T-5 Draft RFP 3 Section M 3.9.2021 FINAL.pdf

SECTION M

EVALUATION FACTORS FOR AWARD

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M.1. SOLICITATION PROVISIONS

FAR 52.217-5 Evaluations of Options (Jul 1990)

Except when it is determined in accordance with FAR 17.206(b) not to be in the Government’s best interests, the Government will evaluate offers for award purposes by adding the total price for all options to the total price for the basic requirement. Evaluation of options will not obligate the Government to exercise the option(s).

M.2. BASIS OF EVALUATION

M.2.1. This is a best value source selection conducted in accordance with Federal Acquisition Regulation (FAR) Part 15.3, Source Selection, as supplemented by the Defense Federal Acquisition Regulation Supplement (DFARS). These regulations are available electronically at https://www.acquisition.gov. The Government will select the best overall offer, based upon an integrated assessment of the technical/risk, past performance, and price/cost factors. The fourth factor, Small Business Participation, will be assessed on an Acceptable/Unacceptable basis, and is not part of the integrated assessment or trade-off process but award will not be made to an Offeror with an unacceptable rating under any factor or subfactor. The Government seeks to award to the Offeror who meets or exceeds the requirements and gives DHA the best value. This may result in an award to a higher rated, higher priced Offeror, where the decision is consistent with the evaluation factors and the Source Selection Authority (SSA) reasonably determines that the overall benefit of the non-price factors outweighs the cost difference. In making the trade-off between the non-price factors and the price factor, the SSA will base the source selection decision on an integrated assessment of proposals against all source selection criteria in the solicitation (described below).

M.2.1.1. The Government intends to select awardees for each region in the following order: (1) West Region, (2) East Region, as outlined in the RFP Regional Map attachment. The Government will award one contract per region to meet the T-5 requirement. Each region will be an evaluation comparing only those Offerors that submitted proposals in that region. For this reason, protests of any award decision in one region will not affect any other award decision in another region. Once an Offeror has been determined the apparent awardee for one region they will no longer be eligible for other regional awards. However, the Government reserves the right to award the Regions in a different order if the Government determines it will best meet the Government’s interests.

M.2.2. Proposals will be reviewed for completeness and conformity with Section L. The Government reserves the right to reject incomplete or non-conforming proposals at the discretion of the Contracting Officer.

M.2.3. Evaluation Approach. The Government will evaluate the extent to which the proposal exhibits a clear understanding of the work requirements and whether the proposal demonstrates an ability to meet or exceed the requirements defined in the Request for https://www.acquisition.gov/

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Proposal (RFP).

M.3. EVALUATION FACTORS. The Government will evaluate each proposal against the following factors and subfactors.

Factor 1 – Technical/Risk

Subfactor 1 – Network Management Subfactor 2 – Clinical Management Subfactor 3 – Admin/Customer Service Subfactor 4 – Claims and Systems Subfactor 5 – Transition Management Subfactor 6 – Planned Demonstrations/Product Improvements

Factor 2 – Past Performance

Factor 3 – Price/Cost

Factor 4 – Small Business Participation

M.4. EVALUATION FACTOR RELATIVE IMPORTANCE

• Factor 1, Technical/Risk, is the most important factor.

• Technical/Risk Subfactors 1 through 5 are weighted equally and are, individually, more important than Technical/Risk Subfactor 6.

• Factor 2, Past Performance, is less important than Factor 1.

• The non-price evaluation factors (Factors 1 and 2) when combined, are significantly more important than Factor 3, Price/Cost.

• Factor 4 does not fall into the relative importance of factors for award because it is

Acceptable/Unacceptable only. Therefore, Factor 4 will not be included in the integrated assessment but is required to be Acceptable to be eligible to receive an award.

M.5. EVALUATION OF FACTOR 1, TECHNICAL/RISK

The Government will determine a Technical Rating (Table M.5.1.) and a Technical Risk Rating (Table M.6.2.) for each of the subfactors. Each proposal for the Technical/Risk factor will be evaluated to determine how well it satisfies the Government’s requirements for the subfactors stated herein. Failure to address any of the specified subfactor requirements may result in an Offeror being ineligible for award.

M.5.1. Technical Rating

M.5.1.1. For each of the subfactors of the Technical/Risk factor, the Government will evaluate the quality of the Offeror’s technical solution for meeting the Government’s requirement and

HT940220R0005 Page M3 of M23 assign a Technical Rating (Table M.5.1.). The color/rating depicts how well the Offeror’s proposal meets and/or exceeds the subfactor requirements. Subfactor ratings will not be rolled up into an overall color rating for the Technical/Risk factor.

M.5.1.2. A “strength” is an aspect of an Offeror's proposal that exceeds specified performance or capability requirements in a way that will be advantageous to the Government during contract performance. Multiple strengths may be assigned to a subfactor; however, if the Government deems an aspect of the proposal to be a strength, that strength will be credited to only one subfactor. The Government will have the sole discretion in determining which subfactor the strength best fits. Strengths will not be assessed for Price/Cost and Small Business Participation Factors. A “deficiency” is a material failure of a proposal to meet a Government requirement or a combination of significant weaknesses in a proposal that increases the risk of unsuccessful contract performance to an unacceptable level. A “weakness” means a flaw in the proposal that increases the risk of unsuccessful contract performance. A “significant weakness” in the proposal is a flaw that appreciably increases the risk of unsuccessful contract performance.

