Special Notice – Military Health System Managed Care Support Services

Notice Type: Special Notice

Posted Date: 30-APR-13

Office Address: Other Defense Agencies; TRICARE Management Activity; Contract Operations Division - Aurora; 16401 E. CenterTech Pkwy. Aurora CO 80011

Subject: Military Health System Managed Care Support Services

Classification Code: Q - Medical services

Solicitation Number: RFINo2forT2017

Contact: Laura L. Sells, Chief, Pricing Support Branch, Phone 3036763894, Email [email protected]

Description: Other Defense Agencies

TRICARE Management Activity

Contract Operations Division - Aurora

TRICARE MANAGEMENT ACTIVITY (TMA) is contemplating the future generation of managed care support contracts which includes cost reimbursable line items, fixed price line items, and requirements line items for the TRICARE Program of the Military Health System (MHS) in the United States to support active duty service members (ADSMs); active duty family members (ADFMs); retired service members and their eligible family members; survivors; Medal of Honor recipients; qualified former spouses; National Guard and Reserve members and their family members (including qualified non-active duty members of the Selected Reserve of the Ready Reserve, Retired Reserve, and certain members of the Individual Ready Reserve). TRICARE supplements the care provided in Department of Defense (DoD) Medical Treatment Facilities (MTFs), as well as provides care to those eligible beneficiaries living in regions without access to MTFs. The period of performance is anticipated to be a transition-in phase of one year, plus five one-year options, and phase-out (if exercised). This Request for Information (RFI) solicits industry's feedback on capabilities currently available to meet the later described MHS requirement. The North American Industry Classification System (NAICS) Class Code is 524114.

The intent of this RFI is to accomplish the following:

To gather information from industry to be utilized by the TMA TRICARE Program as support in our continuous market research for upcoming contract requirements. The information will not be utilized for any purpose other than for market research in determining the proper acquisition strategy and contract requirements, and to achieve its overall objectives under the TRICARE Program.

PROGRAM BACKGROUND:

DISCUSSION: TRICARE is comprised of three health care options: Prime, Standard, and Extra. TRICARE Prime is similar to a Health Maintenance Organization (HMO) with a Point of Service Option and requires beneficiary enrollment. All ADSMs are TRICARE Prime enrollees, although they are required to receive all of their care either in the MTF or under special rules that apply to Active Duty health care, further explained in the TRICARE Operations Manual, Chapter 17. ADFMs may elect to enroll and are not required to pay an annual enrollment fee; other eligible beneficiaries pay an annual enrollment fee to enroll in TRICARE Prime. TRICARE Extra, which requires no enrollment, is an option in which the beneficiary may choose to use a provider in a TRICARE contractor-developed network, at a reduced cost-share for a particular instance of care, but is not restricted to use of the provider network. TRICARE Standard is a fee-for-service option, essentially the program formerly called the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), in which the beneficiary is free to use any authorized provider. The three options of TRICARE are described fully in 32 Code of Federal Regulations (CFR) Parts 199.17 and 199.18. The MHS is organized into three TRICARE Regions within the United States and coverage extends overseas.

CONTRACT PURPOSE: TMA is contemplating the award of a contract utilizing a full and open competition acquisition approach to provide support to MTFs in providing health care services in the United States to ADSMs; ADFMs; retired service members and their eligible family members; survivors; Medal of Honor recipients; qualified former spouses; National Guard and Reserve members and their family members (including qualified non-active duty members of the Selected Reserve of the Ready Reserve, Retired Reserve, and certain members of the Individual Ready Reserve). The Uniformed Services include the U.S. Army, the U.S. Navy, the U.S. Air Force, the U.S. Marine Corps, the U.S. Coast Guard, the Commissioned Corps of the National Oceanic and Atmospheric Administration (NOAA), and the Commissioned Corps of the Public Health Service (PHS).

The anticipated future contract will supplement DoD MTFs by providing medical care provider networks and support services in required Prime Service Areas (PSAs) in the following location: United States.

CONTRACT OBJECTIVES: The following performance-based objectives are to be accomplished in an anticipated future contract:

*Objective 1 - In partnership with the MHS, optimize the delivery of health care services in the direct care system (see the definition of Military Treatment Facility Optimization in the TRICARE Operations Manual, Appendix B) for all MHS beneficiaries (active duty personnel, MTF enrollees, civilian network enrollees, and non-enrollees).

*Objective 2 - Beneficiary satisfaction at the highest level possible throughout the period of performance, through the delivery of world-class health care as well as customer-friendly program services. Beneficiaries must be completely satisfied with each and every service provided by the Contractor during each and every contact.

