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Contract Opportunity

Update 10/06/22: The Defense Health Agency (DHA) seeks industry feedback on the following questions located in the attachment, dated 10062022 from all potential Competitive Plans Demonstration (CPD) vendors or potential offerors, especially those vendors who may operate regionally, locally or have Accountable Care Organization (ACO) or Clinically Integrated Network (CIN) status as defined by their State or Federal government.

Note: If you are an ACO, please indicate if you are also recognized as a CIN when responding to this RFI.

Please follow the provided instructions on Tab 1 of the template.

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Update 04/05/22: The Defense Health Agency has updated the Competitive Plans Demonstration (CPD) – Projected Geographic Locations, attachment now dated April 5, 2022. The attachment is referenced in Question #4 of the Request for Information body of this announcement.

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The Defense Health Agency (DHA) is planning to demonstrate competition for TRICARE beneficiaries at the local and regional level, through a Competitive Plans Demonstration (CPD) project. If the Demonstration is approved, DHA will plan to initiate it in Calendar Year 2024, the CPD will open one or more of 23 potential markets for competition from local or regional health plans. Please see the attachment to this RFI for the 23 potential markets.

Awarded CPD contractors will compete for beneficiary enrollment to provide the TRICARE benefit. The CPD contractors will provide networks, customer service, records management, referral management and healthcare operations to TRICARE-eligible beneficiaries. In selected markets, eligible beneficiaries will have the option of enrolling to either the CPD contractor or to an existing regional TRICARE Managed Care Support Contractor (MCSC) during an annual enrollment period.

The Government intends to publish individual requests for proposals for each future market (local/regional) demonstration project. The period of performance of the Demonstration contract is anticipated to be a transition-in phase of one year, plus three one-year options for healthcare delivery, and a transition-out period.

The TRICARE Program is part of the Military Health System (MHS) in the United States that supports active duty service members (ADSMs); active duty family members (ADFMs); retired service members (RET) and their eligible family members (RETFMs); 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) Military Medical Treatment Facilities (MTFs), provides a variety of care options to beneficiaries under TRICARE Prime and Select, and provides care to those eligible beneficiaries living in areas without access to MTFs. The North American Industry Classification System (NAICS) Class Code is 524114.

The Government is also interested in testing alternative payment and delivery models and understanding a local or regional health plan’s willingness to take up to 100% financial risk for the healthcare and administrative costs for a population of enrollees. These costs may also include pharmacy costs. The capitation rate would be based on the average historical Government cost of TRICARE Prime beneficiaries enrolled to the regional MCSC in the Demonstration market area. The rate would trend for inflation and would be risk-adjusted for age/gender and the health status of your enrollees.

Unless the Demonstration conditions allow for flexibility in this area, the enrolled beneficiaries would be subject to the same enrollment fees, copays, and other cost-shares, by beneficiary category (e.g., ADFM or non-Medicare retirees and their dependents), as specified in the regular TRICARE Prime benefit (see 10 U.S. Code § 1075a). For example, ADFMs enrolled in TRICARE Prime have no copays or other cost-shares for in-network non-pharmacy services. While no decisions have been made, local and regional health plans may assume ADSMs and beneficiaries maintaining other health insurance would not be eligible for enrollment to a competitive plan under this Demonstration.

In an effort reduce barriers for local or regional health plans to participate in the CPD, under a separate acquisition, the DHA is planning to execute the Eligibility, Enrollment and Encounter (EEE) Pilot to provide a HIPAA compliant-enrollment and eligibility function as well as a method to pass clinical and other claim information back to the DHA. The EEE pilot is designed as an enabling capability and interface to facilitate verifying beneficiary eligibility to participate in the CPD, beneficiary CPD enrollment, and processing beneficiary healthcare/CPD encounters.

Additional Resources and References:

Link to T-5 RFP: https://sam.gov/opp/ac9404b009cc4220b957659690960b20/view

Link to T-5 Manuals: https://manuals.health.mil/

This RFI, HT9402-22-RFI-0133 solicits industry's input and feedback on the areas identified below. Interested parties may respond to all questions in the RFI or limit the response to specific areas of interest. Additionally, industry may provide an introductory submission on their company background or a capability statement/profile.

Covered Lives and Beneficiary Choice

1. Approximately how many TRICARE enrollees would a competitive plan need for financial viability and be worthwhile under a fully capitated model (with risk-adjustment for demographics and health status) to incentivize proposal submission?