TABLE M.5.1. – TECHNICAL RATINGS

Color Rating

Adjectival Rating Description

Blue Outstanding Proposal indicates an exceptional approach and understanding of the requirements and contains multiple strengths.

Purple Good Proposal indicates a thorough approach and understanding of the requirements and contains at least one strength.

Green Acceptable Proposal indicates an adequate approach and understanding of the requirements.

Yellow Marginal Proposal has not demonstrated an adequate approach and understanding of the requirements.

Red Unacceptable Proposal does not meet requirements of the solicitation and, thus, contains one or more deficiencies and is unawardable.

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M.6. TECHNICAL RISK RATING

M.6.1. The Government will evaluate the subfactors of the Technical factor for proposal risk. The Government will assess the degree to which the proposed approach has the potential for disruption of schedule, increased cost, degradation of performance, the need for increased Government oversight, and the likelihood of unsuccessful contract performance.

M.6.2. Each of the Technical subfactors will receive one of the risk ratings described in Table M.6.2. Technical Risk Ratings, below. Subfactor ratings will not be rolled up into an overall risk rating for the Technical/Risk factor. The risk evaluation includes, but is not limited to, the proposed approach, method or process of completing tasks, and the demonstrated experience in performing tasks (including experience in performing a proposed approach, method, or process).

TABLE M.6.2. - TECHNICAL RISK RATINGS

Rating Description

Low

Proposal may contain weakness(es) which have little potential to cause disruption of schedule, increased cost or degradation of performance. Normal contractor effort and normal Government monitoring will likely be able to overcome any difficulties.

Moderate

Proposal contains a significant weakness or combination of weaknesses which may potentially cause disruption of schedule, increased cost or degradation of performance.

Special contractor emphasis and close Government monitoring will likely be able to overcome difficulties.

High

Proposal contains a significant weakness or combination of weaknesses which is likely to cause significant disruption of schedule, increased cost or degradation of performance. Is unlikely to overcome any difficulties even with special contractor emphasis and close Government monitoring.

Unacceptable Proposal contains a material failure or a combination of significant weaknesses that increases the risk of unsuccessful performance to an unacceptable level.

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M.7. EVALUATION OF TECHNICAL/RISK SUBFACTORS

M.7.1. RESERVED

M.7.2. Technical Subfactors

M.7.2.1. Subfactor 1 – Network Management

M.7.2.1.1. The Government will evaluate the Offeror’s approach for how it will develop and maintain a provider network that:

a) is accredited by a leading health quality measurement organization,

b) is dynamically managed to meet changing populations, enrollments, health care needs,

c) includes high quality providers,

d) meets access to care standards as defined in 32 CFR 199.17(p)(5),

e) supplements services provided by the Military Medical Treatment Facilities (MTFs), and;

f) maintains access to care standards.

M.7.2.1.2. The Government will evaluate how the Offeror’s network model will:

a) incorporate the beneficiary population;

b) calculate the number of providers required;

c) determine the minimum ratio of providers required;

d) determine the types of providers required;

e) incorporate the needs of MTFs in support of optimization and DHA-PI 18-001;

f) use access to care appointment wait time and drive time standards for the TRICARE benefit;

g) include an approach to monitor and address network shortages.

M.7.2.1.3. Evaluation of Provider Sizing Model. For the purposes of this section, a new network is a network completely outside of an Offeror’s existing network.

M.7.2.1.3.1. The Government will evaluate the Offeror’s proposed network size for each Prime Service Area to determine the effectiveness of the sizing model. The Government will evaluate whether the Offeror’s model calculates an accurately sized network for each stated location and provides provider volumes in attachment L-3e and/or L-3w for each network in in each geographic market. The government will evaluate whether a network is accurately sized based on both population and previous utilization in the markets. The Government will evaluate the timelines for the proposed network build against the required transition timelines.

M.7.2.1.3.2. The Government will evaluate the size and scope of the Offeror’s new network build and the adequacy of the authority to use an existing network not owned by the Offeror. If the Offeror proposes to use a parent or leased network, the Government will evaluate the

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Offeror’s letter of commitment to assess the willingness of the network owner to allow the network to be required to join TRICARE.

M.7.2.1.4. The Government will evaluate the Offeror’s approach to how it will ensure the accuracy of its network provider directory, including how:

a) The Offeror verifies information in the directory;

b) The directory (and updates) will be shared with DHA and maintained in file formats that support software analytics;

c) the Offeror will communicate with network providers to ensure provider information will be updated in the directory within timeliness standards;

d) Provider affiliation with group practices will be maintained in the directory; and

e) How claim information will be used to ensure active provider participation and inclusion (or exclusion) from the directory.

M.7.2.1.5. The Offeror’s proposal will be evaluated on how it will respond to changes in MTF capabilities and capacities including:

a) how the Offeror’ will respond to changes in MTF capabilities;

b) how the Offeror will respond to changes in MTF capacities; and

c) how the Offeror will respond to changes on short notice including its minimum timelines for response to changes to capabilities and capacities in order to meet TRICARE benefits. .

