T-5 Draft RFP Section A-B HT940220R0005.pdf

HT940220R0005

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

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

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

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

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

08/28/2020 X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

NICHOLAS R. CECILIANI 303

NICHOLAS.R.CECILIANI.CIV@

MAIL.676-3997

PAGE(S)

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 12

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

BASE YEAR; TRANSITION-IN PERIOD 1 Jan 2023 – 31

December 2023

0001 TRANSITION-IN (Firm-Fixed Price 1 LO

Planning and Implementation of Transition-In as stated in the Performance Work Statement

(PWS),Section C.2.8. of the solicitation/contract

0002 Contract Data Requirements List (DD Form 1423)

(Not Separately Priced)

0002AA Contract Data Requirements List (DD Form 1423) 1 EA

(Not Separately Priced)

OPTION PERIOD 1 - 1 Jan 2024 – 31 December 2024

1001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

1002 Fixed Fee for CLIN 1001 12 MO

(Option Line Item)

1003 Per Member Per Month (PMPM)

(Option Line Item)

1003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

1003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

Continued ...

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CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

1003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

1004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

1005 Award Fee 1 LO

(Option Line Item)

1006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

1006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

1007 Service Assist Teams 1 LO

(Option Line Item)

1008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 2 - 1 Jan 2025 – 31 December 2025

2001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

2002 Fixed Fee for CLIN 2001 12 MO

4 12

CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

2003 Per Member Per Month (PMPM)

(Option Line Item)

2003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

2003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

2003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

2004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

2005 Award Fee 1 LO

(Option Line Item)

2006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

2006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

2007 Service Assist Teams 1 LO

5 12

CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

2008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 3 - 1 Jan 2026 – 31 December 2026

3001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

3002 Fixed Fee for CLIN 3001 12 MO

(Option Line Item)

3003 Per Member Per Month (PMPM)

(Option Line Item)

3003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

3003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

3003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

3004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

3005 Award Fee 1 LO

6 12

CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

(Option Line Item)

3006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

3006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

3007 Service Assist Teams 1 LO

(Option Line Item)

3008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 4 - 1 Jan 2027 – 31 December 2027

4001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

4002 Fixed Fee for CLIN 4001 12 MO

(Option Line Item)

4003 Per Member Per Month (PMPM)

(Option Line Item)

4003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

4003AB PMPM in accordance with Performance Requirements EA

7 12

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

4003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

4004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

4005 Award Fee 1 LO

(Option Line Item)

4006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

4006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

4007 Service Assist Teams 1 LO

(Option Line Item)

4008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 5 - 1 Jan 2028 – 31 December 2028

5001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

8 12

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

5002 Fixed Fee for CLIN 5001 12 MO

(Option Line Item)

5003 Per Member Per Month (PMPM)

(Option Line Item)

5003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

5003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

5003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

5004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

5005 Award Fee 1 LO

(Option Line Item)

5006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

5006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

5007 Service Assist Teams 1 LO

9 12

CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

(Option Line Item)

5008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 6 - 1 Jan 2029 – 31 December 2029

6001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

6002 Fixed Fee for CLIN 6001 12 MO

(Option Line Item)

6003 Per Member Per Month (PMPM)

(Option Line Item)

6003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

6003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

6003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

6004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

10 12

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

6005 Award Fee 1 LO

(Option Line Item)

6006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

6006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

6007 Service Assist Teams 1 LO

(Option Line Item)

6008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 7 - 1 Jan 2030 – 31 December 2030

7001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

7002 Fixed Fee for CLIN 7001 12 MO

(Option Line Item)

7003 Per Member Per Month (PMPM)

(Option Line Item)

7003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

11 12

CONTINUATION SHEET

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(A) (B) (C) (D) (E) (F)

7003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

7003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

7004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

7005 Award Fee 1 LO

(Option Line Item)

7006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

7006AA Contract Data Requirements List (DD Form 1423) 1 EA

(Option Line Item)

7007 Service Assist Teams 1 LO

(Option Line Item)

7008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

OPTION PERIOD 8 - 1 Jan 2031 – 31 December 2031

8001 Underwritten Health Care Cost for Contractor 1 LO

Network Prime Enrollees and for Non-Prime

12 12

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REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

Underwritten Beneficiaries and MTF Enrollees

(Cost plus fixed fee) (Estimated Cost)

(Option Line Item)

8002 Fixed Fee for CLIN 8001 12 MO

(Option Line Item)

8003 Per Member Per Month (PMPM)

(Option Line Item)

8003AA PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

8003AB PMPM in accordance with Performance Requirements EA

Section C (Fixed Price) (Estimated Quantity)

(Option Line Item)

8003AC PMPM in accordance with Performance Requirements EA

Section C (Fixed Price)(Estimated Quantity)

(Option Line Item)

8004 Earned Performance Incentive for Section H.2. and 1 LO

H.3.

(Option Line Item)

8005 Award Fee 1 LO

(Option Line Item)

8006 Contract Data Requirements List (DD Form 1423)

(Option Line Item)

8006AA Contract Data Requirements List (DD Form 1423) 1 EA

13 12

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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(A) (B) (C) (D) (E) (F)

8007 Service Assist Teams 1 LO

(Option Line Item)

8008 MTF/Guard/Reserve/MSO/VSO Briefings 1 LO

(Cost Reimbursable)

(Option Line Item)

TRANSITION-OUT PERIOD - 1 Jan 2032 – 31 December

9001 Transition Out 1 LO

(Cost Plus Fixed Fee)

(Option Line Item)

9002 Fixed Fee for CLIN 9001 1 LO

(Option Line Item)

EXTENSION PERIOD 1 JAN 2033 - 1 JUN 2033

9003 6-MONTH OPTION PERIOD EXTENSION, IF REQUIRED 1 LO