0036-N.docx

STATE OF WYOMING

DEPARTMENT OF ADMINISTRATION & INFORMATION

GENERAL SERVICES DIVISION, PROCUREMENT SECTION

2323 CAREY AVENUE

CHEYENNE, WY 82002

REQUEST FOR PROPOSAL NUMBER 0036-N

Wyoming Department of Health Division of Healthcare Financing

Medicaid Rate Analysis and Reimbursement Services

PROPOSAL DUE DATE AND TIME

OCTOBER 5, 2026 – 2:00:00 P.M. MOUNTAIN TIME

AGENCY REPRESENTATIVE:

MELISSA GRAHAM

PROCUREMENT REPRESENTATIVE:

DEBI WALKER

debi.walker@wyo.gov 307-777-6707

Table of Contents

PRICING SCHEDULE 1A

PRICING SCHEDULE 1B

PRICING SCHEDULE 1C

PRICING SCHEDULE 1D

PRICING SCHEDULE 1E

PRICING SCHEDULE 2

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK.

SECTION 1: REQUEST FOR PROPOSAL

1. SUBMISSION OF PROPOSALS:

The A&I Procurement Office will receive proposals for providing Medicaid Rate Setting and Rate Analysis Services in healthcare facilities, and research, analysis, and policy compliance for the State of Wyoming, Wyoming Department of Health (WDH), Division of Healthcare Financing (DHCF) (Agency), through the Public Purchase online bidding system. Proposals are due no later than 2:00:00 P.M. (Mountain Time) on OCTOBER 5, 2026.

The technical proposal and cost proposal should be uploaded as separate documents and identified as such.

1.1. Proposals should be accompanied by the attached Proposal Price Sheet and signed by the proper official of the firm. All proposals should be uploaded on the Public Purchase online bidding system. Proposals sent by facsimile, email or paper copy may be rejected.

1.2. Proposals should be submitted through the Public Purchase online bidding system on or before the date and time specified. Proposals received after the date and time specified may be rejected.

1.3. The State of Wyoming reserves the right to withdraw this Request for Proposal, without cause, at any time before a contract has been fully signed and submitted to the A&I Procurement Office.

2. MODIFICATIONS OR WITHDRAWAL OF PROPOSALS:

2.1. A proposal may be altered through the Public Purchase online bidding system before the proposal due date and time contained in this document.

2.2. The proposer may withdraw its proposal through the Public Purchase online bidding system up to the proposal due date and time contained in this document. If a proposal is accepted and the proposer fails to furnish the service agreed upon in the proposal, that proposer may be eliminated from future consideration.

3. PREPARATION OF PROPOSALS:

3.1. A proposal may be rejected if it modifies any of the provisions, specifications or minimum requirements of the Request for Proposal.

3.2. In case of error in the extension of prices in the proposal, unit prices will govern.

4. AWARD AND CONTRACT INFORMATION:

4.1. The State of Wyoming will ensure that minority business enterprises will be afforded full opportunity to submit proposals. The State of Wyoming will not discriminate on the grounds of age, race, color, sex, creed, national origin, or disability status.

4.2. The proposer also, agrees that should their firm be awarded a contract, it will not discriminate against any person who performs work there under because of age, race, color, sex, creed, national origin or disability. In addition, the successful proposer shall comply with the Americans with Disability Act and the Wyoming Fair Employment Practices Act.

4.3. The proposer expressly warrants to the State that it has the ability and expertise to perform the contract if awarded. In doing so, it shall use the highest standards of professional workmanship.

4.4. The State of Wyoming reserves the right to reject any or all proposals, to waive any informality or technical defect in the proposals, or to award the contract in whole or in part, if deemed to be in the best interest of the State to do so. The A&I Procurement Office will award the contract to the firm, determined to have the most responsive and responsible proposal by the Agency.

4.5. The successful proposer will be required to agree to and execute a formal contract with the State containing terms required by the Attorney General with reasonable adjustments acceptable to the State.

