WTC_Health_Program_HPS_TPA_20210909_Draft_PWS.pdf

Performance Work Statement (PWS)

Procurement Request #:

World Trade Center (WTC) Health Program Health Program Support Contractor National Institute for Occupational Safety and Health Centers for Disease Control and Prevention

SECTION 1 – BACKGROUND

On January 2, 2011, the President signed Public Law No. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). Title I of the Zadroga Act amended the Public Health Service Act to add Title XXXIII establishing the World Trade Center (WTC) Health Program, referred to herein as “the Program” within the Department of Health and Human Services (HHS). Title I is codified at 42 U.S.C.

§§ 300mm – 300mm-61. The Zadroga Act was amended in 2015 by Public Law No. 114-113 to provide authority and funding and for the Program to continue through 2090 and further amended in 2019 by Public Law. No 116-59. The Zadroga Act, as amended, can be found at:

https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter31&edition=prelim.

In addition to the statutory requirements for the Program codified in 42 U.S.C. §§ 300mm – 300mm-61, the WTC Program Administrator has also promulgated regulations governing the administration of the Program at 42 C.F.R. pt. 88.

As of March 31, 2021, the Program had 110,198 members enrolled, including 80,745 general responders and 29,453 survivors. Current Program statistics and reports can be found at https://www.cdc.gov/wtc/ataglance.html#enrollmentWTC.

The Program is a limited health benefit program, meaning that treatment is only available for specific covered health condition(s) for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks has been determined to be substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition in an individual member. The Program is administered by the National Institute for Occupational Safety and Health (NIOSH), part of the Centers for Disease Control and Prevention (CDC), a component of HHS, and provides medical monitoring and treatment for Program members. Members comprise responders to the 9/11 terrorist attacks in New York City (NYC), responders at the Pentagon and near Shanksville, Pennsylvania, and survivors in NYC disaster sites. To receive treatment for a specific health condition, members must be both enrolled in the Program and certified for that condition by the Program. Only certain health conditions qualify for coverage; thus, this is a limited benefit plan. Both Program enrollment and certification decisions are made by Program enrollment and certification specialists within NIOSH. The Zadroga Act establishes responsibilities associated with the administration and performance needed to enroll, initially evaluate, medically monitor, manage, and reimburse services for covered health conditions. The Program contracts with partners to carry out specific Program functions and operations of the limited benefit plan.

Monitoring and treatment are administered to members in the New York Metropolitan Area (NYMA) by eight Clinical Centers of Excellence (CCEs), and members outside of the NYMA through the Nationwide Provider Network (NPN); the CCEs and NPN are administered by entities and institutions under separate contracts with the Program. The Program also contracts with a Pharmacy Benefit Manager (PBM) to administer prescription benefits in the Program. In addition to these partnerships, the Program also https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter31&edition=prelim https://www.cdc.gov/wtc/ataglance.html#enrollmentWTC contracts with a Third-Party Administrator (TPA), for which this solicitation refers to herein as “the Contractor,” that receives and processes enrollment and certification applications for NIOSH decision-making, maintains member demographic information, manages a call center, manages, and maintains the NYMA provider network on behalf of the Program, administers benefits, and processes medical claims. These data are maintained by the Contractor and shared with stakeholders, such as other contractor partners (i.e., CCEs, NPN, PBM, DC etc.) based on a pre-determined schedule. See Section 1.2 for descriptions.

SECTION 1.1 – Definitions Abuse: Practices that may directly or indirectly result in unnecessary costs to the Program; includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care. Examples include but are not limited to:

• Billing for services that were not medically necessary

• Charging excessively for services or supplies

• Coding and billing for one hour when the visit was only 15 minutes

Adjunct Condition: Conditions that may be treated under the Program without certification because they are deemed medically necessary to effectively treat a certified WTC-Related Health Condition or certified Health Condition Medically Associated with a WTC-Related Health Condition.

Applicant: An individual that has applied to the Program for enrollment but has not yet received a final decision on their eligibility status.

Appellant: An individual that has submitted an appeal to the Program to reverse an enrollment or certification determination.

Business Days: Monday through Friday, except for designated Federal Holidays.

Benefit Administration: Services performed on behalf of the Program to ensure coverage of medical services aligned with limited benefit requirements per the Zadroga Act and Title 42 Part 88 CFR.

Calendar Days: Monday through Sunday, including designated federal holidays.

CARE Portal: The Centralized Accessible Real-time Enterprise (CARE) Portal is a web application and portal managed by the Program. The CARE Portal allows authorized staff (Program, the Contractor, CCEs/NPN, and other partners) to perform work related responsibilities such as enrolling members, reviewing certifications, and transferring members. The Program’s CARE Portal also ensures secure sharing of Electronic Protected Health Information (ePHI) and Personally Identifiable Information (PII) in a manner that protects patient privacy and complies with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Privacy Act.