M.7.2.1.6. The Government will evaluate the Offeror’s approach for referring beneficiaries to providers with demonstrated high quality outcomes while meeting health plan administrative standards (such as electronic claims processing, return of clear and legible consultation reports when requested, appointment availability, and secure communications with patients). The Government will evaluate how the value based steerage model will:

a) Meet access to care standards;

b) Produce high quality outcomes;

c) Optimize MTF workload optimization;

d) Achieve readiness of the medical force through Knowledge Skill and Ability (KSA) optimization; and

e) Control costs.

M.7.2.1.7. The Offeror’s proposal will be evaluated for its approach to maximizing inclusion of network providers connected to in Health Information Exchanges that can connect with Cerner’s Common Well Platform. The proposal shall clearly demonstrate how the Offeror will include providers connected to Health Information Exchanges in MTF referral networks to facilitate electronic access to clinical data with MHS GENESIS (refer to attachment J-14 MHS Genesis Performance Work Statement).

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M.7.2.2. Subfactor 2 – Clinical Management

M.7.2.2.1. The Offeror’s proposal will be evaluated on the effectiveness of its process for managing referrals between the MTFs and the private sector network in accordance with the Section C, paragraph 2.7 and TRICARE Operations Manual (TOM), Chapter 7, Section 5 and Chapter 8, Section 5 including:

a) How and when the Offeror’s referral management systems and processes direct TRICARE Prime network enrolled beneficiaries to the MTF;

b) How and when its referral management processes enforce the Point of Service Option for TRICARE Prime beneficiaries enrolled to the MTF who decline available care in the MTF;

c) How its processes identify and recapture TRICARE Select beneficiaries into Direct Care who meet MTF capability and capacity for specialty care and procedures;

d) How the Offeror’s beneficiary education process facilitates TRICARE Select enrolled beneficiary knowledge to make an informed decision of about care available at a local MTF or military Center of Excellence when it supports readiness of the medical force;

e) How and when its referral management systems and processes direct beneficiary referrals from the MTF to its network;

f) How its referral management processes support continuity of referrals when beneficiaries change geographical regions;

g) How referral management processes for managing referrals will be supported through network management activities;

h) How the Offeror proposes to meet the referral processing timeliness requirements;

i) How the Offeror proposes to meet the referral processing accuracy requirements;

j) How the Offeror proposes to change referral patterns in response to Government updates to the list of diagnostic and procedure codes correlated with enhancing medical readiness;

k) How the Offeror proposes to ensure an accurate record of care provided to a beneficiary is readily available to all providers involved with the beneficiary’s care, and;

l) How the Offeror’s processes will hold providers accountable for timely return of clinical information.

M.7.2.2.2. The Government will evaluate the Offeror’s proposed approach for designing, implementing, and maintaining integrated, comprehensive medical management programs for all care received by TRICARE-eligible beneficiaries in the civilian sector and for complementing medical management services available within the MTF including:

a) An approach for an integrated medical management program for all TRICARE eligible beneficiaries receiving care in the civilian sector that supports medical care and behavioral health;

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b) How the medical management programs will complement the standardized medical management services available in the MTFs;

c) How its medical management processes will objectively document improvements in clinical outcomes;

d) Tools available to facilitate access to medical management programs and customer service information for providers, MTFs, and beneficiaries;

e) Interoperability of medical management systems with MTFs, civilian inpatient facilities; the TRICARE Pharmacy Benefits Program to provide essential information to providers and case managers and bi-directional feedback to and from purchased care providers; and

f) A strategy to integrate private sector care with the direct care system.

M.7.2.2.3. The Government will evaluate the Offeror’s approach for implementing a Utilization Management (UM) program for TRICARE-eligible beneficiaries that includes:

a) How the Offeror will communicate, collaborate, manage, implement and maintain a UM program for TRICARE-eligible beneficiaries

b) The processes, criteria and systems used to implement and maintain the UM program and framework for continuous improvement;

c) How the program will support the identification, prevention, and reduction or elimination of occurrences of unnecessary care, over- or under-utilization in private sector care, and that care provided is appropriately authorized, and complies with the TRICARE benefits contained in 32 CFR 199.4 and 199.5, and the TPM; and

d) How the Offeror will maintain and comply with its accreditation organization’s written policies and documented procedures.

M.7.2.2.4. The Government will evaluate the Offeror’s proposal for its Case Management (CM) program for TRICARE-eligible beneficiaries and how the program will support and manage the healthcare of individuals with high-cost conditions or with specific diseases for which evidence-based clinical management programs exist that includes how the Offeror will:

a) Support and manage the healthcare of individuals with high-cost, high risk, high utilization conditions or with specific diseases for which evidenced-based clinical management programs exist;

b) employ an effective case management and caseload methodology to support all beneficiaries requiring CM, care coordination, or assistance during transitions of care in addition to beneficiaries with sensitive, rare and high-profile or high-visibility needs through a staffing plan and caseload assignment methodology;

c) ensure CM staff are knowledgeable of community resources where the CM enrolled beneficiary is located;

c) employ assessments and tools to identify beneficiaries for in-home CM services; and

d) Offer timely in-home CM services that reduce the risk of readmission with a first visit within 48-72 hours post discharge.

