The vendor is required to provide of assorted actuarial services, fiscal management analytics, and reporting services, as defined in this request for proposals (RFP) document.
a. Independent annual development and certification of non-emergency (net) services reimbursement
1. Employ and subcontract, at least one (1) certified actuary to perform the independent annual development and certification of net service reimbursement.
2. Project planning
• Work with the department to establish the project structure and required meetings, including periodic meetings with department project leadership, to drive decision-making and planning over the contract period by:
o Developing a project plan with agreed-upon deliverables and timeline.
o Setting up project structure, required meetings, status reporting, and review process.
o Discussing financial status of net program, including the upcoming fiscal year net broker contracting process and anticipated contractual and programmatic changes that may impact the analysis.
o Confirming rating approach, including eligible populations, covered services, rate cohorts, and regional rate structure for the effective period.
3. Data collection, analysis, gap analysis and rectification, and preparation
• Schedule and meet with the department to discuss the modifications made to the encounter data since the previous rate calculations and any known issues with the data to be provided over the contract period.
• Submit a data request and perform a review of the data and assist with identification of key elements to be addressed prior to the rate development process for each fiscal year.
• Gather net program data from the department’s move it secure file transfer protocol, including but not limited to:
o Net-specific encounter data for claims incurred under the full-risk net broker program beginning January 1, 2024, through current.
o Current net broker contracts effective July 1, 2024.
o Net broker financial reports summarizing net expenses, including claims, administrative expenses, underwriting margins, taxes, fees, and other assessments.  
a. Net brokers will provide the awarded bidder the required financial reports.
o Department financial reports summarizing net experience (i.e., claims, enrollment, call volume) to be used to review and supplement the provided claims and enrollment data.
• Using the data gathered in (a)(3)(c):
o Develop a methodology to identify net-eligible populations, regions, net service type, waiver eligible participants, and waiver-related claims within the provided claims and caseload data.
o Develop a methodology to identify net rides and trips, payments, mileage, and unique claims by service type within the provided claims data.
o Provide a description of population, eligibility, and net benefits changes that have occurred during the provided base period data or will occur during the upcoming rating effective period.
o Provide description of known data issues and outliers and methodology to identify and correct data issues and outliers (i.e., incomplete claims, incorrect utilization) including a description of the department’s plan to improve the underlying data in the future.
o Provide updated crosswalks and net procedure code definitions to support the data received
• Review the encounter data compared to the data specifications provided to the department at the close of the prior fiscal year rate certification.
o Identify missing net brokers or fields within the data and summarize identified data gaps, data issues, and significant data questions.
• Collaborate with the department and net brokers to resolve missing data, data gaps, data issues, and address data questions in order to have processes in place designed to produce credible data for the rate certification for each fiscal year, including resolving data issues and questions by communicating with:
o The department to review provided data and address data questions.
o Net brokers to address data questions.
• Review encounter data and facilitate a discussion with the department regarding the implications that the available data would have on the credibility, granularity, and creation of capitation rates to Determine how to proceed with the rate certification.
• Use findings to determine if the data appears credible, complete, and appropriate for the analysis, by reviewing and preparing the data for use in the actuarial analysis by:
o Identifying the claims for the net services and eligible populations to include in the analysis using crosswalk information provided by the department.
o Identifying and correcting significant data issues and outliers.
o Comparing the provided claims and enrollment data against financial reports provided by the department and net brokers for reasonableness.
o Reviewing the emerging claims experience under the full-risk net broker program to determine if the data appears credible or if additional adjustments need to be incorporated to reach a credible data set.
o Comparing the emerging claims experience with historical results used in the prior net actuarial rate certification to understand the impact of the full-risk net broker program and understand data anomalies and significant changes in program costs and utilization.
o Facilitating discussions with the department and net brokers to address data questions.
o Discussing findings with the department to determine appropriate adjustments, verify the quality of the results, and determine the methodology for incorporating the data into the actuarial analysis:
a. Including whether to continue setting rates for the specific cohorts (refer to table 1) or whether population categories should be revised.
4. Rate development and certification
• Develop capitation by rate cohort, region, and population as defined by the department.
o Rates shall be presented in two reports, one covering the first and second cohorts described in table 1 and the other covering all other cohorts.
• Develop a net capitation rate certification which outlines its approach and results in determining the capitation rates.
• Participate in discussions with the CMS or net brokers regarding follow-up questions.
• Participate in calls with the department to discuss the actuarial rate certification.
o Upon request, assist the department in responding to any questions and participate in calls with CMS and net brokers.
c. AC and PCPlus data analysis and reporting.
• Provide, with the delivery of each total cost of care (TCOC) report, including projections, biannual reports, and annual reports, an analysis of the program components based on the current TCOC report findings and the last comparable performance period, specifically:
• MAIN drivers of performance, material changes in attribution, spend, utilization, risk, trend, and other impactful observations for:
o Each AC;
o Comparisons between each AC;
o Comparisons between each ac and non-AC; and
o Comparisons between the ac program in aggregate and non-ac.
• Detailed and actionable explanations of findings and potential contributing factors or remediations.
• Performance metrics described in the fiscal management analytics (refer to part ii, d. below) as they relate to the ac program.
b. Ensure all materials are in a format which allows the department to share information with ACs.
- Contract Period/Term: 2 years
- Questions/Inquires Deadline: May 16, 2025