4.6. If applicable, the State will negotiate payment terms based upon a schedule to be determined by the proposer and the State. Paying invoices will be based upon the proposer successfully completing the deliverables within the stated deadlines, and upon the Agency’s written acceptance of the deliverables or services.

DATED: AUGUST 17, 2026

State of Wyoming Procurement Section Buyer: Debi Walker

SECTION 2: GENERAL PROVISIONS

1. INSURANCE:

1.1. The contract between the successful proposer and the State shall require the successful proposer to carry certain insurance policies. All such insurance policies, except workers’ compensation and unemployment compensation policies, shall contain a waiver of subrogation against the Agency and the State, its agents and employees.

1.2. The contract between the successful proposer and the State shall require cyber liability insurance which shall be sufficiently broad to cover all duties and obligations undertaken by successful proposer and shall include, but not limited to, claims involving infringement of copyright, trademark, trade dress, invasion of privacy violations, information theft, damage to or description of electronic information, release of private information, alteration of electronic information, extortion and network security, with minimum limits as follows:

1.2.1. $2,000,000.00 each occurrence; and

1.2.2. $2,000,000.00 general aggregate.

1.2.3. Coverage should include breach response, regulatory fines and penalties, and credit monitoring expenses, with limits sufficient to respond to these obligations. Higher limits may be required when the contract involves large amounts of protected information or is high risk.

2. LAWS TO BE OBSERVED:

2.1. The proposer shall keep fully informed of, and comply with, all applicable federal and state laws or rules, all local bylaws, regulations and all orders and decrees of bodies or tribunals having any jurisdiction or authority. The proposer shall protect and indemnify the State and its representatives against any claim or liability arising from or based on the violation of any law, bylaw, ordinance, regulation, order or decree whether by himself or its employees.

3. ASSIGNMENT:

3.1. The proposal shall not be assigned by the proposer. Third party participation is authorized only as a joint venture that shall be clearly stated in detail in the original proposal and signed by all parties participating.

3.2. The proposer shall not enter into any subcontracts for any of the work contemplated under this Request for Proposal without the State’s prior written authorization.

4. EXTENSION AND AMENDMENT:

4.1. The proposer and the State covenant and agree that this proposal or subsequent contract may, with the mutual approval of the proposer and the State, be extended one year at a time, for a total contract period not to exceed three (5) years.

5. AUDIT AND ACCESS TO RECORDS:

5.1. The State or any of its duly authorized representatives shall have access to the proposer’s books, documents, papers, electronic data and records that are directly pertinent to this Request for Proposal.

6. CONFLICT OF INTEREST:

6.1. The proposer warrants that no kickbacks, gratuities, or contingency fees have been paid in connection with this Request for Proposal and none have been promised. The proposer warrants that no one being paid pursuant to the proposal is engaged in any activity that would constitute a conflict of interest with respect to the purchases of the proposal.

7. NO FINDER’S FEE:

7.1. The proposer warrants that no finder’s fee, employment agency fee, or any such fee related to the proposal shall be paid.

8. SOVEREIGN IMMUNITY:

8.1. Pursuant to Wyoming Statute § 1-39-104(a), the State of Wyoming and the Agency expressly reserve sovereign immunity and specifically retain all immunities and defenses available to them as sovereigns. The proposer acknowledges that the State of Wyoming has sovereign immunity and only the Wyoming Legislature has the power to waive sovereign immunity. Designation of venue, choice of law, enforcement actions, and similar provisions shall not be construed as a waiver of sovereign immunity. The parties agree that any ambiguity in this Request for Proposal shall not be strictly construed, either against or for either party, except that any ambiguity as to sovereign immunity shall be construed in favor of sovereign immunity.

