T-5 Industry Day Questions Draft RFP 1.1 Public Release 030921.pdf

T-5 Offeror Consolidated Questions Draft RFP 1.1 All Workstreams as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 1 TRICARE Operations Manual

(TOM)

H.16 Innovations contributing to readiness and value

Feedback; Independent physicians contracting directly with the government via a direct contracting entity such as Wellvana, similar to what CMS is doing with direct contracting entities is the single best innovative approach to improving quality, improving the consumer experience, and reducing expense.

Submitted Cover Letter as well Thank you for the feedback. DHA will take that under advisement.

2 TRICARE Operations Manual

(TOM)

H.17 Feedback; Wellvana is interested in participating in small scale demonstration projects in any of our footprint markets.

Thank you for that information.

3 TRICARE Operations Manual

(TOM)

H.16 readiness and value We have all the required capabilities currently. Will minimum beneficiary numbers participating in a contract be based upon the number of participating physicians, or a market, or what?

Thank you. The targeted beneficiary population will be based on the overall number of eligible beneficiaries in the demonstration market.

4 TRICARE Operations Manual

(TOM)

H.16.1.2.3 reimbursement What has the government traditionally paid per beneficiary per year on average, or will claims data be available to determine a PMPM target?

Claims Data should be available from the MCSC in order to assist in determining the PMPM for a population.

5 TRICARE Operations Manual

(TOM)

H.16 geography Are the regional geographies or potential demonstration regions all tied to MTFs? Are there areas where Tricare beneficiaries are being cared for by civilian physicians (potentially Wellvana physicians) that are not located near an MTF? How exactly would a civilian physician work with vs in lieu of an MTF or active duty provider?

Potential demonstration area are not necessarily located near an MTF. Yes, there ae many areas where TRICARE beneficiaries are being cared for that are not near MTFs.

The relationship between a network provider and the MTF would be determined by the nature of the demonstration, whether it is a beneficiary choice demo or a competitive demo.

6 H.16.1.8.; TRICARE Operations Manual (TOM)

H.16.1.8.1.; Chapter 27, Section 1, 2.1.3

Telehealth Accreditation

Does the telehealth network accreditation requirement apply to the contractor or the providers that comprise their network? For example, does the Contractor itself need to hold accreditation in the same manner that the Contractor holds accreditation for medical management? Or, does a contractor need to include telehealth providers in their network that have achieved accreditation? Some contractor's may choose to build their own telehealth network or they may choose to contract with a vendor that has their own established network of telehealth providers. In this latter scenario, if the vendor is accredited, is this sufficient to meet the telehealth accreditation requirement? We recommend that a Contractor be deemed as meeting the Telehealth Network Accreditation requirement when they utilize an accredited sub-contractor's telehealth network.

Submitted Cover Letter as well

URAC's Telehealth Accreditation can accommodate both scenarios but clarity will ensure contractor's utilize and prioritize the correct accreditation strategy. As the largest telehealth accreditation organization in the US, URAC's experience accrediting telehealth providers and working with our health plan stakeholders, most have not developed their own separate network of telehealth providers but have folded payment for telehealth services into their benefit packages as well as contracting with an organization that has their own accredited network of telehealth providers.

It is likely the latter scenario is more applicable to the DHA contract and URAC recommends DHA clarify the intent in this manner.

Some potential offerors will possess their own telehealth network, while others may choose to subcontract with a vendor that has an established network of telehealth providers. In either case, the network shall be accredited.

7 H.16.1.7 H.16.1.7.8 Medical Management/ Health Plan Accreditation

Does DHA have a published list of "nationally recognized accrediting organization(s)" that it recognizes to meet the contractual requirements for medical management programs: utilization management, case management, and population health? If there is no list, are there criteria by which DHA will accept an accreditation as meeting this requirement that can guide the Contractor's pursuit of accreditation? We believe URAC accreditation meets the medical management accreditation requirements and are happy to provide any information to DHA.

As URAC currently accredits several DHA Contractors we know that organizations often plan a year in advance to pursue and achieve accreditation. Additional clarity here may help contractor's choose an accreditor and begin preparations.

No, DHA does not have a published list of accreditation organizations. There are several programs that require "accreditation" in the contract. DHA does not restrict or mandate which one is used, only that a "certification" is not acceptable.

8 H.16.1.7 H.16.1.7.8 Medical Management/ Health Plan Accreditation

Does DHA have a published list of "nationally recognized accrediting organization(s)" that it recognizes to meet the contractual requirements for the Contractor's provider network? If there is no list, are there criteria by which DHA will accept an accreditation as meeting this requirement that can guide the Contractor's pursuit of accreditation? URAC's Health Plan Accreditation and separate Health Network Accreditation both address a plan's network requirements.

As URAC currently accredits several DHA Contractors we know that organizations often plan a year in advance to pursue and achieve accreditation. Additional clarity here may help contractor's choose an accreditor and begin preparations.

No, DHA does not have a published list of accreditation organizations. The Government does not mandate accreditation from a specific nationally recognized organization. Network Accreditation must be from an industry standard accredited body that takes into account factors such as key quality benchmarks for network management, provider credentialing, quality management and improvement, and consumer protection.