Certification: A Program review of a health condition in a particular member for the purpose of identification and approval of a WTC-related health condition included on the List of WTC-Related Health Conditions in 42 CFR 88.15, or a health condition medically associated with a WTC-related health condition.

For a health condition to be certified as WTC-related by the Program, a Program-affiliated provider must determine that the member’s 9/11 exposures are substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition such that the health condition is eligible for treatment by the Program. Program members receive coverage only for services deemed medically necessary to treat certified conditions. Certifications become part of the Member’s record to authorize treatment from the effective date.

Certified Condition: A determination by the Program that authorizes a member’s health condition to be eligible for treatment by the Program. The condition must be included on the List of WTC-Related Health Conditions and it must be determined that the member’s 9/11 exposure is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. Program members receive coverage only for services deemed medically necessary to treat certified conditions.

Certified-Eligible Survivor: Certified-eligible survivors include (1) individuals who have been identified as eligible for medical monitoring and treatment as of January 2, 2011; or (2) screening-eligible survivors who are eligible for follow-up monitoring and treatment pursuant to 42 CFR § 88.12(b).

Clean Claim: A claim that does not require any investigation or external development prior to processing and is filed within the timely filing period.

Controlled Unclassified Information (CUI): Controlled Unclassified Information (CUI) is information that requires safeguarding or dissemination controls pursuant to and consistent with applicable law, regulations, and government-wide policies but is not classified under Executive Order 13526 or the Atomic Energy Act, as amended.

Days: All days shall be considered business days unless otherwise designated as calendar days.

Designated Representative: Designated representative refers to an individual selected by an applicant, WTC responder, or a screening-eligible or certified-eligible survivor to represent his or her interests to the Program.

Enrollment: A determination by the Program that an applicant is eligible as one of the four groups served by the Program (FDNY Responders, WTC General Responders, WTC Survivors, Pentagon/Shanksville Responders) and that their reported 9/11 exposure meets criteria for the activity, location, duration, time period and, if applicable, treatment for or qualifying symptoms of a WTC-related condition as outlined in the Zadroga Act. An approved enrollment entitles a new member to an initial health evaluation/screening visit.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Examples include but are not limited to:

• Providing false statements on an enrollment application to obtain coverage or concealing information about past medical history/preexisting conditions.

• Failing to report other insurance or to disclose claims that were a result of an injury unrelated to 9/11 exposure.

• Billing for services that were not rendered including upcoding and unbundling or providing services that are not medically necessary.

Fulfillment Services: The receipt, processing, and distribution of materials by a third-party on behalf of another organization. This includes processing via mail, facsimile, telephonic, or electronic methods.

Health Condition Medically Associated with a WTC-Related Health Condition: A condition that results from the treatment or progression of a certified WTC-related health condition. Once certified, health conditions medically associated with a WTC-Related Health Condition are eligible for treatment covered by the Program.

Health Program Support (HPS): A vendor to support various Program functions per this Contract herein, including processing member enrollment and certification applications, managing the customer-service call center, managing the provider network, administering benefit plans, processing medical claims, maintaining the member database, and coordinating member communications.

Limited Health Benefit Program: A limited health benefit program covers a specific and restricted set of treatments, services, and supplies for a specific and restricted set of conditions. The Program’s limited health benefit program covers limited medically necessary services to diagnose, monitor, and/or treat qualifying conditions as required in the Zadroga Act, 42 CFR Part 88.

Medical Policy: Medical policy establishes guidelines for determining what medical services, procedures, and supplies are medically necessary for the treatment or monitoring of qualifying conditions and therefore eligible for coverage. Medical policy is grounded in best and most current scientific evidence and is updated to reflect changes in such evidence. For the purposes of the Program, medical policy indicates what services will be covered for each of the Program’s qualifying WTC-Related Conditions, Health Conditions Medically Associated with a WTC-Related Condition, and Adjunct Conditions.

Member: A responder, screening-eligible survivor, or certified-eligible survivor enrolled in the WTC Health Program. A responder may include eligible family members of a Fire Department of the City of New York (FDNY) responder.

Member Services: Member services include all member-facing operations provided by the Contractor to include, operations support for enrollment, certification, and member transfer, mail center administration, member communications, customer service including operation of a call center and self-service portal, and management and maintenance of member demographic information.