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M.7.2.2.5. The Government will evaluate the Offeror’s proposed approach for its population health care platform, including:

a) processes and systems that will be utilized to outreach to at-risk, high-risk, high-cost beneficiaries and deliver person-centered interventions based on identified risks and needs;

b) outcome measures that will be utilized to show the effectiveness of the PH care delivered;

c) how population health care integrates the Offeror’s case management and disease management programs; and

d) disease prevention and wellness services that are integrated into the population health care platform

M.7.2.2.6. The Government will evaluate the Offeror’s approach to providing a network-enrolled, real-time beneficiary-centric data warehouse and industry analytic tools/systems (including predictive analytics), which incorporates a data analysis technique with evidence-based algorithms including:

a) its proposed methodology for applying data stratification and predictive modeling to produce positive patient outcomes and measurable gains.

b) its proposed methodology for providing integrated systems and processes for comprehensively discovering and correcting gaps in care, medical errors, identifying high-risk addictive behaviors, and potential quality issues for Network Prime and TRICARE Select enrolled beneficiaries.

c) systems and processes for standardizing error reduction while maintaining transparency and adhering to evidence-based medicine, and that best enables extraction of actionable data from large databases of information and how that will be utilized to improve quality of care and patient perception of care.

M.7.2.2.7. The Government will evaluate the Offeror’s proposed approach to implement a clinical quality management and patient safety program for TRICARE-eligible beneficiaries that includes:

a) systems and processes for standardizing error reduction;

b) processes to provide oversight of provider adherence to evidence-based medicine protocols;

c) transparency of quality and safety management to the DHA; and

d) processes to utilize quality and patient safety data to improve beneficiary health outcomes.

M.7.2.2.8. The Government will evaluate the Offeror’s proposed approach for designing, implementing, and continuously improving comprehensive telehealth services, supporting episodic and longitudinal care for TRICARE-eligible beneficiaries including:

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b) how the Offeror will use telehealth to reduce network adequacy voids including rural and remote areas.

c) how the Offeror will use telehealth to implement remote monitoring including implementing hub and spoke telehealth models

d) how the Offeror will facilitate and promote integration and information sharing between Private Sector Care and Direct Care networks including machine-to-machine interoperability between MCSCs, network providers, and MHS GENESIS, including the use of any third party interoperability tools.

e) How the Offeror will identify and respond to beneficiary and provider educational needs to promote telehealth services.

f) how the Offeror will use interoperability standards to share information between providers.

M.7.2.3. Subfactor 3 – Administration and Customer Service.

M.7.2.3.1. The Government will evaluate the Offeror’s approach to customer service for how well it will provide accurate, comprehensive customer information with knowledgeable, courteous, and responsive staff and its approach for providing customer service via multiple, avenues of access.

M.7.2.3.2. The Government will evaluate the Offeror’s proposal for creating new, first time appointments in the network on beneficiary request and describes a call center capable of handling incoming beneficiary calls and creating appointments with network providers that:

A) Meet the beneficiary's medical needs (appropriate care);

B) Meet the TRICARE appointment access standards (wait and driving time); and C) Ensure the beneficiary continues to pay in-network rates through completion of the episode of care.

M.7.2.3.3. The Government will evaluate the Offeror’s approach to develop training materials, how it will measure the impact on provider behavior, and how the Offeror will accurately measure provider understanding of TRICARE marketing and training materials. The Government will assess how measurement will be used to improve the provider marketing and training outcomes. The Government will evaluate how the Offeror considered message saturation and impact on provider understanding in its approach.

M.7.2.3.4. The Government will evaluate the Offeror’s methods for outreach to providers and beneficiaries. The Government will evaluate the Offeror’s methods to develop an annual beneficiary outreach plan, its strategy for identifying beneficiary outreach opportunities, measures for evaluating the effectiveness of the strategies and process for updating the plan.

The Government will evaluate how the Offeror will develop an annual education plan and its proposed approaches for monitoring, implementing and updating the annual education plan.

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The Government will evaluate the Offeror’s approach to identifying and responding to:

a) beneficiary education needs and

b) provider educational needs;

The Government will evaluate the outreach methods the Offeror will use to recruit new TRICARE providers and retain existing TRICARE providers. The Government will evaluate the Offeror’s proposed methods that will be used to avoid providing misinformation on the TRICARE benefit to beneficiaries.

M.7.2.3.5. The Government will evaluate the Offeror’s processes for retaining, throughout the life of the contract, qualified leadership personnel who possess knowledge and experience in the following areas:

a. Establishing/Maintaining Networks

b. Referral Management

c. Medical Management

d. Enrollment

e. Customer Service

f. Claims Processing

g. Management

The Government will evaluate the Offeror’s approach to determining which positions require knowledge and experience in integrating the private sector care system with the direct care system as essential for successful contract performance..

M.7.2.3.6. The Offeror’s Quality Management/Quality Improvement Program Plan will be evaluated to determine if an effective internal quality management/quality improvement program is being offered. The Offeror’s approach to communicating problems and resolutions identified as part of the Quality Management/Quality Improvement Program Plan will be evaluated for timeliness, adequacy and appropriate use of communication medium (e.g. email, telephone, face-to-face meeting).

M.7.2.3.7. The Government will evaluate whether the Offerors’ internal, beneficiary facing web page development timeline meets the T-5 implementation timeline and whether wireframe mockup meets the TRICARE brand standards.