9 TRICARE Operations Manual

(TOM)

2.1.5.3 PCMH Accreditation Does DHA have a list of "nationally accepted accrediting organizations" that it will recognize for primary care medical homes? If not a list, what are the criteria by which DHA will allow an accreditation to meet this requirement?

No, DHA does not have a published list of accreditation organizations. There are several programs that require "accreditation" in the contract. DHA does not restrict or mandate which one is used, only that a "certification" is not acceptable.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 10 H.16.1.8.; TRICARE Operations

Manual (TOM) H.16.1.8.1.; Chapter 27, Section 1, 2.1.3

Telehealth Accreditation

Will DHA have a list of "nationally accepted accrediting organizations" that it will recognize for to meet the telehealth accreditation requirement? If not a list, what are the criteria by which DHA will allow an accreditation to meet this requirement?

No, DHA does not have a published list of accreditation organizations. There are several programs that require "accreditation" in the contract. DHA does not restrict or mandate which one is used, only that a "certification" is not acceptable.

11 H.16.1.7 H.16.1.7.8 Medical Management/ Health Plan Accreditation

Does DHA have a list of "nationally recognized accrediting organization(s)"?

A list of organizations and/or accreditation programs would be beneficial.

We also believe that URAC Disease Management Accreditation should be recognized as meeting the population health accreditation requirements for this section. URAC accreditation standards validate an organization's ability to manage the disease of a defined population as outlined in Section C.2.5.

As URAC currently accredits several DHA Contractors we know that organizations often plan a year in advance to pursue and achieve accreditation. Additional clarity here may help contractors choose an accreditor and begin preparations. URAC's Disease Management Accreditation has been used by organizations, including DHA contracted organizations in the past, to manage the health of a defined population specific to a chronic condition and/or disease state. While the terms may not match, the intent and impact between URAC's Disease Management and the expectations of a Contractor's population health program are the same.

No, DHA does not have a published list of accreditation organizations. There are several programs that require "accreditation" in the contract. DHA does not restrict or mandate which one is used, only that a "certification" is not acceptable.

12 A. Solicitation/Contract Form Pre-Bid Meeting and/or Bidder List

Will DHA hold an optional and/or mandatory pre-proposal meeting for potential vendors to attend? If yes, will organizations, individuals, and attendee contact information be available post meeting?

URAC would like to inform potential bidders of our telehealth, health plan, population health, and PCMH accreditation(s)to fulfill requirements of this

RFP.

DHA plans to hold its annual Virtual Industry Day on Jan 27, 2021. The TRICARE Health Plan will participate and pass on contact information from interested parties wanting to partner with potential bidders.

13 H.16 H.16.1.1 Advanced Primary Care For an Advanced Primary Care network to be successful, APCs will need to be connected to MHS GENESIS solution. How does DHA plan to integrate Advanced Primary Care networks with MHS GENESIS? How does DHA plan to leverage the MHS GENESIS longitudinal record to support advanced primary care?

Submitted Cover Letter as well

Clarity

DHA plans to require APCs to be connected to a compatible Health Information Exchange.

14 H.16 H.16.1.2 Beneficiary Choice Demonstration

For Accountable Care Organizations (ACOs) to be successful, ACOs will need to be connected to the MHS GENESIS solution. How does DHA plan to integrate ACOs with MHS GENESIS? How does DHA plan to leverage the MHS GENESIS longitudinal record to support ACOs?

Clarity DHA plans to require health plans to be connected to a compatible Health Information Exchange.

15 H.16 H.16.1.3 Advanced Care Management

How does DHA plan to integrate care plans with the MHS GENESIS solution already deployed?

Clarity DHA does not plan to require integration with care plans in MHS GENESIS as this demonstration will be for non-MTF enrolled beneficiaries.

16 H.16 H.16.1.4 Care Collaboration Tools Requirements

MHS GENESIS has care collaboration tools deployed via the DHMSM Program. How does DHA plan to integrate with the solutions already deployed?

Clarity The PMO is unaware of care collaboration tools in MHS GENESIS that are available for use outside the MHS. Please provide information on tools on contract that support integration with private sector care.

17 H.16 H.16.1.5 Clinically Integrated Networks (CINs)

For CINs to be successful, physicians will need to be integrated with the MHS GENESIS solution. How does DHA plan to integrate CINs with MHS GENESIS? How does DHA plan to leverage the MHS GENESIS longitudinal record to support CINs?

Clarity DHA has not yet specified its Clinically Integrated Network integration requirements. DHA plans to prioritize the start of this demonstration in the next Draft RFP.

18 H.16 H.16.1.8 Advanced Telehealth Video visits are being integrated within the MHS GENESIS beneficiary portal. How does DHA plan to integrate advanced telehealth with the direct care program?

Clarity Currently there are no known integration requirements with the direct care system.

19 H.16 H.16.1.9 Virtual Value Network

(VVN)

How will DHA align metrics for appropriateness of care, clinical outcomes, beneficiary experience and cost against the metrics analyzed within the MHS GENESIS solution?

Clarity The metrics will use HEDIS and other widely available standards.