Monitoring Exam: Periodic physical and mental health assessment of a WTC responder or certified-eligible survivor in relation to exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks and which includes a medical and exposure history, a physical examination and additional medical testing as needed for surveillance or to evaluate symptom(s) to determine whether the individual has a WTC-related health condition. Generally, a WTC responder or certified-eligible survivor receives annual physical and mental health assessments.

OASIS: Online Application Submission Information System (OASIS) is a public-facing Web-based application developed and managed by the Program that allows potential members to apply for enrollment in the Program via a Web browser on any Internet-connected device (e.g., desktop, laptop, tablet, smart phone).

OASIS securely transmits enrollment information directly to the CARE Portal.

Other Health Insurance (OHI): A member’s personal health insurance, whether public or private including group health, government, or workers compensation insurance that must be billed prior to processing claims via the Program in instances when the Program is not primary payer.

Personally Identifiable Information (PII): Any information about an individual maintained by an agency that includes (1) any information that can be used to distinguish or trace an individual's identity, such as name, social security number, date and place of birth, mother's maiden name, or biometric records; or (2) any other information that is linked or linkable to an individual, such as medical, educational, financial, and employment information.

Prior Authorization (PA): A process required to authorize medical services for coverage before services are rendered. The Contractor’s adjudication system will maintain business rules that require approval of prior authorizations before a claim can be processed.

Program Policy: Administrative and operational guidance provided by NIOSH/The Program.

Prospective Member: An individual who is interested in the Program but has not yet been enrolled (may include applicants).

Protected Health Information (PHI): Individually identifiable health information (health information, including demographic information, collected from an individual and created or received by a health care provider, health plan, employer, or health care clearinghouse that relates to the individual’s past, present, or future mental or physical health condition, provision of health care, or payment for care and which identifies the individual or is reasonably believed to make the individual identifiable) that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium. PHI excludes individually identifiable health information in certain education records, certain student medical records, employment records held by a covered entity in its role as employer, and records regarding a person who has been deceased for more than 50 years.

Public Health Data: Digitally recorded factual material commonly accepted in the scientific community as a basis for public health findings, conclusions, and implementation. Public health data includes material from research and non-research activities. Public health data could be quantitative, qualitative, imaging, or genomic output (for example, genome sequencing, arrays, gene expression, etc.). Public health data do not include preliminary analyses, drafts of scientific papers, plans for future research, reports, grantee progress reports, communications with colleagues, or physical objects, such as laboratory notebooks or laboratory specimens.

Responder: An individual who has been identified as eligible for monitoring and treatment as described in Program regulations based on response activities; these include workers or volunteers who provided rescue, recovery, debris cleanup, or related support services on or in the aftermath of the September 11, 2001, terrorist attacks for certain amounts of time between September 11, 2001, and July 31, 2002. There are three groups of responders in the Program: FDNY Responders (and surviving FDNY family members eligible only for mental health benefits); WTC General Responders (including NYPD); and Pentagon and Shanksville, PA Responders.

Screening-Eligible Survivor: Screening-eligible survivors are individuals who are not WTC responders and who claims symptoms of a WTC-related health condition and meets the eligibility criteria for a survivor specified in 42 CFR § 88.8.

Stakeholders: Any individual or entity interested in or affected by the Program, including CCEs and NPN, network providers, nonprofit organizations, the Program Steering Committees, Program personnel, members, government agencies, and other support contractors.

Start of Health Care Delivery (SHCD): Mutually agreed-upon date between Contractor and the Program on which all services per this contract are implemented.

Survivor: An individual who has been identified as eligible for monitoring and treatment per the Zadroga Act, 42 CFR Part 88 based on presence in the dust or dust cloud on September 11, 2001 or living, working, or attending school, childcare, or adult daycare in the NYC Disaster Area for a certain amount of time between September 11, 2001, and July 31, 2002, or certain other specified periods. The Program recognizes both screening-eligible and certified-eligible survivors.

Sustainment: Following the start of health care delivery, the period when operations are underway, and the Contractor is in the maintenance and continuous refinement phase.

Third Party Administrator (TPA): Administrative entity under contract to the Program to provide contract management, member services, network management, medical benefits management, claims adjudication, and data and IT services on behalf of the Program.

Timely Filing Period: The timeframe in which a claim must be submitted to the Contractor. Claims filed outside of the timely filing period will be denied.

Transition-In: Transition-In refers to the implementation period following contract award during which the Contractor and the Program establish operations, processes, and systems to administer the contract and achieve operational readiness.

Transition-Out: Transition-Out refers to a period at the end of the period of performance during which the Contractor and the Program conduct planning, data transfer, and other activities necessary to close out contract operations support the next generation contract.

