult monthly with the Contractor to review recommended website changes and updates.

Customer Service The Contractor shall operate a customer service program to provide customer support through telephone, facsimile, mail and electronic media. The Contractor shall provide long distance telephone access at no cost to potential and enrolled VADIP beneficiaries with available access to a live person.

The Contractor’s customer service center shall, at a minimum, be available to answer enrollee inquiries, in accordance with contract standards, from 8:00 a.m. to 8:00 p.m., Eastern Time, Monday through Friday (except Federal holidays). The Contractor’s customer service center shall be able to communicate with non-English speaking beneficiaries and/or providers, including at a minimum, in Spanish. The Contractor shall respond to written negative customer inquiries within three business days. Likewise, the Contractor shall provide responses to written correspondence received either via hardcopy or electronic media within three business days of receipt. Average Speed of Answer (ASA) shall be 80% of calls answered within 30 seconds.

The Contractor shall staff and train a call center to provide service to VADIP beneficiaries and the insured. The call center shall be responsible for managing, at a minimum, the following call types:

a. Responding to general inquiries about the VADIP program

b. Assisting in initiating the eligibility determination

c. Providing guidance in selection of appropriate plans based on the caller’s situation/need

d. Directing callers to appropriate providers for enrollment, questions about specific coverage, and billing issues

e. Directing callers to other VA VADIP Program Offices as necessary

Claims Processing The Contractor shall process dental care claims to completion (payment or denial) in an accurate manner, within the timeframe established by each state’s insurance policy/regulations or, if not defined at state level, within 30 days of receipt from provider. The Contractor shall retain all claims that contain sufficient information to allow processing and all claims for which missing information may be developed from in-house sources, including Contractor-operated or maintained electronic, paper, or film files.

Dental Explanation of Benefits (DEOB) An industry standard Dental Explanation of Benefits (DEOB) must be provided, by the Contractor, to each beneficiary and provider. Information provided in the DEOB must follow Federal HIPAA and privacy standards.

Appeals Unless otherwise required by State law, when a VADIP Contractor rejects or reduces a claims request, the Contractor must issue a written decision and notify the insured of their appellate rights within 30 days from the date that the claims request was received by the insurer. VADIP Contractors must also, unless otherwise required by State law, issue a written decision and notify the insured of their appellate rights within 30 days of denying a request for voluntary disenrollment.

The Contractor is required to submit the pertinent facts, as required in 13.2.2.f, for denied appeals to ensure contractual compliance. This will be submitted as a quarterly report for appeals and adverse decisions from Contractor provided data.

B.4.3.2 Data Rights The Government has unlimited rights to all documents/ material produced under this contract. All documents and materials, to include the veterans’ personal information and eligibility status, collected under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the Contracting Officer. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

B.4.3.3 Organizational Conflict of Interest

a. It is in the best interest of the Government to avoid situations which might create an organizational conflict of interest or where the Offeror’s performance of work under the contract may provide the Contractor with an unfair competitive advantage. The term “organizational conflict of interest” means that because of other activities or relationships with other persons, a person is unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or the person has an unfair competitive advantage.

b. The Offeror shall provide a statement with its offer which describes, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The Offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The Offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.

c. Based on this…