20 H.16 H.16.1.9.2 Virtual Value Network

(VVN)

The RFP states that, "Contractor shall use claims data to develop and maintain quarterly provider scorecards and submit monthly reports on performance metrics to the Government". Clinical data is required to understand the outcome of the created Virtual Value Network as claims data does not include the clinical outcome of the encounter. Will DHA leverage the longitudinal health record with integrated claims and clinical data to support the Virtual Value Network?

Clarity DHA will take this under consideration as we develop the VVN demonstration. At this point, we anticipate clinical data will need to be collected from sources other than claims, to include the EHR.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 21 H.16 H.16.1.10 Wellness and Disease

Management (Population Health)

How does DHA plan to leverage the MHS GENESIS aligned wellness and disease management platforms being deployed?

Clarity The PMO is unaware of wellness and disease management platforms in MHS GENESIS that are available for use outside the MHS. Please provide information on tools on contract that support integration with private sector care.

22 H.16 H.16.1.11 Centers of Excellence (CoE)

How will Centers of Excellence be integrated within the MTFs? Clarity Currently there are no known integration requirements with the direct care system.

23 Cover Letter Item #2 Draft RFP #2 Clarification of timing. The Geographic areas for the H.17 demonstrations are planned to be released with Draft RFP #2 - when does the Government anticipate the release of Draft RFP #2 to be?

DRAFT RFP #2 was released on December 11, 2020.

24 H.16 H.16 Clarification Will H.16 be evaluated as part of the technical proposal? Now that DHA has added Sections L and M that correspond to section H.16, please clarify whether H.16 will be evaluated as part of the technical proposal. More specifically, please confirm if it is the governments intent to expand the Factor 1 Technical/Management evaluation criteria to include a new Subfactor re: Planned Demonstrations / Product Improvements.

DHA will decide which innovations will be specified in the T-5 proposal. DHA seeks input from industry on which innovations will bring the most value (increased readiness, quality, access or lower costs) to the MHS.

25 H.16 H.16 Clarification Will pricing for H.16 be required with the initial proposal submission? DHA will decide which innovations will be specified in the T-5 proposal. DHA seeks input from industry on which innovations will bring the most value (increased readiness, quality, access or lower costs) to the MHS.

26 H.16 H.16 Clarification Are the demonstrations identified in H.16 contract options or are they considered part of the base contract award? If options, can DHA exercise unilaterally or will there be a bilateral negotiated change to the contract?

H.16 identifies several proposed demonstration projects that can be conducted over the life of the T-5 contract.

The proposed demonstrations will be conducted in conjunction and coordinated with the MCSC as contract modifications.

27 H.16 H.16 Potential Demonstrations

Section H.16.1 contains 11 potential demonstrations project improvements, each separate and distinct. Do bidders/awardees need to be prepared to implement/execute all potential demos/projects or will DHA negotiate select demos with MCSCs post award?

Will implementation timeframes be negotiated for the demos/project DHA elects to implement?

The demos are so diverse that it could be challenging to be prepared for all of them.

Some could be developed/executed more quickly than others.

DHA will negotiate select demos with winning offerors.

DHA intends to implement some of the demonstrations very early in conjunction with SHCD. Other demonstrations may take place later in the contract period.

28 H.16 H.16.1 Beneficiary Enrollment Is the Contractor responsible for identifying beneficiary candidates for the applicable Demonstration programs (e.g. Targeted UM, Population Health) or will these be determined by the Government? Will the same beneficiary be enrolled in multiple programs?

For network enrolled beneficiaries, the contractor will be responsible for identifying beneficiary candidates. MTF enrolled beneficiaries may be referred to the contractor for enrollment in applicable demonstration programs.

29 H.16 H.16.1.1.1.1 Accreditation Are there specific APC certification or accreditations DHA requires? No, DHA does not have a published list of accreditation organizations. There are several programs that require "accreditation" in the contract. DHA does not restrict or mandate which one is used, only that a "certification" is not acceptable.

30 H.16 H.16.1.1.1.3. Value Based Payment Request for clarification It will likely be difficult for contractors to meaningfully contract with the more advanced value based providers without specific commitments from DHA regarding the form and level of value based payment structures that will be allowed under the contract. Please provide this specificity to allow the contractors to provide the greatest value in their proposed solutions.

Specificity will be provided in the offeror's proposal in accordance with TRM Ch. 18, Section 1.

31 H.16 H.16.1.1.2 Risk Adjustment Model Could the DHA provide the specific risk adjustment model it intends to use under the contract?

DHA expects the contractor to develop and propose the risk adjustment model it proposes to use.

32 H.16 H.16.1.1.5. Enrolled Versus Attributed Models

Does DHA intend to use a beneficiary enrollment model with its APC program (i.e., Are the APC’s solely for use in the Beneficiary Choice demonstration or does DHA expect to deploy them more broadly to non-enrolled populations?)?

The more advanced and effective APCs rely upon beneficiaries enrolling with the APC model versus being beneficiaries being attributed behind the scenes. This is true for both the most effective care and payment models currently in use in the industry. This significantly impacts the education and adherence model effectiveness.

The Beneficiary Choice and Advanced Primary Care demonstrations are independent of each other. The contractor may propose APCs as part of the Beneficiary Choice demonstration if they would like to use APCs as part of their ACO or other local/regional plans.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 33 H.16 H.16.1.11 Clinical Centers of

Excellence Based on existing patient care data, as well as training needs for military medical personnel, can the Government specify what conditions or procedures would be most advantageous to the MHS and the TRICARE beneficiary population for MCSC partnerships with CCoEs?