2. Based on a given market, what is the minimum number of enrolled beneficiaries required to provide meaningful cost, quality and performance data to the Government to effectively evaluate success of the Demonstration?

a. What cost, quality and performance measures/metrics should a CPD use to determine success?

b. What is the minimum period of performance necessary to effectively gather data required?

3. What tools and information do beneficiaries need to choose the right health plan based on individual health needs?

Competitive Markets and Healthcare Delivery

4. Looking at the 23 identified potential CPD markets, do you see any that may be problematic to include in the CPD? In which of the potential markets under consideration for the demonstration do you have a high-quality provider network and other necessary health plan features to deliver the TRICARE benefit? (See attachment entitled: Competitive Plans Demonstration (CPD) – Projected Geographic Locations, updated April 5, 2022.)

5. To achieve balance between competition and viability of CPD plans what is the optimal number of competing health plans to be offered to TRICARE beneficiaries in a local market, not counting the traditional regional MCS contractor that administers the TRICARE Prime and Select benefit? What market characteristics would influence your answer?

6. When competing in a given market with the existing Managed Care Support Contractor, what are the top concerns/risks of the potential CPD? During Transition? Post-transition?

7. For the potential Demonstration market(s) in which you have the capability to participate in the CPD, please describe your provider network and other relevant administrative capabilities for delivery of the TRICARE benefit, such as:

a. Briefly describe your network capacity with respect to:

1. Professional providers for primary care and the full range of specialties, including but not limited to behavioral health Hospitals and other necessary institutional providers, including but not limited to behavioral health


2. Hospitals and other necessary institutional providers, including but not limited to behavioral health


3. Urgent care


4. Telehealth


5. Retail pharmacy and mail-order pharmacy, if available


6. Durable medical equipment (DME)


7. Lab, imaging, other ancillary services


8. Physical Therapy (PT)/Occupational Therapy (OT)/Speech Therapy (ST)


9. Other types of providers/services

b. How do you ensure that your provider network delivers high-quality, high-value care within access standards?

c. To what extent do you administer population health (PH), disease management (DM), and/or case management (CM) programs?

Cost Impacts: Risk Sharing and Capitation

8. Are you currently participating in a capitated model or other type of alternative payment model (APM)?

a. How are your financial incentives and profit sharing levels/metrics established under each model?

9. Describe how a risk-adjusted population-based model impacts levels of efficiency, effectiveness of care and beneficiary satisfaction. For example, improved health outcomes for covered beneficiaries, an improved beneficiary experience and/or impacts per capita costs of care for covered beneficiaries.

10. What requirements and reporting should DHA require to maintain Access to Care in a capitated plan? How can access to care be maintained when a risk-adjusted population-based capitated payment model is implemented?

11. If the Government allows TRICARE CPD enrollees access to MTF care, what issues or concerns would this raise? For example: If TRICARE CPD enrollees would be eligible for MTF care, how should the value of any MTF care received be priced for purposes of decrementing DHA’s net monthly capitation payments to the enrolled plan? In other words, how should “prices” for MTF care be set?

Systems Interface

12. For the potential CPD market(s) in which you might participate, please describe your relevant administrative capabilities for delivery of the TRICARE benefit, such as:

a. Would you have a capability to process enrollment fees and pay claims if a TRICARE enrollee to your plan needed to utilize non-network services?

b. Would you be able to electronically submit encounter and pharmacy claim-level data to the demonstration’s EEE contractor for all network and non-network services provided to your TRICARE enrollees?

c. What types of quality and access data for your TRICARE enrollees would you be able to submit to support Government oversight?

d. Are you able to deliver the full TRICARE pharmacy benefit, including use of TRICARE’s formulary, copay tiers and amounts, retail network and mail order option, etc.?

13. Beyond the requirements that would be satisfied or enabled by the EEE contractor, are there other TRICARE requirements (e.g. HIPAA/Privacy, Records Management, Program Integrity, Financial Management, etc.) that would inhibit your participation?

14. From a CPD scope and design perspective, are there any other issues you wish to identify to DHA as it develops this demonstration?

REQUEST FOR INFORMATION: The above questions are provided for consideration during this market research phase of the acquisition. Please note that information gathered from this RFI may be used in the development of the Government’s requirements. Any information provided that is considered proprietary in nature must be clearly marked as such.

RESPONSES: Written responses are requested no later than 22 April 2022.

Responses should be submitted to Mr. Marcus R. Webb, Contracting Officer, marcus.r.webb.civ@mail.mil

Any written questions submitted should include a designated point of contact (name, title, address, phone, email).

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