Treatment Pending Certification: Treatment pending certification refers to treatment provided for WTC- Related Health Conditions or Health Condition Medically Associated with a WTC-Related Health Condition while certification is awaiting adjudication. In order for a CCE or NPN to provide treatment pending certification for a health condition, the condition must be eligible for treatment by the Program and a certification request must have been submitted to the Program but not yet adjudicated. The Program members sometimes require urgent or otherwise time-sensitive care for conditions pending certification and such cases may be covered by the Program if all requirements are met. As directed by Program regulations, authorization for treatment of a WTC-Related Health Conditions or a Health Condition Medically Associated with a WTC-Related Health Condition must be obtained from the Program before treatment is provided, except for the provision of treatment for a medical emergency.

Waste: Failure to control costs or regulated payments due to an inappropriate act or omission by payers with control over or access to government resources. Waste relates primarily to mismanagement, inappropriate actions, or inadequate oversight. Examples include but are not limited to:

• Poor execution or lack of widespread adoption of best practices, such as effective preventive care practices or patient safety best practices.

• Unnecessary hospital readmissions, avoidable complications, and declines in functional status, especially for the chronically ill.

• Use of higher-priced services that have negligible or no health benefits over less expensive alternatives.

• Writing high-cost prescriptions over less expensive but equivalent generic prescriptions.

WTC-Related Health Condition: An illness or health condition for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks, based on an examination by a medical professional with experience in treating or diagnosing the health conditions included in the List of WTC-Related Health Conditions, is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition, including a mental health condition. Only those conditions on the List of WTC-Related Health Conditions codified in Program regulations at 42 CFR pt. 88 may be considered WTC-Related Health Conditions; conditions must be certified before they are eligible for treatment.

SECTION 1.2 – Selected Roles and Business Associates The following is a non-exclusive list of other WTC Health Program contractors and business associates with which the Contractor shall engage while carrying out requirements per this contract.

Clinical Center of Excellence (CCE): A center or centers under contract with the Program that:

(1) Uses an integrated, centralized health care provider approach to create a comprehensive suite of health services that are accessible to enrolled WTC responders, screening-eligible survivors, or certified-eligible survivors; (2) Has experience in caring for WTC responders and screening-eligible survivors, or includes health care providers who have received Program training; (3) Employs health care provider staff with expertise that includes, at a minimum, occupational medicine, environmental medicine, trauma-related psychiatry and psychology, and social services counseling; and (4) Meets such other requirements as specified by the Administrator of the Program. A CCE is a NYMA-based medical facility that, in accordance with the Zadroga Act, operates under an individual contractual relationship with the Program to provide medical monitoring, diagnosis, and treatment services for members in the NYMA. Members indicate preference for and are assigned to a CCE, which is responsible for coordinating their care under the Program. There are currently eight CCEs contracted with the Program: two for the survivor population and six for the responder population.

Comprehensive Cost Avoidance (CCA) Contractor: A vendor who implements a comprehensive cost avoidance, coordination of benefits, and recovery platform from pre- to post-payment processes to facilitate the ability of the Program to improve efficiency and control health care costs without compromising quality of care.

Data Center (DC): One of several centers under contract with the Program to support various functions, including receiving data from the Contractor, CCEs, and NPN; developing examination, monitoring, and treatment protocols; and coordinating outreach activities. See 42 CFR 88.1.

Health Program Evaluation (HPE) Contractor: A vendor providing consulting services for data analytics to support strategic planning and program evaluation.

Nationwide Provider Network (NPN): A network of providers throughout the United States under contract with the Program to provide an initial health evaluation, monitoring, and treatment to enrolled WTC responders, screening-eligible survivors, or certified-eligible survivors who live outside the NYMA.

Generally, the NPN includes health care providers in all 50 states and territories and is administered by a third-party entity under contract with the Program to provide WTC-related health care as well as member services, network management, and claims processing.

Pharmacy Benefits Manager (PBM): A vendor who disseminates the Program’s formulary updates and works closely with the NPN contractor on pharmacy claims adjudication.

SECTION 2 – PURPOSE

The program objective for this procurement is to assist NIOSH in the continued operation and enhancement of the Program. The Contractor shall deliver services to operationalize the Program’s limited health benefit plan, ensuring eligible members are able to receive standardized monitoring, diagnostic services, and medically necessary, clinically appropriate treatment services for their certified condition(s). The Contractor shall adjudicate claims in accordance with the Zadroga Act, The Program regulations, Program Policy, and other applicable law. The Contractor shall manage program administration using advanced and continually improved industry standards (e.g., a secure online service). The Contractor shall provide these services with the goals of streamlining business processes, enhancing data collection and analysis, improving member access to healthcare, and providing superior customer service.