The draft RFP denotes that CCoEs would accommodate care for beneficiaries with conditions or procedures that are high mortality, high cost, or have high variability health outcomes; in addition, it infers these may be useful training platforms for the readiness of military medical personnel for national security contingency operations. Would be helpful to scope the CCoE partnerships to the areas most desired by the MHS.

DHA intends to include a list of procedure and diagnosis codes that supports medical readiness of the medical force as part of the award fee plan. This list will be subject to change as the needs of the military force requires.

34 H.16 H.16.1.11 Clinical Centers of Excellence

Can the Government provide a comprehensive list of current direct care and purchased care Clinical Centers of Excellence in each region?

Can the Government provide a comprehensive list of current direct care and purchased care Clinical Centers of Excellence in each region?

The Government will work with the contractor to prioritize facilities and populations that may benefit from CCoE care and become part of the TRICARE Institutes of Excellence Care. Facilities and providers will have proven reportable outcomes that increase the quality of life and provide a cost savings to the Government for better care received.

35 H.16 H.16.1.11.1 Clinical Centers of Excellence

What is the actual measuring point for the 100 mile measure of distance to a CCoE since designated MTF/market is unclear while beneficiary address would be more specific?

In terms of drive time and distance access, it is measured from beneficiary address to specialty provider. Distance is set in statute and nonnegotiable from PCM zip code. The Government will not consider a change. This measure is also used for Prime Travel benefit calculations for specialty care 100 miles one way from PCM.

https://tricare.mil/primetravel

36 H.16 H.16.1.11.9 Clinical Centers of Excellence

How often does the Government need to be notified about providers losing CCoE status - real time, weekly, monthly or quarterly?

DHA expects to be notified as soon as the contractor is aware of a change in the CCoE status of providers/facilities, but no later than monthly.

37 H.16 H.16.1.2 Beneficiary Choice Demonstrations

Is there a minimum number of enrolled beneficiaries required in the Beneficiary Choice demonstrations?

DHA does not have a minimum number required for beneficiary enrollment, however, market research has demonstrated a population of 10,000 or more beneficiaries provides the greatest information as to the success of an ACO plan.

38 H.16 H.16.1.2.1 Rates Payments under this demonstration will be made on a fully capitated PMPM basis. Is this rate intended to be negotiated at the time of the demonstration or does the Government anticipate prescribing the rate based on other, then available data?

DHA expects to negotiate the PMPM as part of the demonstration implementation process.

39 H.16 H.16.1.2.1 Contractor/BCP Relationship

What relationship(s) does the Government envision between MCSCs and BCPs in their network? Would a subcontracting relationship be precluded?

A subsidiary relationship?

The Mod removed the word “subcontracted” when referring to Beneficiary Choice Plans.

The relationship of the beneficiary choice plan to the MCSC will be up to the MCSC to establish.

40 H.16 H.16.1.2.3 Rates Please confirm that other fees applicable under the contract (e.g. per claim rate) remain applicable and are excluded from the requirement that the “proposed PMPM rates (inclusive of admin and healthcare) for the demonstration do not exceed what the Government would have paid for the same beneficiaries enrolled to the MCSC.”

There is no "per claim rate" in the contract. The PMPM rate for a demonstration is inclusive of all admin and health care costs.

41 H.16 H.16.1.2.6. Benefit Design Flexibility

Does DHA expect to allow benefit design flexibility under the Beneficiary Choice plans to support chronic care management adherence of enrolled beneficiaries?

The plans offered as part of the Beneficiary Choice demonstrations will offer the basic TRICARE benefit and any additional benefit design would be subject to DHA approval.

42 H.16 H.16.1.3.5 Case Management Can the in-home CM support required within 48-72 hours of discharge be rendered virtual?

The expectation by the Government is an in-home visit. A contingency plan should be included by the offeror in the event an in-home visit cannot be done due to public health emergencies or a natural disaster.

43 H.16 H.16.1.6.1.9. Monetary Provider Recognition and Reward payments

Will the incentive structure under this section be evaluated as part of the price evaluation process? If so how?

DHA will not evaluate provider reward in the T-5 solicitation price evaluation.

https://tricare.mil/primetravel https://tricare.mil/primetravel https://tricare.mil/primetravel https://tricare.mil/primetravel https://tricare.mil/primetravel https://tricare.mil/primetravel https://tricare.mil/primetravel as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 44 H.16 H.16.1.6.9 Provider Incentives Does the statement "provider incentives paid either monthly, quarterly, or annually cannot result in payments that exceed TRICARE maximums" mean that all services and associated claims have to be aggregated annually to determine TRICARE maximum allowable which then means incentive payments could not be paid any more frequently than annual?

The payment calculation methodology for Provider Recognition and Reward will be determined at the time the demonstration is incorporated into the contract via modification.

45 H.16 H.16.1.6.1.9 Incentives If the Contractor utilizes monetary incentives are these considered “healthcare” costs and excluded from Cost Accounting requirements or are they considered allowable administrative expenses?

These payments will be submitted on non-TED vouchers which are exempt from cost accounting measures.