9. INDEMNIFICATION:

9.1. The proposer shall release, indemnify, and hold harmless the State, the Agency and its officers, agents, and employees from any and all claims, suits, liabilities, court awards, damages, costs, attorneys’ fees, and expenses arising out of the proposer’s failure to perform any of the proposer’s duties and obligations hereunder or in connection with the negligent performance of proposer’s duties and obligations, including, but not limited to, any claims, suits, liabilities, court awards, damages, costs, attorneys’ fees, and expenses arising out of proposer’s negligence or other tortious conduct.

10. APPLICABLE LAW/VENUE:

10.1. The construction, interpretation, and enforcement of this Request for Proposal shall be governed by the laws of the State of Wyoming, without regard to conflicts of law principles. The terms “hereof,” “hereunder,” “herein,” and words of similar import, are intended to refer to this Request for Proposal as a whole and not to any particular provision or part.

11. RIGHT OF OWNERSHIP AND MARKETING OF INTELLECTUAL PROPERTY AND INTELLECTUAL ASSETS SUBMITTED FOR THE RFP (IF APPLICABLE):

11.1. It is acknowledged and agreed that the only party with a right to market, trademark, patent, copyright, or any like right to any intellectual property or intellectual assets submitted in relation to the Request for Proposal shall be and is solely vested in the State. This includes all intellectual property and intellectual assets related to both the written proposal and the oral presentation and any and all documents, pitches, products, media pitches, web screens, layouts, etc. produced for the written proposal and the oral presentation, and any updates, changes, alterations, or modifications to or derivative works.

SECTION 3: SPECIAL PROVISIONS INFORMATION

PROPOSALS SHOULD BE SUBMITTED THROUGH THE PUBLIC PURCHASE ONLINE BIDDING SYSTEM BY 2:00:00 P.M. MOUNTAIN TIME ON OCTOBER 5, 2026. PROPOSALS RECEIVED AFTER THE DATE AND TIME SPECIFIED MAY BE REJECTED.

It is the responsibility of the proposer to clearly identify all information that is considered confidential in accordance with the Wyoming Public Records Act, Wyoming Statute §16-4-201 through §16-4-205. Please identify each confidential page with the word “CONFIDENTIAL” in capital, bold letters centered at the bottom of each page. Information not clearly marked may be considered public. If the proposer submits information that it believes is confidential, it should include a statement justifying its basis for that belief.

1. STATE PARTIES:

1.1. This Request for Proposal is issued by the Wyoming Department of Administration and Information, General Services Division, Procurement Section (Procurement) on behalf of the Wyoming Department of Health (WDH), Division of Healthcare Financing (DHCF) (Agency).

1.2. Throughout this document and others in connection with this project, various references are made, or will be made to the “State.” Generally, whenever this reference appears, the term “State” incorporates all state agencies working on this project.

1.3. It should be understood that the Director of WDH is empowered to be the signatory on all contracts, agreements, or modifications pertaining to this project. Any contracts, agreements, or modifications not bearing this signature or that of a designee are invalid.

2. CONTENT AND PROCUREMENT POINTS OF CONTACT:

2.1. Procurement is the primary point of contact from the date of release of the Request for Proposal until a proposer is selected and the selection is announced.

2.2. Written questions about the procurement should be submitted through the Public Purchase online bidding system until 2:00:00 P.M. Mountain Time on SEPTEMBER 14, 2026. Any questions received after that deadline may not be accepted or considered. Each question should be submitted individually. It is the proposer’s responsibility to check the Public Purchase online bidding system for answers to questions, addenda, or bid tabulations. Telephone calls, emails or faxes may not be accepted.

2.3. Written responses will be available through the Public Purchase online bidding system. Responses will not identify the firm that submitted the question. Only the written answers issued by the Agency are the official position on an issue, and these answers shall become part of the Request for Proposal.

3. RESTRICTIONS ON COMMUNICATIONS WITH AGENCY STAFF:

3.1. Until a proposer is selected and the selection is announced, proposers shall not communicate with Agency staff except via written questions through the Public Purchase online bidding system.