SECTION 3 – SCOPE OF WORK

The Contractor shall provide Contract Management, Member Services, Provider Network Management, Medical Benefits Administration, Claims Processing, and Data and Business Information Management in support of the Program. In supporting the Program, the Contractor will work closely with the Program and regularly communicate and interact with other Program contractors, including but not limited to the CCEs, the NPN, the Data Centers, and Health Program Evaluation (HPE), Comprehensive Cost Avoidance (CCA), and Pharmacy Benefits Manager (PBM) vendors. The Contractor shall not be responsible for underwriting cost of care or developing and coding new information technology systems.

At a summary level, tasks to be performed include:

1. Transition

2. Contract Management

3. Member Services

4. Provider Network Management

5. Medical Benefit Administration

6. Claims Processing

7. Data and Business Information Management

SECTION 4 – TASKS TO BE PERFORMED

The Contractor shall be responsible for ensuring the accuracy, timeliness, and completion of all tasks assigned under the resulting contract.

SECTION 4.1 – Transition-In SECTION 4.1.1 – Kickoff Meeting The Contractor shall coordinate with the Contracting Officer’s Representative (COR) to schedule and facilitate a Kickoff Meeting either virtually or in-person with key Program personnel within ten business days of award. The Contractor shall, in collaboration with the Program, provide an agenda for the Kickoff Meeting within five business days of award. The Contractor shall create a Kickoff Presentation presenting proposed approaches to transition all tasks to be included in the Transition-In Plan, per Section 4.1.2 In addition, the Kickoff Meeting shall serve as an opportunity for the Contractor to explain how all contract functions will be fulfilled and operationalized within contract parameters. The Contractor shall ensure that all Program requested changes and revisions to approaches presented in the Kickoff Meeting are addressed in the Transition-In Plan, Contract Management Plan, or other relevant deliverable.

The Contractor shall coordinate with the COR to establish dates, location, and an agenda for the Kickoff Meeting. The Contractor shall take meeting minutes, which shall be provided to the Program within five business days of the Kickoff Meeting.

SECTION 4.1.2 – Transition-In Plan The Contractor shall develop a Transition-In Plan to detail how the contract transition will be implemented within a six-to-nine-month timeframe with minimal to no disruption to member services and access to medical benefits. The Transition-In Plan shall delineate the Contractor’s strategies to achieve a state of readiness for Start of Health Care Delivery (SHCD). Initial approaches shall be presented at the Kickoff Meeting with the Transition-In Plan deliverable due ten business days following the Kickoff Meeting. The final Transition-In Plan shall be due ten business days following receipt of Program feedback on the initial draft.

The Contractor shall be responsible for collaborating with the Program, partner stakeholders (i.e., CCE, NPN, PBM, CCA), and the incumbent TPA contractor during the transition period. The Contractor shall dedicate resources to a Transition-In team, led by the Transition-In Team Lead. The Transition-In Team Lead will be designated as “Key Personnel” per Section 4.2.8, to manage all Program transition efforts with the priority of no disruption to members and Program operations. Transition of all system and process shall be completed and ready for all required services to be fully operational within six-to-nine months of award.

The Transition-In Plan shall include sections that address rollout of the following:

1. Transition Approach, including planned transition activities and meetings with key Program staff and schedule. The Contractor shall assign dedicated staff to support transition and internal testing to assess readiness ahead of SHCD and during sustainment. The approach shall include the Contractor’s readiness criteria and critical functionality to demonstrate fulfillment of the requirements in advance of SHCD. The Approach will address the following:

a. Create and maintain a Work Breakdown Structure (WBS) to a minimum of three-levels to define activities, tasks, and outcomes to reach SHCD and complete Transition-In.

b. Integrated Master Schedule (IMS) that depicts the transition of the contract. Identify and include all applicable project milestones in the IMS. The Contractor shall deliver a detailed-level schedule, critical path depiction, and dependency analysis, with breakouts of subsections for individual groups/teams. When data is provided and entered in the IMS that creates overall critical path slippage, the Contractor shall notify the Program within one business day. The notification shall be delivered to the COR in writing.

c. Ensure that a fully detailed and operational project schedule is developed in Microsoft Project, or a similar scheduling platform, with all necessary resources and schedule baselines is in place as part of the submission of the initial Transition-In Plan.

2. Member Services, including implementation of customer service, member-facing call center and self-service portal functionality, transition of member communications, enrollment, certification, and transfer processing, and all other responsibilities detailed in Section 4.3.

3. Provider Network Management, including activities to ramp up operations to adopt and absorb the existing NYMA network, loading the current Program network provider file, assessing the accuracy of the network provider file data, developing all processes required to assume the Program provider network in the NYMA, proposing processes to coordinate with CCEs, and all other responsibilities detailed in Section 4.4.