However, the MCSC will be required to attribute all payments as part of the voucher.

46 H.16 H.16.1.6.1.9 Incentives Attribution of incentives paid to individual claims paid would most likely result in small amounts identified per claim. Is this information required to be reported to the provider or only to the Government? How does the Government anticipate receiving this information? Timing after such payment is made?

See response to question 46 for information on voucher submission.

47 H.16 H.16.1.7 Targeted Utilization Management

How is the Government distinguishing what is intended by a “targeted” utilization management program? Are there specific categories of care or diagnosis related groups (DRG) that are expected to be targeted for the UM program? If so, will these DRGs be specified in the final solicitation?

Generally, a targeted UM program references targeted case management reviews for medical necessity of specific DRGs.

The contractor shall select services, providers, or cases subject to the targeted UM authorization requirements based on evidence based practices with transparency to providers in the services that require authorization. This process should be described in the annual plan, and results reported quarterly throughout the year. In addition, the contractor shall implement a UM evaluation process to identify services that should not require authorization. The evaluation should target specific diagnoses, levels of care, case complexity and provider types to identify procedures and services that are low cost, have high approval rates, or that have low denial rates where eliminating authorizations provides efficiency in the UM process or reduces unnecessary provider burden.

48 H.16 H.16.1.10.1.2 Incentives May the incentives include tangible items such as smart watches or other tracking devices? If the Contractor utilizes monetary incentives or tangible items, are these considered “healthcare” costs and excluded from Cost Accounting requirements or are they considered allowable administrative expenses?

No. All beneficiary Incentives are limited to those authorized by statue and regulation.

49 H.17 H.17.1 Competitive Demonstrations

Will MCSCs administering TRICARE Contracts (or their subsidiaries, JV Partners, subcontractors) be eligible for award of Competitive Demonstration Contracts?

MCSCs will not be eligible for the Competitive Demonstrations in their own respective regions.

50 H.17 H.17.1 Competitive Demonstrations

Will DHA cap enrollment in competitive demos? No. We intend to have a target range of beneficiaries for each market.

51 H.17 H.17.1 Competitive Demonstrations

Will DHA limit geographic areas for competitive demos for the life of the contract?

If DHA allows these demos to expand service area, impact could be very substantial.

DHA intends for each competitive demonstration to be limited to the market it is awarded in.

52 H.17 H.17.1 and 17.3 Competitive Demonstrations

Will there be a defined enrollment period for any non-MCSC demonstrations since this will impact MCSC workload?

DHA can implement demonstrations at any time that would shift beneficiaries from the MCSC programs to other demonstrations.

DHA intends that the enrollment period of the demonstrations to be in conjunction with the Open Enrollment season.

53 H.17 H.17.2 Competitive Demonstrations

Will MCSCs administering TRICARE Contracts (or their subsidiaries, JV Partners, subcontractors) be eligible for award of an eventual EEE Contract?

Yes, subject to FAR 9.505, General Rules, Organizational and Consultant Conflicts of Interests

54 H.17 H.17.2 Enrollment, Eligibility and Encounter (EEE)

Is it the Government’s intention that the EEE role will remain the responsibility of the MCSC throughout the duration of the contract for all operations except those relating to competitive demonstrations?

Need to affirm that the EEE contractor will only be responsible for the competitive demonstrations so that this does not become another mid-contract carve-out.

Yes

55 H.17 H.17.2 Enrollment, Eligibility and Encounter (EEE)

This section indicates DHA intends to acquire a EEE contractor and that the T-5 contractor will “interact” with the EEE contractor. Does that mean that once this contract is awarded, DHA will carve these functions out of the T-5 contractor’s agreement?

No. The MCSC will need to coordinate with the EEE contractor with respect to the enrollment and jurisdiction of claims for the beneficiaries that enroll to the competitive demonstrations.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 56 H.17 H.17.2 Enrollment, Eligibility and Encounter (EEE) N/A Section H.17 calls for Competitive Demonstrations using a separate EEE

(Triple E) contractor. In our opinion this will cause unnecessary fragmentation of critical health care delivery functions, lead to beneficiary confusion, lack of clear accountability for critical functions, and increase administrative cost to the Government. As background, the Uniform Benefit has been a cornerstone of the TRICARE program since its inception.

Guaranteeing that a sailor in San Diego has the same benefit as a sailor in Norfolk has been a hallmark of the program. Establishing Competitive Demonstrations with a separate Triple E contractor will threaten the concept of a Uniform Benefit. As previously stated, moving in this direction will add increased complexity for the Government and the beneficiary, will fragment accountability, and will increase administrative cost to the program. It is strongly recommended that DHA use existing demonstration authority and the competitively awarded T-5 contracts to achieve the stated objectives of H.17.

Thank you for your input. DHA will take it under advisement.

57 H.17 H.17.3 PMPM Reduction How does the Government anticipate that MCSCs can effectively negotiate provider contracts in good faith with discounts and projected volumes to meet TRICARE access standards throughout the designated region where there is no predictability on the timing and scope of competitive demonstrations that will carve-out and essentially void those provider contracts? How will the Government make equitable adjustments to the regional MCSC due to the requisite lost revenue associated with lost enrollees and PMPM reductions?