3.2. If a proposer violates this restriction, the State reserves the right to reject the proposal.

4. EFFECTIVE DATES OF PROPOSAL:

4.1. All terms, conditions and costs quoted in the proposer’s response will be binding on the proposer for one-hundred eighty (180) days from the effective date of the proposal.

5. ADVERTISING AWARD CONDITIONS:

5.1. A fully executed contract should be completed with the State before the successful proposer may advertise the award of the contract or the services being performed. The proposer should agree not to refer to awards in commercial advertising in such a manner that states or implies that the firm or its services are endorsed or preferred by the State of Wyoming.

6. CONTRACT NEGOTIATIONS:

6.1. The State will notify the most qualified/successful proposer and negotiate a contract in accordance with the Wyoming Attorney General’s contract guidelines. The successful proposer will be required to enter into and sign a formal contract with the Agency.

6.2. In the event the Agency determines contract negotiations are making no forward progress, negotiations will be terminated, and at the State’s sole discretion, negotiations may be initiated with the next most qualified/successful proposer, or the RFP may be withdrawn or reissued. This process will be followed until an agreement is reached, or until the State determines that the RFP will be withdrawn or reissued. The State assumes no obligation to a selected proposer until an agreement is reached and a contract is fully executed. The State will not negotiate concurrently with more than one proposer for the same award.

7. BEGINNING WORK:

7.1. The successful proposer may not perform any work that could be billed until a contract has been executed. The State will not pay for any work by the proposer before a contract is executed.

8. COPYRIGHT INFRINGEMENT:

8.1. The proposer warrants that no materials, products, and services proposed will infringe upon or violate any patent, copyright, trade secret, or other proprietary right of any third party. In the event of a claim by any third party against the State, the State shall promptly notify the proposer, and the proposer shall defend the claim. The defense will be at the proposer’s expense.

9. COST OF PREPARING PROPOSALS:

9.1. All costs incurred for preparing the proposal and for other procurement related activities are solely the proposer’s responsibility. The State of Wyoming will not provide reimbursement of these costs.

10. RISKS AND LIABILITIES:

10.1. By submitting a proposal, a proposer assumes any and all risks and liability associated with information in the proposal and its release.

11. AMENDMENTS:

11.1. The State reserves the right to amend this Request for Proposal before the proposal submission date. Amendments shall be uploaded to the Public Purchase online bidding system. It is the proposer’s responsibility to check the Public Purchase online bidding system for amendments.

12. PROPERTY DAMAGE AND LIABILITY INSURANCE:

12.1. The proposer may be required to furnish proof of property damage liability insurance in the amount deemed necessary by the Agency for this project, if applicable.

12.2. Questions regarding required insurance coverage and limits for this project should be submitted in writing, in accordance with instructions outlined in the special provisions.

13. MISREPRESENTATION OF INFORMATION:

13.1. Misrepresentation of a proposer’s status, experience, or capability in the proposal may result in disqualification of that proposer from the selection process. Discovery of litigation or investigations in a similar area of endeavor may, at the discretion of the Agency and after consultation with Procurement, preclude the proposer from the selection process.

14. DISPOSITION OF PROPOSALS:

14.1. All material submitted becomes property of the State of Wyoming, which is under no obligation to return any of the material submitted.

15. LEGAL CONSIDERATIONS:

15.1. This Request for Proposal is issued under Wyoming Statute §9-2-3204.

16. PROPOSER RELATIONS WITH STATE:

16.1. The proposer and its staff will have an ongoing relationship with the State that is based on trust, confidentiality, objectivity and integrity. The proposer will operate at all times in the State’s best interests and in a straightforward, trustworthy and professional manner. The proposer shall:

16.1.1. Work cooperatively with the State’s staff and business partners whenever required.

16.1.2. Work cooperatively with the staff of other proposers whenever required.

SECTION 4: KEY DATES

SECTION 5: ADMINISTRATIVE BACKGROUND

1. INTRODUCTION AND BACKGROUND:

1.1. The Wyoming Department of Health (WDH) is the single State agency appointed pursuant to the Social Security Act to administer the Medicaid program in Wyoming. The Wyoming Medicaid program has operated since 1967 under Title XIX of the Social Security Act, as amended. The WDH's Division of Healthcare Financing (DHCF) directly administers the Medicaid program and is funded by appropriations authorized by the Wyoming State Legislature for each biennium.