4. Medical Benefit Administration, including approach to implement benefit administration, utilization management, and all other responsibilities detailed in Section 4.5.

5. Claims Processing, including incorporation of business rules into claims adjudication system, coordination of benefits, program integrity activities, administrative invoicing to the Program, and all other responsibilities detailed in Section 4.6.

6. Data and Business Information Management, approach shall delineate the data migration and conversion as well as a comprehensive testing process to ensure readiness for all operations on SHCD. The testing shall include a designated testing lead to oversee industry standard QA reviews, end-to-end transactions at least 20 business days prior to SHCD. Processes to establish data security, systems access, data storage and organization compliance, data integrity, connectivity and information exchange, and all other responsibilities detailed in Section 4.7 by SHCD.

SECTION 4.1.3 – Transition Schedule Reports Throughout the course of transition, the Contractor shall generate schedule reports containing the planned versus actual program/project performance against the Transition-In Plan and updated critical path information for the project. Transition schedule reports shall be submitted within five business days of the end of each month throughout transition-in, beginning the month in which the final Transition-In Plan is approved by the Program. The Contractor’s transition schedule reports shall include identification and documentation of project risks that may jeopardize any imminent milestones or the overall project timeline. These risks and any associated mitigation strategies shall be incorporated in the risk register, which shall be included with the transition schedule reports throughout transition per Section 4.2.2.

SECTION 4.1.4 – Readiness for SHCD Readiness for SHCD shall be assessed via integrated systems testing to be conducted prior to SHCD for each functional area (as mutually agreed upon between the Contractor and the Program). To execute the Transition-In Plan, the incoming contractor shall implement its approach to establish full readiness for SHCD. The Contractor shall schedule a systems interface meeting with the Program within 30 business days of award start date. The purpose of the meeting is to review requirements for the establishment of connectivity with Program systems and applications. The incoming Contractor shall collaborate with the Program to establish the required interfaces with Program systems and applications. The Contractor shall facilitate testing sessions for the following functions to demonstrate to Program staff that operations are ready for SHCD, per the Readiness Performance Metrics in Attachment A:

• Member Services – successful completion of end-to-end integration testing to confirm enrollment, certification, and transfer processing, customer service and member communications, call center, mail center operations, and secure self-service portal shall be fully operational for SHCD. The Program accepts attestation of training completion for all enrollment, certification, and transfer processing staff.

• Provider Network Management – successful loading of provider file and availability of provider directory, to include any newly recruited providers. The Program accepts attestation of network absorption.

• Medical Benefit Administration – Program approval of proposed medical policy, achievement of key milestones, per IMS, and successful completion of claim test run in compliance with medical policy.

• Claims Processing – successful completion of end-to-end claims processing testing.

• Data and Business Information Management – successful execution of data conversion and migration plan, bidirectional data exchanges are established and operational, all systems are configured and compliant to support program operations, system access is granted to critical staff, analytical platform and data repository are available for Program staff use.

SECTION 4.1.5 – Transition-Out The Contractor shall perform the transition out and residual service tasks below for this contract at the end of the period of performance or should the Program choose to end the contract for some reason.

Transition-Out (of this contract herein) activities require collaboration with a team comprised of Program and/or successor Contractor personnel. The term transition out is related to activities taking place during and at the request of the Contracting Officer or after the last option period, whichever is first, in which the Contractor is transferring duties and responsibilities to a Program appointed designee, whether a government entity, another Contractor, or a mix of both. Residual services shall be provided by the Contractor for 12 months after the end of the period of performance for any required tasks (e.g., processing claims, enrollment applications, certification request, and/or appeals) that were initiated during the period of performance and have not yet been fully addressed to the standards established in this contract. The Contractor shall coordinate with the Program to ensure that any services not addressed in the prior 12-month window are tracked and communicated to relevant stakeholders. All parties involved in transition out services shall ensure minimal disruption of services to members receiving care and providers delivering care.

The Contractor shall submit a formal Transition-Out Plan at least 90 calendar days prior to the start of the final option year of this contract or sooner at the request of the Contracting Officer. This Contractor shall revise this plan throughout the transition period as additional feedback and information is provided by the Program. The Transition-Out Plan shall delineate how the Transition-Out activities will be fulfilled, including but not limited to the following:

1. Delivery of a Transition-Out plan inclusive of a timeline of major events, regular progress meetings and updates, key positions responsible for each of the functional areas involved in the transition-out and processing of residual service inventories (e.g., Claims, appeals, grievances, data transfers), and staffing and other resources (e.g., transition project manager, transition stakeholders).