The Government anticipates that MCSCs will effectively negotiate provider contracts in good faith with discounts and projected volumes to meet TRICARE access standards throughout the designated region. Because there is not predictability on the timing and scope of competitive demonstrations that will carve-out and essentially void MCSC's provider contracts, please clarify how the Government will manage equitable adjustments to the regional MCSC due to the requisite lost revenue associated with lost enrollees and PMPM reductions?.

The contractor will need to factor the potential loss of beneficiaries to the competitive demonstrations into their pricing structure and proposal.

59 H.17 H.17.3 Competitive Demonstrations

Will TRICARE beneficiaries continue to have a choice in whether to join the competitive demonstration in the designated markets within the MCSC region? If so, would this consequently require a sustained MCSC network overlapping the competitive demonstration market service area?

We need to understand the implications on the network based on planned competitive carve-outs. Other issues may need to be explored, including “right-of-first refusal” for care referrals that are outside the capability of competitive demonstration vendors.

Yes, the competitive demonstration will be a separate option in the designated market.

60 H.17 H.17.3 Competition Against Contractor Beneficiary Choice Plans

Does the Government intend to carve out beneficiaries in Competitive Demonstrations that will directly compete with fully capitated Beneficiary Choice Plans offered by the contractor?

If that is the case, it will likely make it much more difficult for providers to agree to the full capitation with this level of future uncertainty.

DHA does not intend to conduct Beneficiary Choice and Competitive demonstrations in the same markets at the same times.

61 H.17 H.17.3 Beneficiary Carve Outs Impact on Pricing

Will the pricing impact of undefined future beneficiary carve outs be considered under the changes clause?

The potential number of beneficiaries affected by competitive demonstrations is established in Attachment J- 9 for consideration of the offerors PMPM rates.

Therefore, the reduction of administrative costs is not subject to the Changes clause and offerors are advised to consider future impacts in their PMPM pricing. The Government's intent is to treat PMPM pricing in the same manner as beneficiaries that opt into USFHP.

62 L.6.2.6 L.6.2.6 Planned Demonstrations/ Project Improvements

Is the Government’s intent that all potential scenarios outlined in this section be addressed in the T-5 bid? Or is the intent of this section to simply indicate what the Government will expect if it moves forward with implementation of any of these demos/projects?

This section implies that the contractor must describe its approach to each of the potential demos/project improvements listed in H.16, regardless of whether DHA intends to implement any/all of these demos or improvements.

Offerors should be prepared to provide proposals for all of the H.16 demonstrations as part of their T-5 proposal.

63 L.6.2.6 L.6.2.6.1.1 APC Payment Models How will APC payment models be created under existing DHA reimbursement structure constraints?

The contractor is expected to develop and propose payment methodologies to facilitate effective implementation of APCs.

64 L.6.2.6 L.6.2.6.1.1 APC Payment Models How will APC payment models be evaluated in the price evaluation, if at all?

DHA will not evaluate provider recognition and reward payments in the T-5 solicitation price evaluation.

65 L.6.2.6 L.6.2.6.2.2 Beneficiary Choice Demonstrations

If the partner plans' quality, access and cost are equal to the Offeror’s network, would the Government penalize the Offeror for lack of differentiation?

Yes. DHA expects the prime contractor to propose beneficiary choice partners that will be differentiated from the MCSC network.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 67 L.6.2.6 L.6.2.6.2.2 Beneficiary Choice

Demonstrations Are offerors required to offer enrollment in the contractor-run beneficiary demonstrations to all eligible TRICARE beneficiaries residing in the demonstration area(s)?

Not all beneficiaries in the demonstrations markets will be given the choice as to which contractor they want to enroll with. Some beneficiaries may be excluded (e.g. Active Duty Service Members).

68 L.6.2.6 L.6.2.6.5.3.3 CIN Value Based Payment Models

How will CIN value based payment models be created under existing DHA reimbursement model constraints?

The contractor is expected to develop and propose payment methodologies to facilitate effective implementation of CINs.

69 L.6.2.6 L.6.2.6.5.3.3 CIN Value Based Payment Models

How will CIN value based payment models be evaluated in the price evaluation, if at all?

DHA will not evaluate CIN payment models in the T-5 solicitation price evaluation.

70 M.7.2.6 M.7.2.6 Planned Demonstrations/ Project Improvements

Is the Government's intent to penalize bidders who selectively address the potential demos/projects and not write to each potential scenario?

With the demos/improvement projects being fairly broad in description, how will the government ensure a level-playing field for all bidders?

This section implies that the Government will evaluate each bid based on the bidders preparedness to perform each/all of the demos/project improvements listed in H.16, regardless of whether DHA intends to implement any/all of them.

The final RFP will instruct offerors on all of the innovations required in the offerors' proposals.

71 M.7.2.6 M.7.2.6.1.4 Advanced Primary Care How does the Government intend to evaluate “Warfighter Readiness”? Warfighter readiness is equated to prompt return of medical information to the military treatment facilities for Service Members.

72 M.7.2.6 M.7.2.6.1.5 Risk Adjustment Model Used

Does DHA intend to prescribe the risk adjustment model to be used? If not, can the risk adjustment model vary by provider system to maintain consistency for the providers to population managed?