1.2. Wyoming Medicaid serves a population of approximately 104,296 eligible individuals per year with approximately 22,256 enrolled service providers. Approximately 80,842 individuals receive services in any given month through a fee-for-service delivery system. Wyoming does not operate a managed care program.

1.3. WDH currently utilizes contractor services for Medicaid Rate Setting and Rate Analysis practices to establish rates for various reimbursement methodologies. Through this RFP, DHCF seeks to procure a contractor to continue and expand these Medicaid rate setting and rate analysis functions, align rate methodologies with current federal and State requirements, leverage existing systems such as the Wyoming Integrated Next Generation System (WINGS), the Pharmacy Benefits Management System (BMS), and the Data Warehouse, and support transparent, data-driven decision-making for Wyoming Medicaid.

1.4. WDH has utilized the incumbent contractor for Medicaid Rate Setting and Rate Analysis service for twenty (20) years.

1.5. The selected contractor will be responsible for providing comprehensive rate setting and analysis services in these areas:

1.5.1. Ambulance

1.5.2. Care Management Per Member Per Month (PMPM)

1.5.3. Disproportionate Share Hospitals

1.5.4. Durable Medical Equipment (DME)

1.5.5. Federally Qualified Health Center (FQHC)

1.5.6. Home and Community Based Services (HCBS) Waivers

1.5.7. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10)

1.5.8. Inpatient reimbursement, including hospitals and Psychiatric Residential Treatment Facilities (PRTF)

1.5.9. Outpatient Prospective Payment System (OPPS)

1.5.10. Physician Resource Based Relative Value System (RBRVS) for various provider types including, but not limited to, psychologists and Community Mental Health and Substance Abuse Centers

1.5.11. Rural Health Clinics (RHC)

1.6. These services also include reimbursement assistance services, which includes research, policy analysis, and support for State and federal initiatives that impact Medicaid reimbursement strategies and rate setting practices.

1.7. The contractor performs tasks and activities in response to various State and federal initiatives and programs impacting Medicaid reimbursement strategies and rate setting practices. These activities include providing support, as necessary and required, to WDH in hearings and litigation cases. The contractor also assists with development of a long-term plan for reimbursement and an annual Medicaid report.

1.8. Wyoming Medicaid delivers accurate, fair, and compliant Medicaid Rate Setting and Rate Analysis services, while supporting the sustainability and quality of care for Wyoming's citizens. The procurement process will be informed by previous RFPs, current system documentation, and stakeholder input, and will result in a contract that reflects the latest requirements and best practices for Medicaid Rate Setting and Rate Analysis support.

2. PURPOSE AND INTENT:

2.1. The purpose of this RFP is to solicit competitive proposals from experienced and financially sound proposers who can deliver comprehensive Medicaid rate setting, audit, and policy support services to meet the needs and expectations of the Wyoming Department of Health (WDH), as described within this RFP. The selected contractor will play a critical role in supporting the Division of Healthcare Financing (DHCF) in administering Medicaid reimbursement methodologies across multiple programs, including facility based, professional, outpatient, waiver, and supplemental payment programs. The contractor will ensure that Medicaid rate setting, analysis, auditing, and policy compliance activities are accurate, timely, transparent, and fully aligned with applicable State and federal requirements. The specific services required under this RFP include:

2.2. Technical Assistance in Establishing Medicaid Reimbursement Rates

2.2.1. The proposer will provide technical assistance in establishing Medicaid reimbursement rates for Wyoming providers across a broad set of programs, including:

