WTCHP-HPS-RFI_2020 11-30-2020.docx

World Trade Center Health Program Request for Information

HEALTH PLAN SUPPORT

RFI: WTCHP-HPS-RFI_2020

Request for Information (RFI) Number: WTCHP-HPS-RFI_2020 TITLE: Health Plan Support (HPS)

Purpose This is a request for information on industry ability to support the World Trade Center (WTC) Health Program. It is not a solicitation for proposals, proposal abstracts, or quotations. Release of this information should not be construed as a commitment to procure items discussed or to incur costs for which reimbursement would be required or sought. The Program encourages vendors of all sizes (large and small business entities) to respond to this RFI. The Program also encourages all interested respondents to review the WTC Health Program Administrative Manual located at https://www.cdc.gov/wtc/ppm.html before responding to the RFI. This information in conjunction with the written synopsis and background below provides a detailed overview of the essential elements of the current benefit and could help vendors develop RFI responses tailored to the Program’s requirements by describing your capabilities to provide robust solutions for the followings:

1. Provide a robust end-to-end claims administration (hosted external CDC.gov) system with an online self-service automated portal for various users including the providers, members (beneficiaries), Clinical Center of Excellence (CCE) and government (hosted internal CDC.gov) based on a limited health plan model with multiple unique treatment benefit plans.

2. Provide a comprehensive provider network solution for access to quality of care in the New York Metropolitan Area (NYMA) with an established large network with a high degree of control over its providers as it relates to Federal Employees' Compensation Act (FECA) pricing, limited health model, and provider network management system, including training, enrollment and credentialing of various health care systems.

3. Provide comprehensive and compassionate management of the WTCH Health Program's limited benefit plans with cost containment and payment integrity measures that designed to help improve benefit efficiency and effectiveness, reduce healthcare costs and improve healthcare outcomes

4. Provide support for program-wide utilization management and case management services with subject matter experts and systems.

5. Provide claims and payment analytics and meaningful reports with solutions to improve efficiency and financial integrity.

BACKGROUND

On January 2, 2011, the President signed into law the James Zadroga 9/11 Health and Compensation Act of 2010 (the Zadroga Act). The Act established the WTC Health Program within the Department of Health and Human Services, to provide medical monitoring, screening, and treatment for responders and survivors of the 9/11 terrorist attacks. Responders include workers or volunteers who provided services in the aftermath of the September 11, 2001, attacks on the World Trade Center, the Pentagon, and the airliner crash site near Shanksville, PA. Survivors include persons who worked, lived, or attended school, childcare, or adult day care in the New York City disaster area, and were adversely affected by the attacks in New York City. In order to enroll in the Program, survivors and responders must meet certain criteria described in the Zadroga Act

The WTC Health Program is a limited-benefit program: treatment is covered only for a limited set of health conditions and only when a member’s condition is substantially likely to have been aggravated by, contributed to, or caused by the member’s 9/11 exposures. There is a list of applicable WTC-related health conditions that must be diagnosed by a Program provider; meet specified exposure, latency, and symptom-onset requirements; and be certified by the Program for the Program to cover the member’s treatment. Change this to benefit plans and covered conditions as shown and updated on our website. Currently, eight (8) Clinical Centers of Excellence (CCEs) in the New York metropolitan area (NYMA) and one Nationwide Provider Network (NPN) administer the benefits to Members. The complex limited-benefit structure of the Program poses a unique challenge when managing a member’s health plan benefits. The Program must ensure it is covering services and devices for only certified conditions, while also not impeding access beyond appropriate limits.

The current Health Plan Support (HPS) contractor oversees member enrollment and eligibility, the call center, treatment benefit plans, the claims adjudication system, and communications to all members, among many other tasks. The Clinical Centers of Excellence provide the monitoring, treatment, and case management to members within the NYMA and submit claims and benefit authorizations to the HPS for reimbursement. Certain treatment plans may require referrals to providers outside of the CCE which led to the establishment of the NYCA Provider Network. Services rendered by Network Providers outside of the CCE must be authorized at the CCE ensuring “medical necessity” for the WTCHP condition.

The Nationwide Provider Network (NPN) contractor manages the nationwide provider network and provides case management to members living outside of the NYMA. All monitoring and treatment are provided through the NPN. Authorizations for “medical necessity” are reviewed by the NPN contractor clinical staff.

The HPS also provides a claims data that allows stakeholders to run a variety of reports on claims for quality assurance purposes including data analysis for clinical reviews, cost analysis, program decisions. HPS staff provide general support to the WTC Health Program for clinical, operational, and customer service projects and daily requests.