2. Processing of all open healthcare Claims inventories. The outgoing Contractor shall submit weekly status reports of Claim inventories and phase-out activities to the Program beginning the 20th calendar day after notification of the commencement of formal Transition-Out discussion from the Contracting Officer.

3. Providing a current inventory of all Government-owned assets used by the Contractor over the life of the contract along with full support in the reconciliation of the inventory as needed.

4. Providing “shadowing” and other knowledge transfer meetings and opportunities to facilitate the transfer of information, processes, and data needed to continue the services being performed by the Contractor.

5. Providing current and accurate program and system management documents.

6. Transfer all government records and data (including process and policy guidance materials) within a specified transition period without interruption of services.

7. Removal and purging of all non-public or other protected Government Furnished Information from any Contractor owned system, and certification execution.

8. Update of the Transition-Out plan in the last option year of the contract per the direction of the

Government, to accommodate updates and the successor/incoming Contractor’s Transition-In plan.

The list above is not exhaustive. The CO may discuss additional items or considerations related to phasing out services prior to exercising the final option year. The Contractor will receive a notice in writing signaling the commencement of formal Transition-Out discussion within 90 calendar days of contract expiration in accordance with FAR 52.237-3 Continuity of Services – (Jan 1991). The services required to Transition-Out will only be exercised in the event of a need for an actual transition (e.g., the incumbent is not the successful Offeror for the follow-on contract).

SECTION 4.2 – Contract Management The Contractor’s plans for managing ongoing operations and functional areas shall be incorporated into a single Contract Management Plan. The Contractor shall assign a dedicated account team to serve as primary liaison for contract management to the Program throughout the life of the contract. The account team shall include an Executive Account Manager who will serve as key personnel, per Section 4.2.8. The Executive Account Manager shall represent a single point of contact for Program staff and have ultimate accountability for the success of contractor services.

SECTION 4.2.1 – Contract Management Plan The Contractor shall develop a Contract Management Plan (CMP) with a staffing model or organizational chart to identify leaders for each of the designated tasks who will work with Program staff and/or Program contractors to effectively meet requirements. The CMP shall define the Contractor’s management approach for functional areas of the contract. Initial approaches shall be presented at the Kickoff Meeting with the CMP deliverable due ten business days following the Kickoff Meeting. The final Transition-In Plan shall be due ten business days following receipt of Program feedback on the initial draft.

In alignment with standard project management principles (i.e., PMI PMBOK), the Contractor’s CMP shall include how the Contractor will engage with core Program personnel throughout Transition-In and sustainment on activities that prioritize:

• Quality Assurance and continuous performance improvement

• Risk and Issue Management

• Stakeholder engagement and communications initiatives

• Change Control Activities, including testing of system updates

For inclusion in the CMP, the Contractor shall address management approaches for the following:

1. Establishment of a distinct dedicated Account Team, led by the Executive Account Manager, to collaborate with Program personnel and partner contractors to monitor and oversee Transition-In, sustainment, and continuous enhancement/improvement of the program. The dedicated Account Team shall be responsible for onboarding, training, and retaining all staff supporting this contract. A staffing plan shall indicate the Contractor’s management approach to limit degradation or disruption of services due to staffing changes. Changes to the dedicated account team shall require written notification to the government, per section H.

i. Executive Account Manager is responsible for ensuring completed Non-Disclosure Agreements (NDAs) and a roster of Contractor Staff with roles and responsibilities are delivered to the Program prior to the kick-off meeting.

ii. Executive Account Manager shall manage and communicate onboarding and offboarding documentation (Signed Rules of Behavior), equipment submission, per Section 7 – Deliverables.

2. A Change Control Process to address any variance from the baseline plan, established during transition-in, and the contract. Any Contractor-initiated change requests and business justification shall be tracked from identification, through engagement with the Program, possible modification process, and execution. The tracked change requests shall be made available to Program staff upon request.

3. A Communications section to outline internal communications to manage the services required per this contract. The Contractor shall include an approach to communicating action items and issues that require immediate response.

4. A Training section, including reference to, and management approach for ensuring all Contractor and stakeholder staff are trained to support program operations throughout the period of performance, per section 4.2.4. Training section shall include strategy and timeline to develop and execute trainings to support transition and readiness throughout the period of performance, including use of Program systems (i.e., CARE Portal).

i. Contractor staff must complete required HIPAA, CDC, and Program trainings in advance of SHCD

ii. Contractor shall deliver trainings and job aids to support Program staff and partner contractors (i.e., CCE, NPN, CCA, PBM) in alignment with Contractor solutions, processes, and tools.