2.2.1.1. Ambulance

2.2.1.2. Care Management PMPM rates

2.2.1.3. DSH

2.2.1.4. DME through applicable fee schedule and OPPS methodologies

2.2.1.5. FQHC PPS

2.2.1.6. HCBS Waivers

2.2.1.7. ICD-10 related pricing and payment updates

2.2.1.8. Inpatient reimbursement, including hospitals and PRTF

2.2.1.9. OPPS

2.2.1.10. Physician RBRVS for all applicable provider types

2.2.1.11. RHC PPS reimbursement

2.2.2. As part of these services, the proposer will audit or verify provider cost reports, financial submissions, or supplemental documentation as required to support rate setting activities for programs such as inpatient hospital, PRTF, HCBS, and FQHC/RHC, consistent with the methodologies in this RFP.

2.2.3. The proposer will assist WDH in monitoring rate related obligations for selected provider types, including assessment based payments, provider tax requirements, and State and federal Upper Payment Limit (UPL) demonstrations for hospitals, physicians, clinics, ambulatory surgical centers, family planning clinics, county health departments, ESRD providers, inpatient/outpatient hospital services, and other covered provider types identified by WDH

2.3. Audit Services for Healthcare Facilities and Programs

2.3.1. The proposer will provide audit services, as requested, for healthcare facilities and provider types included within the scope of this RFP. These services will support WDH in:

2.3.1.1. Conducting cost settlement actions

2.3.1.2. Reconciling provider cost reports

2.3.1.3. Conducting trend analysis (e.g., trend analysis of program‑specific utilization and cost reporting where applicable)

2.3.1.4. Verifying cost data used for rate setting

2.3.1.5. Addressing audit findings and related inquiries

2.3.2. All audit services must be performed in accordance with Generally Accepted Accounting Principles (GAAP).

2.3.3. The proposer will also be required, on an annual basis, to adhere to federal requirements for Disproportionate Share Hospital (DSH) auditing, at the request of WDH.

2.4. Research, Analysis, and Policy Compliance

2.4.1. The proposer will provide research, analysis, and policy compliance services to support the State’s Medicaid reimbursement methodologies. This includes:

2.4.1.1. Conducting general and targeted research

2.4.1.2. Analyzing State and federal rules, regulations, and policy changes

2.4.1.3. Developing and updating Medicaid reimbursement policies

2.4.1.4. Supporting regulatory compliance related to rate setting

2.4.1.5. Assisting with SPAs, waiver amendments, and Medicaid policy development

3. STAKEHOLDERS:

3.1. The contractor may be required to work with a variety of WDH staff, third-party vendors, and providers to support the scope of work described in this RFP. Primary parties include:

3.2. Wyoming Department of Health (WDH), Division of Healthcare Financing (DHCF):

3.2.1. DHCF is the division of WDH responsible for administering Wyoming’s Medicaid program, including oversight of rate setting services, audit functions, and policy compliance. DHCF will manage the contract, provide direction on technical requirements, and oversee research, analysis, and regulatory compliance activities necessary for rate setting and auditing.

3.3. Other WDH Divisions:

3.3.1. The contractor may be required to collaborate with other divisions within WDH to conduct rate setting, audit functions, and support cross‑divisional initiatives related to Medicaid program operations.

3.4. Wyoming Department of Health’s Fiscal Agent:

3.4.1. The Fiscal Agent is responsible for Medicaid fiscal operations. The contractor will coordinate with the Fiscal Agent to obtain necessary financial and claims data, facilitate cost report analysis, and support payment and reimbursement processes as required by the scope of work.

3.5. Medicaid Providers:

3.5.1. The contractor may be required to work directly with Medicaid providers—including hospitals, clinics, behavioral health providers, ambulance providers, FQHCs, RHCs, DME suppliers, PRTF, physicians, and HCBS waiver providers—to support data collection, rate model validation, reimbursement policy clarification, and analytical work. When communicating with providers, the contractor shall coordinate with and copy communications to WDH.

3.6. Third-Party Vendors and Consultants:

3.6.1. As needed, the contractor may be required to interact with other vendors or consultants engaged by WDH or providers to support technical, operational, or compliance aspects of the project.