M.7.2.4. Subfactor 4 – Claims and Systems

M.7.2.4.1. The Government will evaluate how the Offeror will provide an adaptable (to changing TRICARE claims processing requirements), scalable (describes how the system will adapt to volumes of TRICARE claims and upcoming alternative payment models) claims processing system which incorporates industry best practices. The Government will evaluate the Offeror’s proposed timeline for incorporating TRICARE claims processing

HT940220R0005 Page M12 of M23 changes from change order initiation through testing and implementation. The Government will evaluate the Offeror’s plan to achieve certification its processing system at CMMI Level 4 at the time of contract award. Consideration (reduction of risk) will be given to claims processing systems that are certified CMMI Level 4 at the time of proposal submission.

M.7.2.4.2. The Government will evaluate the Offeror’s claims processes and methods and how they will result in meeting claims processing timeliness and accuracy standards to include achievement of auto adjudication rates and low claims reprocessing rates.

M.7.2.4.3. The Government will evaluate the Offeror’s processes to accurately apply unique elements of the TRICARE benefit: TRICARE deductible, co-pay, coinsurance, cost shares, catastrophic cap, referral/authorization requirements, and point-of-service (POS) provisions by beneficiary type) its claims processing system.

M.7.2.4.4. The Government will evaluate the Offeror’s plan to comply with each of the 14 families of requirements of NIST Special Publication 800-171 for the processing, storage, and transmission of any DoD controlled unclassified information. The Government will evaluate whether the Offeror’s proposed timelines will meet requirements for the T-5 start of health care delivery.

M.7.2.4.4.1. The Government will evaluate the Offeror's summary level score for their current basic self-assessment is in the Supplier Performance Risk System (SPRS).

M.7.2.4.4.2. The Government will evaluate the Offeror's SSP, or extracts thereof, and any associated plans of action.

M.7.2.4.4.3. RESERVED

M.7.2.4.4.4. The Government will evaluate the Offeror's plan to track the flow down of covered defense information, to include DoD controlled unclassified information, and assess their tier-1 level supplier (s)/subcontractor(s).

M.7.2.4.5. The Government will evaluate the Offeror’s approach to interoperability through an analysis of:

a) Technology the Offeror will use to connect MTFs to private sector providers and;

b) Interoperability standards that ensure bi-directional exchange of health care data and;

c) Access methodologies to private sector care referral providers and hospitals Electronic

Health Records and;

d) Connectivity to state and regional HIEs

M.7.2.4.6. The Government will evaluate the Offeror’s process to design and implement Alternate Payment Models that includes a comprehensive description of the following elements:

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a) The method the Offeror will use to compute cost neutrality of proposed APMs

b) A description of the calculation methodology (i.e., population, model-based) for implementing an APM

c) How historic TRICARE program claims data will inform the approach

d) Application of risk and wage adjustments

e) Additional factors that would be contingent on approval by the Government

M.7.2.4.7. The Government will evaluate the Offeror’s approach to negotiating APM contracts network with providers including:

a) How the Offeror will achieve 15% of healthcare payments to network providers through a mix of APMs (HCPLAN categories of 2, 3, and 4) during the base year of the contract;

b) Which provider type(s) the Offeror will target for APM arrangements; and

c) How the Offeror will expand annual APM payments to meet requirements of TRM

Chapter 18.

M.7.2.4.8. The Government will evaluate the Offeror’s sample APM proposal including how the sample APM:

a) Identifies the HCPLAN category and subcategory;

b) Identifies the provider type and targeted beneficiary population. APMs address at least one chronic disease and condition relevant to the TRICARE beneficiary population, including, but not limited to, diabetes, chronic obstructive pulmonary disease, asthma, congestive heart failure, hypertension, history of stroke, coronary artery disease, mood disorders, and obesity.

c) Includes an estimate of expenses paid to providers;

d) Includes a description of how the Offeror will establish accurate attribution methods, the approach to track APM costs and the total percentage of network costs that are covered by APMs;

e) Includes expected savings for the service following implementation of the APM over the initial year, second year, and third year;

f) Demonstrates and measures that that the cost of the APM at the model level, including the cost of care and any special APM payments to providers or amounts collected from providers, did not exceed the aggregate cost of care that would have been incurred under applicable TRICARE maximum allowable charges;

g) proposes effective performance measures and measure levels that evaluate quality of care, patient outcomes and beneficiary satisfaction under the APM.

M.7.2.5. Subfactor 5 - Transition Management

M.7.2.5.1. The Offeror’s proposal will be evaluated for an effective and compliant Integrated Master Schedule and Integrated Master Plan (IMP/IMS) which meets the Government transition in requirements.

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M.7.2.6. Subfactor 6 - Planned Demonstrations/Product Improvements

M.7.2.6.1. Advanced Primary Care:

M.7.2.6.1.1. The Government will evaluate the Offeror’s proposal for its approach to identifying and including Advanced Primary Care (APC) provider groups in its demonstration including how APCs:

a) Are selected for demonstrating high-value in delivery of care using risk-adjusted, industry-standard metrics for appropriateness, clinical outcomes, and financial performance;

b) Provide care through an integrated, multi-disciplinary team utilizing evidence-based medicine;

c) Offer patient-centric options;;

d) Focus on prevention, chronic care management, and management of life style risks; and,

e) Support value-driven care, population-based care payments and robust connections with the medical neighborhood and community-based services.