*Objective 3 - Attain "best value health care" (See TRICARE Operations Manual, Appendix B) services in support of the MHS mission utilizing commercial practices when practical.

*Objective 4 - Fully operational services and systems at the start of health care delivery and minimal disruption to beneficiaries and MTFs.

*Objective 5 - Full and real-time access to Contractor maintained data to support DoD financial planning, health system planning, medical resource management, clinical management, disease management, and contract administration activities.

MAJOR TASKS AND SERVICES: The following tasks and services are anticipated to be the major parts of the contract's scope:

*General medical care provider networks in the location(s) stated above.

*Claims processing and provider reimbursement (cashless/claimless for the ADSM and ADSM beneficiaries).

*Customer service

*Program enrollment and processing related fees/premiums

*Beneficiary and provider education

REQUEST FOR INFORMATION: The following questions and request for information are provided for consideration during this "market research" phase of the acquisition. Please review and provide your responses to the Government for possible consideration/alternatives for satisfying mission needs of the TRICARE Program.

Question #1: What types of metrics or performance standards does the health plan industry typically utilize to monitor its customer service activities Customer service type of performance standards from current TRICARE Managed Care Support Contracts are listed below. If these standards are different than contemporary industry performance standards please describe known or anticipated future industry performance standards for timeliness of answered telephone calls and processed claims.

*Standard #1: When a telephone call is transferred to/answered by an individual, 90% of all calls shall be answered by an individual (not an answering machine/automated voice unit) within 30 seconds.

*Standard #2: 85% of all inquiries shall be fully and completely answered during the initial telephone call. (Applies to all calls transferred to an individual customer service agent.)

*Standard #3: 99.5% of all telephone inquiries not fully and completely answered initially shall be fully and completely answered within 10 workdays.

*Standard #4: 98% of retained claims and adjustments claims shall be processed to completion within 30 calendar days from date of receipt.

*Standard #5: 100% of all claims (both retained and excluded, including adjustments) shall be processed to completion within 90 calendar days unless the Government specifically directs the Contractor to continue pending a claim or group of claims.

Question #2: What types of customer satisfaction surveys are utilized Are customers asked a series of questions at the conclusion of a routine in-coming customer inquiry or are staff members required to actively contact a specified sampling number of beneficiaries during a weekly or monthly time frame to obtain their feedback

Question #3: Please describe contemporary types of rewards or negative incentives from the health plan industry which are applied to primary contractors and subcontractors for exceeding or not meeting customer service performance metrics or standards

Question #4: Are beneficiaries generally referred to on-line services (via a web address) to obtain basic beneficiary information or blank forms

Question #5: From a financial, administrative, and medical management perspective, what are the advantages and disadvantages of allowing an enrollee to obtain services from a network (or non-network) specialty care provider without a referral from the enrollee's Primary Care Manager

Question #6: To what extent and how do commercial health insurance plans use HEDIS measures in the selection of their PPO providers What other types of measures are considered in the selection of PPO providers

Question #7: To what extent and how do commercial health insurance plans use HEDIS and other measure sets to determine reimbursement of their PPO providers What types of reimbursement strategies are used

Question #8: What methods do commercial health insurance plans employ to motivate increases in the HEDIS measures for their covered beneficiaries

Question #9: How do commercial health plans identify areas where quality improvement efforts need to be focused Question #10: What are quality measures beyond the HEDIS set of measures that commercial health plans track

Question #11: What methods do commercial health insurance plans employ to lower the hospital readmission rate for their covered enrollees

Question #12: What are the most effective methods commercial health plans employ to dissuade beneficiaries from inappropriate use of emergency rooms as a source of care

Question #13: Is it your experience that disease management programs are an effective means of assisting beneficiaries manage their own health in a manner that improves overall beneficiary health and leads to decreases in medical costs (short or long term- please specify) If so, which programs have proven to be the most successful in your experience

RESPONSES REQUIRED: Responses to this RFI should be no more than a total of 15pages (including cover page). Responses should be submitted to [email protected] no later than 30 May 2013. Please include reference data for a designated point of contact (name, title, address, phone/fax, email).

Government Primary Point of contact: Laura Sells Contracting Office Address: 16401 East CentreTech Parkway Aurora, Colorado 80011-9066 United States

Place of Contract Performance: United States

Classification Code: Q - Medical Services NAICS Code: Insurance Carriers and Related Activities/524114 - Direct Health and Medical Insurance Carriers

Link/URL: https://www.fbo.gov/notices/abe244ebf9694be9eed0d06034615eea