4. RFP REQUIREMENTS

4.1. WDH, Division of Healthcare Financing defined the requirements stated herein and created this RFP. The Requirement/Specifications document is included as a part of this RFP. Requirements tables are located in Section 6 and the mandatory response table is included as Attachment A. THESE ARE MANDATORY REQUIREMENTS, WHICH MAY BE SUBJECT TO VARIATION AND MODIFICATION ONLY THROUGH THE WRITTEN APPROVAL OF THE AGENCY.

SECTION 6: REQUIREMENTS/SPECIFICATIONS

1. SCOPE OF PROJECT:

The State of Wyoming, Department of Health (WDH), Division of Healthcare Financing (DHCF), is seeking a single contractor to provide comprehensive Medicaid rate setting, analysis, reimbursement assistance, external quality review and independent assessment services, and on request support across all major Medicaid program areas. The contractor will be responsible for supporting DHCF in ensuring that all Medicaid reimbursement methodologies, compliance activities, audit functions, policy analyses, and related operational tasks are accurate, transparent, data driven, and aligned with applicable State and federal requirements.

The Scope of Work for this RFP does not include any information technology services or procurements of any information technology products (such as external systems, software, hardware, or other technical capabilities). The contractor shall be responsible for providing such technology services or tools as are necessary to deliver all services and work proposed.

Scope of Activity requirements are presented for each functional and non-functional area of the RFP. Proposers are expected to include the completed “Proposer Requirements Response” spreadsheet (provided as Attachment A) in their RFP responses according to the valid values for the Proposer Compliance Code column: (a) Comply, (b) Propose Alternative, and (c) Subproposer. Additionally, proposers will be evaluated on their ability to deliver these services and should include details in the proposal response about their capabilities and experience.

1.1. FUNCTIONAL AREAS

1.1.1. Rate Setting & Analysis

The Rate Setting & Analysis functional area encompasses all activities required to develop, update, maintain, monitor, and document Medicaid reimbursement methodologies across the full range of Wyoming Medicaid program areas. These activities include development of institutional, professional, outpatient, ancillary, waiver, and supplemental payment methodologies, along with the analytical, actuarial, cost-based, and policy support necessary to ensure all Medicaid payment methods are transparent, well-supported, and compliant with State and Federal requirements.

Under this functional area, the contractor shall support DHCF through four primary categories of work:

1.1.1.1. Develop Rates

The contractor shall develop, model, update, and maintain Medicaid reimbursement methodologies for all program areas identified by DHCF, including but not limited to ambulance services, Care Management Per Member Per Month (PMPM), Disproportionate Share Hospital (DSH) payments, Psychiatric Residential Treatment Facility (PRTF), durable medical equipment (DME), Federally Qualified Health Center Prospective Payment System (FQHC PPS), Home and Community Based Services waiver (HCBS), inpatient hospital services (APR-DRG), outpatient hospital services (OPPS-EAPG), physician and professional services (RBRVS), Rural Health Clinic Prospective Payment System (RHC PPS), ICD-10 related pricing updates, and all required Upper Payment Limit (UPL) demonstrations.

1.1.1.2. Cost Reporting & Analysis

The contractor shall review, validate, and analyze cost reports and financial submissions for applicable provider types; conduct cost and utilization analysis; support DHCF in actuarial, budget impact, and rate modeling activities; perform rate studies; and assist in the preparation of federal documentation such as SPAs, waiver amendments, and UPL analyses.

1.1.1.3. Administrative Functions

The contractor shall prepare provider rate notices, supporting worksheets, explanatory materials, and related documentation; provide analyses in support of provider inquiries, rate reconsiderations, and appeals; prepare and maintain rate setting documentation including payment policies, State Plan language, and related materials; coordinate with the Fiscal Agent on rate file implementation; and assist DHCF with stakeholder engagement.