M.7.2.6.1.2. The Government will evaluate the Offeror’s proposal for how it will support the integration of APC providers and the overall success of the APC demonstration including how it will

a) Calculate the number of APC providers needed for the demonstration;

b) Determine minimum APC provider ratios;

c) Determine and manage provider panel size;

d) Ensure interoperable medical record and data transfer capabilities;

e) Develop standards for data collection and medication reconciliation; and,

f) Facilitate and tracks timely referrals.

M.7.2.6.1.3. The Government will evaluate the Offeror’s proposal for its approach to monitoring and continuously improving APC performance including:

a) How the Offeror will measure success using metrics for financial performance, beneficiary experience, and risk-adjusted clinical outcomes using standard industry factors and metrics;

b) The integrated systems and processes that will be used to assess APC performance, and comprehensively discover and correct gaps in care, medical errors, and potential quality issues for beneficiaries; and,

c) The mechanisms and processes for delivering continuous feedback to APC providers to improve value-based care delivery.

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M.7.2.6.1.4. The Government will evaluate the Offeror’s proposal for how it will engage and communicate with beneficiaries to drive the use of APC providers. The criteria are met when the proposal clearly describes how it will:

a) Identify and respond to beneficiary educational needs that promote the use of APC providers;

b) Proposed incentives to steer beneficiaries to APC providers that are authorized under the TRICARE program; and

c) Identify and steer individuals with high-cost conditions, who are high risk, who experience high utilization, or who have specific diseases for which evidenced-based clinical management programs exist.

M.7.2.6.1.5. The Government will evaluate the Offeror’s proposal for how it will achieve the goals of the APC demonstration including how the Offeror will:

a) Improve access to care;

b) Improve quality outcomes;

c) Improve beneficiary experience;

d) Improve readiness of the medical force (KSA optimization); and,

e) Control costs.

M.7.2.6.1.6. The Government will evaluate the Offeror’s proposal for its experience that the Offeror has with implementing Advanced Primary Care models. The Government will evaluate:

a) Years providing such program and services;

b) Number of clinics or facilities in operation over period of time;

c) Applicable credentials such as certified Patient Centered Medical Home (PCMH);

d) Vendor partnerships;

e) Performance measurement and improvement tools;

f) Continuous improvement initiatives; and,

g) Value-driven care and population-based care payments.

M.7.2.6.2. RESERVED

M.7.2.6.3. RESERVED

M.7.2.6.4. Care Collaboration Tools Requirements

M.7.2.6.4.1. The Government will evaluate the Offeror’s proposal for its approach to implementing an integrated care collaboration program that facilitates virtual provider-to-provider consultations (eConsult) including:

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a) How it will promote information sharing and collaboration across direct and private sector care networks to ensure coordination of care;

b) How it will support medical force provider Knowledge, Skills, and Abilities (KSAs) through increased access to specialist expertise; and,

c) How it will include e-Consults in its strategy for mitigating network shortages.

M.7.2.6.4.2. The Government will evaluate the Offeror’s proposal for how it supports e- Consults and an integrated care collaboration program. The criteria are met when the proposal clearly describes policies, processes and systems, including:

a) Systems and platforms to facilitate e-Consults;

b) Standards for machine-to-machine interoperability between the Direct Care System and other authorized contractors;

c) Reporting and monitoring mechanisms to track and trend e-Consults by providers, measure provider satisfaction, and assess impact on value; and,

d) Billing and reimbursement methodology for e-Consults.

M.7.2.6.4.3. The Government will evaluate the Offeror’s proposal for how it will communicate with and educate providers on including:

a) e-Consult capabilities, requirements and incentives;

b) e-Consult policies and procedures; and,

c) Billing and reimbursement.

M.7.2.6.5. RESERVED

M.7.2.6.6. RESERVED

M.7.2.6.7. RESERVED

M.7.2.6.8. RESERVED

M.7.2.6.9. Virtual Value Network (VVN)

M.7.2.6.9.1. The Government will evaluate the Offeror’s proposal for its approach to identifying and including high-value providers in its Virtual Value Network including:

a) How it will select high-value providers;

b) How it will use risk-adjusted, industry-standard metrics for appropriateness, clinical outcomes, and financial performance;

c) How it will aggregate and score provider value; and,

d) Which sources of data it will use to assess provider value.

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M.7.2.6.9.2. The Government will evaluate the Offeror’s proposal for how it will provide beneficiaries 24/7 access to VVN provider value ratings and metrics including its ability to:

a) Provide web and app based tools;

b) Provide call center services; and,

c) Use secure, HIPAA compliant technology platforms.

M.7.2.6.9.3. The Government will evaluate the Offeror’s proposal for its approach to monitoring and continuously improving VVN provider performance including:

a) How it will measure success using metrics for financial performance, beneficiary experience, and risk-adjusted clinical outcomes using standard industry factors;

b) The integrated systems and processes that will be used to assess VVN provider performance, and comprehensively discover and correct gaps in care, medical errors, and potential quality issues for beneficiaries; and,

c) The mechanisms and processes for delivering continuous feedback to VVN providers to improve care delivery.