The Program is interested in exploring different models for specifically administering the Claims Adjudication and Provider Network as a separate contract from the enrollment/eligibility, call center, and member communications. The WTC Health Program oversees all health plan operations and develops program policies. The WTC Health Program conducts and oversees all quality assurance activities related to benefits, escalated customer service, and other types of processes. For additional information please consult the World Trade Center Health Program Administrative Manual.

REQUESTED INFORMATION

Claims Adjudication and Management of Benefit Plans The WTCHP currently utilizes a Workers’ Compensation-type model whereby members must be pre-certified for a covered medical condition to access health care benefits under the WTCHP. Health benefits are only allowed for a members’ certified condition. This certification occurs through member visits to the CCE or NPN and, once established, becomes part of the members’ eligibility records. There are currently hundreds of treatment benefit plans that may be assigned to members based on their eligibility and certified conditions. Members may be certified for multiple conditions which opens multiple treatment benefit plans. In addition, all responders have access to an annual monitoring health evaluation and survivors have a onetime health evaluation unless certified.

a. Describe Workers’ Compensation-type benefit programs or limited health model that you have or currently administer and features of the program.

b. Describe your company’s ability to support an end-to-end automated/web-based system to verify member eligibility, benefit plan and coverage verification. Describe your company’s ability maintain a multitude of complex treatment benefit plan database.

· Describe how your company will host a system in a Gov Cloud to adjudicate claims? Does your company have experience hosting systems and data in Gov Cloud?

· Does your company have experience with Plexis and/or other similar claim adjudication system?

· Describe how your company will provide a system or web portal inside the CDC network (cdc.gov) to permit network providers to enroll, submit claims to the company for adjudication, provide remittance advice, coordinate benefits with secondary payors, customer services support, training, and web-based reports, etc.

c. Explain to what extent the Program’s existing treatment benefit plans could be integrated into your existing system and if there would be limitations in maintaining the Program’s current customized benefit plans.

d. Detail the process that would be utilized to update the treatment benefit plans with additions and deletions of services over time and how quickly can they be updated?

e. Explain how and whether the treatment plans with differing utilization management criteria assigned to the service/device from plan to plan can be administered within your programming that would apply to claim’s adjudication process.

f. Describe your company’s ability to permit a “claims exception” where the general membership would not have the ability to access such services/devices, but only in a limited circumstance.

g. Describe your ability to separate claims exceptions from authorization requirements.

h. Describe your company’s ability to provide expertise in areas of benefits management, treatment plan development and industry standard to include benchmarking federal payors?

Provider Networks The current HPS maintains the Provider Network by enrolling and credentialing providers in the NYCA through an agreement with the Centers for Medicaid and Medicare Provider Enrollment, Chain, and Ownership System (PECOS) system. The Program then works with each potential provider to assure they accept Program Terms and Conditions on reimbursement rates and providing authorized treatment. The Program is mandated by law to be reimburse at FECA rates. Describe your company’s ability to establish and maintain two separate networks, where one is in New York City and surrounding areas, and another is a separate network for the Nationwide Provider Network Alternatively, this could be one network that encompasses the entire nation.

a. Explain how these two separate networks can be managed by your company, where pricing may be different between. For example, describe how your company can assure FECA rates are applied for the NYCA network and or reimbursement is at or below FECA rates in the NPN.

b. Explain your company’s ability to leverage the PECOS system (pecos.cms.hhs.gov) to quickly credential providers and maintain a network and/or describe other similar systems.

c. Describe your company’s ability to find providers in rural communities with experience in treating members with conditions on “The List” of conditions certified by WTCHP.

d. Explain your company’s capability to work with WTCHP utilization management staff or vendor and case managers at the CCEs to report on claims?

e. Describe how your company would operationalize a limited health plan benefit by ensuring members are only able to receive services appropriate for their certified condition (based on treatment guidelines established by the WTCHP) through the Program. What process would be utilized for authorizing and adjudicating services?

f. What applications are available to absorb member eligibility information? Explain whether and how these applications may be accessed and utilized by:

Your internal customer support center representatives.

External WTCHP administrative staff.

External CCE staff.

Explain your company ability to support Single Case Agreements to allow for providers who may not wish to be fully contracted.

g. Detail which of the above functions would be performed internally under your existing operations and which of these functions would be outsourced to an outside entity as sub-contractor.

h. Describe your ability to permit providers, CCEs, NPN and government to use your systems.