1.1.1.4. Rate Setting Performance Requirements

The contractor shall monitor the performance and financial impact of Medicaid reimbursement methodologies, evaluate provider cost trends, assess reimbursement adequacy and alignment with federal rules, ensure proper documentation and transition of methodologies over time, and support DHCF in responding to State and federal requirements related to rate setting and reimbursement oversight.

Rate Setting & Analysis requirements are included in Table 1. This functional area applies to all Medicaid provider types and reimbursement methodologies included in the scope of this RFP. Provider participation and program configurations may change over time as new providers enroll or as service delivery models evolve; therefore, the contractor shall adjust its analytical and methodological support accordingly at the direction of DHCF.

Wyoming Medicaid enrolls a diverse mix of provider types across institutional, professional, outpatient, ancillary, behavioral health, waiver, and specialty service categories. Provider participation counts may change over time as new providers enroll or existing providers discontinue services; therefore, the contractor shall adjust analytical and methodological support accordingly.

Table 1: Rate Setting and Rate Analysis Requirements

1.1.2. Reimbursement Assistance

The Reimbursement Assistance functional area encompasses all activities required to support DHCF in maintaining, updating, analyzing, and communicating Medicaid reimbursement methodologies, policies, and related compliance functions. This functional area includes general reimbursement assistance, administrative functions, and provider and recipient surveys. These services are intended to ensure that reimbursement methodologies remain accurate, transparent, and compliant with all applicable State and Federal requirements.

1.1.2.1. General Reimbursement Assistance

The contractor shall provide comprehensive support to DHCF in all areas of Medicaid reimbursement policy development and maintenance. At a minimum, this includes:

1.1.2.1.1. Rules and Regulations Analysis

1.1.2.1.2. Analyze and Update Reimbursement Methodologies

1.1.2.1.3. Policy Development and Recommendations

1.1.2.1.4. Other As‑Needed Support

1.1.2.2. Administrative Functions

The contractor shall support DHCF with administrative activities necessary to maintain accurate and transparent reimbursement methods.

1.1.2.3. Provider and Recipient Surveys

The contractor shall conduct provider or recipient surveys, as requested by DHCF, to support reimbursement methodology development, program evaluation, cost analysis, or policy design.

Reimbursement Assistance requirements are included in Table 2.

Table 2: Reimbursement Assistance Requirements

1.1.3. External Quality Review & Independent Assessment

The External Quality Review (EQR) and Independent Assessment (IA) functional area encompasses all activities necessary to maintain Care Management Entity (CME) compliance with applicable federal and State requirements, including 42 CFR 438, Subpart E and Section 2111(B) of the State Medicaid Manual. This functional area includes mandatory EQR activities required for prepaid ambulatory health plans, as well as all Independent Assessment elements required by CMS. The contractor shall complete all EQR and IA activities within the timelines established by DHCF, including CMS’s requirement that EQR technical reports be available to CMS and the public by April 30 of each year.

The contractor’s responsibilities under this section are organized into four categories:

· CME Compliance

· EQR Protocols

· Independent Assessment Review

· Network Adequacy

1.1.3.1. CME Compliance

The contractor shall provide project management and compliance monitoring activities necessary to ensure the CME program adheres to all applicable federal and State managed care regulations.

1.1.3.2. EQR Protocols

The contractor shall conduct all EQR activities in accordance with CMS protocols.

1.1.3.3. Independent Assessment Review

The contractor shall conduct required Independent Assessment activities and prepare final IA documentation.

1.1.3.4. Network Adequacy

The contractor shall validate compliance with federal requirements in accordance with 42 CFR § 438.66(e) and 42 CFR 438.68.

1.1.3.5. Reporting Requirements

The contractor shall prepare draft and final EQR technical reports, Independent Assessment reports, PIP validations, compliance findings, and survey validation results. Reports must be developed in accordance with CMS standards, and the contractor shall respond to CMS questions, recommendations, or requests for additional information.

EQR and IA requirements are included in Table 3.

Table 3: External Quality Review & Independent Assessment Requirements