5. A Subcontractor Management section to include Contractor’s approach to overseeing all subcontractors:

a. A description of the supplies or services to be subcontracted

b. Identification of the type of subcontract to be used

c. Identification and selection of the proposed subcontractor

d. A description of an oversight and quality assurance plan

6. A Risk and Issue Management section to include identification, tracking, mitigation, and escalation of risks and issues.

7. A Stakeholder Engagement section to include processes for collaborating with Program stakeholders to include members, providers, Program staff, and partner contractors.

8. Approach to comply with the Business Associate Agreement, per Section 4.2.7.

9. A Medical Benefits Administration section to include the Contractor’s approach to administering the Program’s limited benefit and utilization management activities, per section 4.5.

SECTION 4.2.2 – Risk and Issue Management The Contractor shall implement an approach to risk and issue management that incorporates identification, tracking, mitigation, and escalation of risks across all functional areas to enable program integration. The Contractor shall establish and adhere to the Risk and Issue Management section of the

CMP.

The Contractor shall report risks and issues to the Program, via a Risk Register, for all required functions and activities, per this contract, throughout the period of performance. The Risk Register shall include a running log of all identified contract risks associated with performance of the responsibilities detailed in this contract. The Risk Register shall detail any relevant milestones, progress updates, mitigation strategies, and other relevant information associated with identified risks. The Contractor shall include any changes to federal healthcare policy that may affect the contract in the Risk Register along with proposed implementation/risk mitigation strategies as needed. The Risk Register shall also include any risks or proposed changes to Subcontractor management. The Risk Register shall be submitted monthly during

Transition-In with the Transition-In Schedule Reports (Section 4.1.3) and then quarterly as part of the Program Management Report (PMR) once the contract has reached sustainment, per Section 4.2.6.

The Contractor shall keep in communication with the Program so issues that arise are transparent to both parties to prevent escalation. The Contractor shall notify the Program immediately of any urgent or significant risks and issues and shall make the risk register available to the Program upon request within one business day.

As part of risk and issue management, the Contractor shall collaborate with the Program to establish priority, scope, and resources for managing Program risks and issues, as well as assessing and executing mitigation strategies and contingency plans.

SECTION 4.2.3 – Stakeholder Engagement The Contractor shall develop and maintain a Stakeholder Engagement approach as part of the CMP that includes the processes for communicating and collaborating with the wide range of Program stakeholders, including Program personnel (including contractor support), members, applicants, and prospective members, Providers (CCEs, NPN, other providers), and external stakeholders including nonprofit organizations and the media. A full list of Program stakeholders can be accessed via the Bidder’s Library.

Information shall be exchanged across the program and to all relevant contractor partners (including the CCEs, NPN contractor, and the Program) to support claims processing, medical benefits administration, provider network management, and all other relevant functions.

SECTION 4.2.4 – Training The Contractor shall provide onsite and/or virtual training and education to support operational processes and systems to fulfill the requirements of this contract. Training shall be targeted to Contractor staff, Program personnel, and any other users of the Contractor’s systems and associated processes.

The Contractor’s approach for training, per Sections 4.1, 4.3, 4.4, 4.5, 4.6, and 4.7 shall be incorporated in the CMP and implemented to ensure all staff using Contractor systems have access to necessary training materials and job aids and are appropriately trained in advance of SHCD. The Contractor shall submit training materials and job aids to the Program ahead of any training to ensure compliance with Program priorities and policies. Training schedules and timelines shall be mutually agreed upon between Contractor and the Program staff. The Contractor shall review training materials and job aids annually and submit any recommended updates for Program approval within 15 business days of the end of the year.

SECTION 4.2.5 – Quality Assurance – Contractor Performance Metrics The Contractor shall implement a Quality Assurance Plan (QAP) to demonstrate adherence to performance targets established by Attachment A Performance Metrics and throughout this contract. The Program shall utilize the performance measures in Attachment A and update as necessary to monitor the quality of the Contractor’s performance throughout the life of the contract. The oversight of Contractor performance shall help ensure that required standards are met and all metrics are maintained throughout the period of performance. The Contractor shall address all performance metrics in detail, noting performance thresholds missed, met and/or exceeded for each standard as part of the quarterly PMR.

A QAP shall be submitted within ten business days of kickoff meeting, a final QAP shall be submitted ten business days following receipt of Program feedback. The Contractor shall review the QAP annually and submit any recommended updates for Program approval within ten business days of the end of the year.

As part of the Contractor’s performance monitoring and the QAP, the Contractor shall prepare Continuous Improvement Initiatives, on a semi-annual basis, which will support the design, implementation, and evaluation of a spectrum of services focusing on continuously improving Program performance.