DHA expects the contractor to develop and propose the risk adjustment model it proposes to use.

73 M.7.2.6 M.7.2.6.2.2 Competitive Demonstrations

What is the Government's intent in using the term "partner" in reference to Beneficiary Choice Plans included in an MCSC's network as "partners"?

“Partner” can be both a term of art and a vague description of an entity in a relationship.

Alternate health plans under the Beneficiary Choice demonstrations will not be directly contracted with the Government. They are part of the prime contractors proposal and will be facilitated by the prime MCSC and are thereby "partners" with the prime MCSC.

74 H.16 H.16.1.2.1 Beneficiary Choice Demo (BCD)- Target ACOs

Would DHA agree that the beneficiary choice demonstration is better suited for existing MCSC providers and/or ACOs?

The Beneficiary Choice Demonstration requires ACOs to subcontract under the MCSC, making it an unattractive option for large, integrated care delivery models (ICD) like KP and other industry leading ACOs and health plans.

RECOMMENDATION: The BCD will attract smaller, localized ACOs that are more comfortable accepting partial to full risk. DHA should establish specific criteria for ACOs to participate in BCD to differentiate between the two demonstrations (BCD

vs. Competitive). RATIONALE: The BCD is a more incremental approach and reflects the arrangement of the TRICARE KP ACO demonstration in Atlanta, GA as well as aligns with the CMS Next Generation ACO Model. Given KPs experience with the GA demonstration, KP had to deconstruct portions of its integrated system to function as a subcontracted provider to the MCSC. This approach is not scalable nor sustainable for ICD models like KP. While much of this construct was necessary under T-17, it resulted in start-up and operating costs that would be prohibitive to most health systems and are not sustainable or scalable for Kaiser Permanente beyond the current demonstration. The issues inherent with both Beneficiary Choice Demonstration and CMS Next Generation ACO model which resulted in KP’s decision to not participate in this demonstration. Setting ACO’s up for success requires preserving the integrity of their care models, so that DHA and TRICARE beneficiaries can realize the full value of how those models deliver care.

DHA takes no position on what types of entities will be best suited for the Beneficiary Choice Demonstration, as it is up to the offerors to propose their best solutions to meet the requirements.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 75 H.16 H.16.1.2.2 Beneficiary Choice Demo

(BCD)- PMPM Cost Structure

Does the DHA believe that the Beneficiary Choice Demonstration (BCD) will likely only attract existing network providers that are small scale ACOs with established relationships with MCSC?

Beneficiary Choice Cost structure is self-limiting. Competitive Demo cost structure enables ACOs to cover cost with small margin, even when accounting for Triple E admin cost. RATIONALE: DHA's proposed cost structure for BCD inevitably results in duplicative admin costs (MCSC plus ACO), significantly reducing the PMPM the BCD ACO/Health plan will receive for care delivery. This duplication reduces the ACO's margin and potentially jeopardizes quality by attracting less mature ACOs willing to accept a lower PMPM. Comparing ACO rates to the DHA’s total cost of care will enable ACO’s to cover their costs, achieve an appropriate margin, and demonstrate cost savings to the DHA. The CMS approach calculates savings off their fully loaded costs, and we recommend that DHA take the same approach.

MCSCs receive revenue to cover start-up costs at the beginning of a TRICARE contract whereas ACOs will also have start-up costs but will not receive revenue from DHA or the MCSC. Integral to the ability of ACO’s to deliver the TRICARE benefit at a cost savings to the DHA will be how the DHA recognizes its costs. We believe that the DHA should recognize its total costs, including the cost of care (both underwritten and non-underwritten care plus other components such as pharmacy and national advice nurse line) + a partial allocation of direct care.

The MCSCs will be responsible for bringing high quality providers to support beneficiary choice.

76 H.16 H.16.1.2.3 Rate Negotiation How does the government calculate "what the Government would have paid for the same beneficiaries"?

By including provider discounts in the calculation, the government may not be comparing the true potential cost of care to the rate of negotiated with the ACO. Rather, the government should calculate cost of care based on 100% of the TRICARE fee schedule.

This is calculated as the maximum TRICARE allowable charges level.

77 H.16 H.16.1.2.3 Rate Negotiation Will the Government consider start-up costs of ACOs in the calculation? MCSC's have incentives/awards to cover such costs. Yes. PMPM rates should include admin as well as healthcare costs.

79 H.16 H.16.1.2.5 Typo Enrolment Should be corrected to enrollment. Thank you.

80 H.16 H.16.1.2.6 Enrollment How are such incentives funded? Are these applied to the administrative costs of the MCSC? Are they included in the Government's total cost calculation?

DHA cannot fund financial incentives. The T5 offerors will propose appropriate incentives in their proposals.

81 H.16 H.16.1.1-1.10 Future Innovations and

BCD

How are H16 Innovations different from what the MCSC already provides?

Is the intent that ACOs and Health plans participating in the BCD to use the MCSC for these services or can they use their own innovations, if available?

1.Advanced Primary Care (H.16.1.1)

Some of the innovations listed in H.16 are generally integrated into ACO structure. RFP 1.1. language does not clarify a participating BCD ACO can use internal resources, such as advanced care management, to support their enrollees or if they must use MCSC resources. If a BCD ACO uses their own resources, it is unclear if they can simultaneously participate in multiple H.16 demonstrations and receive compensation for performance in each individual innovation.