Coordination of Benefits Coordination of Benefits (COB) is a key aspect of the WTCHP benefit in which our responder member classification has a primary benefit under the program and our survivor member classification has a payer-of-last-resort benefit under the program.

a. Describe your system’s functionality and your procedures for processing COB claims, whereby the member’s primary insurance is billed first, and the WTC Health Program would be billed as the payer-of-last-resort insurance (in the case of the survivor member classification). What process would be used for exceptions to this policy (i.e. someone does not have primary insurance, or primary insurance does not allow for COB)?

b. Detail the information/data and data format required to maintain this COB information.

c. Explain how often this information may be updated or refreshed within your system.

d. If external access to the applications are available, what forms of training for the utilization of these applications are available?

Customer Service Call Center A customer service center (call center/helpdesk) with knowledgeable representatives that are well trained in the specifics of the WTCHP; that are accessible; can provide accurate and timely information to providers, physicians, pharmacies, CCE staff and WTCHP staff; and can resolve issues quickly is vital to the success of the program.

a. Describe the features of your customer service center along with its hours of availability and the systems, applications, and other features that would benefit WTCHP.

b. Detail the training requirements and ongoing training that your customer service representatives would receive for new programs such as WTCHP.

c. Explain whether your company can provide a unique dedicated customer service center for all issues, concerns, and questions related to WTCHP outside of standard TPA function.

d. Explain whether your company can provide a unique dedicated customer service center phone number for WTCHP members, providers, physicians, and staff that would identify to the customer service representatives that a WTCHP associated user is calling.

Dependable Account Management Reliable and dependable account services will be necessary to assist in quality assurance monitoring, payment analytics, financial integrity, risk management and mitigation, early identification of issues and resolutions, and ongoing program improvement.

a. Discuss the role your account services representative would take in serving WTCHP.

b. Would you provide a clinical account service representative in addition to the account services representative and if so, what roles would they take and what value could they add to the program?

c. Explain whether these representatives would be available to spend time with WTCHP personnel to receive background training, meet with staff at the CCEs/NPN, and participate in meetings regarding benefit performance and process improvements as a standard part of serving the program.

d. In addition to account services and clinical representative support, detail any other specialized support personnel that your company provides to its accounts such as a liaison medical change management, data analysts, physicians or other medical personnel, training specialists, and also discuss when higher-level management is available for critical support and time-sensitive problem resolution.

Meaningful Reporting, Data Sharing, & Fraud Waste and Abuse (FWA) Reporting capabilities and functionality for monitoring the program is important in the continuous improvement of the program performance for our members. Controlling for potential fraud, waste, and abuse (FWA) within the benefit is an important goal of the program.

a. Please describe your data systems and reporting capabilities for claims utilization and cost projections. Detail whether you provide standard reporting and what would be included.

b. Describe your company’s ability to provide cost containment strategies through changes in industry through data and claims analysis.

c. Describe your company’s ability to regularly share data with other business associate? For example, enrollment data and treatment benefit plans by member.

d. Describe your client accessible portals and user interfaces including the frequency data is loaded into these applications.

e. Describe if your user interfaces allow client users the ability to customize the report information and data formatting.

a. Detail your FWA detection and prevention strategies and programs you utilize to control for potential gaming of the benefit.

b. Detail your ability to obtain date of death dates and assure fraud waste and abuse are being monitored.

c. Which of these programs would be included within the provision of benefits for WTCHP?

INSTRUCTIONS FOR SUBMISSION

1. Questions about the RFI are due by 3PM EST on 12/02/2020, via email to Eric Lyons at kpy2@cdc.gov.

2. Interested parties are requested to respond to this RFI with a white paper. White papers are due by 11AM EST on 12/15/2020, to Eric Lyons at kpy2@cdc.gov. White papers should list each question identified above and provide the accompanying response immediately following.

3. Interested parties may provide a general corporate capabilities statement in addition to your white paper. Please do not submit a capabilities statement without an accompanying white paper. Capabilities statements should be limited to two (2) pages.

a. Section 1 of the white paper shall provide administrative information, including: a. Company Name, mailing address, phone number, and name and contact information of designated point of contact;

b. DUNS;

c. Business type (small, large, 8(a), women-owned, etc.);

d. Relevant NAICS code proposed for any contract that may follow; and

e. Participation in a GSA Schedule or other government-wide vehicle that may be applicable for this requirement.

RESOURCES:

https://www.cdc.gov/wtc/materials.html https://www.cdc.gov/wtc/laws.html https://www.cdc.gov/wtc/ataglance.html image2.jpeg