M.7.2.6.9.4. The Government will evaluate the Offeror’s proposal for how it will engage and communicate with beneficiaries to drive the use of VVN providers. The criteria are met when the proposal clearly describes how it will:

a) Identify and respond to beneficiary educational needs that promote the use of VVN providers; and,

b) Use incentives to steer beneficiaries to VVN providers that are authorized under TRICARE program.

M.7.2.6.9.5. The Government will evaluate the Offeror’s proposal for how it will achieve the goals of the VVN demonstration including how the Offeror will:

a) Improve quality outcomes;

b) Improved readiness outcomes;

c) Improve beneficiary experience; and,

d) Control costs.

M.7.2.6.9.6. The Government will evaluate the Offeror’s experience in developing and implementing VVNs, including:

a) Years providing such program and services;

b) Vendor partnerships;

c) Performance measurement and improvement tools;

d) Continuous improvement initiatives; and,

e) Incentive programs.

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M.7.2.6.10. RESERVED

M.7.2.6.11. RESERVED

M.7.3. RESERVED

M.8. EVALUATION OF FACTOR 2, PAST PERFORMANCE

M.8.1. The Government will evaluate past performance information, submitted in accordance with Section L and other sources, to determine how well an Offeror has performed in the past on recent, relevant work. The past performance evaluation will result in an assessment of the Offeror’s probability of meeting the solicitation requirements. One performance confidence assessment rating will be assigned for each proposal.

M.8.2. When assessing the Offeror’s performance confidence, the Government will use the Offeror’s past performance proposal, past performance questionnaires, and additional information the Government obtains from the Offeror’s customers listed in the proposal. The Government may or may not, at its sole discretion, use relevant past performance information from other customers known to the Government, Past Performance Information Retrieval System (PPIRS), Contractor Performance Assessment Reporting System (CPARS), Federal Awardee Performance and Integrity Information System (FAPIIS), Electronic Subcontract Reporting System (eSRS), and other sources of useful and relevant information including the Government’s own internal records.

M.8.3. For the purpose of this solicitation, recent past performance means contracts that are currently ongoing or have concluded within three (3) years of the RFP release date. The Government will consider the entire period of performance of the contract(s) to include any transition-in and phase-out periods. The Government will evaluate the recency of each contract through dates of performance on contract documents, CPARs, and Past Performance Questionnaires signed by customers.

M.8.4. The Government will evaluate past performance evaluated as recent (M.8.3) in terms of scope and the magnitude of effort and complexities as it relates to the requirements for this solicitation. Assessment of relevancy will be based on those functions the Contractor or subcontractor will be performing on this solicitation. For example, for the purposes of relevancy, “scope” will only be assessed on claims processing services if that is the only function the subcontractor will be providing. Past performance history rated “Not Relevant” will not be considered when determining the performance confidence rating.

M.8.4.1 The Government will assign one of the following relevancy ratings to each contract provided by the Offeror as specified in table M.8.4.1.

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TABLE M.8.4.1. PAST PERFORMANCE RELEVANCY RATINGS

Degree Description

VERY RELEVANT (VR)

Past/present performance effort involved essentially the same scope and magnitude of effort and complexities this solicitation requires.

RELEVANT (R)

Past/present performance effort involved similar scope and magnitude of effort and complexities this solicitation requires.

SOMEWHAT RELEVANT

(SR)

Past/present performance effort involved some of the scope and magnitude of effort and complexities this solicitation requires.

NOT RELEVANT (NR)

Past/present performance effort involved little or none of the scope and magnitude of effort and complexities this solicitation requires.

M.8.4.2. For the purposes of this solicitation Relevancy of each recent past performance reference will be evaluated by considering Scope, Magnitude and Complexity of the reference in comparison with the requirements of T-5, as identified in Table M.8.4.2.

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TABLE M.8.4.2. T-5 SCOPE, MAGNITUDE AND COMPLEXITY FOR

COMPARISON TO PAST PERFORMANCE REFERENCES

Scope A Federal program

Requires integration with Government health facilities Provides all types of health care

Magnitude Total spend >$5B/year 24 states Network contains 250,000 providers Network contains 6000 facilities 3 million covered lives 25 million claims/year

Complexity The following tasks are to be performed under T-5 requirements:

1) Establish and maintain provider networks

2) Maintains a provider directory

3) Claims processing

4) Uses value based payment models

5) Provides management of referrals to specialty care

6) Provides Medical Management services

7) Provides Utilization Management services

8) Provides Case Management services

9) Uses Predictive Modeling to manage populations

10) Provides a patient safety program

11) Provides telehealth services

12) Customer service

13) Enrollment functions

14) Transition functions

M.8.5. Quality

M.8.5.1. Once a relevancy rating has been determined, the Government will evaluate relevant (M.8.4) past performance information to determine the quality of performance for each of the contracts. The Government will identify negative findings noted in Past Performance Questionnaires (PPQ) and allow the Offeror the opportunity to respond to the findings. Lack of performance information (non-return of a PPQ) will not be considered negative performance.

M.8.5.2. In assessing quality of performance, the Government will consider the Offeror’s past performance in compliance with clause FAR 52.219-8, Utilization of Small Business Concerns;

clause FAR 52.219-9, Small Business Subcontracting Plan.