The MCSC responsible for the BCD will determine which entity is responsible for the innovation. An ACO participating in a demonstration would be able to compensated through the contractual relationship used for each demonstration.

82 H.16 and H.17 H.16.1.2.

H.17.

Beneficiary Choice and Competitive Demonstrations

Can the Government provide specific selection criteria, process, and timing of ACO participation in demonstrations? Just as the T5 bidding process has an organized approach, we recommend demonstration participation also have an organized approach which is shared at ACO Industry Day.

The T5 process (RFI-draft RFP-RFP) allows Contractors time to build their systems, processes, and resources prior to SHCD. ACOs will need a similar time period to prepare for SHCD.

For the Competitive Demonstrations that could award directly to ACOs, a formal/organized approach to the contracting process will be undertaken following standard Government procurement procedures and including industry days and draft solicitations.

83 H.16 H.16.1.2. Beneficiary Choice Demonstrations

In regards to reducing cost, will ACOs be able to provide beneficiaries pharmacy benefits through their retail and mail order pharmacy services/networks?

ACO use of established integrated retail and mail order pharmacy services is an important aspect of successful pharmacy cost management.

Yes. ACOs using these means will be required to provide the same TRICARE benefit.

84 H.16 H.16.1.2. Beneficiary Choice Demonstrations

The draft RFP states that the "Contractor shall offer beneficiaries a choice of enrollment options to subcontracted Accountable Care Organizations (ACOs) or other local or regional plans." If an MCSC proposes Beneficiary Choice demonstrations in multiple markets with one ACO (i.e., San Diego, Seattle and Denver), would this be considered one demonstration or separate demonstrations?

Scalability of broader markets reduces administrative overhead for the Government and ACOs.

This is dependent up on whether the demonstrations are different in design. The requirement is for "alternative" plans, so the same plan for the demonstration just in 3 different areas may still be considered one demonstration.

as of 9 March 2021

Question # RFP/Manual Location Subsection/Citation Subject Question Additional Info/Rationale Government Response 85 H.16 H.16.1.2.2. Beneficiary Choice

Demonstrations The draft RFP states that the "Contractor’s network shall include ACOs and other organizations that have demonstrated high quality outcomes, lower cost, and reduction of waste." What performance criteria will the Government use in selecting ACOs (e.g., HEDIS, NCQA accreditation, CAHPS, CMS Five-Star Quality Rating System, etc.)?

By utilizing industry-standard performance measures, the Government is more likely to contract with the highest-performing ACOs.

The government will not select ACOs, but will evaluate the offeror's proposal for the partner ACOs proposed and the criteria utilized for their inclusion. The government expects the offeror to provide its criteria for its choice of partner plans based on differentiation from its own local network, including its specific criteria for cost, quality and access. The government will develop its own set of evaluation criteria based on industry best practices to be applied to all providers, both within and outside of the demonstrations.

86 H.16 and H.17 H.16.1.2.

H.17.

Beneficiary Choice and Competitive Demonstrations

The draft RFP states that Alternate Payment Methods will be accepted.

What data will be provided to ACOs to support the development of a proposed PMPM capitated rate?

DHA has provided access to a dataset of all beneficiary claims along with the Draft RFP. DHA requests feedback on this dataset for development of a PMPM rate.

87 H.16 and H.17 H.16.1.2.

H.17.

Beneficiary Choice and Competitive Demonstrations

The draft RFP states that beneficiaries will have a "choice of enrollment options to subcontracted Accountable Care Organizations (ACOs) or other local or regional plans" through the Beneficiary Choice and Competitive demonstrations. There is no reference to eligibility in demonstrations. We recommend eligibility in demonstrations be consistent with eligibility for Prime and Select.

By allowing for wider enrollment (e.g., Actives, TYA and TRS) in the demonstrations, more ACOs and other local or regional plans are likely to participate, which will increase access and convenience for TRICARE beneficiaries.

Thank you. The Government will take that under advisement.

88 H.16 and H.17 H.16.2.

H.17.

ACO Requirements Given the requirements in the draft RFP are written for MCSCs, will the Government be providing requirements specific to ACO contractors participating in demonstrations? Will the Government release ACO-specific requirements prior to ACO Industry Day?

As part of the Beneficiary Choice Demonstrations, the procurement process will be coordinated through the MCSC. For the Competitive Demonstrations, a formal/organized approach to the contracting process will be undertaken following standard Government procurement procedures.

89 H.16 H.16.1.11.1 CCoE How are CCoEs defined? Recognizing that the health care industry does not have a consistent standard to define "Centers of Excellence," it's important for Kaiser Permanente to understand how DHA defines CCoEs.

TRICARE is currently working to develop a COE definition and methodology that will align with industry standards for care, patient outcomes, and public reporting. COEs facilities and providers shall be mutually agreed upon between the GDA and MCSC, when not mandated by statute.

90 H.17 H.17. Competitive Demonstrations

The Government noted during Industry Day discussions that Competitive demonstrations will start "mid-contract" to allow the Government additional time to procure an EEE contract. We strongly recommend the Government reevaluate the potential for all demonstrations to begin on the SHCD.

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