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M.8.6. Performance Confidence Assessment

M.8.6.1. The Government will assess a performance confidence assessment rating relative to the Offeror’s ability to successfully perform the requirements of this solicitation through an integrated assessment of the past performance information from M.8.3, M.8.4 and M.8.5.

M.8.6.2. Each Offeror will be assigned one of the performance confidence ratings below as specified in table M.8.5.2.

TABLE M.8.6.2. - PERFORMANCE CONFIDENCE ASSESSMENTS

Rating

Description

SUBSTANTIAL

CONFIDENCE

Based on the Offeror’s recent/relevant performance, the Government has a high expectation that the Offeror will successfully perform the required effort.

SATISFACTORY

CONFIDENCE

Based on the Offeror's recent/relevant performance, the Government has a reasonable expectation that the Offeror will successfully perform the required effort.

NEUTRAL

CONFIDENCE

No recent/relevant performance record is available or the Offeror’s performance record is so sparse that no meaningful confidence assessment rating can be reasonably assigned.

LIMITED

CONFIDENCE

Based on the Offeror’s recent/relevant performance, the Government has a low expectation that the Offeror will successfully perform the required effort.

NO

CONFIDENCE

Based on the Offeror‘s recent/relevant performance, the Government has no expectation that the Offeror will be able to successfully perform the required effort.

M.8.6.3. If an Offeror without past performance history submits information from a predecessor company, a parent organization or joint venture member, this information will be considered in rendering a performance confidence rating. The rating will consider the amount of involvement the parent organization or joint venture member will have in the daily operations of the Offeror.

M.8.6.4. If an Offeror does not have past performance relevant to this solicitation, the Government will assess a “Neutral Confidence” performance confidence rating and the Government will not evaluate the Offeror’s past performance favorably or unfavorably (see FAR 15.305 (a)(2)(iv).

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M.9. EVALUATION OF FACTOR 3, PRICE/COST

M.9.1. Each Offeror’s Price/Cost proposal will be evaluated based upon the Government’s calculated Total Evaluated Price (TEP). Evaluation of options shall not obligate the Government to exercise such options.

M.9.2. Total Evaluated Price (TEP). For the purpose of determining Best Value, the Government will use the TEP for each Offeror. The TEP will be the sum of all priced CLINs.

CLINs X004 Earned Performance Incentive will be excluded from the TEP.

M.9.3. Each Offeror’s Total Compensation Plan (TCP) for professional employees (FAR 52.222-46) shall be evaluated on an acceptable or unacceptable basis. The Government will consider regional or national compensation and inflation surveys submitted by an Offeror to substantiate the Offeror’s proposed TCP. Fringe benefits will be compared to the equivalent of a Federal employee on a qualitative basis (i.e.: defined benefit plan will be considered equivalent to a defined contribution plan). TCP without adequate survey data to substantiate salaries and benefits will be considered unacceptable. An Offeror proposal with an unacceptable TCP will be deemed ineligible for award.

M.9.4. Cost Realism Analysis (Applicable to CLINs X001 Underwritten Healthcare Costs Only).

M.9.4.1. CLINs X001 Underwritten Healthcare Costs.

The Government has provided the reimbursable cost estimates for underwritten healthcare costs. The application of the Offeror’s guaranteed network provider discounts will be the only adjustments to CLINs X001. The Government will make the adjustments to all offers according to the Price Evaluation Template, tab entitled Healthcare Cost & Discount. The Offeror’s proposed underwriting fixed fee will not be subject to a most probable cost evaluation. It will be included as proposed in the Total Evaluated Price.

M.9.4.2. Reserved.

M.9.5. Extension of Services: In the calculation of TEP, the Government will add 50% of the total proposed price of Option Period 8, excluding transition-out, for the 6-month option to extend services under FAR 52.217-8, Option to Extend Services.

M.9.6. Reasonableness. The Government will evaluate the Offeror’s TEP for reasonableness.

CLINs will also be reviewed for unbalanced pricing in accordance with FAR 15.404-1(g). The Government will not conduct any price realism analysis on the TEP or individual CLINS.

M.9.7. Defense Contracting Audit Agency (DCAA). DCAA and/or the Defense Health Agency (DHA) will conduct a review of Offerors’ and/or subcontractors’ healthcare or claims processing cost accounting systems in order to determine if an Offeror’s accounting system is

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M.10. EVALUATION OF FACTOR 4, SMALL BUSINESS PARTICIPATION

M.10.1. The Government will evaluate the subcontracting plan and participation of small businesses on an acceptable/non-acceptable basis. Acceptable – Proposal clearly meets the minimum requirements of the solicitation (Strengths are not assessed for this evaluation).

Unacceptable – Proposal does not clearly meet the minimum requirements of the solicitation.

The Contracting Officer (CO) will evaluate the subcontracting plan submitted under Volume I for compliance with Section L.5.2.

M.10.2. The Government will assess how the Offeror’s proposed subcontracting goals compare with the following subcontracting goals. If the Offeror does not propose the subcontracting goals below, the Government will assess whether the Offeror’s proposed goals are set at levels that are realistic and that the parties can reasonably expect to meet.